Annual report 2016 -17
Contents Foreword:
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About us • Our vision
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• Our values • Our Clinical Commisioning Groups • Clinically led • Our Care Quality Commision rating • Our health campus • SASH+ • Research matters • Our governors and members • SASH Charity Patient experience • What our patients say • Your care matters • Care Opinion • PALS • Supporting carers • Open visiting • Compliments - saying thank you • Making it better - responding to complaints • Digital conversations Our people • Who are we • Staff survey • Our volunteers • Work experience students • Apprentices • SASH Star Awards • Developing our staff • Off-payroll engagements • Equality, diversity and human rights • Health and wellbeing • Staff engagement • League of Friends
7 7 7 8 8 9 9 -13 14 -16 17 19 20 20 20 21 21 21 21 21 22 -25 26 26 26 27 27 27 28 - 29 30 31 31 32 33 31
Our environment • Sustainable development • Energy efficiency Our plans • Our strategy • Our strategic intent • Our strategic objectives • Annual priorities • Sustainability and Transformation Plan (STP) Performance • Emergency department four-hour standard • Cancer waiting times • 18 weeks referral to treatment / diagnostics Accountability Our governance and assurance • Our Board of directors • Declaration of interests • Annual governance statement • Renumeration and staff report Putting people first Keep in touch Financial Our finances Appendices
34 34 - 35 36 36 36 - 37 37 37 38 38 39 39 41 41 42 42 42 42 46 - 66 67 - 75 76 77 78 78 - 88 89 - 92
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Foreword This year, nationally the NHS has continued to see exceptional pressure on its services and this has made for a challenging year for all organisations providing NHS care. Locally, for us this has meant continuing both to manage the pressure and meet the demands in terms of delivering patient care and also the impact this increased demand has on our finances. We are proud that our teams remain committed to providing high quality and specialist care and know the difference this makes, every day, to the people we care for. Each year our staff are invited to complete the national NHS Staff Survey. Once again, and against a backdrop of the increasing demands on all our services, this year we were delighted that our staff ranked us in the top 20% of hospitals across the country as a place to work and receive treatment and also as somewhere patients receive quality treatment and care. To know that our staff feel so positive about working here is great for us all and most especially our patients; as there is a strong link with this and the quality of care they provide to our patients which is welldocumented. This includes the success that our cancer team have achieved with really positive responses in the National Cancer Patient Experience Survey and also in meeting all of the national standards for cancer; ensuring that our patients are getting appointments, diagnostic tests and treatments within the agreed national standards and timescales. The pressure on our teams should not be underestimated and we know that we have certain areas, including our A & E department and the timeframe for referral to treatment for some appointments, where we have felt the impact more. However, we also see in the daily feedback we receive from our patients and their relatives how much they appreciate the professional care they receive, the compassion they are shown and the reassurance this gives them during their time with us.
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We know that this recognition is only made possible by the combined commitment of everyone and the difference this makes in so many ways. When we look back at the successes for individuals and teams this year, for us there are many highlights. Some of these achievements include our SASH+ transformation work and the ever increasing number of people who are now involved and taking an active role in identifying where improvements can be made and then making the changes needed – enabling us to further develop the high quality care our patients have a right to expect. We have been pleased to see how well received the introduction of our Carers’ Passport and open visiting at East Surrey Hospital has been and the valuable support this offers our patients and their carers and other visitors to the hospital. Furthermore, with over 850,000 people currently living with dementia it is vital that we all know more about what we can do to help our patients and we are delighted that nearly 2,000 members of SASH staff have chosen to become a Dementia Friend, an initiative from the Alzheimer’s Society. We are pleased to be a member of John’s Campaign that also aims to improve awareness of the needs of patients with dementia during a hospital stay. A critical part of making sure that we continue to be ready for the future is the development and training of our staff to ensure that we continue to have the skills and expertise needed to deliver high quality and specialist care. In August last year, we launched the Kent Surrey Sussex School of Physician Associates. The school, a partnership between ourselves and Health Education England, is the first of its kind and will provide ongoing support to physician associate students at the local universities. We were also delighted that we were awarded the Skills for Health Quality Mark by Skills for Health and the National Skills Academy in
recognition of the high standard of training and learning we provide to our teams across the organisation. As Chair, I would like to congratulate Michael on being awarded a CBE (Commander of the British Empire) in The Queen’s 90th Birthday Honours for Services to the NHS. This outstanding tribute is a well-deserved recognition of Michael’s devotion and service to the NHS and the tremendous achievements of over 30 years. I was also delighted that we won the Board of the Year in the national Patient Safety Awards. Winning this award is fantastic recognition of the efforts and achievements of everyone across the whole organisation in putting patient safety at the centre of everything we do. Together, we know that every success is a shared one and that these achievements would not be possible without the hard work, commitment and compassion of our clinicians, staff, volunteers and governors. We thank them all; for all that they do every day. Thank you.
Alan McCarthy Chair
Michael Wilson CBE Chief executive
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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. 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.
Our values
Dignity and respect: we value each person as an individual and will challenge disrespectful and inappropriate behaviour One team: we work together and have a can do approach to all that we do recognising that we all add value with equal worth Compassion: we respond with humanity and kindness and search for things we can do, however small; we do not wait to be asked, because we care
East Surrey Hospital is the designated hospital for Gatwick Airport and sections of the M25 and M23 motorways. It has a trauma unit, which cares for seriously injured patients in partnership with the major trauma centres at St George’s University Hospitals NHS Foundation Trust and Royal Sussex County Hospital, Brighton. East Surrey Hospital has 691 beds and ten operating theatres, along with four more theatres at Crawley Hospital in our day surgery unit.
Safety and quality: we take responsibility for our actions decisions and behaviours in delivering safe, high quality care
We are a major local employer, with a diverse workforce of over 4,000 providing healthcare services to the community we serve.
In 2016-17, we held contracts with 11 CCGs; our co-ordinating commissioner for the Sussex contract is Crawley CCG with six associates. East Surrey CCG is our co-ordinating commissioner for the Surrey contract with three associates.
The Trust is an Associated University Hospital of Brighton and Sussex Medical School. Key points about the Trust:
Key points about the Trust: Population of
535,000 4,000 staff
691 beds
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operating theatres
Our vision
• • • • • • •
East Surrey Hospital Redhill Caterham Dene Hospital Oxted Health Centre Earlswood Centre Crawley Hospital Horsham Hospital
We will pursue perfection in the delivery of safe, high quality healthcare that puts the people in our community first.
Our clinical commissioning groups
The services we provide are commissioned by local clinical commissioning groups (CCGs) as well as NHS England.
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.
East Surrey CCG: has 18 GP practices covering the districts of Tandridge, Redhill, Reigate and Horley with a population of just under 178,000 people
NHS Surrey Downs CCG: has 32 GP practices serving a population of over 300,000 people living in Mole Valley, Epsom and Ewell, Banstead and east Elmbridge 7
Crawley CCG: has 12 GP practices covering the Crawley district with a population of over 129,000 people Horsham and Mid Sussex CCG: has 23 GP practices covering the northern part of Horsham District and Mid Sussex District with a population of more than 231,000 people
Clinically led We are a clinically led organisation, focused on putting people first. Our services are led and managed through four divisions:
Cancer and diagnostics Chief
Dr Ed Cetti
Associate director
Jane Griffiths
Chief nurse
Victoria Daley
Medicine Chief
Dr Ben Mearns
Associate director
Alison James
Chief nurse
Nicola Shopland
Surgery
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Chief
Dr Barbara Bray
Associate director
Natasha Hare
Chief nurse
Jamie Moore
Women and children Chief
Dr Zara Nadim
Associate director
Bill Kilvington
Chief nurse - Head of midwifery
Michelle Cudjoe
Our CQC rating The Trust was rated ‘good’ overall by the Care Quality Commission (CQC) in its Chief Inspector of Hospitals inspection in August 2014. The Trust received no further inspections in 2016-17 and no concerns were raised by the CQC. All inspected services were rated as good in the caring domain with end of life care receiving an outstanding rating for responsiveness. This was a significant milestone for the Trust and the inspection team commented that the culture and engagement in the organisation was excellent. There were some recognised areas for improvement in outpatients and significant progress is being made. At that time the outpatient service was rated as requires improvement and the Trust was required to implement a number of actions. In January 2016, the CQC carried out a focused follow-up inspection of outpatients and confirmed that the Trust had met the required regulations. No ‘must do’ recommendations were identified and the Trust were given six ‘should do’ recommendations. The report was published at the end of March 2016. The Trust continues on its journey to become an ‘outstanding’ organisation. The CQC is changing its approach to inspections and is consulting on these changes. As a result, it stopped producing reports on the risk bandings and will be replacing this with a new process during 2017-18.
Our Virginia Mason Institute journey - one year on Sue Jenkins, director of strategy and Kaizen Promotion Office (KPO) lead provides an update on the SASH+ transformation partnership with the Virginia Mason Institute. In March 2015 the NHS Trust Development Authority, now part of NHS Improvement, invited expressions of interest from NHS Trusts to be part of a five year development partnership, which aims to fundamentally improve the quality, performance and financial sustainability of the organisations selected to take part as well as share learning with others.
Our health campus We have a proud history of working in partnership with other Trusts and organisations to provide specialist care to local people living in the communities we serve. Our health campus at East Surrey Hospital includes the St Luke’s Radiotherapy Cancer Centre, a partnership with the Royal Surrey County Hospital Cancer Centre and the Lane Fox REMEO Respiratory Centre, a partnership with Guy’s and St Thomas’s NHS Foundation Trust. In 2016-17 our most recent addition to the health campus the East Surrey Macmillan Cancer Support Centre, the result of a successful partnership between Surrey and Sussex Healthcare NHS Trust and Macmillan Cancer Support, celebrated its first year providing local people with a welcome and calm environment and a wide range of complementary therapies and activities and the very best in holistic care and support closer to home.
SASH, along with four other Trusts is working in partnership with the Virginia Mason Institute (VMI) in Seattle, USA, who have developed a transformational management system that has successfully helped them to deliver better care by reducing waste and variation resulting in improving quality. After a highly competitive selection process, Surrey and Sussex Healthcare NHS Trust was one of the five Trusts chosen to participate in the development program. Virginia Mason has a medical centre (hospital) and also delivers general primary and specialist services to the people of Seattle. Following a visit to the Toyota car manufacturing factory in Japan, VMI adopted and adapted Toyotas production system to develop the Virginia Mason Production System, which is based on lean methodological improvement techniques. Reflecting the Japanese history of the programme some of the references and language used are Japanese in origin, for example: Kaizen Continuous incremental improvement
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Genba Where the work is done Sensei One who has gone before Over the last 15 years, the Virginia Mason Medical Center has become one of the safest and highest rated hospital organisations in the USA. Our aim is to pursue perfection, putting our patients at the forefront of everything we do, improving safety and quality by reducing variation and waste in every process. Our SASH+ work supports an accelerated transformation in quality by providing us with a structured approach to continue our improvement journey taking us from a good to an outstanding organisation. Nationally, the chief executives from each of the five participating Trusts have formed the Transformation Guiding Board (TGB), which oversees and provides strategic direction for the programme. Locally, the Trust has a Trust Guiding Team (TGT) which meets monthly and is responsible for oversight and delivery of the improvement work. Led by the chief executive, our SASH+ TGT has strong clinical leadership involvement – membership of the TGT includes senior clinicians and executives. Our Kaizen promotion office (KPO) team lead the transformation programme; they provide the structure, methods and rigor behind the successful implementation of the SASH+ improvement methodology, alongside training and developing others to lead using the new methods. Over the last year, the SASH+ work has established three value streams (workstreams), which have been specifically selected to help deliver the organisation’s priorities, they are: Inpatient flow: cardiology This value stream starts from when the patient 10
is referred to the cardiology team and ends when the patient is discharged or transferred from the cardiology ward. Outpatients This value stream starts from when the decision to refer for an outpatient appointment is made, usually in primary care, and ends when the patient has attended their first follow-up appointment or been discharged (whichever is sooner). Management of diarrhoea This value stream starts at the onset of symptoms and ends when symptoms have resolved. The addition of a fourth value stream is planned for later in 2017-18. Value stream sponsorship team Each of the value streams has a value stream sponsorship team (VSST) consisting of senior clinical and non-clinical leaders from across the Trust. The sponsorship team is led by an executive sponsor who is a member of the TGT. The role of the VSST is to lead the work of each value stream by: setting high level metrics through which progress can be monitored developing a kaizen plan which includes identifying and prioritising specific processes within the value stream which would benefit from a Rapid Process Improvement Workshop Rapid Process Improvement Workshop A Rapid Process Improvement Workshop (RPIW) is a five day workshop focused on a particular process, within a value stream, in which a multidisciplinary team of staff who do the work come together, empowered to improve the work flow and patient care. To ensure the perspective of the patient remains the priority during each workshop, patient representatives are invited to become a team member for the week working in partnership with staff to redesign processes.
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Prior to each RPIW an extensive planning period is undertaken this involves:
selecting a sponsor (a member of the VSST) whose role it is to guide the work setting the scope for the workshop data collection on the genba so that a current state value stream map can be built. A value stream map is a visual tool which illustrates the flow of a specific process selecting baseline metrics which can be measured during the RPIW week and again at 30, 60 and 90 days post the workshop to assess the effects of changes implemented identifying a process owner whose role it is to prepare the home team, these are the staff who are not members of the RPIW team whose work is affected by the changes; they are encouraged to participate by providing real time ideas and feedback during event planning, the RPIW itself and during the implementation phase. The process owner is also responsible for implementation of changes trialled during the RPIW and re-measure of the metrics
treatment of diarrhoea isolation for patients with diarrhoea
Some of our key RPIW successes include: Cardiology Friends and Family Test scores for cardiology patients maintained at 100% Cardiology patients knowing their expected date of discharge prior to date of discharge has improved from 50% to 88%
Outpatients time from the patient arriving at the hospital to the end of their consultation with the breast clinician reduced more than half from 52 mins to 25 mins the number of breast patients seen after their allocated appointment time has reduced from 94% to 0% time from receipt of urgent ophthalmology referrals to date of first appointment has gone from 28 days and 3 hrs to 10 days (64% improvement) time from receipt of routine referrals to date of first appointment has improved from 107 days 18 hrs to 32 days (67% improvement) number of referral letters in the system At the end of every RPIW the RPIW team present waiting to be processed has reduced from their successes, challenges and learning to staff 1331 to 296 across the Trust. This is known as a report out. the reduction of processing time for medical records to prepare clinic Nine RPIWs have been undertaken focussing on lists for the day from 41 minutes to a variety of different processes across the Trust 9 minutes (78% improvement) including: Management of diarrhoea the time it takes for a patient to be told Cardiology value stream: the potential cause/s of their diarrhoea inpatient referral to the cardiology team discharge from the cardiology ward from the identification of their symptoms in hospital has reduced from 2 days and 9 hours to 6 hours which is 91% Outpatient value stream: improvement ophthalmology appointments the time spent by nurses gathering breast clinic supplies to attend to the personal care medical records preparation needs of a patient has reduced from 7.5 minutes to 1.5 minutes the number of times a nurse is interrupted Management of diarrhoea value stream: whilst undertaking the drug round has identification and diagnosis of diarrhoea
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reduced from 25 times to zero
To continue our journey of improvement, RPIWs focussing on wide variety of processes across the Trust are planned on a seven week basis in 2017-18. Education and training To share and embed a sustainable culture of continuous improvement across the Trust staff from the Board to ward are undertaking a variety of SASH+ training and development programs, including: SASH+ taster sessions: An introduction to the SASH+ improvement methodology. Lean for Leaders: A nine month development programme during which leaders learn about the SASH+ improvement methodology supported by an extensive range of tools and techniques which help them to transform the services they deliver on a daily basis. The first two cohorts completed the course at the beginning of March 2017. There are a further four cohorts due to commence their training during 2017-18.
high levels of staff engagement and commitment to the work and the positive benefits the transformation programme is bringing to patients across the Trust. We are on an exciting journey and we are proud of the significant and sustainable transformation changes we have already successfully made and look forward to continuing to improve the high quality of care we provide to local people. We are also proud of the positive impact involvement in making change has on individuals and teams and feel that this is reflected in how our staff rank the organisation in the national NHS Staff Survey.
It’s an eye opening, jaw dropping, gobsmacking, superfizzin’ Trust. Roy Lilley NHS commentator
Advanced Lean Training: An intensive learning experience which enables staff to deepen their knowledge of the SASH+ improvement methodology, refine their skills and build the capacity to teach, coach and mentor others in the tools and techniques. Two cohorts are due to start this program later in 2017-18. Stakeholder visits A wide range of stakeholders have visited the Trust to see, first-hand, the SASH+ transformation work that is taking place. We have been pleased to host visits from:
Chris Wormald Permanent Secretary at the Department of Health Professor Jane Cummings, chief nursing officer for NHS England Roy Lilley, broadcaster and NHS commentator They each have been hugely impressed by the 13
Research matters Ann Shears, head of research, gives an insight into our commitment to research and offering patients the best care available Participation in clinical research We undertake research to improve healthcare for the future. Involvement in clinical research demonstrates our commitment to improving clinical treatments, care and outcomes for our patients. Participation in research helps to ensure that our staff are aware of the latest treatment options and can offer our patients the best care available. Recruitment performance and targets In 2016-17, the Trust set a target of 650 patients recruited to research studies conducted at the Trust. In 2016-17 we increased the number of research studies available to our patients and comfortably exceeded that target with 840 patients gaining access to research studies this year as part of their clinical care. This is our highest achievement to date and we are committed to increasing recruitment of patients so that we can offer research to as many patients as possible within the areas we serve. Patient experience ‘It made me feel good to know I was helping.’ Recruitment to research studies is the first step on the patient’s research pathway. Research delivery teams consisting of principal and coinvestigators, research nurses, co-ordinators and research administrators continue to support patients on follow up and continued treatment after they enter a study. Research is well received by our patients. In 2016-17, 54 different studies have been available, ranging from studies assessing symptoms or involving simple testing to full clinical trials where an alternative or innovative treatment can be offered.
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840 patients have agreed to take part in research, in 54 different studies Research highlights: from one study running this year in Urology How research can help us to improve patient care and services: A simple and timely urine test may help with ruling out of bladder cancer for patients presenting with haematuria symptoms. Future patients could be spared the time, inconvenience and discomfort of undergoing a urinary tract ultrasound and cystoscopy which up to now has been the only way of determining whether the presence of haematuria is due to bladder cancer. Over 300 of our patients attending the haematuria clinics at the Trust have been offered the opportunity to take part in this simple study. The Uromark assay under validation in this research has shown promising signs of detecting changes of cells in urine which might indicate the presence of bladder cancer and so the research study is exploring the accuracy of the test in predicting the cancer. The study has been incredibly well received by patients and, as a result over 200 patients have consented to take part. ‘I’ve enjoyed it and hope it makes a difference.’
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SASH research recruitment by speciality – National Institute for Health Research (NIHR) studies Number of studies recruiting International
International recruits
Observational Observational recruits
Total studies
Total recruits
Anaesthetics
2
7
2
126
4
133
Cardiology
3
38
3
30
6
68
Dermatology
4
20
4
51
8
71
Diabetes
2
3
3
9
5
12
Emergency and critical care
0
0
2
31
2
31
Gastroenterology and hepatology
0
0
1
1
1
1
Oncology (incl palliative) 5
93
7
65
12
158
Paediatrics
1
0
4
24
5
24
Reproductive health
1
54
0
0
1
54
Respiratory
1
4
1
17
2
21
Rheumatology
0
0
2
19
2
19
Stroke
1
12
2
7
3
19
Urology
1
0
2
229
3
229
Totals
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231
33
609
54
840
2016-17
2013-14
2014-15
2015-16
2016-17
Number of studies open to recruitment
40
45
50
54
Number of pharmaceutical industry studies*
5
11
12
6
771
448
840
Number of research 506 participants
* Included within total number of studies open figure 16
Our governors and members Our governors have an important part to play within the Trust and make a very positive contribution to how we deliver services. They work with and represent members of their constituencies and oversee the activities of the Trust. A key role for governors is in shaping the mind-set of the Trust towards the needs and experience of patients and local people, in effect by making sure ‘patients are always in the room’ when services are being discussed and decisions made. During 2016-17 governors have been actively involved in: PLACE assessments (Patient-Led Assessments of the Care Environment) SASH Hot Topic events hand hygiene audits the patient experience sub-committee surveys shaping the Trust’s strategy giving feedback on the quality account priorities organ donation working group SASH+ outpatient working group membership development staff health and wellbeing And are regular observers at Trust Board meetings held in public each month. Although we have not yet been authorised as an NHS Foundation Trust; in 2016 our Trust Board made the decision to formalise the role of our Shadow Council of Governors and following a very positive seminar with governors we were able to propose a new role which became effective in January 2017. Our Council of Governors continue to be involved in a variety of roles within the Trust including acting as a conduit and a voice between patients, members, others and the Trust leadership team raising issues, concerns and suggestions and communicating and advocating Trust strategies and plans. They also have a role as a critical friend and advisor, representing the interests of
the organisation; staff; members and the wider public with opportunities to use their expertise in the following ways: shaping the Trust’s patient and public engagement strategy and action plan help the Trust recruit a representative membership represent the interests of the members input into Trust strategy development playing an active role in the improvement work for the Trust as part of SASH+ supporting the Trust in public consultations membership on key working groups participation in the interview process for senior staff participation in the re-validation process for consultants Trust ambassadors for joint working with the voluntary and community sector fundraising champions The Council of Governors are elected by members of the constituency of which they are a member and which they represent. The Council is made up of: 14 public and patient governors 1 patient governor (from outside of our catchment area) 4 staff governors 8 partner organisation governors. Members also play a key role in our Trust. Anyone aged 14 and over can join and become a member as long as they are, or have been a patient or carer in the past five years, or live in the Trust’s catchment area, which is made up of the following local council areas: Crawley Horsham Mid Sussex Mole Valley Reigate and Banstead Tandridge Croydon (Coulsdon East ward, Coulsdon West ward, Kenley ward, Sanderstead ward and Purley ward). Membership is free and new members can register online at www.sash.nhs.uk/ft We look forward to continuing to work in 17
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partnership with our Council of Governors during 2017-18. If you would like to get in touch with any of our governors or have any questions about the Council of Governors, please contact SASH Foundation Trust membership on 01737 768 511 x2862 or email sashFT.membership@nhs.net
we provide. We have a number of cash collection boxes positioned around the hospital and these continue to be a regular source of income. 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 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 with dementia being cared for at East Surrey Hospital. We are pleased that the response from a wide range of individuals and groups continues and now also includes knitted items for babies being cared for in our neo-natal unit.
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 2016-17, the charity’s income totalled £105,604K and it spent £167,280k in year. The closing balance, as at 31 March 2017, was £480,006k. We regularly receive a number of generous donations to SASH Charity 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 air conditioning for the obstetric ultrasound rooms and patient reception, an ultrasound probe for the new breast ultrasound to a professional musician for dementia patients and donations 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
SASH Charity supports our SASH Star Awards ceremony, which recognises individual staff and team achievements and in recognition of their contributions towards improving the care patients receive. SASH Charity is overseen 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.
SASH Charity: http://www.sashcharity.org/ 19
Patient experience What our patients say
The principle of encouraging patients, their families, carers and friends to tell us what they thought of the care they received is well established across the Trust. Feedback can be given using our online Your Care Matters platform; the Friends and Family Test, contacting our patient advice and liaison service (PALS); through our website (www.surreyandsussex.nhs. uk), or sharing their story on the NHS Choices or Care Opinion websites. Based on comments we have received we continue to make changes at all levels across the Trust, for example in 2016-17 we have: removed visiting times and established open visiting to inpatient wards piloted post-discharge follow-up calls for surgical patients introduced information boards in outpatient areas to keep visitors updated with key information, including waiting times introduced the principles of the safer care bundle across inpatient wards established protocols to improve how we manage phone calls and make the best use of our phone system to improve communication and management of calls information for carers is displayed on posters and digital screens across the Trust
Your Care Matters
The number of responses to our bespoke patient feedback survey has continued to increase. In the last three months of 2016-17 we received over 1,600 responses each month. From 2017-18 a new provider of our Your Care Matters survey will be in place.
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Year
Month
Number of responses
2016
April
1429
May
1466
June
1419
July
1729
August
1571
September
1603
October
1508
November
1267
December
1332
January
1732
February
1654
March
1967
2017
In 2017-18 we will be making greater use of text reminders that include a link straight through to the survey and the reporting capability will be enhanced. Whilst the survey is anonymous it will give participants the option of leaving contact details if they rate their experience negatively which will allow our staff to follow-up and discuss their concerns with them. We anticipate that our ability to engage with harder to reach groups will also be improved through greater use of technology – for example being able to use different designs for online surveys, accessed through an iPad or tablet, that will appeal to different audiences such as children and patients with dementia. Your Care Matters will continue to provide participants with the opportunity of commending staff members when they feel that an individual has gone ‘above and beyond’ in delivering exceptional care. These thank you messages are greatly appreciated by our staff and are used in their annual achievement reviews.
Care Opinion
Care Opinion is an independent website that gives patients and their friends and family the option to tell their story online. We continue to be seen as an exemplar organisation for our proactive approach in engaging with Care Opinion, both in encouraging patients to tell their stories and in responding to the comments they post with many responses coming from clinical staff. During 2016-17 a member of staff was asked to lead a WebEx discussing best practice on responding to posts. The Trust has also been nominated as Care Opinion hero of the day on a number of occasions throughout the year.
can support, value and involve carers. We have strong links with Carers Support across Surrey and Sussex. Raising awareness of carers is on-going through fortnightly visits to wards and slots on audit days and regular meeting agendas. Our carer’s passport is now well established across inpatient wards and offers main carers parking concessions and staff discounts in our restaurant. It also serves to recognise and value the important role carers play in delivering patientcentred care.
Open visiting
In 2016-17 over 320 patients have told their In September 2016 we introduced open visiting stories and these comments have been read over to our inpatient wards. Our approach emphasises 50,000 times. the important role carers, family and friends can play in collaborating with staff on the ward to keep our patients as mentally and physically able Patient Advice and Liaison Service as we can. (PALS) The Patient Advice and Liaison Service (PALS) team provide prompt and confidential support to resolve queries or minor concerns that our service users may have. They liaise with hospital staff and managers to ensure that where possible enquirers receive a prompt resolution and also assist in guiding people through the different services that are available and signpost them to appropriate support services.
Over the last twelve months our PALS team have remained focused on continuing to improve the efficiency with which Trust staff resolve issues that are brought to the service. Our PALS team assisted with over 2,600 enquiries needing advice and information and around 1,000 concerns during 2016-17 (compared to 1,400 and 700 respectively in 2015-16).
Supporting carers
Our support for carers has gone from strength to strength during 2016-17. We have an agreed carers’ strategy and an established carers’ steering group, the membership of which includes carers. As part of the dementia link nurse training we ask a carer to tell their story, this is followed by a session on how our staff
We have developed a set of guidelines that clearly encourages visitors to work with us to ensure that the needs of every patient are met, this includes assisting a loved one with daily routines, eating together and/or helping them to eat and staying mentally fit. We also encourage a nominated carer or relative to be with their loved one during doctors’ ward rounds.
Compliments – saying thank you
We regularly receive many compliments from our patients and the people we care for. In 201617, in addition to the feedback from Your Care Matters and Care Opinion, we received 226 unsolicited compliments. This positive feedback is always appreciated and makes our staff feel valued and the high quality care they provide recognised.
Making it better - responding to complaints
We always aim to provide the best possible care for our patients however, occasionally things can go wrong, which is why we take complaints very seriously and investigate them fully. Where issues are identified, we work with 21
the patient and their family to address them and learn from them for the future. Our complaints process is integral to the improvement of our services. If our patients feel unable to discuss their concerns directly with our staff and wish to formally complain, they can do this by contacting our complaints team or the Patient Advice and Liaison Service (PALS). During 2016-17 the Trust received 602 formal complaints; an increase of 5.6% on 2015-16. The two main themes identified were in the categories of care implementation and communication. A key role of the patient experience committee is to communicate lessons learnt from patient complaints and also from compliments made to our staff. A key focus has been to emphasise the need to improve the timeliness and appropriateness of communication and engagement with patients and families. In 2016-17 the complaints team’s main objective was to improve performance, satisfaction and learning from complaints. Changes to the complaints process were implemented to provide a more personal and responsive service. All complainants now receive a telephone call from the complaints manager to agree the scope of the investigation to ensure that the response will address all the issues raised. We have had positive feedback about this change with complainants telling us that they feel ‘listened to’ and that the phone call was very quick and very professional. The revised process uses a template which ensures that each point raised by the complainant is considered and a response provided. It also demonstrates that learning is clearly aligned to the issues raised and that remedial actions are clearly owned by the clinical service involved. One complainant has fed back that the response template ‘made easy reading’. The Trust expects to acknowledge all complaints within three working days. In 2016-17 the complaints team achieved this target in 99.3% of cases. Overall, 58% of complainants received their response within the timeframe agreed with them, which we are working to improve. 22
Complaints continue to be reviewed and monitored at divisional governance meetings to ensure clinical ownership of complaints and to provide further confirmation that a comprehensive, sensitive and clinically correct response is provided. Nationally, referrals and investigations undertaken by the Parliamentary Health Service Ombudsman (PHSO) have increased. During 2016-17, 16 of our complaints were referred to the PHSO. Of these none were fully upheld, four were partially upheld and four were not upheld; one case was not taken on for investigation and a further seven cases are still awaiting an outcome. The Trust has seen a growth in the number of complaints received electronically to over 60% of the total received. In 2015-16 an online feedback form was introduced, which allows patients to register complaints quickly and efficiently. During 2016-17 we have seen a 50% increase in the use of this form.
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
www.surreyandsussex.nhs.uk Most visited pages:
Home page
Infection control
Working for us
A-Z of services
Crawley Hospital
The numbers of people following and linking with SASH through our social media sites continues to grow:
Facebook www.facebook.com/sash.nhs
The numbers
1,214,308 page views
April 2016: Followers
1,225
March 2017:
1,864
639
321,836
new likes in the past year
unique users
551,706
Twitter @sashnhs
sessions
9,720
sessions referred from social media
April 2016:
Followers
9,009
March 2017:
10,263
1,254
We also have many visitors to our website who have connected through our social media sites and this continues to grow:
new followers in the past year
Traffic from social media LinkedIn
www.linkedin.com/company/surrey-&sussex-healthcare-nhs-trust
7,759 sessions
79.83%
Twitter 1,165 sessions
11.99%
Linked in 707 sessions
April 2016: Followers
1,243
March 2017:
1,557
384
new followers in the past year
7.27% Other
89 sessions
8.91%
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Instagram @sashnhs
Our audience has grown by 284% since we started actively posting in June 2016 June 2016:
Followers
91 259
March 2017:
350
new followers since June 2016
You Tube
www.youtube.com/user/sashnhs
April 2016: Subscribers
75
March 2017:
158
73
new subscribers in the past year
Digital communications and social media are integral to many of our campaigns and we continue to use them successfully to update and engage with our patients and local people.
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Our people We have a workforce of over 4,000 people in a broad range of clinically registered professions and support roles and value everyone for the part they play in delivering high quality care to our patients through our one team approach. Staff group
Number
%
Professional, scientific and technical Additional clinical services Administrative and clerical Allied health professionals Estates and ancillary Healthcare scientists Medical and dental Nursing and midwifery (registered) Total 4095
107
2.61
766
18.71
773
18.88
195
4.76
354
8.64
86
0.21
627
15.31
1187
28.99
National NHS Staff Survey The National NHS Staff Survey results were, overall, very positive with staff ranking us in the top 20% of hospitals across the country. Our response rate of 66% was the highest the Trust has ever recorded. The Trust’s scores for staff engagement and for staff recommending SASH as a place to work and receive treatment were higher than in 201516, placing us in the top 20% nationally. Key findings: Of the 32 key findings from the survey, we recorded: 22 in the top 20% 3 better than average 3 average 26
3 below average 1 in the lowest 20%
Where we are in the top 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 Percentage agreeing that their role makes a difference to patients / service users 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 Percentage able to contribute towards improvements at work Staff satisfaction with level of responsibility and involvement Effective team working Support from immediate managers Quality of appraisals Quality of non-mandatory training, learning or development Staff satisfaction with resourcing and support Percentage of staff satisfied with the opportunities for flexible working patterns Percentage of staff feeling unwell due to work related stress in last 12 months Organisation and management interest in and action on health and wellbeing Percentage believing the organisation provides equal opportunities for career progression / promotion Low numbers of staff saying they have experienced harassment, bullying or abuse from staff in last 12 months Confidence to report experience of harassment, bullying or abuse Fairness and effectiveness of procedures for reporting errors, bullying or abuse Staff confidence and security in reporting unsafe clinical practice Staff feeling there is the effective use of patient /service user feedback
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. “I am delighted to see how positive staff feel about working at SASH and the strong link with this and the quality of care they know they are able to provide. Not only is this important for everyone at SASH it is, of course, especially important for our patients and the people we care for.” Michael Wilson CBE Chief executive Our volunteers There are currently 230 active volunteers who kindly dedicate their time for free to support the Trust each year in a variety of settings, helping us to provide a positive experience to our patients, visitors and the people we care for. Our volunteer roles include: the development and ongoing upkeep of our courtyard garden areas, maintenance of our various fish tanks across East Surrey Hospital Pets as Therapy dogs who visit our patients Sunshine Day Nursery staffing our information desks. New for 2016/17 has been the introduction of SASH volunteers providing support for patients and their families at the East Surrey Macmillan Cancer Support Centre. Radio Redhill, which has been hitting the airways since 1975, has 70 volunteers who work as presenters and music request collectors. Each evening the presenters walk around the hospital collecting requests with the station receiving on average, a staggering 8,000 requests a year. At the SASH Star Awards 2016, two volunteers from Capel Ward were delighted to jointly receive
the award for Volunteer of the Year for assisting patients by taking them out for walks outside, chatting with them and helping them with their meals. “A special thank you goes to all our volunteers for their commitment, hard work and generosity that play a supportive role across the organisation in ensuring the people we care for have a positive experience.” Michael Wilson CBE Chief executive Work experience This year the Trust was able to offer over 90 work experience placements in a variety of suitable work settings. We received more than 270 applicants for the scheme. Our work experience programme is a key way for us to engage with local schools and colleges to promote healthcare careers and the Trust as a large local employer of choice. We also offered shadowing opportunities to adults considering a change in career. Many students validate the experience by citing it on their university applications and tell us that the opportunity helped them to confirm their career choice before committing to a course of study. Alongside the work experience programme we have also attended seven local careers events to further promote the Trust and to raise the awareness of the breadth and variety of careers and apprenticeship opportunities within the NHS. The wide range of careers offered by the Trust was demonstrated by the inclusion of a profile of Holly Case, outreach librarian, on the NHS Careers website and in the Health Informatics Careers Guide. Apprentices Over the last two years we have seen a steady increase in the number of apprenticeships offered with eight currently employed in an apprenticeship post across administration and training functions and in our pharmacy team. 27
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Apprenticeships fit within the widening access agenda to help with the recruitment of staff from our local community. As well as specific apprenticeship posts, we have 46 staff enrolled on level 2 qualifications in: business administration, customer care, hospitality cleaning, team leading, pharmacy support and professional cookery. We also celebrated success with our physiotherapy rehabilitation assistant completing a level 3 apprenticeship in allied health professional support. They were also nominated for, and won, a HEKSS Unsung Heroes Award for the category of apprenticeship ambassador. We are piloting an apprenticeship pathway for nursing assistants in clinical healthcare after successful completion of their Care Certificate and we are developing a multi-professional plan for the 2017 apprenticeship scheme in preparation for the introduction of the apprenticeship levy in April 2017.
SASH Star 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 acknowledge and celebrate an individual or team’s exceptional contribution to the Trust’s ongoing success at our annual SASH Star Awards. Our Awards are aligned to reflect our core values: Dignity and respect One team
Compassion Safety and quality and were presented to individuals and teams who work ‘above and beyond’ to provide the best service at all times in the following categories: Improving patient experience Supporting diversity in the workplace Innovation and service improvement SASH values Frontline employee of the year Behind the scenes employee of the year One team - frontline team of the year One team - behind the scenes team of the year Volunteer of the year Developing our staff Following a review of the delivery of our mandatory and statutory training (MAST) programme, we are now regularly meeting our internal target that 80% of mandatory training is completed by staff each month. We have also been recognised by staff for our non-mandatory training who placed us in the top 20% of Trusts nationally in the 2016 staff survey for the quality of our non-mandatory training, learning and development. 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. As part of this we review skills requirements through our annual achievement review (appraisal) programme. In 2016, 97% of staff had a completed appraisal and this was recognised in the results of the national staff survey, which ranked us in the top 20% nationally for the quality of appraisals staff received. 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.
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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 customer care
We continue to support 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. 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 multi-professional bursary panel that supports the development of staff through the provision of funded learning opportunities. The bursary panel makes funding decisions and ensures the resources for training and development of staff are 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 2016-17 the bursary panel approved over one hundred applications from a wide range of members of staff - supporting their ongoing professional and personal development. Our library and knowledge service supports not only staff within the Trust but also partners within the local health economy including those working in primary care and community organisations. We have provided access to literature, evidence and research to support clinical and non-clinical staff and in the wider health economy have undertaken specific work to support the implementation of sustainability and transformation plans and to inform workforce strategy development at a national level. For the third successive year the team has 30
achieved 100% across all 54 criteria for the NHS Library and Knowledge Services Quality Assurance Framework. Off-payroll engagements 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. In 2016-17, 11 members of staff were on offpayroll engagements for more than £220 per day and more than six months #. These contracts were reviewed to enable the Trust to seek assurance as to their tax obligations. Equality, diversity and human rights ‘The NHS belongs to the people,’ is the first line of the NHS Constitution and, 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. We are committed to delivering on the equality duties outlined in the Constitution. To support this we developed the SASH One Team Inclusion Plan for 2016/17, which set out the actions required to deliver our overall Inclusion agenda. We have been working with Birmingham Race Action Partnership (BRAP), an equalities and human rights charity, who have worked extensively in the NHS to support diverse and inclusive workplaces, on our inclusion plan, as well as the development of our three year inclusion strategy. We held a Trust Board Seminar to consider our priorities for diversity and inclusion and formulate our equality objectives and a further seminar was held for other key stakeholders within the Trust to review and agree the objectives. Both were
facilitated by BRAP.
Surrey Hospital site smoke-free.
Black Asian Minority Ethnic (BAME) Network We launched the Trust’s first Black Asian Minority Ethnic (BAME) Network Group and we have been supporting and promoting other national equality initiatives throughout the year. In the 2016 Staff Survey Report, we scored in the top 20% nationally for providing staff with equal opportunities to progress their career.
SASH Active In 2016-17 we launched SASH Active, which is our health and wellbeing programme. Working in partnership with internal and external stakeholders. Staff were offered the opportunity to take part in a range of activities: YMCA - Healthy Measures Campaign Living Streets Walking campaign SASH NHS Community Choir Gentle Hands - Provider of alternative therapies for staff SLaM NHS FT - Providing mental health awareness support for staff
Surrey Choices 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 recognise the importance of health and wellbeing for all our staff and how this supports their ability to provide services to our patients.
We also offer staff: flu vaccination clinics (we achieved a 63% take up of front line staff which is the Trust’s highest year recorded) 24-hour confidential free advice line for staff and their immediate family fast-track physiotherapy referrals counselling service regular updates in our staff magazine Insight and displays in our library at East Surrey Hospital on health and wellbeing activity linked to national health promotion awareness campaigns.
Following the appointment of our new health, safety and wellbeing manager, we have reviewed our health and wellbeing strategy to ensure it supports our staff appropriately.
We are in the top 20% nationally in the 2016 Staff Survey for the following key findings, (all of which have had a positive increase/decrease in scores compared to the previous survey):
The Trust is also actively engaged in a number of national NHS inclusion strategies including the Workforce Race Equality Standard and we have met our Public Sector Equalities Duties.
Occupational health We have recently opened a new purposebuilt Occupational Health Unit at East Surrey Hospital which extends our ability to deliver first class services for our staff. The new unit provides clinics and consultations, as well as hosting complementary therapists for staff. Our health and safety team are also based in the new unit, building on our collaborative working and enhancing our ability to provide a safe and supportive environment for all our staff. As part of our overall commitment to health and wellbeing, we have committed to making the East 31
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organisation and management interest in and action on health / wellbeing staff recommendation of the organisation as a place to work or recive treatement percentage of staff feeling unwell due to work related stress in last 12 months
Staff engagement Healthcare is a people-delivered service and the quality of care that patients receive depends wholly on the skill and dedication of our staff. It is recognised that highly engaged and motivated staff are more likely to be pro-active and collaborate effectively with other colleagues which improves overall patient outcomes. In the 2016 National Staff Survey, our overall staff engagement score was in the top 20% nationally and this has improved year-on-year for the past six years. The staff engagement score is calculated on three sub-dimensions:
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
Our established staff engagement strategy supports ongoing work to ensure that all our staff maintain a strong connection with the vision and values of the organisation. We have been delivering national initiatives on a local basis, for example, Freedom to Speak Up Guardian and Guardian of Safe Working and have been engaging with relevant stakeholders in doing so.
rate for the Trust was 66% in 2016, which is in the highest 20% when compared against other acute Trusts quarterly Staff Friends and Family Test trade union survey SASH+ improvement work. divisional led briefings and team meetings
We are proud of the contribution that our staff make to our continuing success and high quality care we provide to our patients and community. Our annual SASH Star Awards recognises and acknowledges individuals and teams for their involvement and engagement. League of Friends The team of volunteers from East Surrey Hospital’s League of Friends continue their commitment to raising funds through the Friends’ Coffee Shop situated at the east entrance of East Surrey Hospital. In 2016-17 they made many generous contributions for the benefit of the people we care for including: £15,000 for a liposculpture device for theatres £3,100 for a hydraulic chair for Tilgate Annexe (respiratory care) £2,200 for three mannequin for male/ female catheterisation training £1,500 for a Neonatal resuscitation mannequin £1,400 for a Silver Song box for singing therapy in our care of the elderly wards £360 for upright birthing stools
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
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Our environment Sustainable development In 2016-17 the Board reinforced the Trust’s commitment to environmentally friendly working by adopting a new sustainable development management plan (SDMP). The plan was developed in response to the Sustainable Development Strategy for the NHS, Public Health and Social Care Systems (2014), which reinforces the urgent need for all NHS organisations to take action to reduce their environmental impact and embed sustainability into their strategies, cultures and communities. As a Trust, our 4,000 staff provide acute healthcare services to a population of around 535,000. We are fully committed to becoming a more sustainable healthcare organisation. The SDMP establishes a set of principles and targeted interventions aimed at moving towards a more sustainable model of healthcare.
environmental impact of travel Procurement – creating an ethical and resource efficient supply chain Culture – informing, empowering and motivating our staff, patients and community to make sustainable choices Wellbeing – enhancing the wellbeing of our workforce Adaptation – ensuring infrastructure and services are resilient to climate change Governance – embedding sustainability in our corporate governance processes
By taking action in this way, we expect to improve the wellbeing of our people. There are also significant savings to be made by 2020. Based on achieving a 34% reduction in utilities alone and accounting for inflation, delivery of this SDMP could achieve:
cumulative savings of £4.6 million cumulative reduction of over 20,000 tonnes CO2e
The NHS is facing three big challenges:
1. 2. 3.
Our more detailed carbon road-mapping study identifies specific measures with estimated annual savings as follows:
a £30 billion funding gap by 2020 a huge carbon footprint (the largest public sector emitter of CO2 in the UK), and a target to reduce that by 34% by 2020 as the largest employer in Europe the productivity of its 1.3 million staff has been highlighted as a key area for improvement
Moving to a more sustainable model of care is about rising to these three challenges in a coordinated way, focusing on actions that support and reinforce finance, carbon and the health and wellbeing of both of our staff and our patients at the same time. In our SDMP we have set commitments to decarbonise our operations and promote healthy, low carbon lifestyles. We will achieve this by working across seven key areas between now and 2020:
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Buildings – reducing the environmental impact of our estate Journeys – minimising the health and
nearly £760,000 over 3,100 tonnes of CO2e
Energy efficiency In 2016-17 we implemented a number of schemes that support our SDMP, these included:
Continued implementation of a number of estates energy efficiency measures including expanding the use of gas driven air conditioning systems; utilising heat recovery; reducing incoming supply voltage and starting a replacement window programme which will be implemented over three years Defined energy efficient requirements for new installations and refurbishments, such as the use of inverter driven motors and fans and LED lighting to replace traditional fluorescents Introduced a new managed print service, which will cut the Trust’s current printing
costs by at least 21%, reduce paper use and lower electricity consumption due to fewer, lowerenergy devices Redeveloped the medical records building, leading to increased accessibility of records, less travel required for movement of records and co-location of services providing a more efficient estate Recycled 8% of our general waste by weight, with the remainder being sent for energy recovery. This has meant we have achieved zero non-healthcare waste to landfill and reduced our costs Initiated introduction of the offensive waste stream at East Surrey Hospital, working towards Environment Agency requirements and reducing costs Ensured the provision of showers and secure cycle parks with parking for 136 cycles at East Surrey Hospital
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Our plans Our strategy
Our strategy Reviewing our strategy Our organisational strategy is reviewed each year and includes a review of our: vision values strategic intent strategic objectives Those involved in our annual strategy review include:
To become an outstanding organisation, which is responsive and agile, clinically led and where patients are at the centre. We link with community services and establish a health campus through our partnerships. Our strategy on a page Our strategy on a page has been updated to make it simpler and is used as a communication tool for staff across the organisation.
Our vision the executive team, which includes clinical Our vision has been updated to include the chiefs people of our community and that it also clinical leads recognises the importance of the individual the Shadow Council of Governors patients, carers and their families. Trust Board We will pursue perfection in the delivery of safe, In 2016-17 we updated our strategy statement to high quality healthcare that puts the people in our reflect the importance of being both responsive community first. and agile to the changing local and national NHS climate: 36
Our vison Excellence
Safe
Effective Caring Responsive
Affordability
Deliver excellence reduce harm and variation
Improve productivity
Well led
Use technology
Work with partners
Locally based services
Leadership Clinical leadership External influence Work with partners
Bring services closer to home where possible
Develop services in the community
Work with others to ensure the clinical sustainability of services
Our values Our values remain unchanged. They were developed more than six years ago and are well embedded in the organisation and regularly used as a reference point for recruitment and the delivery of services. Dignity and respect: we value each person as an individual and will challenge disrespectful and inappropriate behaviour One team: we work together and have a ‘can do’ approach to all that we do recognising that we all add value with equal worth Compassion: we respond with humanity and kindness and search for things we can do, however small; we do not wait to be asked, because we care
Safety and quality: we take responsibility for our actions decisions and behaviours in delivering safe, high quality care Our strategic intent Our definition of locally based services has been updated to reflect the importance of working in partnership with others to develop clinically sustainable services for patients. Our strategic objectives Our strategic objectives underpin each of our supporting strategies and corporate and divisional annual objectives. These, in turn, underpin departmental, team and individual objectives. We have updated our strategic objectives to be:
Safe Deliver safe, high quality care and improving services which pursue perfection and be in the top 25% of our peers
Effective As a teaching hospital, deliver effective and improving sustainable clinical services within the local heath economy
Caring Work with compassion in partnership with patients, staff, families, carers and community partners
Responsive To continue to be the secondary care provider of choice for people of our community
Well-led To be a high quality employer of choice and deliver financial and clinical sustainability around a patient centred, clinically led leadership model 37
Annual priorities Our annual priorities for 2017-18 are: To improve the efficiency and responsiveness of elective care To continue to improve the health, wellbeing and working lives of our staff To create, promote and impellent the best environment for patients and those caring for them To reduce avoidable harm To improve discharge planning so that is timely, patient-centred and effective Sustainability and Transformation Plan (STP) Sussex and East Surrey is one of 44 geographical Sustainability and Transformation Plan (STP) areas, known as footprints, across the country who have been asked to produce a long-term plan outlining how local health and care services will evolve, improve and continue over the next five years. The Sussex and East Surrey Sustainability and Transformation Plan (STP), published in November 2016, outlines how local health and social care services will work together to transform and integrate services to meet the changing needs of local people. There are four ‘place based plans’ to help ensure that people can get the care they need as close to home as possible. The four place based plans are: Coastal Care Central Sussex and East Surrey Alliance – North Central Sussex and East Surrey Alliance – South East Sussex Better Together There are 23 organisations in our partnership - clinical commissioning groups, providers and local authorities. It is the first time that we have all worked together in this way and it gives us an opportunity to bring about significant improvements in health and care over the next five years.
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This approach will help deliver community based, integrated health and care services through ‘accountable care systems’ which make sure services work together, tailoring their services to the needs of individuals. The aims are to:
help people to stay well support people to manage existing conditions and retain their independence avoid unnecessary hospital visits
Three STP wide priorities have been identified across the area for us to develop and share the best models of care: – Urgent and emergency care Frailty Primary care The STP will build on existing engagement work with local stakeholders; including the public and patients and will continue to engage and consult with the people living and working in the communities we serve as we look to shape and sustain our services for the future.
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.
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.
This year, 2016-17, was a challenging year for both emergency and elective access standards with an increase in the numbers of people attending our emergency department (ED), nonelective admissions and outpatient referrals. This growth put pressure on the capacity of the Trust across beds, clinics and diagnostics.
Emergency department four-hour standard The ED four hour standard has been a significant challenge nationally and continues to be a key priority for the Trust.
ED attendance Out-patient appointments Emergency admissions Births Elective admissions
Despite narrowly missing the ED four hour standard in 2016/17, the Trust benchmarks
2015-16
2016-17
Change
%Change
91,256
96,149
4,893
5.4%
341,676
363,385
21,709
6.4%
34,068
33,978
-90
-0.3%
4,551
4,545
-6
-0.1%
44,177
47,177
3,000
6.8%
2015-16
2016-17
Standard
ED 4hr standard
94%
94%
95%
ED 12 hr breaches
0
0
0
Cancer two week rule (TWR)
93%
94%
93%
Cancer 62 day
86%
87%
85%
Referral to treatments (RTT) incompletes
92.4%
91.7%
92%
Diagnostics over six weeks
0.3%
4.1%
1%
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consistently in the upper quartile for this measure and on a monthly basis achieved the standard from May through to November 2016 as well as in March 2017. Cancer waiting times Cancer access has been a significant focus in 2016-17 and has seen increases in performance for both the two week wait and 62 Day standards (both achieved in 2016-17) Detailed analysis was undertaken and capacity re-configured in Q2 to support improvements in access at the start of the cancer pathway. This has ensured that appointments, diagnostic test and treatments happen within agreed timescales for patients referred to us for cancer investigations. We are delighted that in 2016-17 we achieved and met all of the cancer waiting times performance indicators providing patients with the right care. 18 weeks referral to treatment/diagnostics The 18 week referral to treatment standard has been challenging throughout the year with increased referrals, prioritisation of capacity for emergency and cancer pathways as well as the impact of changes to national RTT rules. As a result, the incomplete standard has not been achieved since December 2016. Our annual performance is 0.3% below the 92% standard. Following a significant loss of endoscopy capacity, the six week diagnostic standard was not achieved from August to December 2016 before returning to expected levels in Q4. As a result, the standard was not achieved for the year as a whole with a performance of 4.1% Signed:
Michael Wilson CBE Chief executive 41
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. Our Board of directors Our Board of Directors consists of five voting executive directors and six non-executive directors (including the chair) and meets every month in public. The minutes and papers are made freely available and this includes publishing them on our website: 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 Designate non-executive director (non- voting) 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 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 42
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 necessary financial, human and physical resources are in place to enable the Trust to meet its priorities and objectives and periodically reviewing management performance ensuring that the Trust complies with these rules of procedure; standing orders; standing financial Instructions; scheme of delegation and statutory obligations at all times Board members and declarations of interest Non-executive directors (NEDs): Non-executive directors have a wide variety of experience in the voluntary, public and private sectors. They are all part-time. Their declarations of interest for 201617 are: Alan McCarthy, chair Chair of Charity Commissioning Performance for ’Sick’ Festival Trustee of Brighton Dome and Festival Board Vice chair Brighton Aldridge Community Academy Trustee of Albion in the Community Richard Durban (vice-chair) Magistrate (Justice of the Peace) on Surrey Bench Alan Hall (until 28 February 2017) 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
Medical director of Kent, Surrey & Sussex Academic Health Science Network (one day per week) Non-executive director (NED) of South East Health Technology Alliance
Fiona Allsop, chief nurse Pauline Lambert Specialist advisor, Care Quality Part-time clinical paediatric safeguarding Commission (CQC) name nurse: Queen Victoria Hospital NHS Foundation Trust. Angela Stevenson, chief operating officer No declarations Caroline Warner (1 October 2017 - designate) Councillor Tandridge District Council Gillian Francis-Musanu, director of corporate Member Consumer Council for Water affairs (non-voting member) Member Fairchildes Academy Community Home Office Authorised Person (Marriage Trust Registrar): London Borough of Hounslow David Sadler (1 March 2017) Owner/director – David Sadler Advisory Ltd Director Coach Associates Ltd
Mark Preston, director of people and organisational development (non-voting member) No declarations
Executive directors The executive directors are all full-time employees of the Trust. Details of their remuneration can be found in the remuneration report section of this report.
Ian Mackenzie, director of estates and facilities (non-voting member) No declarations
Michael Wilson CBE, 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 Member of the Health Education England Tele-enhanced Learning Programme Member of the National Trust Guiding Board – Virginia Mason Institute Programme CEO Lead for Sussex and East Surrey STP Paul Simpson, chief finance officer and deputy chief executive No declarations Dr Des Holden, medical director
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 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. 43
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.
going development and delivery of the Trust’s safety and quality strategy and that this drives the Trust’s overall strategy. The duties of the committee shall ensure the implementation, delivery and monitoring of the Trust’s quality and clinical strategies. The committee shall also be responsible for managing the safety of patients through ensuring compliance and the implementation of effective internal controls.
Core Board sub-committee structure The key functions of the Board sub-committees are:
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
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 the total reward for executive directors, ensuring transparency, fairness, consistency and succession planning. The committee shall receive reports from the chair 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 on44
Charitable funds committee: Meets three times a year to oversee the generation, management, investment and disbursement of charitable funds within the regulations provided by the Charities Commission. The executive committee and executive committee for quality and risk The executive committee meets weekly and a twice monthly executive committee for quality and risk which is supported by series of subcommittees to consider, on a rolling basis, managerial delivery of the Board of directors’ strategy, quality of services provided and the effectiveness of risk management, the delivery and management of all performance and the management of each clinical division. Five executive sub-committees have been formed to both guide management decisions and provide assurance for safety; responsiveness; clinical effectiveness; patient experience and workforce. Board assurance framework The Board Assurance Framework (BAF) is a key element of the Trust’s system of internal control. It provides a clear methodology for the focused management of risks in the delivery of the Trust’s
strategic objectives. The executive team oversees and reviews the assurance framework, which is then discussed and challenged at the Trust Board prior to its acceptance. The assurance framework and the Significant Risk Register are presented monthly to the public Board. Significant risk register Details all risks on the Trust risk register system that are recorded as significant and links to the Board assurance framework. The
executive committee oversees (through the head of corporate governance) the maintenance and review of the BAF. It is then discussed and challenged at the Trust Board prior to its acceptance. The BAF and significant risk register are presented at each public Board meeting. Accountability Each director confirms that they have 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
Chair Paul Biddle
Chair Alan McCarthy
Chair Richard Shaw
Chair Richard Durban
Charitable funds committee
Chair Caroline Warner (from 1March 2017) Alan Hall (until 28 February 2017)
Members* Richard Durban Richard Shaw In attendance Chief finance officer Director of corporate affairs Other members of the executive and non-executive team are invited to attend as and when required
Members* All NEDs
Members* Alan McCarthy Pauline Lambert Alan Hall (until 28 In attendance Chief executive February 2017) Director of people Caroline Warner and organisational (from 1 October development 2017) Chief nurse Medical director Chief operating officer Chief finance officer Clinical chiefs
Members* Alan Hall (until 28 February 2017) Paul Biddle David Sadler (from 1 March 2017) Chief finance officer Director of people and organisational development Director of information and facilities. Director of corporate affairs Chief nurse
Members* Pauline Lambert Paul Biddle Chief finance officer Chief nurse Director of corporate affairs Director of information and facilities
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*As Accountable Officer, the Chief Executive has an open invitation to attend each Board subcommittee Signed:
Michael Wilson CBE Chief executive
Annual governance statement 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 and lead the executive team who have clear accountabilities and annual objectives which are drawn from the Trust’s strategy. The Trust has worked in partnership with other health and social care organisations in the area, but notably the local Clinical Commissioning Groups (CCGs). The contracts between us provides clarity on our shared priorities and officers of the Trust meet regularly with our 46
Clinical Commissioning Groups to take forward developments and monitor the delivery of our shared healthcare plans. I also account to 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 single oversight framework requires it. I, and officers of the Trust, regularly meet with officers of NHS Improvement to discuss performance. NHS Improvement has been involved in monthly meetings with the Trust over its performance during 2016-17. 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 (updated September 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 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. 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 and internal control. Assurance in his formal Opinion (the details of this Opinion are referred to later). The governance framework and the escalation framework for the Trust are described in the diagrams on the next page.
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SASH committee structure Council of Governors
Board
Audit and assurance committee
Nomination and renumeration committee
Finance and workforce committee
Effectiveness
Access and responsiveness
Patient Experience
Workforce
Specialty Deep Dives (Reports to ECQR)
Serious Incident Review Group
Clinical Specialist Sub-Groups, Mortality Group (eg. IPCAS)
Corporate Functions (CHIG, Info Gov)
Divisional Governance
Grand Rounds
Specialty Governance
Mortality and Morbidity
Wards and Departments
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Charitable funds
Executive Committee and Executive Committee for Quality and Risk
Divisional performance reviews
Patient Safety
Safety and quality 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 also meets monthly in private and regularly holds Board Seminars for awareness, development and training. The director of corporate affairs and company secretary remains a non-voting member of the Trust Board, as does the Director of Information and Facilities and the Director of Organisational Development and People. 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 2016-17. The Board has reviewed its effectiveness, – the output of that is the development of a Board development programme for 2017/18. The Board continues to review NHS Improvements Well-Led Framework against the current NHS & CQC standards and has made good progress. This is complimented by other actions that have been taken through the appraisal of Board members by either the Trust Chairman or I, respectively. 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 and was aligned with the single oversight framework in January 2017. Throughout the year the Board discussed national issues and local events considering the potential impact for the Trust, of note the Board
discussed the local and national developments around sustainability and transformation plans (STPs), the continued work on operational productivity (including signing off transformation plans for pharmacy and procurement) and focussed on financial (liquidity, delivery of control totals and the financial position of the health system) and workforce issues (staffing and, particularly, 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. 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, insight and learning, ensuring that patient safety and outcomes are at the forefront of Board discussions. 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 financial risk and influenced how the Board looks at sustainability and transformation plans and action relating to the ongoing impact of the challenged financial environment that the NHS faces. 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 49
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 NHSI performance indicators, and the monthly finance report as part of the Integrated Performance Report. These reports detail the Trust’s sustained improvements in safety and the challenges that have been faced throughout the winter pressures that have affected the 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 on the next page.
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April May June July Aug Sept Oct Nov Dec Jan Feb Mar 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 Alan McCarthy
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Angela Stevenson
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The terms of reference of each committee set out the remit of responsibility delegated by the Board of Directors. This in turn sets out the information requirements of the committee, how it should interact with the information it receives and use this to reach a conclusion about assurance. Where assurance cannot be robustly established the Chair of the Committee reports this to the Board of Directors. A review of the Trust’s Rule of Procedure has been commenced during the financial year to update the terms of references of all board sub committees. The Board of Directors receives a report from each chair at the next available public board meeting. On receiving a report that identifies a lack of assurance in relation to an aspect of the business the Board of Directors can either hold me to account (managerial aspects) or seek independent assurance by referring the matter to its Audit and Assurance Committee. The Executive Committee The Executive Committee is the most senior managerial decision making group in the Trust. Its membership comprises the entire executive director team and the clinical chiefs of service for each division. The committee has significant senior clinical membership to ensure effective clinical leadership and decision making. As Chief Executive I have directed that the Executive Committee to meet weekly to consider, on a rolling basis, managerial delivery of the Board of Directors’ strategy, quality of services provided and the effectiveness of risk management, the delivery and management of all performance and the management of each clinical division. The Executive Committee and its five sub committees have specific terms of reference for each meeting to enable it to deliver their duties. Fuller details of all of these committees, including terms of reference are set out in the Rules of Procedure. Performance Management The Trust has developed a series of performance 52
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, both at the Executive Committee (and its sub committees) and at operational meetings to address variances from objectives, standards and targets. Where variance is identified, action plans are established to address them and reviews of action plans undertaken to ensure that the desired results are achieved. These are monitored by division specific performance meetings. 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 well-managed and defined risk management, acknowledging that service development, innovation and improvements in quality requires risk taking. This position is based on the expectation that there is a demonstrated capability to anticipate and manage the associated risks as well. This stance is defined by the Boards risk appetite which is reviewed annually and included in reports presented to each public board meeting. The Board of Directors will also identify risk through its review of the Board Assurance Framework at its meetings, the reports received from the Board sub-committees, the Trust significant risk register and any self assessment exercise required for regulators or commissioners of service. Clinical risks and non-clinical risks are reviewed by the Executive Committee, The Executive Committee for Quality & Risk, 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 co- coordinators within each Division to work with Associate Directors of Operations, Clinical Chiefs of Service, Divisional Chiefs of Nursing and Heads of Corporate Departments to identify and assess risk. Staff are trained and equipped to manage risk in a way appropriate to their authority and duties: - Staff receive a breadth of risk management information and training at mandatory corporate induction days, ongoing training as part of a mandatory programme and through distribution of relevant documents. - The Board has implemented a system of annual review of its risk appetite and Board Assurance Framework. At this review the Board discusses and agrees the risk appetite and tolerances that are set for different types of strategic and operational risk. These provide the Board with an opportunity to refresh the principles of risk management and identify key issues. - Guidelines on the Trust 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
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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 (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, e.g. appraisal, alcohol use/abuse policies, professional counselling and occupational health services. The Trust has in place a counter fraud contractor whose services are embedded within the Trust. More details are provided below. 4. Risk and control framework The Trust’s system of internal control is designed to manage the risks associated with achieving aims, objectives and policies to a reasonable level. The system of internal control has been in place in Surrey and Sussex Healthcare NHS Trust for the year ended 31 March 2017 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 internal controls map, which provides management assurance of control and good assurance to the Audit and Assurance Committee; 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. 55
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 2016-17 described four “red rated risks where Trust objectives may not be achieved and listed in Section 5 – with two areas listed as significant control issues (activity and financial risk). 4.2 The Trust Internal Controls Map The AAC has asked the Executive Team to develop an internal controls map, which provides details of the Trust’s key controls. This map details key controls, comparison to best practice and an assessment of risk associated with each designated area. Each control has an Executive lead and is reviewed by the AAC on a rolling basis. 4.3 Care Quality Commission Registration The Care Quality Commission (CQC) carried out a focused follow up 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. 4.4 Performance against national priorities
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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 2016-17 The table below sets out the Trusts performance against the key standards. Throughout the year the Trust has been one of the top performers on the ED 4hr Standard, however performance over the winter period 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 2017/18. Cancer access has been a key priority at both a national and local level. The Trust has delivered the 62 Day GP access standard throughout the year and continues to work to improve pathways to support the implementation of the national cancer strategy over the coming years. The 18 week referral to treatment standard has been challenging throughout the year with increased referrals, prioritisation of capacity for emergency and cancer pathways as well as the impact of changes to national RTT rules. As a result, the Incomplete Standard has not been achieved since December 2016 with performance expected to return to over 92% in early 2017/18. Following a significant loss of endoscopy capacity, the 6 week diagnostic standard was not achieved from August 16 to December 16 before
returning to expected levels in Q4.
identification of clinical risk
The Trust is assured on the accuracy of waiting time data through several key mechanisms: the integrated RTT Data Quality team who have undergone specialist training and form a key part of the daily waiting list management processes Periodic Internal Audit reviews of RTT data In 2016-17 a full review of the system was undertaken by an external company with expertise of RTT pathways systems management.
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.
4.5 Quality Governance As required the Trust produces an annual “quality account”, which details the Trust’s performance against a series of quality indicators and details the Trusts plans to continually improve the quality of its services. This is developed internally and shared with our local health partners before publication and submission to NHS England. The Executive Team provides me with assurance and regular updates on the drafting of the account. With regards the 2016-17 Quality Account. 4.5 a The Quality Risk Structure Each division has a governance group which reports to and can be instructed by the 5 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 sub-committees 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. 4.5.b The management of incidents and
The Trust Quality Scorecard is presented at Executive Committee Quality and Risk; it allows key threats and risks to patient safety and quality to be identified with more detail being reviewed by the relevant Trust Board sub-committee. 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 one incident in 2016-17 as a never event (wrong site surgery), which has been investigated thoroughly. The patient had presented with a large spinal disc prolapse which was more prominent on the left side than the right. The incident occurred when the surgeon took a right sided approach to the spinal disc excising only the right side, not the left. The surgeon realised that an error had occurred before the end of the procedure and was able to perform the left sided prolapsed disc excision. The correct surgical procedure was performed in the wrong order resulting in no harm to the patient. As a consequence of this incident the surgical team have revised their surgical checklist to ensure that a brief surgical pause takes place in the operating theatre immediately before incision. During the pause all members of the operating verbally confirm the identity of the patient, the operative site and the procedure to 57
be performed. 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 Trust’s annual staff survey benchmarks well for safety culture. This is positive assurance to support our efforts to continue to learn from incidents and share our findings. 4.5.c Clinical audit The Trust has an established clinical audit programme as detailed in the Trust’s Quality Account. This year’s focus has been on the national audit programme, royal college and CNST driven audits together with some locally chosen audits based on risks or complaints. Almost all audits on the programme were started over 2016-17 demonstrating a commitment to drive continuous improvement of services and quality of care through clinical audit. A review by internal audit also recognised significant improvements to the clinical audit programme since the last review. 4.5.d Information governance Information governance is a framework for managing information, particularly personal information of patients and employees. It should ensure that personal information is dealt with legally, securely, efficiently and effectively. The Department of Health provides the standards and a self-assessment tool-kit and Trusts’ compliance is measured according to the indicators in the tool-kit. The Care Quality Commission is informed of the Trust’s results.
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Our aim is to improve our compliance year on year and a key element in achieving this is ensuring that all staff receives annual training and regular updates relating to Information Governance. All Information Governance risks are added to the Trust risk register and reported in line with the Trust Risk Management Policy. The Trust has not identified any Information Governance Serious Incidents during the financial year. There are processes in place for incident reporting and investigation of serious incidents. During 2016-17 all reported information governance incidents were of minor significance. 4.5.e 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. 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.
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 NHS Improvement, the Care Quality Commission, MHRA, other agencies of the Department of Health, our commissioners and private consultancy companies commissioned by the Trust, have provided me with reports about controls, compliance with standards, financial management and performance in delivering targets.
The 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 The main points from my review are as follows: development and maintenance of the system of internal control provide me with 5.1 Assurance framework assurance. The March 2017, end of financial year, Board The Board Assurance Framework itself Assurance Framework (BAF) identifies 4 provides me with evidence that the effectiveness of controls that manage the main strategic risks to the Trusts meeting its objectives. These are as follows: risks to the organisation achieving its Risk description
Current rating
Target / residual risk score
4.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the necessary capacity, which will have an adverse impact on income, expenditure and ultimately quality objectives. 5. 3 Unable to deliver medium term financial plan.
S5 x L3 = 15
S5 x L2 = 10
S5 x L3 = 15
S4 x L2 = 8
5. 4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position.
S5 x L3 = 15
S4 x L3 = 12
5.6 The continuing challenge S3 x L5 = 15 to recruit and retain clinical staff is impacting on the Trust’s ability to maximize financial and quality benefits.
S3 x L2 = 6
59
5.2 Governance The Executive Committee which I chair reviews and manages all areas of strategic development, performance and quality on a rolling basis and is therefore supported by a series of Executive sub committees aligned with the five areas of quality described by the CQC. The Trust was inspected by the CQC in May 2014 and received an overall ”Good” rating across all elements of quality; safe, caring, effective, responsive and well led The inspection team highlighted elements of outstanding care in their report and the Trust maintains its position in the lowest risk banding on the CQC intelligence monitoring profile. In terms of the 8 core services that were reviewed the Trust received a “good” rating for all services apart from Outpatients services which were rated as “requires improvement”. The Trust implemented an action plan with four key work streams to improve the quality of outpatient services; Environment, Workforce and leadership skills, Communications and Systems and processes. These 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). 60
monitored by the Executive Committee and AAC. The Head of Internal Audit Opinion provides assurance concerning the effectiveness of the Trust’s internal controls. 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 ‘no assurance’ opinion reports in 2016-17. 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 2017 public board.
The Trust has been pro-active in its investigation of all issues raised in the year and has sought external involvement in those that required it. This has been a particular strength of the systems operating within the organisation.
5.3 Performance The Trust has developed a performance management system from which I get regular The Trust has developed an internal updates on both day to day performance and controls map which details the main long term trends. This system has allowed the controls (systems and processes) that the Trust’s management team to significantly improve performance to the point where we are one of the Trust uses to maintain control of its day to day business. best performing Trusts in the country. The Trusts Internal audit reviews the existing system effectiveness committee now regularly reviews of internal control and the overall long term data on performance and mortality arrangements to gain assurances that the whilst the responsiveness committee keeps a controls are designed to meet the regular track of operational issues. As such there objectives and are consistently applied. are no particular services at the Trust that is Action plans are developed for any of such a concern that is significant enough to areas of control which can be improved; I record as a governance issue. am satisfied with the efforts to ensure continuous improvement of the Trust’s 5.4 Counter fraud internal controls and these actions are The Trust’s Counter Fraud Systems are well
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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. NHS Protect’s SRT was completed and submitted within deadline. The overall rating was Green. Areas within the review that rated an Amber rating are to be addressed within 17/18 in an effort to achieve a green rating in 17/18 SRT. A fraud risk assessment was undertaken during 2016 which highlighted areas of good practice and areas for action which are being addressed as part of the Counter Fraud 2017/18 work plan. 5.5 Information governance During the financial year no data protection incidents met the criteria for external reporting (incidents with a severity rating of 2 or higher) during 2016-17 financial year as mentioned above in Section 4. 6. Significant control issues I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Audit and Assurance Committee and the Board (described above). Those aspects that should be categorised as significant control issues are described below. 6.1 Activity The Trust’s most significant issues relating to quality of services have been linked to continued growth of emergency activity and the shortage of appropriate capacity in the community to ensure that patients with on-going needs can be discharged from an acute hospital bed as 62
soon as they are clinically able. Both issues are mirrored across our local health economy and the NHS nationally. These factors significantly impacted our Emergency Department standards and our ability to carry out elective work particularly in the final third of the financial year. The Board was clearly sighted on these issues and took assurance on the safety of services from the Trust’s continuing low mortality, delivery of the cancer access standards throughout winter and the effectiveness of business continuity plans that mitigated the potential risks. Maintaining safety and quality has had significant financial impact throughout the year. Costs were incurred as the Trust called on bank and agency staff to ensure that safe staffing levels were maintained throughout peak periods of activity and income was lost as we were unable to carry out planned levels of elective activity. While this winter has been particularly challenging, standards have been maintained through the dedication and commitment of the Trust’s staff to provide high quality care to our local population. 6.2 Finance There are two specific financial control issues as follows: 1.
Statutory breakeven duty, overall and recurrent financial position: The Trust delivered a £3.7m surplus for the financial year 2016-17, taking account of £0.3m post technical item adjustments for donated assets. This is £11.5m adverse to the position originally planned, but £1.3m adverse to the final notified forecast.
The £3.7m surplus is a significant improvement on the £(6.5)m (post technical) adjusted deficit posted in 2015-16. 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 30 of the Local Audit &
Accountability Act 2014 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 30 letter” within the Trust’s accounts in 2016-17. The reported deficit was supported by £4.9m of sustainability and transformation funding and £3.0m of non-recurrent funding in the form of income from NHS England to support activity volumes. Factoring in non recurrent savings and technical adjustments the underlying position in 2016-17 becomes a £(7.2)m deficit. With the surplus position forecast at Q3, the Board Assurance Framework amended items 5.1 (“failure to deliver the income plan”) and item 5.2 (“failure to stop divisional overspending”) to “amber”. However, noting the level of financial risk within the health system, item 5.3 (“unable to deliver medium term financial plan”) was left at “red” at the March Board.
Signed:
Michael Wilson CBE Chief executive Date: 1 June 2017
2. Liquidity: This is described in a Board Assurance Framework indicator (BAF ref 4.1.d - “Liquidity: inability to pay creditors / staff resulting from insufficient cash due to poor liquid position”). The Trust secured a working capital facility which was increased to £19.5m at its largest point during 2016-17 and is now being partly repaid (as the Trust moves into 2017/18). This has allowed the impact of in-year cash flow delays to be managed, and supported the year to date deficit the Trust had in the early months of the year. 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.
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Appendix 1: Risk Appetite – 2016-17 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 well-managed and defined risk management, acknowledging that service development, innovation and improvements in quality requires risk taking. This position is based on the expectation that there is a demonstrated capability to anticipate and manage the associated risks as well. 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 only 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 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. The Board acknowledges that financial challenges throughout 2016-17 will be significant and 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 Remuneration and staff 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 and 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 65
of people and organisational development attends the committee as adviser and is responsible for taking minutes of the meetings. The chief executive 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 nonexecutive directors of the Trust are determined in accordance with the NHS Improvement. We do not operate any system of performance related pay. The performance of non-executive 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. The chief executive and all directors are on permanent contracts as at 31 March 2017 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 CBE Chief executive Date: 1 June 2017
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Salaries and allowances 2016 - 17 Name
Title
(a) Salary (bands of £5,000)
Allsop, Mrs. Fiona Margaret
Chief Nurse
Francis-Musanu, Mrs. Gillian Josephine
(b) Expense payments (taxable) total to nearest £100
(c) Performance pay and bonuses (bands of £5,000
(d) Long term performance pay and bonuses (bands of £5,000)
(e) All pensionrelated benefits (bands of £2,500)
(f) TOTAL (a to e) (bands of £5,000)
120-125
30-32.5
145-150
Director of Corporate Affairs
90-95
20-22.5
110-115
Holden, Dr Desmond Philip
Chief Medical Officer
135-140
0
165-170
Mackenzie, Mr. Ian Duncan
Director of Information and Facilities
100-105
15-17.5
115-120
Pink, Mr Colin
Director of Corporate Affairs (Interim)
0-5
2.5-5
5-10
Preston, Mr Mark
Director of Organisation Development and People 105-110
130-132.5
230-235
Simpson, Mr. Paul Fraser
Chief Financial Officer
135-140
37.5-40
170-175
Stevenson, Mrs Angela
Chief Operating Officer
120-125
1
142.5-145
260-265
Wilson, Mr. Michael Anthony
Chief Executive
170-175
2
5-7.5
180-185
Biddle, Mr. Paul
Non-Executive Director
5-10
2
5-10
Durban, Mr. Richard Don
Non-Executive Director
5-10
2
5-10
Hall, Mr. Alan J
Non-Executive Director
5-10
Lambert, Ms. Pauline
Non-Executive Director
5-10
2
5-10
McCarthy, Mr. Alan Roy
Chairman
30-35
5
30-35
Sadler, Mr. David
Non-Executive Director
0-5
Shaw, Mr. Richard Oliver
Non-Executive Director
5-10
1
5-10
Warner, Mrs. Caroline
Non-Executive Director
0-5
1
0-5
Band of Highest Paid Director’s Total Remuneration (£’000)
180-185
Executive Directors
* 25-30
Non-Executive Directors
5-10
0-5
Mid Point of the Banded Total Remuneration of £182,500 Highest Paid Director (£’000) Median Total Remuneration
£25,298
Ratio
7.21
* Represents clinical excellence award payments.
67
Salaries and allowances 2015-16 Name
Title
(a) Salary (bands of £5,000)
Allsop, Mrs. Fiona Margaret
Chief Nurse
110-115
Bostock, Mr. Paul Justin
Chief Operating Officer
50-55
Francis-Musanu, Mrs. Gillian Josephine
Director of Corporate Affairs
85-90
Holden, Dr Desmond Philip
Chief Medical Officer
135-140
Mackenzie, Mr. Ian Duncan
Director of Information and Facilities
Parker, Mrs. Yvonne
Director of Human Resources
Preston, Mr Mark
(b) Expense payments (taxable) total to nearest £100
(c) Performance pay and bonuses (bands of £5,000
(d) Long term performance pay and bonuses (bands of £5,000)
(e) All pensionrelated 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
Director of Organisation Development and People 25-30
15-17.5
40-45
Simpson, Mr. Paul Fraser
Chief Financial Officer
125-130
30-32.5
160-165
Stevenson, Mrs Angela
Chief Operating Officer
100-105
75-77.5
180-185
Wilson, Mr. Michael Anthony
Chief Executive
170-175
1
27.5-30
200-205
Biddle, Mr. Paul
Non-Executive Director
5-10
2
5-10
Durban, Mr. Richard Don
Non-Executive Director
5-10
2
5-10
Hall, Mr. Alan J
Non-Executive Director
5-10
Lambert, Ms. Pauline
Non-Executive Director
5-10
1
5-10
McCarthy, Mr. Alan Roy
Chairman
30-35
5
30-35
Robbins, Ms. Yvette Anita
Deputy Chairman/Non-Executive Director
0-5
Shaw, Mr. Richard Oliver
Non-Executive Director
5-10
Band of Highest Paid Director’s Total Remuneration (£’000)
200-205
Executive Directors
1
* 25-30
Non-Executive Directors
Mid Point of the Banded Total Remuneration of £202,500 Highest Paid Director (£’000) Median Total Remuneration Ratio
* Represents clinical excellence award payments.
68
£24,063
8.42
5-10
0-5 1
5-10
Salaries and allowances 2016 - 17 Name
Title
(a) Real Increase in pension at age 60 (bands of £2,500)
(b) Real increase in pension lump sum at aged 60 (bands of £2,500)
(c) Total Accrued Pension at age 60 at 31 March 2017 (bands of £5,000)
(d) Lump sum at age 60 related to accrued pension at 31 March 2017 (bands of £5000)
(e) Cash Equivalent Transfer Value at 1 April 2016
(f) Cash Equivalent Transfer Value at 31 March 2017
(g) Real increase in Cash Equivalent Transfer Value
(h) Employer’s contribution to stakeholder pension
£000
£000
£000
£000
£000
£000
£000
£000
Allsop, Mrs. Fiona Margaret
Chief Nurse
0-2.5
0-2.5
15-20
5-10
242
286
44
17
Stevenson, Mrs Angela
Chief Operating Officer
5-7.5
12.5-15
40-45
115-120
544
659
115
17
Francis-Musanu, Mrs. Gillian Josephine
Director of Corporate Affairs
0-2.5
0-2.5
25-30
65-70
506
539
33
13
Mackenzie, Mr. Ian Duncan
Director of Information and Facilities
0-2.5
2.5-5
40-45
120-125
791
839
48
15
Simpson, Mr. Paul Fraser
Chief Financial Officer
2.5-5
7.5-10
25-30
75-80
461
528
67
19
Pink, Mr Colin
Director of Corporate Affairs (Interim)
0-2.5
0-2.5
1 0-15
15-20
130
150
2
1
Preston, Mr Mark
Director of Organisation Development and People
5-7.5
12.5-15
25-30
70-75
344
452
108
15
Wilson, Mr. Michael Anthony
Chief Executive
0-2.5
0-2.5
75-80
230-235
1,526
1,581
55
6
NHSLA publication Disclosure of Senior Managers Remuneration (Greenbury) 2017
1.00
1.00%
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 the financial year 2016-17 was £180,000-£185,000. This approximates to 7.21 times (2015/16, 8.42 times) the median remuneration of the workforce, which is £25,298 (2015/16, £24,063).
in-kind as well as severance payments. 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 3,920 in 2015-16 to 4,025 in 2016-17.
In 2016-17 nine employees received remuneration in excess of the highestpaid director, (2015-16, nine employees). Remuneration ranged from £15,251 to £265,821 (2015/16, £15,100 to £205,767). Total remuneration includes salary, nonconsolidated performance-related pay, benefits69
Financial monitoring and accounts forms Reporting of other compensation schemes - exit packages 2016-17 Exit package cost band (including any special payment element)
*Number of compulsory redundancies
*Cost of compulsory redundancies
Number of other departures agreed
Cost of other departures agreed
Total number of exit packages
Total cost of exit packages
0
0
2
25,304
£25,001 - £50,000
0
0
£50,001 - £100,000
0
0
£100,001 - £150,000
0
0
£150,001 - £200,000
0
0
>£200,000
0
0
2
25,304
Less than £10,000
2
£10,000 - £25,000
Total
0
0
2
25,304
25,304
Number of departures where special payments have been made
Cost of special payment element included in exit packages
0
0
Number of departures where special payments have been made
Cost of special payment element included in exit packages
0
0
Reporting of other compensation schemes - exit packages 2015-16 Exit package cost band (including any special payment element)
*Cost of compulsory redundancies
Number of other departures agreed
Cost of other departures agreed
Total number of exit packages
Total cost of exit packages
Less than £10,000
1
5,351
1
5,351
£10,000 - £25,000
1
11,975
1
11,975
£25,001 - £50,000
0
0
£50,001 - £100,000
0
0
£100,001 - £150,000
0
0
£150,001 - £200,000
0
0
>£200,000
0
0
2
17,326
Total
70
*Number of compulsory redundancies
0
0
2
17,326
Other exit packages 2016-17 Other Exit packages - disclosures (Exclude Compulsory Redundancies)
Number of exit package agreements
Total Value of agreements £’s
15/16 Number of exit package agreements
15/16 Total Value of agreements
Voluntary redundancies including early retirement contractual costs Mutually agreed resignations (MARS) contractual costs Early retirements in the efficiency of the service contractual costs Contractual payments in lieu of notice
2
25
2
17
2
25
2
17
0
0
Exit payments following Employment Tribunals or court orders Non contractual payments requiring HMT approval * Total Non-contractual payments made to individuals where the payment value was more than 12 months of their annual salary
Note * this includes any non-contractual severance payment following judicial mediation and amounts relating to non-contractual payments in lieu of notice. Details must be disclosed in the Trusts Annual Report and Accounts. Details should be consistent with related disclosures in (a) the remuneration report and (b) the losses and special payments note.
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Staff report
72
Average Staff Numbers
Total YTD number
Permanently Employed Number
Other Number Costs £000’s
Permanently Employed Costs £000’s
Other Costs £000’s
Medical and dental
573
526
47
58,388
50,801
7,587
Ambulance staff
-
-
-
-
-
-
Administration and estates
818
681
137
33,624
30,317
3,307
Healthcare assistants and other support staff
868
751
117
14,686
11,832
2,854
Nursing, midwifery and health visiting staff
1,301
1,030
271
60,809
44,927
15,882
Nursing, midwifery and health visiting learners
-
-
-
-
-
-
Scientific, 379 therapeutic and technical staff
353
26
15,369
16,894
(1,525)
Social Care Staff
-
-
-
-
-
-
Healthcare Science Staff
86
84
2
3,488
3,125
363
Other
-
-
-
-
-
-
TOTAL
4,025
3,425
600
186,364
157,896
28,468
Staff engaged on capital projects (included above)
2
1
1
149
149
-
Staff composition
Total YTD Number
Permanently Employed Number
Other Number Female Number
Male Number
Directors
8
8
-
3
5
Medical and dental
573
526
47
297
276
Ambulance staff
-
-
-
-
-
Administration and estates
810
673
137
586
224
Healthcare assistants and other support staff
868
751
117
685
183
Nursing, midwifery and health visiting staff
1,301
1,030
271
1,191
110
Nursing, midwifery and health visiting learners
-
-
-
-
-
Scientific, therapeutic and technical staff
379
353
26
318
61
Social Care Staff
-
-
-
-
-
Healthcare Science Staff
86
84
2
55
31
Other
-
-
-
-
-
TOTAL
4,025
3,425
600
3,135
890
1
1
-
-
Staff Sickness Absence
Total Number
Total Prior Year Number
Total Days Lost
26,252
28,209
Total staff years
3,449
3,275
Average working Days Lost
8
9
Number of persons retired early on ill health grounds
4
3
Total additional pensions liabilities accrued in the year (ÂŁ000s)
228
158
Staff engaged on capital projects 2 (included above)
73
Table 1: Off-payroll engagements longer than 6 months For all off-payroll engagements as of 31 March 2017, for more than ÂŁ220 per day and that last longer than six months: Number Number of existing engagements as of 31 March
11
Of which the number that have existed: for less than one year at the time of reporting
1
for between one and two years at the time of reporting
4
for between two and three years at the time of reporting
2
for between three and four years at the time of reporting
1
for four or more years at the time of reporting
3
Table 2: New Off-payroll engagements For all new off-payroll engagements between 1 April 2016 and 31 March 2017, for more than ÂŁ220 per day and that last longer than six months: Number Number of new engagements, or those that reached six months in duration, between 0 1 April 2016 and 31 March Number if new engagementswhich include contractual clauses giving the (entity 0 name) the right to request assusrance in reation to income tax and National Insurance obligations Number for whom assurance has been requested 0 Of which
74
assurance has been recieved
0
assurance has not been recieved
0
Engagements terminated as a result of assurance not being recieved
0
Table 3: New Off-payroll board member/senior official engagements For any off-payroll engagements of board members, and/or, senior officials with significant financial responsibility, between 1 April 2016 and 31 March 2017 Number Number of off-payroll engagements of board members, and/or senior officers with significant financial responsibility, during the financial year Total no. of individuals on payroll and off-payroll that have been deemed “board members, and/or, senior officials with significant financial responsibility�, during the financial year. This figure should include both on and off-payroll engagements.
0 0
Disability Policy The Trust Board has considered issues relating to our public sector duties, including disability. As part of our inclusion work, we are part of the employers network and are working with BRAP a nationally recognised body on the inclusion and diversity agenda. Specifically on diversity we are a Disability Confident Employer and as such are accredited to use the logo on our recruitment and workforce literature. The scheme replaces the former two tick system and demonstrates the Trust’s commitment to being an equitable employer and encourages applications for employment by disabled people. The accreditation provides the basis for further work to attract and retain disabled people and potentially apply for enhanced accreditation of the scheme in the future. Further details are available from the Trust upon request.
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Putting people first ‘Every day, throughout the year I see the professionalism of everyone at Surrey and Sussex Healthcare NHS Trust in providing the best care to our patients. I am proud of their shared commitment to getting it right first time, every time and I see their success reflected in the many positive compliments and comments from our patients and their families.
Signed:
I also see the difference that this caring, compassion and dedication makes to the experience of every person we care for – I thank them all.’
Michael Wilson CBE Chief executive Surrey and Sussex Healthcare NHS Trust
Keep in touch Surrey and Sussex Healthcare NHS Trust Trust Headquarters Canada Avenue Redhill Surrey RH1 5RH 01737 768511 enquiries@sash.nhs.uk www.surreyandsussex.nhs.uk Twitter: @sashnhs Surrey and Sussex Healthcare NHS Trust provides emergency and non-emergency services at: East Surrey Hospital Redhill Surrey RH1 5RH 01737 768511 Surrey and Sussex Healthcare NHS Trust provides non-emergency services at Crawley Hospital which is managed by NHS Property Services.
10 Gresham Road Oxted RH8 0BQ 01883 734000 The Earlswood Centre Royal Earlswood Park 1 Anderson Court Redhill Surrey RH1 6TP 01737 768511 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 concerns, suggestions or queries from our patients and the people we care for • help sort out problems quickly on their behalf
Crawley Hospital Crawley West Sussex RH11 7DH 01293 600300
Contact PALS: • 01737 768511 x6922 or x6831 (for all sites) • pals@sash.nhs.uk • PALS, East Surrey Hospital, Redhill, Surrey, RH1 5RH
We also provide a number of services at four community sites:
You can ask a member of staff to contact PALS on your behalf
Caterham Dene Hospital Church Road Caterham Surrey CR3 5RA 01883 837500
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Horsham Hospital Hurst Road Horsham West Sussex RH12 2DR 01403 227000 Oxted Health Centre 77
Financial Our finances The year in context The Trust ended 2016-17 with a surplus of £3.7m (post technical adjustments, and the figure used for describing NHS financial performance). The position before technical adjustments (net of donated asset receipts and impairments) was a surplus of £3.4m.
The Trust’s cost per weighted activity unit (a measure introduced as part of Lord Carter’s and NHS Improvement’s Operational Productivity work) was £3,010, the second lowest in England. Our reference cost index (where 100 is the index level) was 86 – again the second lowest in England.
This performance is against a context of significant deficits in acute trusts across the country, and continued activity pressure. Emergency attendances rose to their. highest In summary, the Trust: ever levels in 2016/17. So, although the Trust’s new internal pathways (introduced with the help Achieved £9.2m of savings (meeting its of commissioners) helped to maintain the number planned savings target). Received non-recurrent income of £3.0m of emergency admissions [to Trust beds] at more from NHS England (for additional activity) manageable levels, we still did not have sufficient capacity to treat the expected level of planned and £4.9m of care (elective) patients referred to us. Sustainability & Transformation Funding (STF) from NHS Improvement. [1] The £1.1m of capital resource limit (CRL) handed back to NHS In conjunction with other Improvement al resource limit will be returned to the Trust, adding non-recurrent items, the underlying that amount to the CRL in 2017-18. position was a £7.2m deficit, but please note that reverts to a recurrent surplus In 2015/16, the Trust was not paid significant in 2017-18 with changes to tariff prices amounts of income for emergency admissions setting off these amounts. because the marginal rate emergency tariff Stayed within its External Financing Limit reduced the payment to 70% for numbers of Delivered its £11.3m capital resource limit, patients above 2008 levels. However, in 2016 which had been reduced by £1.1m after 17 agreement was reached with East Surrey delaying some projects in order to Clinical Commissioning Group (CCG) to cover hand back resource to NHS the full charge for their population’s emergency Improvement to help support the admissions above 2008 levels and Sussex CCGs national NHS financial position[1]. agreed a 50:50 arrangement. Met the terms of its loan agreements, repaying £1.6m of the outstanding Income and expenditure performance is principal. described in the chart below, which provides a Had an improved cash position - the view back to the creation of the Trust in 1998/99. surplus represents a significant The substantial surplus planned for 2017-18 improvement on the 2015-16 deficit (to meet the control total given to the Trust by of £(6.5)m and consequently NHS Improvement) includes non-recurrent the cash position improved. sustainability and transformation funding, which is explained later. The Trust was not able to achieve the financial control total initially given it by NHS Improvement (a surplus of £15.2m), and agreed a revised forecast outturn during the year. The surplus delivered is £1.3m adverse to the final expected position.
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The journey to 2016-17 – a brief financial history As the graph above describes, the Trust has experienced dramatically fluctuating financial fortunes. We went into deficit very soon after the Trust’s creation (from the merger of the hospitals in East Surrey and Crawley) and after a deceptive respite in 2002-03 the Trust went into a very serious financial decline.
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.
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.
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.
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
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. 79
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 and cost per weighted activity unit (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 three years, 2014-15 to 2016-17, 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 both 2015-16 and 2016-17), while other pressure has come from the cost of agency staff (as the Trust uses these staff to fill vacancies). The Trust implemented changes in 2016-17 to focus on how it could better manage the volumes of patients within its physical capacity, and within its budget. This has seen action on two fronts, inside and, with partners, outside hospital. In 2015-16, we reported how the stronger working with partners in the health system was manifested by the creation of an integrated reablement unit operated (and paid for equally) by the Trust, East Surrey CCG and Surrey County Council. That has been operating for a year [this gets patients out of hospital more quickly], and has been joined by the establishment of the Pendleton Unit [which prevents admissions of frail elderly patients, operating since October] and the presence of GPs in our A&E department [to refer people arriving at the hospital to out of hospital services]. Internally we have implemented ways of working to ensure our processes are consistent with best practice (the “SAFER” care bundle), altered how patients pass through our wards and improved 80
how we work with partners to discharge patients more quickly – on the latter point we will appoint a new integrated discharge lead nurse in 201718 funded jointly by Trust and CCGs. The emphasis on productivity continues, and the SaSH plus programme in collaboration with the Virginia Mason Institute (reported elsewhere in this Annual Report) has been live for 18 months of its five year initial timeframe. In the year, the programme has completed work on its initial workstreams (all still running) and created new ones while establishing the “Lean For Leaders” programme. This latter will eventually see all senior staff from all disciplines (clinical and non-clinical) being accredited in SaSH Plus techniques. Finally, to explain the further improved surplus planned for 2017-18, 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 (£21.3m surplus), and includes receipt of £8.8m of non recurrent sustainability and transformation funding. Reference costs and cost per weighted activity unit The 2015-16 NHS reference costs (the most recent) are translated into an index to allow comparison between trusts, where the national average is an index of 100. The Trust’s index score has changed as described in the table below, with the 2015-16 figure at 86. 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 increasing our unit costs. The Trust’s reference costs were 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 operational productivity and efficiency has used the reference cost to create a cost per weighted activity unit
measure. This is a value describing the cost to deliver the treatments carried out for patients, as adjusted and weighted for complexity of treatment, that can be compared with the average unit cost across the country. The Trust has a cost per weighted activity unit of £3,010, the second lowest in England.
Model hospital: Cost per weighted activity unit distribution of trusts in England
Trust productivity metrics Reference Adjusted cost index treatment cost 2006/7
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
£0.88
2015/16
86
£3,010
Cost per weighted activity unit
Chart shows ranking position for all trusts with data reported in the Model Hospital - colour candings reflect quartile - darker green (left) is best quartile, darker red (right) worst quartile.
The loan and the statutory breakeven duty Surrey and Sussex Healthcare NHS Trust secured its £56.0m working capital loan at the end of 2006/07 to cover debts from its poor financial performance up to that time. At that time, this was the largest loan allowed for any NHS trust.
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Loan repayment plan
2007/08 (£m)
2008/09 (£m)
2009/10 (£m)
2010/11 (£m)
2011/12 (£m)
2012/13 (£m)
2013/14 (£m)
2014/15 (£m)
2015/16 (£m)
2016/17 FOT (£m)
2017/18 Plan (£m)
Loan outstanding
(55.9)
(53.7)
(20.7)
(4.8)
(4.5)
(4.3)
(4.1)
(3.9)
(3.6)
(3.4)
(3.2)
26.0
8.0
Conversion to PDC 2.2
7.0
7.9
0.3
0.2
0.2
0.2
0.2
0.2
0.2
0.2
Loan carried forward
(53.7)
(20.7)
(4.8)
(4.5)
(4.3)
(4.1)
(3.9)
(3.6)
(3.4)
(3.2)
(3.0)
Loan outstanding
Trust repayment
The current position on the loan is described above, with only £3.2m left outstanding. The Trust is now making the scheduled payments required by its 25 year loan agreement against that balance. The loan repayment plan had been acting as a proxy for meeting the statutory breakeven duty, which the Trust has been in breach of since 2007/08. The statutory breakeven duty is set out in Schedule 5 of the NHS Act 2006 and case law states that a surplus of an equal size to any past deficits needs to be accumulated in a period of 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 82
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 secured a £19.8m working capital facility. This facility acts likes an overdraft (a limit against which the Trust can borrow). The trust borrowed £12.5m against this facility in 2015/16. It borrowed a further £7.3m against this facility in 2016/17, making £19.8m in total. It repaid £3.8m in 2016/17 leaving a balance of £16m as at 31st March 2017. It repaid a further £3.5m in April 2017. As the Trust moves further into surplus more of the facility will be repaid, noting that the facility can be withdrawn if the Trust’s cash position does not require it. 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 £8.9m left to repay at 31 March 2017. Liquidity The Annual Report has, for each of the last few years, provided a description of the weakness of the Trust’s balance sheet and outlined what that means in terms of effective and efficient operational functioning. Liquidity has sat resolutely on the Board Assurance Framework as
one of our main strategic risks for many years. The Trust has done well to keep the organisation operating with such a weak balance sheet for the last nine years. In 2011-12 it needed an injection of cash and the fragility of the position exacerbated by the deficit and late payments, meant that in 2015-16, the Trust secured the working capital facility referred to above. 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 at the time, it did not cover the full extent of the liquidity problem. The solution that is really needed is a significant injection of cash, either from a new working capital loan, a further working capital facility or a straight forward payment of equity (for NHS trusts that would be as public dividend capital). To get to a sustainable position the value of this cash injection is estimated to be more than £30m for this Trust. Delivery of the planned £21.3m surplus in 2017-18 will reduce the need to increase borrowing. 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: 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 around these objectives. However, 2016-17 has been a better year and the year has seen the delivery of a non- recurrent surplus that becomes recurrent as the Trust moves into 2017-18. The financial plan is supported by an operational plan, describing the activity changes that would allow the management of demand and the balancing of non-elective to elective activity (maximising higher contribution income). 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 prevented its effective use. As described above (at the end of the “brief financial history”), 2016-17 saw better management of emergency work from the creation of new units and new ways of working. However, this was not enough to create the capacity needed to do the elective work available, and the Trust did not deliver its elective income plan, and saw its 18 week referral to treatment standard delivery fluctuate uncomfortably in the year. 2017-18 Budget 83
The 2017-18 revenue budget has been constructed to facilitate delivery of the £21.3m I & E control total surplus. The Control Total has been set by NHS Improvement and the Board confirmed its acceptance in the Trust’s Plan submission in December 2016, subject to a covering letter. The covering letter providing caveats noting the scale of the surplus expected and the level of risk around it.
The Model Hospital data shows that the Trust has one of the lowest overall productivity gains to achieve when benchmarked against other English trusts (the Trust ranks seventh from lowest opportunity in the chart below). Model hospital: productivity benchmark
Part of the reason for the large surplus target (which is £5.1m more than the control total in 2016-17) is due to the Trust’s receipt of significant additional income from the higher prices for tariff activity as a result of the change to HRG4+, and the surplus will also be supported by additional sustainability and transformation funding. The revenue budget includes: a) Receipt of £8.8m sustainability and transformation funding (S&T Funding); b) A combined cost improvement and productivity programme totalling £11.2m (3.5% of turnover); c) £3.0m financial contingency against non- delivery of the above savings and productivity programme; d) £12.4m expected benefit from HRG 4+ (the new tariff prices). 2017-18 Savings and Productivity In addition to the data about the Trust’s cost per weighted activity unit referred to above, the Carter programme (NHS Improvement operational productivity) has established a broad range of workstreams with benchmarking and other data set out on a new web-based portal called the Model Hospital. The Trust benchmarks well in the majority of categories (which include nursing, pathology services, medicines management, back office, estates and facilities, procurement and the first of the detail Getting It Right First Time programme specialties, orthopaedics).
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Chart shows ranking position for all trusts with data reported in the Model Hospital - colour candings reflect quartile - darker green (left) is best quartile, darker red (right) worst quartile.
This reduces the opportunity for further cost improvements, however the Trust continues to look at what it can do to reduce its costs while maintaining and improving its services. The combined value of savings and productivity in 2017/18 is £11.3m which represents 3.5% of 2017/18 turnover, of which the formal savings plan is £6.2m or 2%. The savings plan approach is three-fold: 1) Workstreams led by Directors focusing on key areas of spend and applying top-down actions, and the securing buy- in from Divisions to deliver (currently the stated savings budget, excluding productivity, below); 2) A productivity planning approach (led by the Chief Operating Officer and reported to the Finance & Workforce Committee) has seen action planning at Divisional level (which completes the stated savings budget); 3) Divisionally developed savings that will
overlap with #1 and provide additional savings to supplement productivity gain and support full delivery of the rest of the programme.. Further information on the Trust’s approach to improving its productivity and efficiency is set out elsewhere in this Annual Report and summarised above in the “brief financial history” section, describing our SaSH plus programme and other initiatives.
Income 2017-18 – looking forward In 2017-18 our income is forecast to total £323.2m, taking into account £8.8m of sustainability and transformation funding.
Analysis of financial data The key financial statements from the 2016-17 accounts are in the appendix. The table below provides a fuller summary of our income and expenditure performance since 2007-8, using the EBITDA* presentation. Detail of overall income and expenditure performance since 2007-8 Income and expenditure
2007/8
2008/9
2009/10
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
2017/17
EBITDA presentation
(£m)
(£m)
(£m)
(£m)
(£m)
(£m)
(£m)
(£m)
(£m)
(£m)
Income from patient care
153.4
172.1
174.1
179.8
189.3
197.0
210.6
224.8
240.9
258.0
Other operating income
17.6
15.9
20.8
16.4
20.3
29.0
20.8
19.0
24.0
28.4
Net operating income
171.0
188.0
194.9
196.2
209.6
226.0
231.4
243.8
264.9
286.3
Operating expenses
(158.1)
(171.9)
(178.9)
(187.2)
(207.0)
(215.0)
(220.4)
(234.5)
(258.2)
(268.6)
EBITDA (op surplus/deficit))
12.9
16.1
16.0
9.0
2.6
11.0
11.0
9.3
6.7
17.7
Net interest and other items
(2.3)
(1.5)
(0.8)
(0.3)
(0.4)
(0.3)
(0.3)
(0.3)
(0.5)
(0.4)
Depreciation
(5.2)
(5.7)
(4.5)
(4.7)
(5.4)
(7.3)
(7.2)
(7.8)
(8.7)
(9.2)
PDC dividents payable
(1.4)
(1.8)
(2.9)
(3.0)
(3.0)
(3.1)
(3.2)
(3.6)
(3.9)
(4.4)
Impairments/ donated assets
(3.9)
NHS performance surplus/(deficit)
0.0
1.0
(6.1)
0.3
0.3
(2.4)
(6.5)
3.7
(4.8)
0.0
0.1
0.0
0.0
2.4
(0.2)
(0.2) 7.0
7.6
Impairments/ donated assets NET SURPLUS/ (DEFICIT)
0.0
7.0
7.6
(3.7)
(6.1)
0.4
0.3
(2.4)
(4.1)
3.4
Underlying surplus deficit
(2.6)
(2.7)
(0.2)
(2.2)
(13.3)
(9.2)
(4.3)
(5.2)
(7.2)
(7.2)
B’even duty: Cumulative deficit
(54.1)
(47.0)
(39.4)
(38.4)
(44.5)
(44.2)
(43.9)
(46.3)
(51.9)
(49.2)
*EBITDA – earnings before interest, tax, depreciation and amortisation
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Income 2017-18 – looking forward In 2017-18 our income is forecast to total £323.2m, taking into account £8.8m of sustainability and transformation funding.
Trust income since 2006-7 – looking back
a. The transfer of Crawley Hospital and Surrey HIS caused a reduction in income between 2005-6 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 2007-8 – 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: i) 86
here is from extra activity, not non recurrent funding (the non-recurrent funding line has been adjusted).
ii) c. d.
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. 2009-0 saw activity income fully consolidated as contract payment (being paid for what is done, and with some increase) but suppressed by the income agreement that year (the Trust has reached agreements on overall annual Contract income with its local PCTs to settle contractual disputes through overall annual memoranda of understanding (MoU’s) in several of the last few years). The increase seen in 2010-11 is therefore partly a delay in seeing 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. 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 none 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 a significant jump in non elective activity gradient has got steeper in 2014- but also the additional activity necessary 15 and again in 2015-16 with to meet the 18 week target. The income increased activity in the hospital from this increase was lost at the (both non-elective and elective) – time to contract challenges by PCTs but even after the impact of the then replaced with non recurrent funding – marginal rate for emergency tariff in summary however, the income increase
h.
reduction and the stated base value deduction for specialised commissioning. Note:2015-16 and 16-17 income excludes donated asset benefits. In 2016-17 income growth has continued at the previous rate, with the additional non-recurrent income making the gradient a little steeper in year.
Costs 2017-18 – looking forward Costs in 2015-16 are forecast to total £282.6m, split as described in the table and chart below. Trust forecast costs 2017-18
Trust costs since 2006-7 – looking back Costs from 2006-7 (income for same period inset)
a Pay costs fell from 2004-5 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. b 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. c 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. d The increase in 2010-11 non pay is mainly due to the £4.8m non recurrent impairment. e 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 were substantial in year (£1.6m between them). f 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. g 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 87
h
both years is greater than the income increase – resulting in the reported deficits in both years. Pay spend growth in 2016-17 is not as steep as in 2015-16 and the gradient of the overall spend lines is shallower than the income chart. Spend was less than income, resulting in the stated surplus.
Capital In 2016-17 the Trust spent £11.3m on capital investment. (buildings, IT and equipment), and has deferred £1.1m of the programme in order to hand back capital resource limit to the Department of Health to support the national financial position. That will be returned to the Trust in 2017-18. The Trust structures its programme to ensure that maintenance and refurbishment is completed, that we invest in improving patient areas and support the Trust strategy to ensure patients are treated in a safe, high-quality environment, and which is welcoming and convenient for them and their families. The programme is successfully transforming the estate and has reduced the cost of maintenance as we modernise the hospital A wide-range of different projects were delivered in-year , a lot of smaller projects in fact, with the principle focus being investment in estate to improve how the Trust works and improve care for patients, including the following projects: Medical records building - a new 2 storey building costing £2.3m in 2016-17 was completed behind Trust HQ as the final part of work to ensure better access to medical records. Last year we signed a contract moving our off-site storage from Southampton (a long way away) to Salfords (1 ½ miles away), and we have new IT that allows better tracking of records. Together these changes have seen significant improvement in the availability of medical notes; The resuscitation area of the emergency 88
department (ED) was made larger and equipped better, and a CT scanner was installed in ED to avoid the need for patients to be transferred along the corridor to the main CT scanner (so freeing up capacity there) – total cost £1.0m; East Surrey CCG paid £0.4m to build the Pendleton Unit, which sees frail elderly patients without them needing to pass through A&E and which is intended to look to enable those patients to be returned home or referred into out of hospital care without them being admitted into a bed; In 2017-18 the Trust has a larger capital budget, subject to agreement over loans, which will see the next stage of the enhancement of our Electronic patient Records System amongst other projects. We have also been successful in securing an additional £1.0m to make further improvements to our A&E department that will bring more GPs into the service to help manage emergency demand.
Appendices Statement of Comprehensive Income for year ended 31 March 2017 2016-17
2015-16
£000s
£000s
Gross employee benefits
(186,215)
(177,967)
Other operating costs
(91,605)
(86,567)
Revenue from patient care activities
257,968
240,905
Other operating revenue
28,367
23,974
Operating surplus
8,515
345
Investment revenue
23
26
Other gains and (losses)
(27)
(47)
Finance costs
(977)
(519)
Surplus/(deficit) for the financial year
7,534
(195)
Public dividend capital dividends payable
(4,098)
(3,943)
Retained surplus/(deficit) for the year
3,436
(4,138)
Other Comprehensive Income
2016-17
2015-16
£000s
£000s
Net gain on revaluation of property, plant & equipment
5,106
10,657
Total comprehensive income for the year
8,542
6,519
3,436
(4,138)
Financial performance for the year Retained surplus/(deficit) for the year Impairments (excluding IFRIC 12 impairments)
1,110
Adjustments in respect of donated asset reserve elimination
236
(3,503)
Adjusted retained surplus/(deficit)
3,672
(6,531)
The Trust’s reported NHS financial performance position is derived from its current surplus but adjusted for the treatment of donated assets and impairments. This adjustment is not considered part of the organisation’s operating position.
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Statement of Financial Position as at 31 March 2017 31 March 2017
31 March 2016
£000s
£000s
Property, plant and equipment
170,185
162,541
Intangible assets
1,822
2,265
Trade and other receivables
3,931
3,972
Total non-current assets
175,938
168,778
Inventories
4,479
3,610
Trade and other receivables
17,504
20,284
Cash and cash equivalents
5,575
2,521
Total current assets
27,558
26,415
Total assets
203,496
195,193
Trade and other payables
(26,825)
(31,727)
Provisions
(304)
(429)
Borrowings
(286)
(231)
DH revenue support loan
(216)
(216)
DH capital loan
(1,346)
(1,346)
Total current liabilities
(28,977)
(33,949)
Net current (liabilities)
(1,419)
(7,534)
Total assets less current liablilities
174,519
161,244
Trade and other payables
(3,312)
(3,428)
Provisions
(1,935)
(1,889)
Borrowings
(2,278)
(2,443)
DH revenue support loan
(19,062)
(15,748)
DH capital loan
(7,535)
(8,881)
Total non-current liabilities
(34,122)
(32,389)
Total assets employed:
140,397
128,855
Public Dividend Capital
151,849
148,849
Retained earnings
(55,085)
(59,379)
Revaluation reserve
43,633
39,385
Total Taxpayers’ Equity:
140,397
128,855
Non-current assets:
Current assets:
Current liabilities:
Non-current liabilities:
Financed by:
The notes on pages 7 to 32 form part of this account. The financial statements on pages 3 to 6 were approved by the Board on 25th May 2017 and signed on its behalf by: Chief Executive:
90
Statement of changes in taxpayers’ equity for the year ending 31 March 2017 Public Dividend
Retained earnings
Revaluation
£000s
£000s
£000s
£000s
148,849
(59,379)
39,385
128,855
capital
Balance at 1 April 2016
Total reserves
reserve
Changes in taxpayers’ equity for 2016-17 Retained surplus for
3,436
3,436
the year Net gain on revaluation of property, plant,
5,106
5,106
equipment
858
Transfers between reserves
(858)
Reclassification Adjustments Temporary and permanent PDC
3,000
3,000
received - cash Net recognised
3,000
4,294
4,248
11,542
151,849
(55,085)
43,633
140,397
151,299
(55,783)
29,270
124,786
revenue for the year Balance at 31 March 2017
Balance at 1 April 2015 Changes in taxpayers’ equity for the year ended 31 March 2016 Retained (deficit) for
(4,138)
(4,138)
the year Net gain on revaluation of property, plant,
10,657
10,657
equipment Transfers between
542
(542)
reserves Reclassification Adjustments New PDC received - cash
550
550
PDC repaid in year
(3,000)
Net recognised revenue/(expense)
(2,450)
(3,596)
10,115
4,069
148,849
(59,379)
39,385
128,855
(3,000)
for the year Balance at 31 March 2016
91
Statement of cash flow for the year ended 31 March 2017 Note
2016-17
2015-16
£000s
£000s
8,515
345
9,267
8,730
Cash flows from operating activities Operating surplus Depreciation and amortisation
8
Impairments and reversals
18
1,110
(Increase) in Inventories
(869)
(105)
(Increase)/Decrease in Trade and Other Receivables
716
(3,229)
Increase/(Decrease) in Trade and Other Payables
(3,159)
1,847
Provisions utilised
206
180
(Decrease) in movement in non cash provisions
59
541
Net Cash Inflow from Operating Activities
14,205
7,977
Interest Received
23
27
(Payments) for Property, Plant and Equipment
(10,210)
(14,470)
(Payments) for Intangible Assets
(1,106)
(2,296)
Net Cash (Outflow) from Investing Activities
(11,293)
(16,739)
Net Cash Inflow/(Outflow) before Financing
2,912
(8,672)
3,000
550
Cash Flows from Investing Activities
Cash Flows from Financing Activities Gross Temporary and Permanent PDC Received Gross Temporary and Permanent PDC Repaid
(3,000)
Loans received from DH - New Capital Investment Loans
4,400
Loans received from DH - New Revenue Support Loans
7,280
12,500
Loans repaid to DH Capital Investment Loans Repayment of Principal
(1,346)
(906)
Loans repaid to DH Working Capital Loans/ Revenue Support Loans
(3,966)
(216)
Interest paid
(956)
(435)
PDC Dividend (paid)
(3,870)
(4,213)
Net Cash Inflow from Financing Activities
142
8,680
NET INCREASE/ (DECREASE) IN CASH AND CASH EQUIVALENTS
3,054
82
Cash and Cash Equivalents at Beginning of the Period
2,521
2,603
5,575
2,521
Cash and Cash Equivalents at year end
92
26
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