Annual Report 2015 - 16
Produced and published by: Communications Surrey and Sussex Healthcare NHS Trust For additional copies please contact: 01737 768511 x6199
Contents Foreword
5
Overview: About us • Our vision • Our values • Our Clinical Commissioning Groups • Clinically led – structure • CQC • Our health campus • SASH+ - Virginia Mason Institute partnership • Foundation Trust journey • Staff awards • SASH Charity
10 11 12 12
Patient experience • What our patients say • Your care matters • Patient Opinion • PALS • Supporting carers • Standards of behaviour • Responding to complaints • Compliments – saying thank you • Digital conversations
15 15 15 15 16 16 16 17 18 19
Our people • Who we are • Gender profile • Staff survey • Our volunteers • Work experience • Apprentices
Surrey and Sussex Healthcare NHS Trust
7 8 8 8 8 9 9
21 21 21 21 22 23 23
• Developing our staff • Off-payroll engagements • Equality, diversity human rights • Health and wellbeing • Staff engagement • League of Friends
23 24 24 25 25 26
Our environment • Travel plan • Recycling • Energy efficiency
29 29 29 29
Our plans • Strategic objectives • Delivery plan • Sustainability and Transformation Plan (STP)
33 33 33
Performance: • A&E four hour standard • Cancer waiting time standard
35 35 36
Accountability: Our governance and assurance Annual governance statement
39 39 43
Putting people first
59
Keep in touch
59
Appendices
60
Financial: Our finances
61
33
3
Foreword This year has seen unprecedented demands and challenges for the NHS across the country – challenges that have had a significant impact on all providers of NHS care. The year has been a financially challenging one for us all. Locally, we have continued to strive to meet the pressures of increasing activity and substantial demands upon the services we provide with a limited workforce and significantly restrained finances. It is not easy and it is a credit to our teams and their focus and dedication that we continue to provide high quality, specialist care to local people. We are proud that, together, our teams have sought to meet the challenges and pleased that this year has been a year that has seen Surrey and Sussex Healthcare NHS Trust continue to develop and extend services for our patients. Recognition of our success and the positive reputation of the care we deliver at East Surrey Hospital and at other sites continues to grow both nationally and locally. Most importantly, we are especially pleased to hear and read the positive feedback from the people we care for – it is their expressions of gratitude and appreciation that give real meaning to the hard work and dedication that each
of our clinicians, staff and volunteers give every day. We were delighted that this commitment was reflected in the Trust being named as one of the 120 best places to work in the NHS by respected healthcare publication the Health Service Journal in partnership with NHS Employers. Based on our national NHS Staff Survey results this fantastic accolade puts the Trust among the best providers of NHS services across the country. Our ongoing focus on continuing to develop and improve care for patients was also recognised in our successful bid to be part of a ground-breaking scheme to transform care for patients. The scheme is a partnership with the Virginia Mason Institute (VMI) based in Seattle in the USA, who have developed a transformational management system that has seen the Virginia Mason Medical Center (Hospital) become one of the safest and highest rated hospitals in the USA and culminated in them receiving the prestigious Hospital of the Decade award. More than sixty NHS Trusts applied and in July 2015, after a highly competitive selection process, the five Trusts chosen to participate in a five year development
Surrey and Sussex Healthcare NHS Trust
programme were announced by the Secretary of State for Health in a speech to the House of Commons. The programme, part of our SASH+ improvement initiatives, is now underway and we are pleased to see teams use the learning and support from VMI to begin to put in place changes to how we deliver care that will enable us to provide even better care for our patients. It will also give us an opportunity to share our learning with others. This year also saw our health campus grow further with the building; completion and opening in January 2016 of the fantastic East Surrey Macmillan Cancer Support Centre. Opened just one year after the launch of a ÂŁ1.3million fundraising appeal the new state-ofthe-art centre allows us to enhance the quality care our staff give to cancer patients and their families by bringing together support and information in one purpose designed building closer to home. The Centre is already supporting patients and their families with a range of activities, complementary therapies and advice. Designed by experts and people affected by cancer, the centre provides all-round support in a calm, nonclinical environment, with the simple goal of helping people 5
affected by cancer to live their lives as well as possible. Another new addition is an Integrated Reablement Unit at East Surrey Hospital that is the result of a partnership between us, Surrey County Council and East Surrey CCG (Clinical Commissioning Group). The Unit provides care for older people who no longer need acute care as their rehabilitation and care packages that will be provided in their own homes or community settings are finalised to meet their individual needs. It is a brilliant example of finding better ways to support local people and get them home from hospital. We have been delighted to see the specialist care we provide receive recognition. This has included the standard of care given to children during their stay at East Surrey Hospital being rated in the Care Quality Commission (CQC) 2014 National Children’s Inpatient and Day Case Survey as the best in Kent, Surrey and Sussex and one of the best in the country for overall experience. Alongside this development we have also had a very successful year of enhancing our academic profile and building on our relationship with the University of Surrey. This excellent partnership, that also includes working with Health Education Kent, Surrey and Sussex, will see us jointly fund a Professor 6
of Medicine and Professor of Nursing along with two lecturer posts and two amazing opportunities for PhD students to develop new ways of caring for people that will be applied both locally and nationally. As a founding member of the Academic Health Science Networks (AHSN) we are fully committed to and take part in all AHSN programmes including enhancing quality and Living Well for Longer. We are delighted that the acknowledgment of our clinical expertise has led to our medical director and three senior clinical leads having responsibility for key leadership roles and involvement in the programmes. Our innovative Mouth Care Matters programme has seen the introduction of a specialist Mouth Care Matters team that provides training to all hospital staff so that patients receive good mouth care during their stay at East Surrey Hospital. We are proud that we are the first Trust in the country to have a Mouth Care Matters Team on its wards and delighted that Mili Doshi, our consultant special care dentist who initiated the Mouth Care Matters programme was awarded NHS Innovator of the Year at the Kent, Surrey, Sussex NHS Leadership Recognition Awards 2015. The programme is now being supported by Health Education Kent, Surrey and
Sussex and adopted by other hospital Trusts – further recognition of our clinical expertise. Also, this year, our School of Physician Associates has seen the development of programmes at four universities across Kent, Surrey and Sussex. East Surrey Hospital was also officially recognised by Surrey Choices for its efforts in supporting people with disability, living in Surrey, to find employment and make a valuable contribution to the workplace. We were given first place in the Pulling It All Together category of the Surrey Choice Employability – Making a Difference Awards. We know that none of these achievements and the excellent care detailed in this report would be possible without the commitment, professionalism and hard work of each of our clinicians, staff and SASH volunteers. Together, they provide high quality care and a positive experience for the people we care for. We thank each and every one for everything they do; every day. Thank you.
Alan McCarthy Chair
Michael Wilson Chief executive Annual Report 2015-16
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 and Oxted Health Centre in Surrey and at Crawley and Horsham Hospitals in West Sussex.
Population of 535,000
Serving a growing 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.
4,000 staff
691 beds
East Surrey Hospital is the designated hospital for Gatwick Airport and
14 operating theatres
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 691 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 4,000 providing healthcare services to the community we serve. The Trust is an Associated University Hospital of Brighton and Sussex Medical School. M2
Croydon
M3
M20 M25
Woking
Caterham Dene Hospital Oxted Health Centre
Maidstone
Earlswood
Guildford
East Surrey Hospital Tonbridge
Crawley Hospital
M23
Tunbridge Wells
Horsham Hospital Haywards Heath
Surrey and Sussex Healthcare NHS Trust
7
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
Safety and quality We take responsibility for our actions decisions and behaviours in delivering safe, high quality care
Our 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
Our clinical commissioning groups The services we provide are commissioned by local clinical commissioning groups (CCGs). In 2015-16 we held contracts with 11 CCGs; our co-ordinating commissioner for the Sussex contract is Crawley CCG with six associates. East Surrey 8
CCG is our co-ordinating commissioner for the Surrey contract with three associates. The Trust has a contract with NHS England, who commission specialised services and secondary care dental. The Trust also has a contract with Sussex MSK (musculoskeletal) which is a partnership hosted by a limited company. Crawley CCG: has 12 GP practices and a population of more than 120,000 people
• Croydon CCG has 59 GP practices serving a population of 370,000 people • East Surrey CCG has 18 GP practices in south East Surrey covering Caterham; Horley; Reigate; Redhill and Oxted with a population of nearly 178,000 people • Horsham and Mid Sussex CCG has 23 GP practices and a population of 225,000 people • NHS Surrey Downs CCG has 32 GP practices serving a population of 300,000 people Clinically led We are a clinically led organisation, focused on putting people first. Our services are led and managed through four divisions: Annual Report 2015-16
Cancer
Medicine
Surgery
Women and children
Dr Ben Mearns
(from October 2015)
Dr Zara Nadim
(from December 2015)
Chief
Dr Ed Cetti
Associate director
Jane Griffiths
Alison James
Natasha Hare
Bill Kilvington
Divisional Chief nurse
Victoria Daley
Nicola Shopland
Jamie Moore
Michell Cudjoe
Dr Virach Phongsathorn (until September 2015)
(from January 2016)
(from August 2015)
Dr Barbara Bray
Dr Debbie Pullen (until November 2015)
(Head of midwifery)
Our CQC rating The Trust was rated ‘good’ overall by the CQC in its Chief Inspector of Hospitals inspection in August 2014. In its quarterly monitoring the CQC has rated the Trust in the lowest risk category in respect of the quality of its services in each return since then. One area rated as requires improvement was outpatients and in February 2016 the CQC completed a follow up review. This report confirmed that the Trust had addressed the issues raised in the earlier full inspection and was compliant with the 2014 requirement notice. Our health campus Our health campus at East Surrey Hospital has continued to grow in 201516 with the addition of the new East Surrey Macmillan Cancer Support Centre – the result of a successful partnership between Surrey and Sussex Healthcare NHS Trust and Macmillan Cancer Support and supported by The Olive Tree in Crawley. Costing £1.3m the Centre
opened on 25 January 2016 exactly one year after the fundraising appeal to help raise funds towards the Centre was launched. Building began in April 2015 and the keys to building were handed over in November 2015. The innovative design and layout provide a welcome and calm environment for cancer patients and their
Surrey and Sussex Healthcare NHS Trust
family, friends and carers and offers a range of services including: • information and advice on coping with cancer and its treatment • counselling services • complementary therapies; including reflexology and reiki • exercise programmes • financial advice and support • cancer support groups 9
The East Surrey Macmillan Cancer Support Centre provides local people the very best in holistic care and support closer to home and puts to an end the need to travel further afield.
SASH+ - Virginia Mason Institute partnership Following a highly competitive application process involving 63 Trusts, Surrey and Sussex Healthcare NHS Trust was selected as one of only five NHS trusts in the country to benefit from an initiative launched by Health Secretary Jeremy Hunt and the NHS Trust Development Authority (TDA, now NHS Improvement). The unique partnership with the Virginia Mason Institute (VMI) shares
learning and techniques that has transformed Virginia Mason Medical Centre in Seattle, USA, to become widely regarded as one of the safest hospitals in the world. Known as SASH+, the transformation partnership will support us in developing new ways of working based on tried and tested LEAN techniques – prioritising the needs of patients and staff through eliminating waste and embedding a culture of continuous improvement. We have a Trust guiding team (TGT) of senior clinicians and leaders who are responsible for overseeing and delivering the move to the Virginia Mason way of working over the coming five years. Our aim is to continue to put our patients at the forefront of everything we do and to improve safety and quality by reducing waste as much as possible. We will continue to develop and embed a culture of innovation and
“The East Surrey Macmillan Cancer Support Centre is the result of a fantastic partnership - it allows us to enhance the quality care we give to our cancer patients and their families and brings this care and support together in one place. The wonderful building also gives us the flexibility to develop the services we can offer by listening to our patients and their families.” Michael Wilson, chief executive
improvement which meets the needs of patients. Local teams will use tried and tested tools and techniques to demonstrate how their part of the organisation runs day to day, and be able to demonstrate how they improve the journey for patients on a continuous basis. Improvement and reducing waste will become part of the day job – for everyone, all of the time. The transformation that has taken place in recent years is a great platform to build on and we know that, as an organisation, we are in a much better place today than we were five years ago; even more importantly, we know that patients receive care that is safer, of higher quality, with better outcomes and supporting a better experience. The system used by VMI is based on a production system used by Toyota and many of the terms originate from Japan. We now have a Kaizen Promotion Office (KPO) team who are completing VMI training and certification who lead the transformation work.
Kaizen (Continuous improvement) Annual Report 2015-16
Our initial workstreams will focus on: • Cardiology inpatient flow: this will focus on maximising the flow of patients from referral and the sequence of events which occur from referral to when a patient is considered ready for discharge. This work will let us concentrate on timing, effectiveness, waste, and the value of the multidisciplinary team and how they work together • Outpatients – from referral to discharge: this area has been chosen as it was highlighted in our CQC report last year and an improvement plan is underway. We are building on the work undertaken so far • Management of diarrhoea: this workstream touches all of our inpatient areas and work will progress across the organisation The cardiology workstream is underway with the initial data collection and scoping work done the first rapid improvement process workshop (RPIW) was successfully completed by a team of multi-disciplinary specialists each with a role to play in a cardiology patient’s journey. Although improvements in many of the areas highlighted in the RPIW can be made immediately others require more detailed planning and will be implemented
“I want to make the NHS the safest healthcare system in the world, powered by a culture of learning and continuous improvement. The achievements at Virginia Mason over the past decade are truly inspirational and I am delighted they will now help NHS staff to learn the lessons that made their hospital one of the safest in the world through a detailed and – patients will see real planned schedule. With benefits as a result.” each change making a positive difference to the care we provide and the experience of our care for our patients.
Jeremy Hunt, Secretary of State for Health
Foundation Trust journey We have continued our Foundation Trust journey with the successful election of our first Council of Governors. Representing our members, which number over 10,000, our Governors who currently operate in shadow form have an important engagement role to play as we plan for the future. From a strong field of 84 candidates 15 people were elected as Governors to represent the Trust members in eight geographical areas and four were elected as staff Governors to represent staff members. They will join a further nine invited partner governors. The shadow Council of Governors plays an important role, linking the Trust to the communities it serves across east Surrey and West Sussex. It also represents the views of Trust members to the Board.
Surrey and Sussex Healthcare NHS Trust
11
A Foundation Trust is made up of members who can help shape the future development of healthcare in the area. Membership is free and members can get involved as little or as much as they like. Following the general election in May 2015 the new Government announced the coming together of the Trust Development Authority (TDA) and Monitor that created some ambiguity for Trusts currently in the assessment pipeline to become a Foundation Trust. In light of this, the Board made the decision to pause the assessment phase until after the planning round with commissioners for 2016-17 was completed. Our members and shadow governors are a key part of our application for Foundation Trust status and our shadow Council of Governors, who meet at least four times a year, are committed to representing our members and supporting us as we continue to develop the excellent care we provide. Staff awards Every day our staff are focused on putting our patients and the people we care for at the centre of everything we do. Every day we can see the difference that this high quality care makes to local people in the feedback we receive. Every year we celebrate 12
this commitment and hard work at our annual Staff Excellence Awards that recognise the dedication of individuals from frontline and support teams from across the organisation. Over 90 individuals and teams were nominated in 11 categories: • Dignity and respect • Compassion • One Team - frontline team of the year • One Team - behind the scenes team of the year • Safety and Quality • Your Care Matters improving the patient experience • Innovation and service improvement • Frontline employee of the Year • Behind the scenes employee of the year • Volunteer of the year • Qualifications received
from relatives and friends in memory of their loved ones who were cared for at SASH. Often these donations have been made to specific areas of the hospital and for specified items ranging from comfy chairs for relatives and televisions on stands for patients and relatives in ICU to money donated to the East Surrey Macmillan Cancer Support Centre. Donations to teams have also been used to fund additional training for staff that enhances their specialist knowledge and skills to benefit the care we provide. We have a number of cash collection boxes positioned around the hospital and these continue to be a regular source of income.
SASH Charity SASH Charity is the charity for Surrey and Sussex Healthcare NHS Trust NHS Charitable Fund (registered charity no.1054072). The charity relies on donations as its primary source of income. In 2015-16, the charity’s funds totalled £73k and it spent £104k in year. We regularly receive a number of generous donations to SASH Charity
This year we have also seen a number of donations of items and gifts made through the charity – this has included toys and games for the children’s wards, gifts from Father Christmas and 150 gift bags for patients on our care of the elderly wards at Christmas time. We have also, through SASH Charity, sought the help of local people to help make comfort blankets or mitts for patients Annual Report 2015-16
with dementia being cared for at East Surrey Hospital. We have been delighted at the response to this appeal from a wide range of individuals and groups. SASH Charity supported our staff awards ceremony, which recognised individual staff and team achievements and in recognition of their contributions towards improving the care patients receive. Staff were presented with awards and gift vouchers. 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.
Surrey and Sussex Healthcare NHS Trust
13
Patient experience What our patients say As well as high quality, safe care, the experience our patients have of the care they receive is vitally important.
to make changes, from the small things that make a difference at ward or clinic level, to changes that apply across the Trust. Over the last year we have:
patients who have mobile phones. Patients can take part online, by using a Freephone number or, for some services, completing a paper copy of the survey.
Throughout the year we have worked closely with clinical staff to further embed the principle of inviting feedback from patients and their families, either using the Friends and Family Test (FFT) or by taking part in the Trust’s Your Care Matters (YCM) survey. We have enlisted the help of volunteers to assist with this and have versions that make it easier for specific groups of patients such as children, patients with dementia and those with learning disabilities to tell us about their experience.
• Introduced take home and settle packs for patients who are discharged in the late afternoon or early evening • Reviewed how we can improve how we manage noise at night on wards • Provided more widespread availability of earplugs and headphones • Improved the consistency of food service across inpatient wards • Established a set of standards of behaviour that we expect all staff to work to • Piloted a carer’s passport to support carers in supporting the person that care for when they are admitted to hospital
The survey gives respondents the opportunity to make comments or suggestions on things that they feel could be improved and provides patients with an opportunity to thank individuals or groups of staff when they feel they have received exceptional care.
In addition to the FFT and YCM survey, patients and their families can post feedback on our Trust website, can tell their story on NHS Choices or Patient Opinion or visit our Patient Advice and Liaison (PALS) service. Regardless of the method by which we receive comments and suggestions they are reviewed at both Trust and service level to help inform what we do and make improvements where we can. Based on comments we have received we continue
Your Care Matters The number of responses to our Your Care Matters patient feedback survey increased over the last quarter of 2015-16 and we currently receive in excess of 1,200 responses a month. We have introduced a text reminder to increase the ease of taking part for those
Surrey and Sussex Healthcare NHS Trust
These commendations are shared with team and senior managers and also the chief nurse. Results allow us to monitor performance on key issues such as dignity and respect, communication with doctors and nurses, how well medications were explained and also the discharge process. Patient Opinion Patient Opinion is an 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 continue to be seen as an exemplar organisation because of our proactive approach to in encouraging our patients to tell their stories. 15
A direct link to Patient Opinion is included at the end of the Your Care Matters survey and we remain one of only a few organisations nationally to have a Patient Opinion live-feed of comments about Surrey and Sussex Healthcare NHS Trust on our website homepage. 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, The coverage of Patient Opinion grows steadily each year. In the past 12 months 362 patients have told their story and their comments were viewed more than 72,000 times. Patient Advice and Liaison Service (PALS) The Patient Advice and Liaison Service (PALS) supports patients, relatives or carers who may sometimes need to turn to someone for additional help or advice. The PALS team provide prompt and confidential support to resolve any queries or minor concerns and can also guide people through the different services available from the NHS. They also liaise with hospital staff and managers to ensure a prompt response and resolution and are committed to ensuring that the best possible experience 16
is enjoyed by everyone using the services provided by Surrey and Sussex Healthcare NHS Trust. PALS has remained focused on continuing to improve the experience of the people we care for. 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 non-English speakers • text translation services for non-English speaking patients • information about the Trust’s complaints process • access to independent complaints advocacy services During 2015-16 the PALS team has continued to provide a high standard of service to patients, relatives and visitors to Surrey and Sussex Healthcare NHS Trust. In excess of 1,400 people were assisted with advice and information and a further 700 concerns were resolved for patients. Supporting carers During the year we have reviewed how we can offer greater assistance to carers in signposting them
to sources of support. We have piloted a carer’s passport which can be issued to a patient’s main carer and welcomes them to the ward to continue supporting their loved one. Passport holders can obtain concessions such as reduced parking costs, discounts in the restaurants and refreshments on the ward. This is in support of John’s Campaign, a nationally recognised campaign to introduce similar rights for carers to those given to parents of children in hospital. Standards of behaviour
one team one way
Our one team, one way standards of behaviour were developed by a working group of staff from across the organisation. They identify ten key themes and describe what is expected of staff and provide clear and transparent expectations of how our staff and others working at the Trust should behave. Annual Report 2015-16
Responding to complaints Surrey and Sussex Healthcare NHS Trust is committed to using patient feedback as a practice guide to improving patient experience. The NHS complaints system is a powerful and useful mechanism for improving the quality of care, both for individual complainants and for the wider patient body. We are grateful to those patients, or their relatives and carers, who take the time to share with us their experience of care and treatment, especially where it identifies issues in a service that lead to change and improvement. We have actively encouraged feedback from patients throughout the year. During 2015-16 we received 568 formal complaints; an increase of 14% on 2014-15. This may, in part, be explained by an increase in the number of patients treated by the Trust. The two main themes identified were in the categories of care implementation and communication. We have Surrey and Sussex Healthcare NHS Trust
“My short stay...was made as pleasurable as possible due to the professional, friendly and positive attitude of all staff from cleaners to ward manager.” An inpatient
“I bumped into a nurse who had looked after my wife the previous day. Her kindness and caring compassion were honest and obvious and calmed me immensely.” A patient’s relative 17
acknowledged these issues and taken steps to rectify any problems identified and this includes our one team, one way standards of behaviour standards of behaviour.
ownership of complaints, enhance the lessons learned process and to provide further confirmation that a comprehensive, sensitive and clinically correct response was provided.
During the year the complaints team reviewed the complaints management system and have made a number of changes to the process. The changes, which started during quarter four, specifically address issues identified to the team by patients and other service users. The underlying principles of the new system are to provide a more personal and responsive service to complainants and to simplify the content of the response where it is given in writing or to offer a meeting if this is preferred. The revised complaints management arrangements will be monitored regularly and evaluate periodically throughout 2016-17.
Complaints often form the basis of discussion at the weekly patient safety executive briefings at which clinical and non-clinical teams meet to discuss an aspect of patient safety or experience.
The Trust is expected to acknowledge all complaints within three working days, in 2015-16 the complaints team achieved this target in 96% of cases. Over the year 57% of complaints were responded to within 25 working days, more complex investigations took longer. Overall, 87% of complainants received their response within the timeframe agreed with them. Complaints are reviewed and monitored at divisional governance meetings to ensure clinical 18
We are grateful not just to the complaints staff but also to the ward-based staff, clinicians and managers, who have provided support and expertise in the timely and appropriate resolution of complaints. Compliments saying thank you In addition to feedback received through Patient Opinion and Your Care Matters, every month we are very pleased to receive around twenty unsolicited compliments from patients or their relatives. Each compliment describes an individual’s first-hand experience of care within the Trust which has, in many cases, surpassed their expectations. The letters can be deeply moving and highlight areas of excellent practice and acknowledge the hard work of our staff. We acknowledge every compliment individually and
will always pass a copy to the relevant individual, team or department. “They are clearly well led, organised and motivated. I found the whole team from cleaners, caring staff and in particular the nursing staff, hardworking, positive, effective and caring… You seem to have combined the best of traditional nursing with modern best practice. Your team are smartly turned out, energetic, thoughtful in their approach, everyone is prepared to get their hands dirty and do their bit to create a happy, clean and lively ward.” A visitor was escorted to the ward by one of the porters about whom she wrote: “In this day and age I found Daniel’s attitude to me refreshing - how few young people find time for us ‘oldies’ - also his obvious love of his job and loyalty to the hospital in which he works. From start to finish the service was focused, considerate, timely, professional and confident. Information was communicated and attention was given to all patients at all times.” A patient who received care from a student nurse wrote to say: The young lady was so kind, thoughtful, caring and attentive. I felt she went way, way beyond the call of Annual Report 2015-16
duty in looking after me and helping me recover. Nothing was a problem and she was constantly by my side willing me to recover and regain my strength. If she carries on in that manner she’s going to go a very long way. Digital conversations We continue to see a steady increase in visitors and traffic to our website and social media sites. Through these digital channels our patients, relatives and visitors are able to give the people we care for and the communities we serve an immediate and direct way of making comments, sharing their views and recognising the care they have received. Website Most visited pages: 1. Home page 2. Infection control 3. Working for us 4. Consultant directory 5. A-Z of services
• Twitter – 1,574 sessions (15.27%) • LinkedIn – 752 sessions (7.3%)
April 2015: 384 likes March 2016: 1,201 likes 817 new likes in the past year
April 2015: 7,617 followers March 2016: 9,021 followers 1,404 new followers in the past year
Visit us at: www.surreyandsussex.nhs.uk
(Recruitment: 8,048 sessions on the working for us page for 2015-16) • • • •
1,110,192 page views 289,586 users 590,954 sessions 10,308 of total sessions were referrals from social media
Social media sessions • Facebook – 7,956 sessions (77.18% of all social referrals)
Digital communications and social media are integral to many of our campaigns and we continue to use them to update and engage with our patients and local people.
April 2015: 798 followers March 2016: 1,221 followers 423 new followers in the past year
Facebook: www.facebook.com/sash.nhs Twitter: @sashnhs YouTube: www.youtube.com/user/sashnhs
April 2015: 41 subscribers March 2016: 72 subscribers 31 new subscribers in the past year
Surrey and Sussex Healthcare NHS Trust
LinkedIn: www.linkedin,com/company/ surrey-&-sussex-healthcarenhs-Trust 19
Our people Who we are Staff group headcount
Number
%
Professional scientific and technical
92
2.31
Additional clinical services
756
18.98
Administrative and clerical
745
18.70
Allied health professionals
189
4.74
Estates and ancillary
371
9.31
Healthcare scientists
87
2.18
Medical and dental
574
14.41
Nursing and midwifery (registered)
1170
29.37
Total Headcount
3984
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. This balance is fairly typical of NHS acute trusts and does not present any significant issues for us. Female %
Male %
Professional scientific and technic
75
25
Additional clinical services
79.44
20.82
Administrative and clerical
82.95
17.05
Allied health professionals
87.83
12.17
Estates and ancillary
49.06
50.94
Healthcare scientists
63.22
36.78
Medical and dental
51.05
48.95
Nursing and midwifery (registered)
91.45
8.55
Total %
76.61
23.39
National NHS Staff Survey Results from the national NHS Staff Survey ranked Surrey and Sussex Healthcare NHS Trust in the top 20% of hospitals nationally as a place to work and receive treatment and
also as somewhere patients receive quality treatment and care. A total of 62% of staff from across the organisation responded to the survey, which is in the highest 20% nationally when
Surrey and Sussex Healthcare NHS Trust
compared against other Acute Trusts, with the very positive response from staff putting Surrey and Sussex Healthcare NHS Trust in the top 20% nationally for: • Staff motivation • Staff recommending the Trust as a place to work or receive treatment • Effective team working • Support from managers • Quality training, learning or development • Using feedback from patients inform decisions about the care provided • Managers being interested in the health and well-being of staff • Satisfaction with resourcing and support • Staff confidence and security in reporting unsafe clinical practice • Quality of appraisals The 2015 response rate is an improvement on the 56% response rate in 2014 The data is used by the Survey Coordination Centre (Picker Institute) in the NHS Benchmark Reports.The NHS Benchmark Report presents the data under the four staff pledges and three additional themes of equality and diversity, errors and incidents, and patient experience measures. The 2015 Staff Survey reported on 32 key areas known as key findings as 21
well as a measure of overall Staff Engagement. Of the key findings our results were: • 17 in the best 20% • Six better than average • Three average • Three worse than average • Three in the lowest 20% • Three key findings improved since 2014 • One key finding deteriorated since 2014 • 18 key findings showed no statistically significant change since 2014
“I am pleased that staff feel motivated, recognised and valued by their colleagues and managers and that they feel able to get involved with decisions about our plans for the future, which is especially encouraging given the ongoing pressures we have experienced locally and in the NHS more generally. satisfied with the • •
Key findings: Where we are in the best 20% of Trusts • Staff recommendation of the organisation as a place to work or receive treatment • Staff satisfaction with the quality of work and patient care they are able to deliver • Staff motivation at work • Recognition and value of staff by managers and the organisation • Percentage of staff reporting good communication between senior management and staff • Staff satisfaction with level of responsibility and involvement • Effective team working • Support from immediate managers • Quality of appraisals • Quality of nonmandatory training, learning or development • Staff satisfaction with resourcing and support • Percentage of staff 22
•
• •
opportunities for flexible working patterns Percentage of staff suffering work related stress in last 12 months Organisation and management interest in and action on health and wellbeing Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months Staff confidence and security in reporting unsafe clinical practice Effective use of patient and service user feedback
Where we have improved since 2014-15 • Staff recommendation of the organisation as a place to work or receive treatment • Staff motivation at work • Staff satisfaction with level of responsibility and involvement Our volunteers We also have the support of around 230 volunteers who each year donate many thousands of hours of their time to support our teams and the people we care for. A further 50 volunteers
Michael Wilson Chief executive
staff Radio Redhill, which is broadcast to the patients and staff at East Surrey Hospital and available online and on the hospital’s internal radio system too.
230 volunteers Youngest 16 years old Oldest 89 years old Longest serving 25 years
Volunteer, Gordon Thomson, age 89, was awarded an individual award at the Reigate and Banstead Mayor’s Awards 2015 in recognition of his commitment. We thank all our volunteers for their commitment, hard work and generosity that play a supportive role across the organisation in ensuring Annual Report 2015-16
the people we care for have a positive experience. Work experience This year we offered 182 work experience placements to our local community. The majority (75%) were school students to assist them to make an informed career choice. We also offered shadowing opportunities to adults considering a change in career. Many students validate the experience by citing it on their university application and tell us that the opportunity helped them to confirm their career choice before committing to a course of study. Separately, Redhill Golf Club, based at East Surrey Hospital also has a proud tradition of offering work experience. Students from Route 4 at Warwick School, Redhill, who are at risk of exclusion from school, undertake a placement with the golf club green-keeper to learn job skills and what the role entails. Apprentices Wherever we can we are committed to offering apprenticeships in our band
1-4 roles. Apprenticeships fit within the widening access agenda to help with the recruitment of staff from our local community. During 2015-16, we employed two apprentices in our human resources division. Both successfully achieved their Diploma in Business Administration in December 2015 and, following formal applications and interviews, have been successfully recruited to roles within the Trust. We also celebrated seventeen members of our housekeeping and porters team who successfully achieved qualifications in cleaning services, hospitality and healthcare support services through our apprenticeship scheme. We have exciting future plans for our apprenticeship programme and since March 2015 have already advertised for four new apprentices across business administration and pharmacy services. Other teams are also now recognising the value of the scheme and planning for their own apprentice recruitment in 2016-17. We are also expanding the opportunity to existing staff to use the apprenticeship programme to develop their skills and career options. One of the first projects will be to offer apprenticeships in clinical healthcare to our nursing assistants after their successful completion of the Care Certificate.
Surrey and Sussex Healthcare NHS Trust
Developing our staff Our 2015 staff survey results placed us in the top 20% of Trusts across the country for the quality of our nonmandatory training and development. However, we did not achieve our internal target of 80% of mandatory training to be completed in the year. Developing our staff to have the right skills and competencies to provide the best patient care and high quality services remains a key priority for our organisation. Over the last year, we have revised our induction programme to include a workshop on our SASH values and one team, one way standards of behaviour along with a marketplace for new staff to meet colleagues from different areas of the Trust. Our workforce development team have started a number of new programmes to respond to our staff survey results including coaching and mentoring skills, essentials of management, resilience and mindfulness and customer care. In 2015-16 we supported our highest ever number of clinical students, working in partnership with Health Education Kent, Surrey and Sussex, to provide high quality placements to students who are beginning their careers in the NHS. We anticipate a further increase in 2016-17. 23
Off-payroll engagements In 2015-16 there were ten members of staff on offpayroll engagements for more than ÂŁ220 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.
Our practice development team provides education and training for nursing and support staff, covering clinical skills, preceptorship, revalidation, overseas recruitment, career development and the national Care Certificate programme. The Trust has a multiprofessional bursary panel that supports the development of staff through the provision of funded learning opportunities. The bursary panel makes funding decisions and ensure the resources for training and development of staff are 24
utilised effectively. The bursary panel is comprised of senior managers from across the organisation in order to provide fair representation and promote balanced decision-making. In 2015-16, the bursary panel approved over one hundred applications from a wide range of members of staff - supporting their ongoing professional and personal development. 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 require contractors to comply with the relevant tax and national insurance requirements.
Equality, diversity and human rights The NHS belongs to the people is the first line of the NHS Constitution and this remit is mirrored in our Putting People First focus. Under the first principle of the Constitution, we have a duty to ensure we provide equal access and opportunity to all of our people, whether they are our staff, patients or the public and regardless of whether they have a protected characteristic such as gender, race or age. The Trust is actively engaged in a number of national NHS inclusion strategies including the Workforce Race Equality Standard and the Equality Delivery System and we are currently developing our plans to embed these. We are working with BRAP, an equalities and Annual Report 2015-16
human rights charity who have worked extensively in the NHS to support diverse and inclusive workplaces to consider our priorities for diversity and inclusion and formulate our equality objectives for the next four years. We continue to work in partnership with Surrey County Council through the Surrey Choices Employability scheme to provide work placements for young adults with learning disabilities.
• • •
• • •
We are very proud that a former Surrey Choices student is now undertaking an apprenticeship in our finance team. • 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 2015-15 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 of with weekly sessions and performances fast-track physiotherapy referrals 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
collaborate effectively with other colleagues which improves overall patient outcomes. In the 2015 National Staff Survey, our overall staff engagement score was in the top 20% nationally (3.92/5.00) and this has improved year-on-year for the past five years. The staff engagement score is calculated on three subdimensions: • Staff recommendation of the Trust as a place to work or receive treatment • Staff motivation at work • Staff ability to contribute towards improvement at work • We scored in the top 20% nationally for the first two and better than average for the third.
Staff engagement Health care is a peopledelivered service and the quality of care that patients receive depends wholly on the skill and dedication of NHS staff. It is recognised that highly engaged and motivated staff are more likely to be pro-active and
25
Our established staff engagement strategy supports ongoing work to ensure that all our staff maintains a strong connection with the vision and values of the organisation. This work is by a framework to ensure key areas of focus continue to have a positive impact. These include: • Health and wellbeing for all staff • Supporting personal development through the Achievement Review (appraisal) process • Developing supportive management and leadership • Involvement of staff in decision making • Ensuring every role counts Our staff engagement activities continue to provide staff across the organisation with opportunities to learn and to share their views and suggestions. These activities include: • TeamTalk briefings • Chief executive’s weekly message • Executive drop-in sessions • Annual NHS Staff Survey - The response rate for the Trust was 62% in 2015, which is in the highest 20% when compared against other acute Trusts • Quarterly Staff Friends and Family Test • Trade Union Survey 26
We are proud of the contribution that our staff make to the continuing successes and high quality care we provide to our patients and community. Our annual Staff Excellence Awards recognise and acknowledge individuals and teams for their involvement and engagement. League of Friends East Surrey Hospital’s League of Friends team of volunteers continue their commitment to raising funds rough the Friends’ Coffee Shop situated at the east entrance of East Surrey Hospital. In 2015-16 they made many generous contributions for the benefit of the people we care for including: • £200,000 towards the angiography suite in the
• • • •
new Surrey and Sussex Heart Centre at East Surrey Hospital £150,000 towards equipment for Tandridge Ward and stroke team £44,000 towards echocardiography equipment £47,000 towards ECG patient monitoring equipment £6,500 towards new furniture for intensive care unit relatives’ room Annual Report 2015-16
27
Our environment We respect our environment and take an active role in continuing to find ways to ensure that we manage and reduce any potential impact on our surroundings and the world we live in. Actions we have taken include: Travel plan We continue to encourage the use of more sustainable ways to travel including: • 49 cycle lockers and 20 bike racks • a dedicated changing room and shower is now available for staff who walk, run or cycle to work or exercise in their break times • power points for recharging electric cars free of charge • a display of a range of demonstration electric vehicles at regular roadshows • ongoing 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 • additional increases in the number of car parking spaces for visitors and staff at East Surrey Hospital Recycling We continue to seek more efficient ways to manage the
waste we create and reduce the environmental and financial costs. Each month we recycle: • 3.5 tonnes of our general waste – up from 3 tonnes in 2014-15 • 8 tonnes of cardboard waste – up from 7 tonnes in 2014-15 In 2015-16 we saved: • Approximately 1,500kg of ink cartridges and mobile phones from being dumped in UK landfills where is would have stayed for over 1000 years decomposing Offensive waste is health care waste that is deemed as non-infectious but offensive in appearance and smell. In 2015-16 we trialled a new waste process that has successfully made a 33% cost saving per tonne and the potential to cut our CO2 emissions by nearly 200 tonnes per annum, this has been achieved by diverting waste to energy and less to landfill. Our annual eco-savings are: Trees saved
465
CO2 saved (kg)
194,058
Power generated (MWh)
356.09
Energy efficiency Whilst not always visible, this year we have continued to maximise savings in both
Surrey and Sussex Healthcare NHS Trust
environmental and financial terms through a number of initiatives, projects and changes. This has included: • Continuing with gas driven air conditioning in IRU, Capel and Tilgate annex and theatres 1-4 – including, where appropriate, bi-generation in that we utilise the waste heat generated by the units to pre-heat incoming air, when required. 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. There is a three-year rolling update programme that will focus on ward and patient areas as a priority. 29
• Use of LED lighting to replace traditional fluorescents during updates and projects. LED lighting provides a better light quality with much lower running costs and less maintenance. LED lighting is now standard in all designs unless specialist option required. • 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. Inverters have been included in all new plant installed during the year. • 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. A car lease scheme has been initiated with several all-electric and hybrid vehicles brought to site for staff to test drive. 30
Annual Report 2015-16
31
Our plans Strategic objectives Central to our plans are four themes: • Excellence • Affordability • Leadership • Locally based services These themes provide a reference point for all of our plans and strategies. We understand that we cannot deliver our services in isolation and it is therefore imperative that we work in partnership with our NHS and commercial partners to develop and deliver integrated services and models of care, which include utilising clinical networks. Partnership and integration means working with others across the whole health and care economy, both providers and commissioners, working to the same agenda of delivering high quality, safe and affordable care. Our strategic objectives over the next five years are based on the CQC five domains with our local priorities. • Safe: Deliver safe high quality and improving services which pursue perfection and be in the top 20% against our peers • Effective: As a teaching hospital, deliver effective, improving and sustainable clinical services within the local health economy • Responsive: Become the secondary care provider of choice for our catchment
population • Caring: Working in partnership with staff, families and carers • Well led: To become an employer of choice and deliver financial and clinical sustainability around a patient led clinical model
actions, key milestones and the lead director for each element. Sustainability and Transformation Plan (STP) In the last quarter of 201516, in accordance with the NHS Shared Planning Guidance, the Sustainability and Transformation Plan (STP) Footprint has been agreed jointly by our health and social system and covers the geographical areas of Sussex and East Surrey. The chief executive for Surrey and Sussex Healthcare NHS Trust has been appointed as the lead and the STP group has begun meeting on a regular basis.
Our strategic objectives underpin each of our supporting strategies and corporate and divisional annual objectives. These, in turn, underpin departmental, team and individual objectives. Strategic plan The Trust is working to a five year strategic plan as outlined in its integrated business plan. The core elements of our strategy are in the triangle below.
The early thinking is that 201617 will be a difficult year for the health and social care system. Key deliverables include service transformation; partnerships; wider strategic change along with delivery of the workforce challenges going forward. The STP is on target to meet the milestones as Patient set within the national planning guidance. Vision
Delivery plan As in previous years a high level delivery plan was developed which sets out, for each strategic objective, the overall Values priorities, Safety & quality high level Dignity & respect
We pursue perfection in the delivery of safe, high quality care that puts the community first
One team Compassion
Strategic intent excellence
affordability
leadership
locally based services
v Strategic objectives safe
effective
well-led
caring
responsive
Through integration and partnership to become both a provider and employer of choice
Our strategic plan
Surrey and Sussex Healthcare NHS Trust
33
Performance Working together, our teams are focused on delivering high quality services to the people we care for. Many of the key areas for delivery are measured by national standards and we have listed these below. This year, 2015-16, was a challenging year for both emergency and elective access standards with an increase in the numbers of people attending our emergency department (ED), non-elective admissions and outpatient referrals. This growth put pressure on the capacity of the Trust across beds, clinics and diagnostics. Performance data supports us to continue to provide high quality care and is a valuable tool in helping us to ensure that we manage the demands and pressures on our services and any impact on our patients.
Despite the challenges of increasing demand, this year, we achieved all but two of the key access standards – that is the four hour ED standard and the cancer and two week rule: breast symptomatic standard (92%). The Trust also benchmarks in the upper quartile for the diagnostic standard and above average for the cancer 62 Day referral to treatment standard.The cancer two week wait; cancer two week rule breast symptomatic and referral to treatment incomplete pathways benchmark below average and are a key focus for us in 2016-17. Emergency Department four-hour standard Despite narrowly missing the ED four hour standard the Trust benchmarks in the upper quartile for this measure and, in fact, achieved this standard for the first six months of 201516.
2014-15
2015-16
Change
%Change
ED attends
86,361
91,256
4,895
5.7%
Out-patient appointments
321,010
340,522
19,512
6.1%
Emergency admissions
32,001
34,097
2,096
6.5%
Births
4,449
4,560
111
2.5%
Elective admissions
41,421
44,188
2,767
6.7%
Surrey and Sussex Healthcare NHS Trust
35
2014-15
2015-16
Standard
ED 4hr
95.05%
94.3%
95%
ED 12 hr Breaches
0
0
0
Cancer two week rule
93%
93%
93%
Cancer 62 Day
86.5%
86%
85%
RTT incompletes
94.1%
92.4%
92%
Diagnostics over six Weeks
0%
0.4%
0
Never events
1
2
n/a
MRSA
1
2
0
C.difficile
24
34*
15
Acute Bed Occupancy
94.3%
89.9%
ED FFT
95.5%
95.5%
n/a
Inpatient FFT
95.3%
95.4%
n/a
11.4%
7.70%
n/a
Excluding day cases
Vacancy rate
* Each Clostridium difficile case has a root cause analysis carried out by members of the clinical team in conjunction with members of the infection prevention and control team. All 34 cases have been reviewed with the co-ordinating commissioner to determine whether there have been any lapses in care. A lapse in care is defined as evidence that policies and procedures were not followed, regardless of whether the lapse contributed to the root cause of the infection; 19 cases were assessed as no lapse identified, 12 cases were assessed as a lapse but this would not have affected the outcome and 3 cases assessed as a lapse in that a different outcome could reasonably have been expected had this lapse not occurred. There is no epidemiological evidence of cross infection from the cases.
Cancer waiting times The Trust met all cancer waiting times standards for the year with the exception of the breast symptomatic standard. Analysis of this pathway is being undertaken to identify required improvements to ensure this standard is also achieved in the coming year. In addition to this specific work we are striving for continual improvements 36
in patient cancer waiting times by regularly reviewing all pathways not regularly achieving performance indicators.
The Trust is currently in the top 50% of performers nationally for 62 day GP referral to treatment standard. The development of an innovative and unique real time patient tracking system and cancer dashboard within the Trust has significantly contributed to the success of the 62 day standard. We are participating in a pilot project, the Accelerated Coordinated and Evaluated (ACE) programme streamlining cancer diagnostic pathways and looking to the future we are in the process of submitting an expression of interest to become one of five pilot sites nationally for 28 days to diagnosis.
Performance for all measures is shown in the table below: Apr 15
May 15
Jun 15
Jul 15
Aug 15
Sep 15
Oct 15
Nov 15
Dec 15
Jan 16
Feb 16
Mar 16
Annual
ED 95% in 4 hours
95.9%
95.8%
94.6%
90.9%
94.3%
Cancer two week rule
93.5%
91.9%
92.9%
93.1%
93.0%
Cancer TWR Breast Symptomatic
93.3%
93.6%
94.5%
87.9%
92.2%
Cancer 31 Day Second or Subsequent Treatment (Surgery)
100.0%
100.0%
100.0%
97.2%
99.0%
Cancer 31 Day Second or Subsequent Treatment (Drug)
100.0%
100.0%
100.0%
100.0%
100.0%
Cancer 31 Day Diagnosis to Treatment
98.4%
99.2%
96.9%
96.3%
97.6%
Cancer 62 Day Referral to Treatment Standard
86.3%
83.8%
86.6%
85.1%
85.4%
Cancer 62 Day Referral to Treatment Screening
90.0%
93.1%
93.8%
97.2%
93.4%
RTT Incomplete Pathways % waiting less than 18 weeks
93.6% 93.5% 92.6% 92.2% 92.0% 92.1% 92.2% 92.0% 92.1% 92.0% 92.0% 92.2%
92.4%
RTT Patients over 52 weeks on incomplete pathways
0
0
0
0
0
0
0
0
0
0
0
0
0
Percentage of patients waiting 6 weeks or more for diagnostic
1.0%
0.2%
0.8%
1.0%
0.1%
0.5%
1.0%
0.1%
0.5%
0.0%
0.0%
0.0%
0.3%
Signed:
Date: 31st May 2016
Michael Wilson Chief executive
Accountability Our governance and assurance We remain committed to ensuring that our governance systems and arrangements are cohesive and ensure that our approach is coordinated and combined. 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: www.surreyandsussex.nhs. uk/boardpapers The Board also meets for Board seminars on a regular basis. 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 • The Chief Executive and Accountable Officer • Chief Finance Officer and
Deputy Chief Executive Chief Operating Officer Medical Director Chief Nurse Director of Information and Facilities (non-voting) • Director of Corporate Affairs (non-voting) • Director of People and Organisational Development (non-voting) • • • •
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 • setting the Trust’s values and standards • the safety and quality of services • holding the organisation to account for the delivery of the strategy and through seeking • assurance that systems of internal control are robust and reliable • ensuring that the
Surrey and Sussex Healthcare NHS Trust
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) are from all walks of life and have a wide variety of experience in the voluntary, public and private sectors. They are all parttime. Their declarations of interest for 2015-16 are: Alan McCarthy, Chair • Chair of The Basement Charity • Trustee of Brighton Dome and Festival Board • Vice Chair Brighton Aldridge Community Academy • Trustee of Albion in the Community Yvette Robbins, Vicechairman (until 8 May 2015) • Director, Galaxy Investment Ltd • Company Secretary in Galaxy Homes; Galaxy 39
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 Richard Durban (Vice-chair from 30 July 2015) • Magistrate (Justice of the Peace) on SW Surrey Bench Alan Hall • Director of Network Planning – OpenReach (A division of BT Group Plc) Richard Shaw • Governor of Brooklands College of Further Education Paul Biddle • 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 - Sussex Community NHS Trust Executive Directors • The executive directors are all fulltime employees of the Trust. Details of their remuneration can be found in the 40
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 and Deputy Chief Executive • 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 (until August 2015) • No declarations Angela Stevenson, Chief Operating Officer (from September 2015) • 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 until 1st November 2015) • No declarations Mark Preston, Director of People and Organisational Development (non-voting member - January 2016) • No declarations Ian Mackenzie, Director of Estates and Facilities (non-voting member) • No declarations Our clinical chiefs of service are members of the executive committee to ensure the right clinical balance of decision making. Key committees 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 non-executive membership) always includes the Chief Executive. The terms of reference of each committee sets out the remit of responsibility delegated by the Board of Directors and sets out the Annual Report 2015-16
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 Board sub-committee structure The key functions of the Board sub-committees are: 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. 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
Surrey and Sussex Healthcare NHS Trust
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: • business planning including strategic financial and workforce planning • approving investment decisions • 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 41
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 Head of Corporate Governance) 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.
Audit and Assurance Committee
Nomination and Remuneration Committee
Safety and Quality Committee
Finance and Workforce Committee
Charitable Funds Committee
Chair Paul Biddle
Chair Alan McCarthy
Chair Richard Shaw
Chair Richard Durban
Chair Alan Hall Yvette Robbins (until 8 May 2015)
Members*
Members*
Members*
Members*
Members*
Richard Durban
All NEDs
Alan Hall
Pauline Lambert
In attendance
Yvette Robbins (until 8 May 2015)
Paul Biddle
Paul Biddle
Chief Executive
Pauline Lambert
Chief Finance Officer
Chief Finance Officer
Director of People and OD
Alan Hall
Director of People and OD
Chief Nurse
Richard Shaw Yvette Robbins (until 8 May 2015)
Chief Nurse
In attendance
Medical Director
Chief Financial Officer
Chief Operating Officer
Director of Corporate Affairs
Chief Finance Officer
Other members of the executive and nonexecutive team are invited to attend as and when required
Clinical Chiefs of Service
Signed:
Date: 31st May 2016
Director of Information and Facilities Director of Corporate Affairs Chief Nurse
Director of Corporate Affairs Director of Information and Facilities
*As Accountable Officer, the Chief Executive has an open invitation to attend each Board sub-committee
Michael Wilson Chief executive 42
Annual Report 2015-16
Annual Governance Statement This governance statement forms a mandatory part of our annual report and accounts and aims to draw together position statements and evidence on both corporate and quality governance, risk management and control. It supports the aims and objectives of Surrey and Sussex Healthcare NHS Trust and provides details of how successfully we have met the challenges we have faced, our management of risk and our delivery of national priorities and standards. 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 strategies, 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 provide 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. The co-ordinating Commissioning Group is required to intervene more strongly in performance management if the quarterly rating in the NHS performance framework requires it. This arrangement will carry forward into 2016-17. I also account to NHS Trust Development Authority (TDA)/NHS Improvement – This body monitors the Trust and intervenes in performance management if there is other adverse information of sufficient importance or the quarterly rating in its performance framework requires it. I, and officers of the Trust, regularly meet with officers of the TDA/NHS
Surrey and Sussex Healthcare NHS Trust
Improvement to discuss performance. The TDA has been involved in monthly meetings with the Trust over its performance during 2015-16. 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 2015), this is supported by the Corporate Governance Manual (reviewed January 2016) 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. Throughout the year these policies have been strengthened in light 43
with the shadow council of governors who are providing both insightful and robust challenge in the development of plans.
of local and national issues relating to declarations of interest. All of these documents are available on the Trust website. The Board is responsible for providing effective and proactive leadership of the Trust within a framework of processes, procedures and controls which enable risk to be assessed and managed. 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. The Trust is in the final stages of the aspirant foundation trust pipeline during the year we have elected a council of governors who operate in shadow form. This shadow council of governors is not yet legally constituted and as such do not have the powers or full remit. We have started to share our strategies and priorities
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: 1. Ward/operational reporting to Board relevant issues 2. The Board disseminating its strategy 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 of Directors has identified no departures from the Corporate Governance Code and the head of internal audit has stated that the organisation has an adequate and effective framework for risk management, governance Annual Report 2015-16
and internal control. Assurance in his formal opinion (the details of this opinion are referred to later).
Board
Audit and Assurance Committee
The governance framework and the escalation framework for the Trust are described in the diagrams to the right.
Finance and Workforce Committee
The Board of directors The Board consists of five voting executive directors, six non-executive directors (including the Chair). The Board meets every month in public, its minutes and papers are made freely available, including on the Trust website. The Board meets regularly for Board Seminars. The Director of Corporate Affairs and Company Secretary remains a non-voting member of the Trust Board. 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 2015-16. 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 complemented by other actions that have been
Shadow Council of Governors
Safety and Quality Committee
Executive Committee and Executive Committee for Quality and Risk Patient safety
Effectiveness
Access and Responsiveness
Patient Experience
Workforce
Speciality Deep Dives (Reports to ECQR)
Mortality Group meetings
Clinical Specialist sub-groups (e.g. IPCAS
Corporate functions
Divisional Governance
Grand Rounds
Speciality Governance
M+M’s
Wards and departments
taken through the appraisal of Board members by either the Trust Chairman or I, respectively. On the 19 March 2015 the TDA Board formally recommended that the Trust moved to the Monitor stage of assessment of aspirant foundation Trusts. Following the general election in May 2015 the new Government announced the coming
Surrey and Sussex Healthcare NHS Trust
together of the Trust Development Authority (TDA) and Monitor that created some ambiguity for Trusts currently in the assessment pipeline to become a Foundation Trust. In light of this, the Board made the decision to pause the assessment phase until after the planning round with commissioners for 2016-17 was completed. 45
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. 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, the Carter productivity report and focused on financial (liquidity and cost improvement plans) and workforce issues (staffing and agency issues). 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. 46
During the financial year the Board has agreed that its long term vision is the pursuit of perfection in which quality of care and patient safety are key indicators. The Board regularly discusses patient safety and patient experience data in order to gain assurance and drive quality improvements. These conversations are supported by regular patient stories and clinical presentations that both provide narrative ensuring that patient safety and outcomes are at the forefront of Board conversations. In July 2015 the Trust was selected to take place in the national five year programme of work linking to the Virginia Mason Institute, following an extremely competitive selection process. The Trust is one of just five NHS trusts nationally set to benefit from the influence of internationally acclaimed healthcare experts as part of a new initiative launched by Health Secretary Jeremy Hunt and the NHS Trust Development Authority. The Trust’s Audit and Assurance Committee (AAC) is constituted to provide the Board of Directors with an independent and objective review of its system of internal control, financial information, system of internal control and compliance with laws, guidance and regulations governing the NHS. As such
throughout the financial year the AAC has gained assurance and driven improvements in controls from reviews of the Trust’s internal control systems for corporate, financial and clinical governance. The AAC have scrutinised the board assurance framework and added value to the description of strategic risks, provided strong challenge to the management and recording of finical 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 have received independent assurance from internal audit on a series of controls both corporate and clinical. The Committee continues to receive and consider internal and independent assurances and has adopted the ‘three lines of defence’ model to provide context and depth of assurance. 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 Annual Report 2015-16
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 hospitals 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 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. The terms of reference of each committee set out the remit of responsibility delegated by the Board of Directors.
Name
April May June July Aug Sept Oct Nov Dec Jan Feb Mar 2015 2015 2015 2015 2015 2015 2015 2015 2015 2015 2015 2015
Alan McCarthy Michael Wilson Fiona Allsop Paul Bostock Des Holden Paul Simpson Angela Stevenson Paul Biddle Richard Durban Alan Hall Pauline Lambert Richard Shaw Yvette Robbins
The Board of Directors receives a report from each chair at the next 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
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 about assurance. Where assurance cannot be robustly established the Chair of the Committee reports this to the Board of Directors. The Trust’s Rule of Procedure has been reviewed during the financial year to update the terms of references of all board sub committees. Surrey and Sussex Healthcare NHS Trust
47
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 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. 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 48
(and its sub committees) or 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 its risk appetite which details the principles of risk that the Trust is prepared to accept, seek and tolerate whilst in the pursuit of its objectives (Appendix 1). The Board actively encourages wellmanaged 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
Annual Report 2015-16
commissioners of service. Clinical risks and non-clinical risks are reviewed by the executive committee, The executive committee for quality and risk, the safety and quality committee 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 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. • 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
Surrey and Sussex Healthcare NHS Trust
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 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 49
(including Serious Incidents - SIs). This has been further improved during the financial year and the Trust has implemented systems to support Duty of Candour which is driving change in culture. • 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, eg 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 50
in Surrey and Sussex Healthcare NHS Trust for the year ended 31 March 2016 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 2015) 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 downwards 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 controls assurance map • 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. The final Board Assurance Framework report presented to the Board for 2015-16 described seven red rated risks were Trust objectives Annual Report 2015-16
may not be achieved and listed in Section 5 with two areas listed as significant control issues (activity and financial risk). 4.2 Care Quality Commission Registration The Care Quality Commission (CQC) carried out a focused follow up Apr 15
ED 95% in 4 hours Patients waiting in ED for over 12 hours following DTA
May 15
inspection of the Trust’s Outpatient services in January 2016. This was a positive inspection and provided assurance that the Trust had introduced systems to regularly assess and monitor the quality of outpatient services and had resolved the issues identified during the previous inspection. Jun 15
Jul 15
95.9%
0
Aug 15
Sep 15
Oct 15
95.8%
0
0
0
0
4.3 Performance against national priorities The Trust is committed to delivery of the national priorities and the NHS constitution which has been a key national focus over the course of 2015-16 The table below sets out the Trusts performance against the key standards: Nov 15
Dec 15
Jan 16
94.6%
0
0
0
Feb 16
90.9%
0
0
0
Cancer TWR
93.5%
91.9%
92.9%
93.1%
Cancer TWR Breast Symptomatic
93.3%
93.6%
94.5%
87.9%
Cancer 31 Day Second or Subsequent Treatment (Surgery)
100.0%
100.0%
100.0%
98.0%
Cancer 31 Day Second or Subsequent Treatment (Drug)
100.0%
100.0%
100.0%
100.0%
Cancer 31 Day Diagnosis to Treatment
98.4%
99.2%
96.9%
96.1%
Cancer 62 Day Referral to Treatment Standard
86.3%
83.8%
86.6%
85.0%
Cancer 62 Day Referral to Treatment Screening
90.0%
93.1%
93.8%
96.9%
RTT Incomplete Pathways % waiting less than 18 93.6% weeks
93.5%
92.6%
92.2%
92.0%
92.1%
92.2%
0
0
0
0
0
0
0
0
0.0%
0.0%
2.0%
0.0%
0.0%
0.0%
0.0%
0.0%
RTT Patients over 52 weeks on incomplete pathways Percentage of patients waiting 6 weeks or more for diagnostic
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.
We are working with the local health system to ensure that plans are put in place to support delivery of the standard going forward particularly into winter 2016-17.
Surrey and Sussex Healthcare NHS Trust
Mar 16
92.0% 92.1%
0
92.0%
92.0%
92.2%
0
0
0
0
0.0%
6.3%
3.0%
At a national level, cancer access has been an issue throughout 2015-16 and a key priority has been improvement on the 62 day referral tor Treatment standard. Eight High 51
Impact Actions have been developed nationally and implemented across the NHS. With the exception of Q2, the Trust has delivered the 62 Day access standard and continues to work to improve pathways to support the implementation of the national cancer strategy over the coming years. On the 18 week referral to treatment standard, a national review of performance measures was undertaken and revised guidance issued. While some specialties have been adversely impacted by winter bed pressures/ high levels of emergency growth, the Trust has delivered the incomplete pathway standard and six week diagnostic standard throughout the year. However, as a result of the emergency demand, a number of elective patients cancelled on the day were not able to be treated within 28 days. 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 52
updates on the drafting of the account. With regards to the 2014-15 Quality Account, external audit audited the completion of the account providing a review of methodology to prepare quality accounts, two key quality metrics and the action plans developed to management performance. External audit gave an unqualified limited assurance opinion of the formation of the quality account which is the strongest level of assurance possible relating to the formation of the account. 4.4.1 The quality risk structure 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 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. 4.4.2 The management of incidents and identification of clinical risk 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. The Trust Quality Scorecard is presented at Executive Committee Quality and Risk; it allows key threats and risks to patient safety and Annual Report 2015-16
action plan were discussed with the family and our commissioners.
quality to be identified with more detail being reviewed by the relevant Trust Board sub-committee. 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. The Trust reported a never event in April 2015 which has been investigated thoroughly. The patient’s family were key witnesses to the incident and contributed to the investigation process. The conclusion of the investigation and the
Throughout the financial year the Trust has looked to strengthen its system to support the management of investigation of incidents that cause significant harm, defined by the national serious incident reporting structure. As such the Trust management of investigations has improved as has reporting and discussion of harm and patient stories at our public board. A key success in raising the awareness of patient safety has been the weekly Patient Safety Executive which brings together clinical and non-clinical teams from across the Trust to discuss quality and safety issues. The aim of the meeting is to ensure that transferrable lessons from incidents, complaints and claims are shared. The first national benchmarking of the Trust’s capability to learn from incidents has been published and the Trust has benchmarked well nationally. This is positive assurance to support our efforts to continue to learn from incidents and share our findings. 4.4.3 Clinical audit The Trust has an established clinical audit program
Surrey and Sussex Healthcare NHS Trust
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 specialty teams assurance. The Trust has described the aspiration that the clinical audit program will also be used to drive continuous improvement of services and quality of care. 4.4.4 Information governance The NHS Information Governance Framework sets the processes and procedures by which the NHS handles information about patients and employees, in particular personal identifiable information. The NHS Information Governance Framework is supported by an information governance toolkit and the annual submission process provides assurances to the Care Quality Commission, other organisations and to individuals that personal information is dealt with legally, securely, efficiently and effectively. The Trust places high importance on ensuring there are robust information governance systems and processes in place to help protect patient and corporate information. We have established an information governance management framework and are developing information governance processes and procedures 53
in line with the information governance toolkit. We carried out an information governance work programme and undertake assessment by the IG Toolkit annually. Delivery of the information governance work programme was overseen by the Information Governance Steering Group, which is chaired by the Senior Information Risk Owner. We have ensured all staff undertake annual information governance training and have implemented a set of policies and procedures to ensure staff are aware of their information governance roles and responsibilities. There are processes in place for incident reporting and investigation of serious incidents. During 2015-16 all reported information governance incidents were of minor significance. 4.4.5 Patient feedback There are a number of ways for patients and their families to provide feedback on their experiences and to tell their stories. Both the Friends and Family Test and our bespoke Your Care Matters (YCM) survey are well established and cover all clinical pathways. All comments that are made are collated, along with monthly dashboards and relayed back to managers of individual wards and departments. 54
Their performance is then reviewed and changes are made where appropriate. At the end of the YCM survey respondents are given the opportunity to share their story on Patient Opinion which also interfaces with comments posted on NHS Choices.
•
We are considered an exemplar organisation by Patient Opinion for providing timely and appropriate responses, often posted by clinical staff, to comments that are made.
•
Other aspects 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. 5. Review of effectiveness 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 Executive Directors within the organisation who have responsibility for the development and maintenance of the system of internal control provide me with assurance The Board Assurance Framework itself provides me with evidence that the 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. Annual Report 2015-16
The main points from my review are as follows:
measured by the Care Quality Commission.
5.1 Assurance framework The Board Assurance Framework (BAF) identifies seven main strategic risks to the Trusts meeting its objectives. These are as follows: 2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity to deliver the activity income that underpins the long term financial model. 3.1 The continuing challenge to recruit and retain clinical staff is impacting on the Trust’s ability to maximise financial and quality benefits. 4.1 Failure to maintain Emergency Department performance because of lack of capacity in health system to manage pressures has a significant impact on the Trust’s ability to deliver high quality care. 5.1 Failure to deliver income plan. 5.2 Failure to stop divisional overspending against budget. 5.3 Unable to deliver medium term financial plan. 5.4 Liquidity: Inability to pay creditors/ staff resulting from insufficient cash due to poor liquid position.
However the seven risks described above are all elements of the 2 main control issues that the Board has managed throughout the year; activity and finances.
The BAF is split into the five domains of quality
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 eight 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 implemented an action plan
Surrey and Sussex Healthcare NHS Trust
with four key work streams to improve the quality of outpatient services; environment, workforce and leadership skills, communications and systems and processes. These issues have now been resolved and re-inspected by the CQC who confirmed that the requirements identified in the last inspection have been met (see section 4.2). • 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. The Head of Internal Audit Opinion provides assurance concerning the effectiveness of the Trust’s internal controls. 55
Stating that: • ‘The organisation has an adequate and effective framework for risk management, governance and internal control. However our work has identified further enhancements to the framework of risk management, governance and internal control to ensure that it remains adequate and effective.’ • 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 2015-16. • 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 2016 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. 56
5.3 Performance The Trust has developed a performance management system from which I get regular updates on 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’s counter fraud systems are well embedded and considered regularly both proactively and reactively. During the year the Trust has been successful in mitigating against fraud, identifying potential weaknesses and strengthening controls. The Audit and Assurance Committee regularly reviews information from the Trust’s counter fraud services and gains assurance. The Trust’s Counter Fraud systems were reviewed by NHS Protect during 2015-16 using the new assessment Self Review Toolkits (SRTs). This provided strong assurance but identified an issue relating to the
Trust’s uploading of reactive investigations onto the NHS Protect investigations database; this issue has now been resolved. It is anticipated that the SRT for 2016-17 will be completed in the early part of the new financial year. 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) 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 Activity 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 capacity position had a similar effect on Annual Report 2015-16
the Trust’s Emergency Department standards and elective activity which effected 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 internal assurance from the Safety and Quality Committee and Executive Committee for Quality and Risk and the effectiveness of business continuity plans that mitigate against the impact of emergency activity. This issue would have been more focussed had it not been for the dedication and commitment of the Trust’s staff to provide high quality care recognised.
6.2 Finance There are two specific financial control issues as follows: 1. Statutory breakeven duty, overall and recurrent financial position:
To date, the Trust has worked effectively with local CCG’s and council bodies to develop real plans to strengthen controls, improve joint working and share emergency activity risks. This is evidenced by the opening of the joint funded and managed Integrated Reablement Unit in partnership with Surrey County Council and East Surrey CCG. The Trust has started to develop joint plans for a frailty unit which is aimed to reduce the need for admission. Similarly the Trust has agreed timeframes with Sussex CCG to ensure that similar models of care are developed through 2016-17. Surrey and Sussex Healthcare NHS Trust
The Trust delivered a £6.5m deficit for the financial year 201516, taking account of technical adjustments for donated assets. This was adverse to the position originally planned and a worsening against the deficit reported in 201415 (of £2.4m). 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 or the potential the Trust may incur illegal expenditure. The Auditor did so in a Section 19 letter with the Trust’s accounts in 2013-14. A further referral in 2015/16 was not necessary as the position has not materially changed since. The reported deficit was supported by £3m of non-recurrent funding in the form of income from the Trust Development Authority and the non-recurrent
benefit of changes to balance sheet provisions. After taking account of non-recurrent set-offs in respect of income lost from industrial action and other items, the underlying (as opposed to normalised) deficit is calculated as ÂŁ7.2m, which is also adverse to the position originally planned. The adverse financial position has been driven by emergency activity significantly above planned levels (providing increased costs and reduced income from elective activity that has been displaced) and the impact of adverse delivery against the cost improvement plan (CIP), which has been significantly affected by increased agency costs in the year (which in turn were also partly affected by the level of emergency activity requiring additional staffing). Adverse CIP delivery (effectiveness) is highlighted in the Head of Internal Audit Opinion, noting that the management of CIPs was rated as satisfactory. The Board Assurance Framework for 201516 records items 5.1 (failure to deliver the income plan) item 5.2 (failure to stop divisional overspending) and item 5.3 (unable to deliver medium term financial 58
plan) as red rated at the March Board reflecting the adverse financial position recorded for 2015-16. 2. Liquidity: This is described in a Board Assurance Framework indicator (BAF ref 4.1.d - Liquidity: inability to pay creditors or staff resulting from insufficient cash due to poor liquid position). The Trust secured a ÂŁ6m working capital facility in August, which was increased to ÂŁ12.5m in February and has allowed the impact of the deficit and in-year cash flow delays to be managed. Cash management will continue to be an area of focus along the same lines as in the last few years, 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: 31st May 2016 Annual Report 2015-16
Putting people first “Every day I am reminded of the commitment everyone at Surrey and Sussex Healthcare NHS Trust has to providing high quality care to local people. I see it the way they care for our patients and the way they work together to make it right each time.
Keep in touch
Surrey and Sussex Healthcare NHS Trust provides emergency and non-emergency services at:
I know from the many compliments and comments from patients and their families just what a difference this caring, compassion and enthusiasm makes to the experience of all those we care for. I thank each and every one of you.”
East Surrey Hospital Redhill, Surrey RH1 5RH Tel: 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 Tel: 01293 600300 We also provide a number of services at four community sites: Caterham Dene Hospital Church Road, Caterham, Surrey CR3 5RA Tel: 01883 837500
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Michael Wilson Chief executive Surrey and Sussex Healthcare NHS Trust
Need help or advice? The Patient Advice and Liaison Service (PALS) focuses on improving services for NHS patients. It aims to: • advise and support patients, their families and carers • provide information on NHS services • listen to your concerns, suggestions or queries • help sort out problems quickly on your behalf
You can contact PALS by: Horsham Hospital • telephone: 01737 768511 x 6922 or 6831 Hurst Road, Horsham, West Sussex RH12 2DR (for all sites) Tel: 01403 227000 • e-mail: pals@sash.nhs.uk • writing to: PALS, c/o East Surrey Hospital, Oxted Health Centre Redhill, Surrey RH1 5RH 10 Gresham Road, Oxted RH8 0BQ Tel: 01883 734000 You can ask a member of staff to contact PALS on your behalf Surrey and Sussex Healthcare NHS Trust Trust Headquarters, Canada Avenue, Redhill This information is available in other Surrey RH1 5RH languages and formats including audio tape, large print and braille. For further Tel: 01737 768511 information please contact PALS (Patient Email: enquiries@sash.nhs.uk Advisory Liaison Service) on 01737 231958 www.surreyandsussex.nhs.uk or email: enquiries@sash.nhs.uk Twitter: @sashnhs Surrey and Sussex Healthcare NHS Trust
59
Appendices Appendix 1: Risk Appetite – 2015-16 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. The Board actively encourages wellmanaged 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. The key following principles further define this stance with an opinion from the Board: Quality: The quality of our services, measured by clinical effectiveness, safety, experience and responsiveness is our core business. We will only put the quality of our services at risk if, upon consideration, the benefits of the risk improve quality are justifiable and the management controls in place are well defined and practicable. Target: Green Innovation: The Trust is highly supportive of service development and innovation and will seek to encourage and support it at 60
all levels with a high degree of earned autonomy. We recognise that innovation is a key enabler of service improvement and drives challenge to current practice both internally and across the wider health economy. Target: Amber Well-led: The Board acknowledges that healthcare and the NHS operates within a highly regulated environment, and that it has to meet high levels of compliance expectations from a large number of regulatory sources. It will meet those expectations within a framework of prudent controls, balancing the prospect of risk reduction and elimination against pragmatic operational imperatives. The Board will seek to innovate and take risks where there is potential to develop inspirational leadership as it recognises that this is key to both becoming the local employer of choice and developing strategic partnerships with new bodies. Target: Green Financial: The Trust is prepared to invest for return and minimise the possibility of financial loss by managing risk to a tolerable level. The Board will take decisions that may result in an adverse financial
performance rating in the face of opportunities that balance safety and quality and are of compelling value and benefit to the organisation. There will be an expectation of aggressive risk reduction strategies and increased scrutiny of mitigating actions. Target: Amber Reputation: The Board is prepared to take decisions that have the potential to bring scrutiny of the organisation, provided that potential benefits outweigh the risks and by prospectively managing any reputational consequences. Target: Green Workforce: The good will of our staff is important to the Trust. Any decision that places at risk staff morale and has the potential to adversely affect any aspect of the working life of our employees will be balanced very carefully against any potential consequent benefits and will only be considered if the inherent risk is low. The Board recognises the complications attached to recruitment and retention that are caused by geographical and national position and takes this into account when reviewing workforce related risks. Target: Amber Annual Report 2015-16
Our finances The year in context The Trust ended 2015-16 with a deficit of £6.5m (post technical adjustments). The position before technical adjustments (net donated asset receipts and impairments) was a deficit of £4.1m.
conjunction with other non-recurrent items, the underlying position is a £7.2m recurring shortfall. • Stayed within its reduced capital programme financial resource limit. The Trust’s adjusted treatment cost (a measure introduced as part of Lord Carter’s efficiency work based on reference costs) was £0.88, the second lowest in England. This performance is against a context of significant deficits in acute trusts across the country, and, as in 201415, the deficit has been driven by emergency activity above plan (more people admitted for emergency treatment). This affects the operation of the whole trust
In summary, the Trust: • Achieved £5.5m of savings representing 67% of the 2015-16 £8.2m planned savings programme. • Stayed within its External Financing Limit. The Trust’s deficit was supported by nonrecurrent income from NHS Improvement of £3.0m, reflecting a planned undershoot against the capital resource limit[1], and in
with its three-fold impact of additional cost, income for the extra patients paid at only 70% (the marginal rate emergency tariff) and the loss of income not being able to do as much planned (elective) work as intended. The shortfall against the savings plan was primarily due to not achieving the reduction in agency usage, but also shortfall against some other cost improvement plans. Income and expenditure performance is described in the chart below, which provides a view back to the creation of the Trust in 1998/99. The surplus planned for 2016-17 includes nonrecurrent sustainability and transformation funding, which is explained later.
I&E surplus/(deficit) - net and recurrent (underlying)
15.0
(£m)
5.0
(5.0)
(15.0)
Adverse
Underlying surp/(def)
(25.0)
(35.0)
Net surp/(def)
1998/99 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/04 2014/15
2015/16 FOT
2016/17 plan
Underlying surp/(def)
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)
(7.2)
7.5
Net surp/(def)
0.9
(5.0)
(4.6)
(0.2)
6.7
(4.1)
(26.4)
(10.8)
(12.2)
0.0
7.0
7.6
1.0
6.1
0.3
0.3
(2.4)
(6.6)
15.2
The journey to 2015-16 – 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
Surrey and Sussex Healthcare NHS Trust
Trust’s creation (from the merger of the hospitals in East Surrey and Crawley) and after a deceptive 61
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 and in 2007 had to borrow £56m to cover the deficits. 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 £56m loan in just three years and in 2008-09 the Trust’s categorisation as financially challenged was formally lifted. 62
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 few 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. 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 last two years, 201415 and 2015-16, have seen emergency activity continue to increase above planned levels, noting that the rates of growth differ geographically (there is more growth from Sussex than in Surrey in 2015-16), while other pressure has come from the cost of agency staff (as the Trust uses these staff to fill vacancies) and non-delivery of other cost improvement schemes. As the Trust moves into 2016-17, there continues to be growth in emergency and planned activity and the Trust is focusing on how it can better manage the volumes of patients within its physical capacity, and within its budget. This means action on two fronts, inside and, with partners, outside hospital. In 2015-16 stronger working with partners in the health system has been manifested by the creation of an integrated reablement unit operated (and paid for equally) by the Trust, East Surrey CCG and Surrey County Council. Internally the emphasis on productivity continues, and improved working in the longer term (the SaSH plus programme) is being supported through a five year collaboration with the Virginia Mason Annual Report 2015-16
Finally, to explain the improved surplus planned for 2016-17, NHS Improvement has provided control total I&E targets along with payment of sustainability and transformation funding. The interim budget set by the Trust meets this control total (£15.2m surplus), and includes receipt of £9.7m of non recurrent sustainability and transformation funding. Reference and adjusted treatment costs The 2014-15 NHS reference costs (the most recent) are translated into an index to allow comparison between trusts. The national average is an index of 100 and the Trust’s index score has changed as described in the table below. The 2014-15 figure is 88. This describes cost management over a long period as well as the granular reporting of work done, and suggests that we have managed the investment in services without markedly increasing our unit costs. The 2014-15 reference cost was audited in 2015-16 on behalf of the Department of Health and the Trust was found to be materially compliant in its reference cost processes and calculation.
The Lord Carter work on trust efficiency has used the reference cost index to create an adjusted treatment cost, which is a relative value describing the unit cost to deliver the treatments carried out for patients in the year adjusted to compare with the average cost across the country. The index of 88 therefore translates to an adjusted £0.88 cost, meaning the Trust’s unit cost was 12% lower than the national average, and the second lowest in England. In 2014-15 this meant that the same volume of output cost the Trust £29.4m less than the average cost across the country. The loan and the statutory breakeven duty Surrey and Sussex Healthcare NHS Trust secured its £56m working capital loan at the end of 2006/07 to cover debts from its poor financial performance up to that time. This was, and probably still is, the largest loan allowed for any NHS trust.
Trust reference cost indices Reference costs
Index value
2006/07
116
2007/08
95
2008/09
86
2009/10
94
2010/11
97
2011/12
89
2012/13
92
2013/14
92
2014/15
88
Adjusted treatment cost
£0.88
The current position on the loan is described above, with only £3.5m 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
Loan repayment schedule Loan repayment plan
Loan outstanding
2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 (£m) (£m) (£m) (£m) (£m) (£m) (£m) (£m) (£m) (£m)
(55.9)
Trust repayment Loan carried forward
(4.8)
(4.5)
(4.3)
(4.1)
(3.9)
(3.7)
(3.5)
7.9
0.3
0.2
0.2
0.2
0.2
0.2
0.2
(4.8)
(4.5)
(4.3)
(4.1)
(3.9)
(3.7)
(3.5)
(3.3)
(53.7)
(20.7)
26.0
8.0
2.2
7.0
(53.7)
(20.7)
Conversion to PDC
Loan outstanding
60.0 50.0 Loan outstanding (£m)
Institute funded by the Department of Health (discussed elsewhere in this annual report).
Surrey and Sussex Healthcare NHS Trust
40.0 30.0 20.0 10.0 0.0 2007/08
2008/09
2009/10
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
2016/17
63
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 five 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. Other cash borrowing In order to manage its cash flow (partly from the deficit in 2015-16 and 2014-15 but also because of delays in payments) the Trust has secured a £12.5m working capital facility that will remain in place as it moves into 2016-17. This is not a loan like the £56m one above and is like an overdraft (a limit 64
against which the Trust can borrow). Repayment can be expected at any time (subject to discussion between the lender and the Trust) and the facility can be withdrawn if the Trust’s cash position does not require it, which is the expectation in 2016-17. Finally, the Trust has also borrowed cash to support its capital programme (for building works and equipment) over the years. Overall it has borrowed £13.5m since 2010/11 in three separate loans. There is £11.1m left to repay at 31 March 2016. 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 seven years. In 2011-12 we needed an injection of cash and the fragility of the position exacerbated by the deficit and late payments, has meant, in 2015-16,
that with we have secured the working capital facility referred to above. 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. The solution is a significant injection of cash, either from a new working capital loan, a further 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 more than £24m for this Trust. Annual Report 2015-16
Looking forward – sustainability: financial strategy overview The Trust’s financial strategy is to establish the Trust’s long term financial stability through short term and medium term objectives as follows:
recovering the 2015-16 recurrent deficit, and the
Short term: • stabilising the Trust’s clinical services in the face of increasing emergency demand to provide sufficient capacity to deliver clinical and financial plans; • recover the normalised position of the Trust by 2017-18 Medium term: • Become a financially sustainable organisation through continuous operational efficiency, improving health outcomes and working in fuller and more effective partnership with commissioners, local authorities and other providers. • Creating a flexible and commercial organisation able to quickly and effectively respond to all the demands of the changing NHS environment. The financial plan connection to the operational plan. The deficits of the last two years have affected original timescales. The need to manage demand from urgent care is key to
revised plan is described as in the diagram below.
2014-15
2015-16
2016-17
Future state
SASH establishes clinical stability
SASH manages demand impact increases capacity
Increased productivity and integrated urgent care with partners
SASH right sized and transition to recurrent surplus
S&T Surplus
Surplus
Deficit
Performance and productivity improvement
Partnership Opportunities
The financial plan is supported by an operational plan, as in the diagram below, describing the activity changes that would
allow the management of demand and the balancing of non-elective to elective activity (maximising higher contribution income).
Trust operational plan Performance and productivity improvement in all areas
2014-15
2015-16
2016-17
Non elective activity
Manage activity in non elective base - stop overcrowding
Manage activity growth, increase capacity, improve discharge, reduce XSBDs
1) Integrated urgent care with partners. 2) Deliver LoS reduction and create capacity to manage peaks
Flexible operational position to cope with changing healthcare pathways
Elective activity
1) Ring fence extant elective capacity; 2) Minimal outsourcing; 3) Absorb growth
1) Ring fence & MAINTAIN; 2) Create additional capacity; 3) Productivity changes.
1) Consolidate;
Strong elective base, competitive market position and flexibility to support health system/choice initiatives
Surrey and Sussex Healthcare NHS Trust
2) Absorb displaced RTT work from south... increase market share
Future state
65
Additional capacity for elective activity was created in 2015-16 (an additional elective ward and an additional theatre, plus additional day case capacity) but the level of emergency demand has prevented its effective use. Plans for 2016-17 create capacity for emergency and elective work from the following: • Productivity improvements (length of stay) and better internal working (e.g.: breaking the cycle a periodic change to how clinical teams work that takes them away from other duties temporarily) to manage emergency demand and facilitate discharges; • Structural changes (changes to the physical layout and space in the emergency department (ED), increased capacity for ambulance handovers, diagnostics in ED, the full opening of cardiac services within the new Surrey and Sussex Heart Centre, and upgrades to the electronic patient record system) • Integrated urgent care services with CCGs and councils (new pathways created through a reablement unit and, planned in 2016-17, a frailty unit) and improved working around management of urgent care across the health system (so, more coordination of out of hospital capacity to get 66
people out of hospital faster and reduction in hand-offs between the many organisations involved in each pathway). 2016-17 budget The financial plan takes account of sustainability and transformation (S&T) funding and the stated control total. The amount of S&T funding included in the plan is £9.7m, and the control total is £15.2m. S&T funding is treated as non recurrent. [The Trust has provided caveats that would reduce the control total – these have not yet been agreed, and the items the caveats relate to have not been resolved as at 18 April 2016]. The Trust set a core budget with a £0.25m surplus. Net of the receipt of £9.7m S&T funding, the £5.3m bridge to achieve the £15.2m control total consists of benefit from the virtual abolition of marginal rate and readmission penalties and a £0.28m additional contribution from Trust reserves. Because contracts with commissioners are unsigned the 2016-17 budget agreed in March 2016 was an interim budget. Key points The key points from the budget for 2016-17 are as follows: • EBITDA and net surplus: At 9.7%,
EBITDA (the operating surplus) is at the higher end of the financial sustainability measures applied by Monitor in past foundation trust applications and translates to a £15.2m net surplus position; • Cost improvement and efficiency: The core cost improvement plan (CIP savings) is set at £9.2m (3.1% of turnover) and the financial productivity gain associated with part of the income growth is set at £2.7m (i.e.: additional to the CIP). Together these equate to £11.9m or 4.0% of turnover, twice the tariff efficiency gain required. • Cost improvements are modelled to come from all areas of the Trust but major on agency reduction, procurement, usage of consumables and services, reduction in CCG fines and additional duty costs (extra payments for staff to clear waiting lists). Efficiencies contributing to the productivity gain flow from outpatient demand and capacity work, reducing length of stay for non-elective patients and theatre efficiency. As stated above, the Trust’s adjusted treatment cost (ATC) from the Lord Carter work is £0.88, the second lowest in England. • Agency rules: Agency costs are a serious issue across the NHS, and Annual Report 2015-16
NHS Improvement has introduced Agency Rules to apply downward pressure on agency usage across the provider sector. These consist of price-caps (capping the hourly rate that can be paid) and providing an overall target for total spend in year. The rules have a break glass clause to ensure that agency usage is permitted if patient safety might be compromised. The Trust has historically high levels of vacancies and was non-compliant in 2015-16 with the price cap and the total spend. As mentioned above a significant part of the CIP is from reducing agency usage, and this is profiled to deliver the target, allowing the maintenance of clinical capacity and
safe staffing levels while the Trust recruits to vacancies and continues to bear down on costs. Agency usage in the plan is below the spend cap notified. • Income and activity: as discussed above, past assumptions on the delivery of reductions in emergency activity have proved misplaced and growth in this activity has been at the root of adverse operational and financial performance for the Trust. Those assumptions have now been revised to reflect growth in 2015-16. Assumptions on elective and outpatient activity are also based on the outturn for 2015-16, and the full year effect of that growth and current referral rates. • Income tariff changes: The tariff changes mean
an overall increase in the price paid for Trust clinical income (and takes account of the national insurance and NHS Litigation Authority charge increases). Notionally this is a 1.1% overall increase. The Trust also benefits financially from the suspension of the stated base value (SBV) adjustment for specialised commissioning (which saw all additional growth paid at 70% of tariff). Analysis of financial data The key financial statements from the 2015-16 accounts are in the appendix. The table below provides a fuller summary of our income and expenditure performance since 2007-8, and the plan for 2015-16.
Detail of overall income and expenditure performance since 2007-8 20092010
20102011
20112012
20122013
20132014
20142015
20152016
20162017
(£m)
(£m)
(£m)
(£m)
(£m)
(£m)
(£m)
plan (£m)
Income from patient care Other operating income Net operating income
174.1 20.8 194.9
179.8 16.4 196.2
189.3 20.3 209.6
197.0 29.0 226.0
210.7 21.0 231.7
225.4 18.7 244.0
240.9 24.0 264.9
267.0 30.7 297.7
Operating expenses
(178.9)
(187.2)
(207.0)
(215.1)
(220.7)
(234.7)
(257.1)
(268.3)
EBITDA (op surplus/(deficit))
16.0
9.0
2.6
11.0
16.0
9.3
7.8
29.5
Net interest and other items Depreciation PDC dividends payable Impairments/donated assets
(0.8) (4.5) (2.9) (0.2)
(0.3) (4.7) (3.0)
(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) (9.8) (3.9)
(0.8) (9.2) (4.3)
NHS performance surplus/(deficit)
7.6
1.0
(6.1)
0.3
0.3
(2.4)
(6.5)
15.2
(4.8)
0.0
0.1
0.0
0.0
2.4
0.0
7.6
(3.7)
(6.1)
0.4
0.3
(2.4)
(4.1)
15.2
(39.4)
(38.4)
(44.5)
(44.2)
(43.9)
(46.3)
(52.8)
(37.6)
Income and Expenditure: EBITDA presentation
Impairments/donated assets NET SURPLUS/(DEFICIT) B’even duty: Cumulative deficit
Surrey and Sussex Healthcare NHS Trust
67
Income and costs – looking forward In 2016-17 our income is forecast to total £297.7m, taking into account £9.7m of sustainability and transformation funding. Trust forecast income 2016-17 Other income 8%
S&T Funding 3%
NHS clinical income 89%
Income
2016-17 Forecast (£m)
CCG income/patient care
265.4
Other operating income
22.6
S&T funding
9.7
Total income
297.7
a. The transfer of Crawley Hospital and Surrey HIS caused a reduction in income between 20056 and 2007-8, 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 20078 – as a result the Trust was in deficit until this point. b. 2008-9 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). • 2008-9 was also the last year of 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. c. 2009-2010 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
Trust income since 2006-07 270.0
45.0
250.0
(£m)
230.0
30.0
210.0
190.0
15.0
170.0
150.0
2006/07
2007/08 6.8
2008/09 10.5
2009/10 6.8
2010/11 4.9
2011/12 12.6
2012/13 13.4
2013/14 3.5
2014/15 3.1
2015/16 3
Total income
163.3
163.3
188.0
194.9
196.2
209.6
226.0
231.4
243.8
261.379
Rec income
163.3
163.3
177.5
188.1
191.3
197.0
212.6
227.9
240.7
258.79
Non rec income
68
0.0
Annual Report 2015-16
disputes through overall annual memoranda of understanding (MoU) in several of the last few years). The increase seen in 2010-11 is therefore partly a delay in seeing 2009-10 benefit. There was significant loss of recharge (non-contract) income in 2010-11, contributing to a decline in total income compared to that from activities. d. 2011-12 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. e. 2012-13 shows a continuation of 2011-12, increased productivity and more activity, unfortunately
without the reduction in non-electives. The change since 2010-11 is noticeable in the chart. f. 2013-14 sees income increasing at a reduced rate with tariff deflation taking effect. g. 2014-15 and 2015-16 – the income gradient has got steeper in 2014-15 and again in 2015-16 with increased activity in the hospital (both non-elective and elective) – even after the impact of the marginal rate for emergency tariff reduction and the stated base value deduction for specialised commissioning. Note: 2015-16 income excludes donated asset benefits.
Trust income since 2006-07 PDC dividend 1.5% Deprec. 3.1%
Net interest 0.3%
Non pay 28.4%
Costs in 2015-16 are forecast to total £282.6m, split as described in the table and chart to the right.
Pay costs 66.6%
Operating Costs
2016-17 Forecast (£m)
Pay costs
188.3
Non pay costs
80.3
Sub-total: operating costs
268.5
Depreciation
8.9
PDC dividend
4.3
Net interest paid/received
0.9
Total costs
282.6
Trust costs since 2006-07 180.0
160.0
(£m)
140.0
120.0
100.0
80.0
60.0
40.0 Pay Non pay
2006/07 106.3
2007/08 102.7
2008/09 116.2
2009/10 125.1
2010/11 131.6
2011/12 140.8
2012/13 147.2
2013/14 155.1
2014/15 164.0
2015/16 177.967
65.9
64.5
61.5
58.5
65.0
71.5
75.0
72.5
79.3
85.504
Surrey and Sussex Healthcare NHS Trust
69
h. Pay costs fell from 20045 to 2007-8 with the loss of Crawley Hospital, the Surrey HIS and other smaller services that were absorbed by other parts of the local NHS. i. 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. j. At the same time, activity increased significantly in 2008-9 and 3 additional wards were opened at this time. In 2009 Surrey HIS broke up, with staff returning. The rise in pay costs from 2007-8 is the main driver behind the Trust’s increasing cost base, noting that simultaneously reference costs remained at below average levels. k. The increase in 2010-11 non pay is mainly due to the £4.8m non recurrent impairment. l. In 2011-12 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 70
were substantial in year (£1.6m between them). m. 2012-13 and 2013-14 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 2013-14. n. 2014-15 and 2015-16 see increases in both pay and non-pay to deliver the increased income, with a reduced level of cost improvements/ increased level of agency spend in 2015/16. To state the obvious, the cost increase in both years is greater than the income increase – resulting in the reported deficits in both years. Capital In 2015-16 the Trust spent £14.1m on capital investment. (buildings, IT and equipment). In addition, partners have also invested in two projects, the construction of the integrated reablement unit (costs shared equally with East Surrey CCG and Surrey County Council) and the MacMillan
cancer information centre (MacMillan funded the majority of the build). 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 inyear but the principle focus was investment in the Trust’s estate, and by year end the programme had delivered: • The theatres refurbishment phase 2 was completed, completing the project and giving the Trust new state of the art operating theatres – this project will have cost £14m in total, spread over two years • The new cardiology facilities (part of the Surrey and Sussex Heart Centre) were completed and opened, providing additional capacity and again providing state of the art equipment and facilities • The first part of the medical records and administration building (which will streamline the availability of Annual Report 2015-16
medical records in the hospital – along with the relocation of our medical records storage to a company only two miles down the road this provides an important improvement to an essential support service) In 2016-17 the Trust has a slightly smaller capital budget which will see the completion of the medical records build, the refurbishment of the resuscitation area in the emergency department as well as the location of a new CT scanner in the department, a radiology day care unit, continuation of the ward refurbishment programme and the replacement of medical equipment. Remuneration report This report includes details regarding senior managers’ remuneration in accordance with Section 234b and Schedule 7a of the Companies Act. We have an established Nomination & Remuneration Committee to advise and assist the Board in meeting our responsibilities to ensure appropriate remuneration, allowances and terms of service for the Chief Executive and Directors. Membership of the Committee comprises of the Trust Chair and non-executive directors. The Chief Executive or the other executive Directors can be invited to attend in an advisory capacity (except
in relation to their own terms and conditions). The Director of HR attends the committee as adviser and is responsible for minuting the meetings. The Chief Executive’s and Directors’ remuneration is determined on the basis of reports to the remuneration committee taking account of any independent evaluation of the post, national guidance on pay rates and market rates. Pay rates for other senior managers are determined in accordance with Agenda for Change job evaluations and central NHS review body pay awards. Pay rates for the Chair and Non-Executive Directors of the Trust are determined in accordance with the Trust Development Authority We do not operate any system of performance related pay. The performance of NonExecutive Directors is appraised by the Chair. The performance of the Chief Executive is appraised by the Chair. The performance of Trust Executive Directors is appraised by the Chief Executive.
Surrey and Sussex Healthcare NHS Trust
The Chief Executive and all Directors are on permanent contracts as at 31 March 2016 and subject to six months’ notice period. Termination arrangements are applied in accordance with statutory regulations as modified by national NHS conditions of service agreements and the NHS pension scheme. Tables attached show details of salaries, allowances and any other remuneration and pension entitlements of senior managers. No significant awards have been made in the past year to senior managers. Signed:
Michael Wilson Chief executive Date: 31st May 2016
Salaries and allowances 2015-16
Name
Title
Executive Directors Allsop, Mrs. Fiona Margaret
Chief Nurse (from 01/10/2013)
Bostock, Mr. Paul Justin
Chief Operating Officer (left 13/09/15)
Francis-Musanu, Mrs. Gillian Josephine
Director of Corporate Affairs
Holden, Dr. Desmond Philip
Chief Medical Officer
Mackenzie, Mr. Ian Duncan
Director of Information and Facilities
Parker, Mrs. Yvonne
Director of Human Resources
Preston, Mr. Mark
Director of Organisation Development and People (from 04/01/2016)
Simpson, Mr. Paul Fraser
Chief Financial Officer
Stevenson, Mrs. Angela
Chief Operating Officer
Wilson, Mr. Michael Anthony
Chief Executive
Non-Executive Directors Biddle, Mr. Paul
Non-Executive Director
Congdon, Mr. Richard John
Non-Executive Director
Durban, Mr. Richard Don
Non-Executive Director
Hall, Mr. Alan J
Non-Executive Director
Lambert, Ms. Pauline
Non-Executive Director
McCarthy, Mr. Alan Roy
Chairman
Robbins, Ms. Yvette Anita
Deputy Chairman/Non-Executive Director (left 07/05/15)
Shaw, Mr. Richard Oliver
Non-Executive Director
Band of highest paid director’s total remuneration (£’000) Mid point of the banded total remunerration of highest paid Director (£’000) Median total remuneration Ratio *Represents clinical excellence award payments
72
Annual Report 2015-16
2015-16 (b) Expense payments (taxable) total to nearest £100
(d) Long term performance pay and bonuses (bands of £5,000)
(e) All pensonrelated benefits (bands of £2,500)
(f) TOTAL (a to e) (bands of £5,000)
37.5-40
150-155
5-7.5
55-60
0
85-90
0
165-170
100-105
17.5-20
120-125
40-45
0-2.5
40-45
25-30
15-17.5
40-45
125-130
30-32.5
160-165
100-105
75-77.5
180-185
27.5-30
200-205
(a) Salary (bands of £5,00)
(c) Performance pay and bonuses (bands of £5,000)
110-115 50-55
1
85-90 *25-30
135-140
170-175
1
5-10
2
5-10
5-10
2
5-10 5-10
5-10 5-10
1
5-10
30-35
5
30-35 0-5
0-5 5-10
1
5-10
200-205 £202,500 £24,063 8.42
Surrey and Sussex Healthcare NHS Trust
73
Salaries and allowances 2014-15
Name
Title
Executive Directors Allsop, Mrs. Fiona Margaret
Chief Nurse (from 01/10/2013)
Bostock, Mr. Paul Justin
Chief Operating Officer (left 13/09/15)
Bray, Dr. Barbara
(Interim) Chief Medical Officer (01/03/2014 - 31/03/2014)
Francis-Musanu, Mrs. Gillian Josephine
Director of Corporate Affairs
Holden, Dr. Desmond Philip
Chief Medical Officer
Mackenzie, Mr. Ian Duncan
Director of Information and Facilities
Parker, Mrs. Yvonne
Director of Human Resources
Simpson, Mr. Paul Fraser
Chief Financial Officer
Wilson, Mr. Michael Anthony
Chief Executive
Non-Executive Directors Biddle, Mr. Paul
Non-Executive Director
Congdon, Mr. Richard John
Non-Executive Director
Durban, Mr. Richard Don
Non-Executive Director
Hall, Mr. Alan J
Non-Executive Director
Lambert, Ms. Pauline
Non-Executive Director
McCarthy, Mr. Alan Roy
Chairman
Power, Mr. John Christopher
Non-Executive Director (left 10/08/2014)
Robbins, Ms. Yvette Anita
Deputy Chairman/Non-Executive Director (left 07/05/15)
Shaw, Mr. Richard Oliver
Non-Executive Director
Band of highest paid director’s total remuneration (£’000)
170-175
Mid point of the banded total remunerration of highest paid Director (£’000)
£172,500
Median total remuneration
£23,825
Ratio
7.24
*Represents clinical excellence award payments
74
Annual Report 2015-16
2015-16 (b) Expense payments (taxable) total to nearest £100
(d) Long term performance pay and bonuses (bands of £5,000)
(e) All pensonrelated benefits (bands of £2,500)
(f) TOTAL (a to e) (bands of £5,000)
40-42.5
155-160
65-67.5
180-185
15-20
0-2.5
15-20
80-85
5-7.5
90-95
0-2.5
165-170
100-105
27.5-30
125-130
100-105
17.5-20
120-125
125-130
22.5-25
150-155
2.5-5
175-180
(a) Salary (bands of £5,00)
(c) Performance pay and bonuses (bands of £5,000)
110-115 110-115
1
135-140
25-30
170-175
1
0-5
2
0-5 0-5
0-5 5-10
4
5-10 5-10
5-10 0-5
1
0-5
30-35
6
30-35
0-5
1
0-5
5-10
2
5-10
5-10
3
5-10
Surrey and Sussex Healthcare NHS Trust
75
Pension Benefits 2015-16
Title
(a) Real increase in pension at age 60 (bands of £2,500)
Allsop, Mrs. Fiona Margaret
Chief Nurse
0-2.5
Stevenson, Mrs. Angela
Chief Operating Officer - 200 days
2.5-5
Bostock, Mr. Paul Justin
Chief Operating Officer - 166 days
0-2.5
Francis-Musanu, Mrs. Gillian Josephine
Director of Corporate Affairs
0
Mackenzie, Mr. Ian Duncan
Director of Information and Facilities
0-2.5
Parker, Mrs. Yvonne
Direector of Human Resources
0-2.5
Simpson, Mr. Paul Fraser
Chief Financial Officer
0-2.5
Preston, Mr. Mark
Director of Organisational Development and People - 88 days
0-2.5
Wilson, Mr. Michael Anthony
Chief Executive
0-2.5
Name Executive Directors
NHSLA publication - disclosure of senior managers remuneration (Greenbury) 2016
On 16 March 2016, the Chancellor of the Exchequer announced a change in the Superannuation Contributions Adjusted for Past Experience (SCAPE) discount rate from 3.0% to 2.8%. This rate affects the calculation of CETV figures in this report. Due to the lead time required to perform calculations and prepare annual reports, the CETV figures quoted in this report for members of the NHS Pension scheme are based on the previous discount 76
1.012
rate and have not been recalculated. 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. The banded remuneration of the highest paid director within the Trust in financial year 2015-16 was £200,000-£205,000. This approximates to 8.42 times (2014-15, 7.24 times)
1.2%
the median remuneration of the workforce, which was £24,063 (2014-15, £23,825). In 2015-16 nine employees received remuneration in excess of the highest-paid director, (in 2014-15 it was 13). Remuneration ranged from £15,100 to £205,767 (in 2014-15 it was £14,294 to £205,108). Total remuneration includes salary, non-consolidated performance-related pay, benefits-in-kind as well as severance payments. Annual Report 2015-16
(b) Real increase in pension lump sum at aged 60 (bands of £2,500)
(c) Total accured pension at age 60 at 31 March 2016 (bands of £5,000)
(d) Lump sum at age 60 related to accured pension at 31 March 2016 (bands of £5,000)
0
10-15
5-7.5
(e) Cash equivalent transfer value at 1 April 2015
(f) Cash equivalent transfer value at 31 March 2016
(g) Real increase in cash equivalent transfer value
(h) Employer’s contribution to stakeholder pension
5-10
213
242
26
16
35-40
100-105
441
544
54
15
0
25-30
75-80
402
412
2
7
0
30-35
90-95
575
587
5
13
0-2.5
40-45
120-125
760
791
22
15
0-2.5
15-20
55-60
0
0
0
3
2.5-5
20-25
65-70
424
461
31
19
0-2.5
20-25
55-60
288
344
12
4
0-2.5
75-80
230-235
1,471
1,526
36
25
It does not include employer pension contributions and the cash equivalent transfer value of pensions. The number of employees based on average number of WTE (whole time equivalent including temporary staff) at the trust rose from 3,768 in 2014-15 to 3,920 in 2015-16.
Statement of Comprehensive Income for year ended: 31 March 2016
NOTE
2015-16 £000s
2014-15 £000s
10.1
(177,967)
(163,116)
Other operating costs
8
(86,567)
(79,326)
Revenue from patient care activities
5
240,905
225,354
Other operating revenue
6
23,974
18,653
345
1,565
Gross employee benefits
Operating surplus
Investment revenue
12
26
24
Other gains and (losses)
13
(47)
0
Finance costs
14
(519)
(324)
(195)
1,265
Public dividend capital dividends payable
(3,943)
(3,647)
Retained Deficit for the year
(4,138)
(2,382)
10,657
14,066
6,519
11,684
(4,138)
(2,382)
1,110
-
Adjustments in respect of donated gov’t grant asset reserve elimination
(3,503)
8
Adjusted retained deficit
(6,531)
(2,374)
Deficit for the financial year
Other Comprehensive Income Net gain on revaluation of property, plant & equipment Total comprehensive income for the year
Financial performance for the year Retained deficit for the year Impairments (excluding IFRIC 12 impairments)
The Trust’s reported NHS financial performance position is derived from its current deficit, but adjusted for the treatment of donated assets and impairments. This adjustment is not considered part of the organisation’s operating position. NOTE
31 March 2016 £000s
31 March 2015 £000s
Property, plant and equipment
15
162,541
144,114
Intangible assets
16
2,265
2,147
22.1
3,972
3,917
168,778
150,178
21
3,610
3,505
22.1
20,284
17,110
26
2,521
2,603
26,415
23,218
195,193
173,396
Statement of Financial Position as at: 31 March 2016 Non-current assets:
Trade and other receivables Total non-current assets Current assets:
Inventories Trade and other receivables Cash and cash equivalents Total current assets Total assets
78
Annual Report 2015-16
NOTE
31 March 2016 £000s
31 March 2015 £000s
Trade and other payables
28
(31,727)
(31,551)
Provisions
35
(429)
(936)
Borrowings
30
(231)
(83)
DH revenue support loan
30
(216)
(216)
DH capital loan
30
(1,346)
(906)
(33,949)
(33,692)
(7,534)
(10,474)
161,244
139,704
Current liabilities
Total current liabilities Net current liabilities Total assets less current liabilities
Non-current liabilities Trade and other payables
28
(3,428)
(3,543)
Provisions
35
(1,889)
(2,084)
Borrowings
30
(2,443)
-
DH revenue support loan
30
(15,748)
(3,464)
DH capital loan
30
(8,881)
(5,827)
Total non-current liabilities
(32,389)
(14,918)
Total assets employed:
128,855
124,786
31 March 2016 £000s
31 March 2015 £000s
Public Dividend Capital
148,849
151,299
Retained earnings
(59,379)
(55,783)
39,385
29,270
128,855
124,786
Statement of Financial Position as at: 31 March 2016 (continued)
NOTE
FINANCED BY:
Revaluation reserve Total Taxpayers’ Equity: The notes on pages 7 to 28 form part of this account.
The primary financial statements on pages 3 to 6 were approved by the Board on 26 May 2016 and signed on its behalf by
Michael Wilson Chief executive Date: 31st May 2016
Surrey and Sussex Healthcare NHS Trust
79
Statement of Changes in Taxpayers’ Equity for the ended: 31 March 2016
Public Dividend Retained Revaluation Other Total capital earnings reserve reserves reserves £000s
£000s
£000s
151,299
(55,783)
29,270
Retained deficit for the year
-
(4,138)
Net gain on revaluation of property, plant, equipment
-
Transfers between reserves
-
Balance at 1 April 2015
£000s
£000s - 124,786
Changes in taxpayers’ equity for 2015-16 -
(4,138)
10,657
-
10,657
542
(542)
-
-
550
-
-
-
550
Permanent PDC repaid in year
(3,000)
-
-
-
(3,000)
Net recognised revenue/(expense) for the year
(2,450)
(3,596)
10,115
-
4,069
Balance at 31 March 2016
148,849
(59,379)
39,385
- 128,855
Balance at 1 April 2014
145,105
(53,676)
15,479
- 106,908
Reclassification Adjustments Permanent PDC received - cash
Changes in taxpayers’ equity for the year ended 31 March 2015 Retained deficit for the year
(2,382)
Net gain on revaluation of property, plant, equipment
(2,382) 14,066
Transfers between reserves
275
14,066
(275)
-
-
Reclassification Adjustments New temporary and permanent PDC received - cash
8,194
New temporary and permanent PDC repaid in year
(2,000)
Net recognised revenue/(expense) for the year Balance at 31 March 2015
Statement of Cash Flows for the Year ended: 31 March 2016
6,194 151,299
8,194 (2,000) (2,107) (55,783)
-
13,791
-
29,270
17,878 124,786
2015-16 £000s
2014-15 £000s
345
1,565
8
8,730
7,774
17
1,110
-
(435)
(295)
(4,213)
(3,581)
(105)
(156)
(3,229)
(2,798)
1,847
6,368
-
347
(180)
(181)
NOTE
Cash Flows from Operating Activities Operating surplus Depreciation and amortisation Impairments and reversals Interest paid PDC Dividend paid Increase in Inventories Increase in Trade and Other Receivables Increase in Trade and Other Payables Decrease in Other Current Liabilities Provisions utilised
80
Annual Report 2015-16
Statement of Cash Flows for the Year ended: 31 March 2016 (continued)
2015-16 £000s
2014-15 £000s
Increase/(Decrease) in movement in non cash provisions
(541)
130
Net Cash Inflow from Operating Activities
3,329
9,173
2015-16 £000s
2014-15 £000s
27
25
(14,470)
(17,795)
(2,296)
(998)
Net Cash Outflow from Investing Activities
(16,739)
(18,768)
Net Cash outflow before Financing
(13,410)
(9,595)
550
8,194
(3,000)
(2,000)
4,000
4,400
12,500
-
Loans repaid to DH - Capital Investment Loans Repayment of Principal
(906)
(686)
Loans repaid to DH - Working Capital Loans/Revenue Support Loans
(216)
(216)
-
(89)
13,328
9,603
(82)
8
2,603
2,595
2,521
2,603
Statement of Cash Flows for the Year ended: 31 March 2016 (continued)
NOTE
NOTE
Cash Flows from Investing Activities Interest Received (Payments) for Property, Plant and Equipment (Payments) for Intangible Assets
Cash Flows from Financing Activities Gross Temporary and Permanent PDC Received Gross Temporary and Permanent PDC Repaid Loans received from DH - New Capital Investment Loans Loans received from DH - New Revenue Support Loans
Capital Element of Payments in Respect of Finance Leases and On-SoFP PFI and LIFT Net Cash Inflow from Financing Activities
NET INCREASE/(DECREASE) IN CASH AND CASH EQUIVALENTS
Cash and Cash Equivalents (and Bank Overdraft) at Beginning of the Period Cash and Cash Equivalents at year end
Surrey and Sussex Healthcare NHS Trust
26
81
“All staff in the unit showed respect and dignity to all patients. In particular they all dealt with a patient in the next bed to me who had dementia with great patience. They had to continually explain to, and work with, the patient - each time they did so with dignity, patience and tenderness.”
“All of your staff are shining examples of true compassion and dedication, I will never hear a bad word about your hospital, or the NHS again.” 82
r
www.surreyandsussex.nhs.uk