The meeting of the Board of Directors
To be held on Tuesday 23 May 2017 at 9.00am in the Boardroom, Doncaster Royal Infirmary AGENDA Part I
Enclosures
1. Apologies for absence (Verbal)
2. Declarations of Interest (Verbal)
3. Actions from the previous meeting Enclosure A
Presentation
4. Research and Development at DBTH Presentation Trevor Rogers – Director of Research and Development Emma Hannaford – Research Management and Governance Manager
Reports for decision
5. Annual Report 2016/17 (including quality report) Enclosure B Emma Shaheen – Head of Communications and Engagement
6. Draft Accounts 2016/17 Enclosure C Jon Sargeant – Director of Finance
7. NHSI Self-Certification 2016/17 Enclosure D Richard Parker – Chief Executive
8. Review of Board Committee Structure Enclosure E Matthew Kane – Trust Board Secretary
9. Managing Conflicts of Interest in the NHS Enclosure F Matthew Kane – Trust Board Secretary
Reports for assurance 10. National Cyber Security Issues and Response at DBTH Enclosure G Simon Marsh – Chief Information Officer (to follow)
11. DBTH’s Approach to Recruitment Enclosure H Karen Barnard – Director of People and Organisational Development (to follow)
12. Strategy & Improvement Report Enclosure I Marie Purdue – Acting Director of Strategy & Improvement
13. Finance Report as at 30 April 2017 Enclosure J Jon Sargeant – Director of Finance
14. Business Intelligence Report as at 30 April 2017 Enclosure K Led by David Purdue – Chief Operating Officer
15. Nursing Workforce Report Enclosure L Moira Hardy – Acting Director of Nursing, Midwifery & Quality
16. Board Assurance Framework & Corporate Risk Register Q4 Enclosure M Matthew Kane – Trust Board Secretary
Reports for information 17. Chair and NEDs’ Report Enclosure N Suzy Brain England – Chair
18. Chief Executive’s Report & Progress against Q4 Objectives Enclosure O Richard Parker –Chief Executive (objectives to follow)
19. Minutes of the Financial Oversight Committee held on 24 April 2017 Enclosure P Neil Rhodes – Non-Executive Director
20. Items escalated from sub-committees 21. To note: Enclosure Q Board of Directors Agenda Calendar Matthew Kane – Trust Board Secretary
Minutes 22. To approve the minutes of the previous meeting held 25 April 2017 Enclosure R 23. Any other business (to be agreed with the Chair prior to the meeting)
24. Governor questions regarding the business of the meeting
25. Date and time of next meeting Date: 27 June 2017 Time: 9.00am Venue: Boardroom, Doncaster Royal Infirmary
26. Withdrawal of Press and Public Board to resolve: That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.
Suzy Brain England Chair of the Board
Action Notes
Meeting: Board of Directors Date of meeting: 25 April 2017 Location: Boardroom, DRI Attendees: SBE, KB, DC, DJ, MH, MM, DP, SS, NR, RP, LP, JS, PS Apologies: None
No. Minute No Action Responsibility Target Date Update 1. 16/10/13 Ophthalmology Department post- DP June 2017 Action not yet due. implementation review to be undertaken.
2. 16/10/22 A review of the Intermediate Health DP May 2017 Action not yet due. (b) and Social Care Review to be brought to a future Board.
3. 16/12/107 An item regarding how governors can MK June 2017 Action not yet due. get involved in undertaking F&F to be placed on an upcoming Timeout.
No. Minute No Action Responsibility Target Date Update 4. 17/01/11 Lessons learned from NLAG cyber- SM May 2017 Complete – contained within the report to Board crime episode to be shared at future regarding cyber security 23 May 2017. Board.
5. 17/01/13 Director of Education to share the MK June 2017 Identified as item for future Board strategy work. Teaching Hospital phase two development plan at a future Board.
6. 17/02/44 Report on workforce to be brought to KB May 2017 Complete. Item on agenda, 23 May 2017. Board.
7. 17/03/07 A paper be prepared on how the Trust JS/KEJ June 2017 Awaiting response to Trust’s letter from NHS can assure itself that support is in Protect. place concerning changes to NHS Protect.
8. 17/04/17 Send letter of thanks to PJ Paralysis MK May 2017 Complete. Team.
9. 17/04/24 Include measures of success and KB May 2017 Complete. Revised version of staff survey action SMART objectives within staff survey plan appended to this action log. action plan. Provide details of individual care group responses to non-executives.
No. Minute No Action Responsibility Target Date Update 10. 17/04/32 Timetable six month review of CIPs. MP November 2017 Action not yet due.
11. 17/04/54 Invite NEDs to future quality summit. MH June 2017 Action not yet due.
12. 17/04/61 Bring Learning from Deaths report MK June 2017 Action not yet due. back to Board in May.
13. C/17/04/16 Request CCG to review information ES May 2017 Complete. around clinical values.
Date of next meeting: 23 May 2017 Action notes prepared by: M Kane Dated: 13 May 2017 Circulation: SBE, AA, NR, KB, DJ, MH, MM, DP, JS, SS, JP, RP, LP, PS
Staff survey action plan 2017
Area of focus Actions Addressing staff survey Success measure question/ area Overall staff Ensure stablished dedicated resource in place to support a Response rate Improved response rate experience/engagement programme of staff engagement following the programme appointment of the Communications Manager Recommendation as place to Improvement in work and receive treatment recommendation of DBTH as Create staff experience group building on the membership place to work and to receive of the recovery team formed during the turnaround Staff engagement score care programme Improvement in staff engagement score Opportunity for employee Introduce a formalised approach to the collation of staff Key finding 3: percentage of Improvements in scores in voice and involvement feedback received during a specific period through the staff agreeing their role relevant key findings existing channels. makes a difference to patients/ service users (6b) Reduced number of grievances Timely analysis of the number of comments/ feedback and the tone (to act as a morale barometer, supplementing the Key finding 5: recognition Staff FFT work). This would provide the Board with an and value of staff by understanding of staff reaction to certain updates/changes organisation and managers (5a,5f,7g) Agreed approach to engagement through organisational change agreed with staff side Key finding 6: Percentage of staff reporting good Revision to appraisal paperwork to complement discussions communication between between line managers and their staff members senior management and staff (81-d)
Demonstrate a clearer ‘you said’ ‘we did’ approach so Key finding 7: Percentage of Improvements in scores of employees see the value in having a voice and provide staff able to contribute relevant key findings shared learning about where that has been done well. towards improvements at work (4a,4b,4d) Improvements in morale Responses to be formed based on insights gathered measured through regular through champions and the staff experience group as well Key finding 3: percentage of barometers as all staff feedback (including the staff survey). staff agreeing their role makes a difference to Develop case studies around staff survey improvements for patients/ service users (6b) Care Groups/ Corporate Directorates using the ‘you said we did’ approach. Care Group/Directorate action plans to be developed in conjunction with staff to ensure the priorities meet their needs. Increase in service improvement projects led by Develop DBTH approach to service improvement to include front line services the involvement of front line staff, thereby empowering staff to feel able to suggest and implement change to improve patient and staff experience. Quality improvement and innovation strategy in place Communicating Clearer representation/ visibility of executive team- Key finding 5: recognition Questions to be included in vision/strategy especially within their senior teams communicating the and value of staff by FFT Q2 questionnaire ‘future’. organisation and managers (5a,5f,7g) Identified senior management presence on Bassetlaw site Key finding 6: Percentage of Create a programme of engagement opportunities and staff reporting good engagement KPIs for the executive teams including communication between presentation of staff brief, STAR awards presentations, senior management and staff
back to the floor exercises and bespoke Q/A forum sessions (81-d) with a wide ranging group of staff (such as CEO breakfast sessions with medics).
Involve all staff(including staff side) in in an engagement/ Key finding 7: Percentage of Number of contributions/ consultation exercise in developing the new strategy, staff able to contribute suggestions made by staff ensuring it is easy to communicate and engage with for all towards improvements at stakeholders at all levels work (4a,4b,4d)
Deliver a series of staff engagement events (big health Key finding 8: Staff Number of contributions/ conversation/ let’s talk DBTH) supported by additional satisfaction with level of suggestions from staff re what digital engagement. responsibility and they can do to support the involvement (3a,3b,4c,5d,5e) delivery of the strategy Ensure senior staff/ line managers can support staff to make sense of their role within the context of the Key finding 3: percentage of organisational strategy. staff agreeing that their role makes a difference to patients/ service users (6b) Develop a communications and engagement champions Key finding 7: Percentage of Improvements to key findings model, with key representatives from all Care Group/ staff able to contribute Corporate Directorates committed to attendance at key towards improvements at Improved attendance at Staff events to hear and feedback (including staff brief, annual work (4a,4b,4d) Brief members meeting, transformation workshops). Key finding 8: Staff Staff experience group Create a ‘staff experience group’ which will also include satisfaction with level of established senior members of staff, staff side and governors. responsibility and involvement (3a,3b,4c,5d,5e) Continued increase in use of Continue to deliver pro-active communications campaigns social media. Alternative making use of varied media. means of communication
identified through engagement with staff Supporting and engaging with Improve current intranet provision in order to provide line Key finding 10: Support from Improvement in key findings managers managers with all the key information, guidance and immediate managers (5b, 7a- policies they need to manage staff enabling a self-service e) Measure use of intranet site approach.
Develop a line manager bulletin/ blog/ portal to include Key Finding 9. Effective team Improvements in key findings support and guidance on key people issues. Contents could working (4h-j) include: Reduced sickness absence - Steps to delivering quality appraisals including key Key finding 10: Support from rates messages to staff (video of a good appraisal) immediate managers - Effective team working Improved appraisal rates - The importance of supporting health and wellbeing Key finding 11: Percentage of of staff with particular focus on mental wellbeing staff appraised in the last 12 Reduced grievances and resilience (links to CQUIN for 2017/18 months (20a) - Sickness absence management best practice Key finding 12: Quality of appraisals (20b-d)
Key finding 13: Quality of non-mandatory training, learning or development (18b-d)
Key Finding 19: Organisation and management interest in and action on health and wellbeing (7f, 9a)
Adopt a line manager first approach for all communications Key finding 10: Support from Improvement in key findings involving significant change. This will enable managers to immediate managers understand the reasons for change and to feel equipped to Line managers questionnaire support their staff and help them to make sense of their as part of the launch of the roles in the change. Key finding 7: Percentage of bulletin/blog/portal staff able to contribute Ensure all Care Groups and Directorates understand and towards improvements at Staff survey engagement share staff survey feedback – engaging with staff to work (4a,4b,4d) events taken place in Care understand the results and develop actions to address Groups and three areas for areas for concern in their survey results. focus identified for monitoring at accountability meetings Explore with the senior leadership team across the Trust how best to communicate with them
Develop a leadership strategy and programme for the Key finding 8: Staff Improvement in key findings organisation to include talent management and succession satisfaction with level of planning responsibility and Strategy in place and involvement (3a,3b,4c,5d,5e) programmes identified
Re-launch DBTH management programme to ensure Key finding 10: Support from Improvement in key findings managers are equipped to manage people issues immediate managers appropriately Positive evaluation of programme
Title Draft Annual Report (Including Quality Report)
Report to: Board of Directors Date: 23 May 2017
Author: Adam Tingle, Communications Manager
For: Approval Purpose of Paper: Executive Summary containing key messages and issues
The purpose of this paper is to enable the Board to approve the Annual Report which incorporates all changes and amends from the previous draft, and to update the Board on the status/progress for submission of the Annual Report and Accounts 2016/17.
There is a statutory requirement for all Foundation Trusts to produce an annual report providing a narrative account of the Trust’s performance over the year. The report must meet the requirements set by NHS Improvement in the Financial Reporting Manual.
Recommendation
The Board is asked to APPROVE the draft report.
Delivering the Values – We Care We always put the patient first Everyone counts – we treat each other with courtesy, honesty, respect and dignity Committed to quality and continuously improving patient experience Always caring and compassionate Responsible and accountable for our actions – taking pride in our work Encouraging and valuing our diverse staff and rewarding ability and innovation
Related Strategic Objectives
Provide the safest, most effective care possible Control and reduce the cost of healthcare Focus on innovation for improvement Develop responsibly, delivering the right services with the right staff
Analysis of risks Resource – There will be a cost associated with printing hard copies of the Annual Report for distribution to interested members of the public and other stakeholders. Governance – There is a statutory and corporate governance requirement to produce an Annual Report. Equality and Diversity - There is a requirement to report on quality and diversity within the Annual Report. PR and Communications – The report is a public account of the Trust’s performance in 2016/17. It will be formally launched and discussed at the Annual Members Meeting in September and will be published on our website. Patient, Public and Member Involvement – The Annual Report is a public document, and is received by the Members and Board of Governors at the Annual Members Meeting.
Board Assurance Framework Failure to deliver accurate financial reporting underpinned by 4 x 5 = 20 effective financial governance
Doncaster and Bassetlaw Hospitals NHS Foundation Trust Annual Report and Accounts 2015/16
Presented to Parliament pursuant to Schedule 7, paragraph 25 (4)(a) of the National Health Service Act 2006
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Contents
Performance Report
Chair and Chief Executive’s statement 5 Who we are and what we do 8 Our vision, mission, values and strategy 9 Review of the year 10 Financial performance 15 Operational performance 18 Improving patient care – awards and accolades 20 Social, community and human rights 22 Being green and sustainable 24 Key developments since the end of 2015/16 25 Principal risks and uncertainties and factors affecting future performance 25 Going concern 27
Accountability Report
Director’s report 28 Composition of the Board 28 Quality Governance 33 Disclosures to auditors 34 Income disclosures 34 Remuneration report 34 Our staff 43 Governance report 57 Board of Directors 57 Board of Governors 59 Membership 63 NHS Foundation Trust Code of Governance 65 Single Oversight Framework 68 Statement of accounting officer’s responsibilities 69 Annual governance statement 70 Independent auditor’s report to the Board of Governors 79
Quality Accounts
Chief Executive’s statement 89 Looking forward to our priorities for improvement in 2017/18 91 Looking back to our priorities for improvement 2016/17 92 Statements of assurance 93 Review of Quality Performance 2016/17 112 Definitions used for audited indicators 114 Comments on the 2016/17 Quality Account 116 Statement of Directors’ responsibilities in respect of the Quality Account/Report 119
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Independent Auditor’s Report to the Board of Governors 117
Financial Review
Foreword to accounts 120
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Chair and Chief Executive’s statement
Over the past 18 months, the Trust has gone through some substantial changes, some challenging, and others exciting, but all pointing towards a bright future for our patients, services and staff.
The highlight of the year undoubtedly came in January 2017 as we were awarded teaching hospital status, becoming Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust (DBTH). We gained this accreditation due to our longstanding commitment to improving education and growing research, as well as ensuring that we are an integral partner in the sculpting of clinical and medical staff in the region. Becoming a teaching hospital will be of huge benefit to our patients and staff with further improvements to be made in innovative and quality health care, delivered by our professional team that is actively teaching and involved in research initiatives.
In 2018, the Trust is projecting to train 25% of medical students in the region, which adds to the fact that we are already training 30% of other healthcare professional students, something which will benefit the communities we serve in Doncaster, Bassetlaw and beyond. This is a fantastic achievement and is a credit to every member of Team DBTH and shows just how far we have come.
As a Trust, we are extremely proud of the excellent improvements in the quality of care we continue to provide to our patients, an achievement we have sustained for the fourth year in a row. As part of this achievement, we have seen further reductions in severe avoidable pressure ulcers, falls and infections while our mortality rate has also reduced in comparison to last year and is well within the expected range.
Following financial challenges which presented last year, we have also made great progress in our cost saving and ‘Turnaround’ efforts. Thanks to our identified savings and a one-off support payment from NHS Improvement for our strong performance against our financial plan, this means that since April 2016 we have delivered savings of around £11.9 m, against an original target of £11 million, finishing the year with a substantially reduced deficit of £6.7m.
Our development as an organisation in such a short time has been recognised by our regulators NHS Improvement, while our Strategy and Improvement team were awarded NHS Leadership Academy’s regional Outstanding Achievement of the Year (Non-Clinical) for their role in directing Turnaround activities.
The progress we have made has been due to a number of factors, but can be mostly attributed to the ‘can-do’ attitude and enthusiasm of our staff, who have been working in different and innovative ways. Throughout this process it has been our goal to ensure that the patient remains at the heart of everything we do and we believe that, despite increased demands and challenges, we have achieved this.
Due to the scale of the financial challenge, the organisation has moved at pace with a number of cost saving programmes, and although efforts were made to involve and engage
5 staff in these projects, in 2017/18 we will be looking to improve workforce involvement and partnership working across the Trust.
While we have made great strides in this financial year, we still have a substantial deficit to contend with, and will continue to address this in 2017/18, with a savings figure of £14.5m to achieve. We will continue to work with NHS Improvement to develop our financial position, focussing on providing the highest quality and safest services for our patients as efficiently as possible.
Throughout the year we have seen significant capital developments and achievements to improve patient care and services. In November 2016, we opened the Fred and Ann Green Eye Centre, after investment from the Fred and Ann Green Legacy, while we also invested £275k in a new Children’s Outpatients Department at Bassetlaw Hospital.
Research and Development at the Trust has continued to grow, alongside our new teaching hospital status. This activity has increased, and our commitment to research has been acknowledged externally, both in our change in status and as our Clinical Research Team were shortlisted in the Nursing Times’ 2016 awards.
Over the year we have strengthened our links with health and care partners in South Yorkshire and Bassetlaw, working as part of the Working Together Vanguard to develop new care models. We are also an integral partner of the South Yorkshire and Bassetlaw Sustainability and Transformation Plan (STP) which is set to become a first wave Accountable Care System. This is thanks to established strong relationships with neighbouring Trusts and Clinical Commissioning Groups and a proven history of working together to improve health and care for our population.
As ever, Trust staff and services have been shortlisted for an abundance of local, regional and national awards. These improvements and achievements have been made as a result of our collective commitment and hard work.
Of particular note this year were the improvements in flu vaccination. Thanks to the efforts of our Health and Wellbeing Team, we were the first acute Trust in the country to vaccinate over 75% of our front line staff, giving the jab to over 3,500 doctors and nurses in just two months. These efforts have since been recognised by NHS Employers.
Amongst the positives, we have also seen challenges this year in terms of staffing, encountered no more acutely than the Paediatric Ward (A3) at Bassetlaw Hospital, which has closed to admissions from 7pm each day. In order to address these issues, we are looking at new and innovative schemes to fill these workforce gaps, something our new teaching hospital status will undoubtedly aid, as well as improvements such as better use of locums and moving all clinical staff onto the Trust’s internal bank.
This has also been a year of great change for the Trust. In January 2017, Chief Executive, Mike Pinkerton, and Chair, Chris Scholey, stepped down from their respective positions. We want to say thank you to both Mike and Chris for their fantastic service in helming the organisation over the past number of years. Their leadership has helped develop the
6 organisation into one of the top performing acute providers in the country and many future developments and improvements are of direct result of their dedication to providing the best quality health care for the people of Doncaster, Bassetlaw and beyond.
Finally, we are coming to the end of our five year strategic direction ‘Looking Forward to our Future’. As we look to the year ahead, we are refreshing this strategy and intend to engage with staff, external partners, patients and other stakeholders to ensure that this future vision continues to fit with the needs of the wider health community we serve, while working in tandem with national and regional directives.
We would like to take this opportunity to thank our staff, governors, members, volunteers, partner organisations, commissioners, regulators and everyone else who has worked with us over the past year. Their positive support has been overwhelming and has contributed to what has been a successful, yet challenging, year for the Trust.
The Annual Report and Quality Accounts set out openly and honestly, in detail, how we performed in 2016/17, and what we plan to achieve in 2017/18. We hope you enjoy reading them and once again thank you for continued support.
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Who we are and what we do
As well as being an acute foundation trust with one of the busiest emergency services in the country, we are also one of only five teaching hospitals in the Yorkshire region, working closely with the University of Sheffield and Sheffield Hallam University. As a Trust we also maintain strong links with Health Education England and our local Clinical Commissioning Groups in both Doncaster and Bassetlaw.
We are fully licensed by NHS Improvement and fully registered (without conditions) by the Care Quality Commission (CQC) to provide the following regulated activities and healthcare services:
Treatment of disease, disorder or injury Nursing care Surgical procedures Maternity and midwifery services Diagnostic and screening procedures Family planning Termination of pregnancies Transport services, triage and medical advice provided remotely Assessment or medical treatment for persons detained under the Mental Health Act 1983
We provide the full range of local hospital services, some community services, including family planning and audiology, and some specialist tertiary services including vascular surgery.
We serve a population of more than 420,000 across South Yorkshire, North Nottinghamshire and the surrounding areas and we run three hospitals:
Doncaster Royal Infirmary (DRI) DRI is a large acute hospital with over 500 beds, a 24-hour Emergency Department (ED), and trauma unit status. In addition to the full range of district general hospital care it also provides some specialist services including vascular surgery. It has inpatient, day case and outpatient facilities.
Bassetlaw Hospital in Worksop (BH) BH is an acute hospital with over 170 beds, a 24-hour Emergency Department (ED) and the full range of district general hospital services including a breast care unit and renal dialysis. It has inpatient, day case and outpatient facilities.
Montagu Hospital in Mexborough Montagu is a small non-acute hospital with over 50 inpatient beds for people who need further rehabilitation before they can be discharged. There is a nurse-led Minor Injuries Unit, open 9am-9pm. It also has a day surgery unit, renal dialysis, a chronic pain management unit and a wide range of outpatient clinics. Montagu is the site of our
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Rehabilitation Centre, Clinical Simulation Centre and the base for the Abdominal Aortic Aneurysm screening programme.
We are also registered to provide outpatient and other health services at Retford Hospital, including clinical therapies and medical imaging. Our site at the Chequer Road Clinic in Doncaster town centre offers audiology and breast screening services. We also provide some services in community settings across South Yorkshire and Bassetlaw. The rehabilitation beds we used to have at Tickhill Road Hospital in Doncaster transferred to Montagu Hospital in August 2012 however we still provide outpatient care of older people there.
Alongside our teaching hospital status, in 2004, Doncaster and Bassetlaw Hospitals became one of the first 10 NHS trusts in the country to be awarded foundation trust status. This means we have more freedom to act than a traditional NHS trust, although we are still very closely regulated and must comply with the same strict quality measures as non-foundation trusts.
Our headquarters are at Doncaster Royal Infirmary:
Chief Executive’s Office Doncaster Royal Infirmary Armthorpe Road Doncaster DN2 5LT
Tel: 01302 366666
Our vision, mission, values and strategy
Vision Our vision is to become recognised as the best healthcare provider in our class, consistently performing in the top 10% nationally.
Mission We are here to safeguard the health and wellbeing of the population and communities we serve, to add life to years and years to life. We aim to combine the very highest levels of knowledge and skill with the personal care and compassion that we would want for our friends and families at times of need. In short: We Care for You.
Values Our values show WE CARE:
We always put the patient first. Everyone counts – we treat each other with courtesy, honesty, respect and dignity. Committed to quality and continuously improving patient experience. Always caring and compassionate. Responsible and accountable for our actions – taking pride in our work.
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Encouraging and valuing our diverse staff and rewarding ability and innovation.
Strategic themes Our strategic direction is founded on four core principles and themes:
Provide the safest, most effective care possible. Control and reduce the cost of healthcare. Develop responsibly, delivering the right services with the right staff. Focus on innovation and improvement.
Review of the year
2016/17 has been a challenging year for the Trust. Successful cost-saving (Turnaround) activities have been underway to affect a number of changes to ensure we achieve targets as set by our regulator NHS Improvement. Driven by the newly formed Directorate of Strategy and Improvement, the Trust has made savings of £11.9m against a projected target of £11m; see pXX for a detailed report.
This year has also marked the start of an exciting new chapter for DBTH. Despite our challenging financial position we have made some significant improvements in the quality of care we provide for our patients and in January 2017 gained teaching hospital status. This marks a fantastic achievement for the organisation and one that will benefit not only members of Team DBTH, but also the communities we serve in Doncaster, Bassetlaw and beyond.
In January, Chief Executive, Mike Pinkerton, and Chair, Chris Scholey, stepped down from their positions, with successors Richard Parker and Suzy Brain England appointed to respective posts. Furthermore, new appointments have been made to the Board of Directors, with a new and refreshed management team in place to guide the Trust into a promising future.
Provide the safest most effective care possible
For the fourth year in a row we continued to make excellent improvements in patient safety key quality indicators including:
18.75% reduction in Clostridium Difficile, our performance is better than our predicted trajectory 14% reduction in serious falls, delivered through the implementation and roll out of a Falls Coordinator role 25% reduction in severe avoidable pressure ulcers in the year, delivered as a whole organisation approach 4.7% reduction in our Hospital Standardised Mortality Ratio (HSMR), representing an 18% decrease since 2013 57.1% reduction in the number of serious incidents reported at the Trust.
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We continue on our journey in delivering the pledges set out in our Sign Up to Safety Plan, which focus on the key quality indicators above, recognising that there is more to be done to eliminate Never Events at the Trust, further reduce our infection risks in order to improve our patient safety indicators and achieve targets of a reduction in avoidable harm by 50% over three years ending in 2018.
Our serious falls rate has continued to decline, with the Trust performing 14% better than last year. This has been achieved through a number of initiatives, such as the implementation of an Enhanced Care Team which offers increased and tailored care for frail and vulnerable patients, particularly those usually more susceptible to falls.
This year also saw a significant reduction of severe avoidable pressure ulcers at the Trust, with 25% less than reported last year. An organisational achievement, these efforts have been driven in part by the newly formed Skin Integrity Team as well as a number of schemes such as ‘React to Red’ training, which has given Health Care Assistants the ability to spot potential ulcers and act before they become serious. A culmination of this approach, the Mallard Ward (care for dementia and delirium) celebrated 1,000 days without a severe avoidable pressure sore in January 2017.
Improvements made to safety and quality have resulted in excellent mortality performance, with our Hospital Standardised Mortality Ratio (HSMR) reducing by 4.54 points from 95.62 last year to 91.08 this year (lower than the expected range) for the 12 month period. The Standardised Hospital Mortality Indicator (SHMI), which also includes deaths following discharge from hospital, has also improved, reducing 3.7 points from 105.7 to 102, however slightly missing the target.
In 2016/17 the number of our patients waiting over four hours in our Emergency Department increased, reflecting the national picture of increased demand on emergency services. Although we did not achieve the 95% standard, we have consistently been one of the best performing Trusts in the region.
In order to improve our four-hour access, we continue to work with NHS Doncaster Clinical Commissioning Group (CCG) to further embed and streamline the Front Door Assessment Signposting Service (FDASS). This service is now being piloted at Bassetlaw Hospital.
In October, we introduced ‘Freedom To Speak Up Guardians’ at the Trust. These staff champions help support the Trust to become a more open place to work, where all staff feel confident to speak up about patient care at all times. Made up of the Trust’s public and staff governors as well as a doctor, the Guardians work alongside the organisation’s leadership teams in order to elevate the profile of raising concerns.
Control and reduce the cost of healthcare
In October 2015 the Trust reported a significant change in the financial position, moving from forecasting a small end of year surplus to predicting a substantial deficit, ending 2015/16 £36.4m in deficit. For this financial year, the Trust has made significant progress, ending the year with a substantially reduced deficit of £6.7m.
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The year-end position is a £17m deficit, in-line with the financial forecast. In response to the strong performance against the original financial plan, the Trust has received one-off support from the NHS Improvement in the form of a bonus payment which reduces this deficit to £6.7m.
Since April 2016, we have delivered savings of around £11.9m, against an original target of £11m and we will end the financial year with a substantially reduced deficit, progress that has been nothing short of amazing given our position just 12 months ago.
Typically for NHS organisations, Turnaround initiatives tend to be directed by external partners, however, the Board, with permission from regulator NHS Improvement, felt that an internal team would be capable of delivering the change needed in the organisation and that this would be met with a much more positive reception from staff, increasing engagement with the process.
Led by the directorate of Strategy and Improvement, 12 cost-saving work streams were initiated, worked up in partnership with Trust managers, clinicians and other staff members in order to understand how best to deliver these efficiencies, ultimately with great success.
More detailed information is set out in the financial performance section on page 15.
Develop responsibly, delivering the right services with the right staff
In January 2017, we became Doncaster and Bassetlaw Teaching Hospitals. Achieving this status will not only allow us to enhance our services, but is also a recognition of our achievements in providing high quality education and research and will be a huge benefit, both in our local communities and regionally. By 2018, the Trust is projecting to train 25% of the medical students in the region and is already training 30% of all non-medical students.
This dedication to furthering education and research at the Trust was also evidenced by the nomination of our research clinicians and medics for the Nursing Times 2016 Awards, in the Clinical Researching Nursing category. The team have overseen a 41% increase in the number of patients taking part in clinical research across the Trust in just one year, with a further 18% rise in research studies in specialities which previously had not participated in studies.
Throughout 2016/17, the Trust has worked in close partnership with the organisations involved in the South Yorkshire and Bassetlaw Sustainability and Transformation Plan (STP). The project is looking at how trusts and CCGs can better work together to make the best use of resource in the region for the betterment of patient care and treatment.
The STP, made up of health and care providers within Doncaster, Bassetlaw, Sheffield, Rotherham and Barnsley, is the local approach to delivering the national ‘Five Year Forward View’ plan, as put forward by NHS England. 25 health care partners from across the region are involved in the plan, along with HealthWatch and voluntary sector organisations, and the Trust’s future plans will work in tandem and partnership with the STP.
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Relating to this work, the Trust has also been involved in Commissioners Working Together, a partnership between South and Mid Yorkshire, Bassetlaw and North Derbyshire. This project is currently looking at changes to Hyper Acute Stroke Unit (HASU) activity and Children’s Surgery and Anaesthesia which will directly affect the Trust’s service. As these projects went out to public consultation, the Trust has worked in partnership to promote this engagement activity both with service users and staff.
We were also selected as partners in the Working Together Vanguard Partnership, one of 50 nationally chosen partnerships that take a lead on the development of new care models. The aim is for the vanguards to act as blueprints for the NHS moving forward and the inspiration to the rest of the health and care system. Over the past year Working Together has continued to deliver effective partnership solutions, for example the partnership has now saved over £1m through joined up procurement exercises.
In 2016/17 we remained focused on safe staffing levels and investments were made in-line with national recommendations from evidence based tools including Association of UK University Hospitals (AUKUH), e-panda, Baseline Emergency Staffing Tool (BEST) and Birth Rate plus. Over the year more than 98.5% of shifts identified were filled with the nursing workforce required to meet the needs of our patients, in accordance with the assessments.
We have worked to reduce our reliance on locums. Working with neighbouring trusts, North Lincolnshire and Goole Hospitals and United Lincolnshire Hospitals, the Trust’s procurement team secured an improved deal for locum and agency workers, saving the Trust £3.6m on 146,662 agency hours and £300k on agency fees.
In August, the Trust switched to an auto-registration model, in partnership with NHS Professionals, moving all of our nursing, midwifery and health care staff on to the organisations internal bank. By moving to this model it means the Trust is less reliant on agency workers and will be able to draw from a larger bank pool to fill gaps in rotas.
In line with improvements to our workforce, the Service Department has introduced a new ‘zone’ model for cleaning and portering at Doncaster Royal Infirmary. This follows an extensive revamp of the current service and aims to give wards, clinical areas and patients an improved service to better meet the 24/7 day working arrangements. Due to the size, the DRI site will have seven cleaning and portering geographical ‘zones’, with a dedicated team of service assistants headed up by a Team Leader and Zone Coordinator.
In July, a Family Suite was officially opened at the Bassetlaw Hospital Labour Ward. The new facility, funded by £40k in charitable donations in partnership with charity JOEL: The Complete Package, offers bereaved parents a place to spend time with their baby following a still birth.
In November, we officially opened our newly transformed eye service following an extensive seven month building project. Renamed the Fred and Ann Green Eye Centre, the space has a new waiting area, 15 examination rooms, seven vision lanes and three treatment rooms to care for patients with a range of eye disorders from common problems like conjunctivitis to
13 more severe conditions which can affect vision such as cataract and glaucoma. Following this improvement, we secured a contract with NHS England to bring Bassetlaw’s Diabetic Eye Screening Programme in-house and the service was transferred to the Trust in April 2017.
Also in November, work was completed on a new Children’s Outpatients Department at Bassetlaw Hospital, following a £278k investment. The newly created space is co-located to the, existing, Children’s Ward, improving clinical links between the two areas and allowing nursing teams to work across both, ultimately enhancing the care for younger patients.
Throughout 2016/17, the Trust faced significant challenge in staffing the Children’s Ward, known as A3, at Bassetlaw Hospital. Due to gaps in nursing staff and the junior doctor rota, the decision was taken in partnership with NHS Bassetlaw Clinical Commissioning Group (CCG) to close the ward to overnight admissions until suitable staffing could be recruited and the service operated overnight safely. All children needing overnight observation are transferred to Doncaster Royal Infirmary, via a private ambulance commissioned in partnership by the Trust and CCG.
Focus on innovation for improvement
Continuing our international partnerships, a consultant at Doncaster and Bassetlaw Hospitals has become the first British Ear, Nose and Throat (ENT) surgeon to receive visiting professor status at a top medical university in China. Mr Shahed Quraishi was awarded the accolade by the Capital Medical University, in Beijing, China, following a series of successful ENT master classes held in Beijing and Hong Kong in May 2016.
The Trust was the first in the country to vaccinate over 75% of front line staff against the flu. The Health and Wellbeing team marshalled the organisation’s dedicated army of ‘Flu Busters’, peer vaccinators to vaccinate doctors, nurses and other healthcare workers on wards and outpatient areas, even carrying out special sessions for weekend workers and night staff. Thanks to their efforts, over 3,500 members of Team DBTH were vaccinated. In March 2017, the Health and Wellbeing Lead, Helen Houghton, was named Flu Fighter Champion of the year by NHS Employers, thanks to her efforts coordinating this achievement.
End of life care provided by the Trust was named among the best in England, according to a report by the Royal College of Physicians (RCP). The review scored the Trust higher than the national average in 10 of 13 categories for clinical and organisational care, which included recognising that the patient was in the last days of life, providing an around-the-clock palliative care service and involving those close to the dying person in decisions about the care provided.
A new service that hopes to enhance the care of frail and vulnerable older patients launched initially at Bassetlaw Hospital. Running as a six-month pilot, and further embedded permanently across both sites, the Enhanced Care Team provides specialist care for patients who have confusion, delirium or dementia. Going beyond ‘normal’ ward care, patients
14 under the supervision of the team will receive one-to-one attention to improve their hospital experience and help keep them free from harm.
The Trust was highly rated in the National Diabetes Inpatient Audit (NaDIA). At Doncaster Royal Infirmary and Montagu Hospital, 124 inpatients with diabetes took part in the audit. The results for the Trust show a huge improvement for inpatient diabetes care, despite the disease being more prevalent in the borough than the national average. The audit, carried out by the Health and Social Care Information Centre (HSCIC), looked at the care of all inpatients with diabetes on a single day in all trusts across England and Wales.
A team that specialises in protecting patients from pressure ulcers at the Trust won first place at the Tissue Viability Society’s 2016 conference for a unique skin care routine that counteracts the effects of skin damage. The Skin Integrity Team explored the development of a new single skin care regime for both superficial pressure ulcers and incontinence associated dermatitis (IAD). They reviewed and assessed the effectiveness of several skin care products in use on the wards and designed a quick and easy way for staff to cleanse, protect and restore the skin for both conditions. The team road tested the new routine for three months with results showing a 26% reduction in low grade pressure ulcers and IAD in 31 patients and by a further 10% in 28 patients.
Financial performance
NHS Improvement has directed that foundation trusts’ financial statements should meet the accounting requirements of the NHS Foundation Trust Annual Reporting Manual (FT ARM), as agreed with HM Treasury.
Our financial statements have been prepared in accordance with the 2016/17 FT ARM and follow International Financial Reporting Standards (IFRS) and HM Treasury’s Financial Reporting Manual to the extent to which they are meaningful and appropriate to NHS foundation trusts. Accounting policies are applied consistently in dealing with items considered material in relation to the accounts.
This is the third year that the accounts of the Trust’s charitable funds have been consolidated with the accounts of the Foundation Trust, to produce ‘group’ accounts (in-line with the guidance above). The comments below refer to the financial performance of the Foundation Trust, with a separate annual report for the Charity being published at a later date.
2016/17 in review
In November 2016, Jon Sergeant took up the position of Director of Finance, replacing interim Jeremy Cook, as a permanent member of staff.
Throughout the year, our Finance and Strategy and Improvement teams have worked closely to deliver savings of £11.9m for the Trust, against a target of £11m set by NHS Improvement.
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A summary of our financial performance (set out in more detail in the annual accounts) is as follows:
Savings We delivered cost savings of £11.9m for 2016/17 with a target of savings set at £14.5m for 2017/18.
Working capital Cash balances held at 31 March 2017 were £3.187m. Total loans received during 2016/17 were £21.134m. The Trust now has £80.170m of loans.
Public Dividend Capital (PDC) dividend A charge of 3.5% of average relevant net assets is payable to the Department of Health as PDC dividend, reflecting the forecast cost of the capital we used. A dividend of £3.180m was paid during 2016/17.
Income
We received a total of £385.647m income in 2016/17, which is growth of 7.25% from the previous year, reflecting the funding received for the additional activity we delivered in the year.
Our main sources of income continue to be Doncaster CCG and Bassetlaw CCG, as shown in the pie chart below.
Sources of income
Doncaster CCG 50% Bassetlaw CCG 17% Rotherham CCG 3% Barnsley CCG 2% NHS England 8% Other CCGs 7% National STF funding 6% Education and training 3% NHS Trusts 2% Other income 4%
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Revenue expenditure During the year the Foundation Trust spent a total of £387.52m. As in previous years the vast majority of our expenditure in on staffing – 62.80% with nursing staff and medical staff continue to be our biggest areas of expenditure. For 2016/17 an increased proportion of our staffing spend was on non-substantive staff, reflecting both the national challenges in recruiting in a range of key areas and the in-year increase in staffing requirements in response to the growth in demand.
Revenue Expenditure
Staff cost 64%
Drugs 10%
Clinical supplies 8%
Other expenditure 6%
Clinical insurance 5%
Subcontracting of healthcare services 4% Depreciation 2%
Capital expenditure Expenditure on larger items with a life of more than one year, typically buildings and equipment, was £7.337m of which £2.077m was funded by charitable donations. The major capital schemes in year were:
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Operational Performance
Q1 Q2 Q3 Q4 Area Indicator Standard YTD 16/17 16/17 16/17 16/17
40 Full Clostridium Difficile 10 5 8 5 26 Year
Safety MRSA 0 1 1 1 0 3
31 day wait for second or subsequent treatment: 94.00% 100% 95% 100% 97.7% 99.5% surgery 31 day wait for second or subsequent treatment: 98.00% 100% 100% 100% 100% 100% anti-cancer drug
treatments 31 day wait for second or subsequent treatment: 94.00% 100% 100% 100% 100% 100% Quality radiotherapy 62 day wait for first treatment from urgent GP 85.00% 87.7% 86.6% 85% 86.7% 86.5% referral to treatment 62 day wait for first treatment from 90.00% 97.9% 92.8% 95% 88% 93.5% consultant screening
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service referral
31 day wait for diagnosis to first treatment- all 96.00% 99.1% 99.8% 99.8% 99.3% 99.5% cancers Two week wait from referral to date first seen: 93.00% 93.4% 94.6% 94.7% 89% 92.8% all urgent cancer referrals (cancer suspected) Two week wait from referral to date first seen: symptomatic breast 93% 94.2% 96.5% 96.1% 93.3% 95.1% patients (cancer not initially suspected) A&E: Maximum waiting time of four hours from 95.00% 93.5% 93% 90.1% 88.9% 91.4% arrival/ admission/ transfer/ discharge Maximum time of 18 weeks from point of 92.00% 92.8% 92.1% 90.1% 90.5% 90.5% referral to treatment- incomplete pathway
Green: Performance achieved Orange: Performance close to achievement Red: Performance not achieved
Four hour access target
Although we failed to achieve the four hour access target, 2016/17 saw the Trust outperform many of the Trusts in the region and we were amongst the best performing organisations in the country. Despite seeing very high attendances, the Trust managed to stay above 90% 10 months out of the year, with Bassetlaw Hospital’s Emergency Department achieving over 95% for six separate months, routinely being in the top 10 of best performing departments.
As reflects the national picture, we have faced a very difficult winter period with increased demands often from older more ill patients, a position not unique to this Trust. Unfortunately this resulted in patients waiting longer than expected, with the final quarter of the year achieving 88.9% against the 95% four hour wait standard, bringing our end of year position to 91.4%, missing the standard.
Despite missing the target, we have still managed a strong performance throughout the year which has been undoubtedly due to all the staff working extremely hard in our emergency services pathways.
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18 week Referral to Treatment (RTT) targets
We narrowly missed the target of 92% for the singular target of complete pathways for 2016/17, achieving 90.5%. There were eight speciality pathways not achieving at the end of the year, mainly due to increasing levels of referrals in the year. These were General Surgery, Urology, Trauma and Orthopaedics, Ears Nose and Throat (ENT), Ophthalmology, Pain Services, Gynaecology and Cardiology.
Diagnostic waits
Improvements in pathways, and the hard work of the staff in medical imaging department, ensured that diagnostic waits for imaging were achieved at 99.3%. The overall Trust position achieved 98.8%. The only area to not achieve diagnostic waits was Audiology.
Cancer targets
For 2016/17, we have achieved the 62 day wait for first treatment, coming in at 93.5%. We also achieved our two week referral rates when cancer in not suspected, but narrowly missed out on suspected cases, achieving 92.8% instead of the required 93%. All 31 day targets were achieved.
To help achieve this target in the future, the Trust has transitioned all two week referrals to the Electronic Referral System, with all GP practices within Doncaster and Bassetlaw moved to this method 3 April 2017.
Other quality targets, including internal targets
Details of our performance against our quality targets can be found in our Quality Report on page 88.
Improving patient care - awards and accolades
Our team work incredibly hard to continuously improve our services and deliver the best possible care for our patients. It was no surprise that a number of them received external acknowledgment for their hard work by being shortlisted for awards in 2016/17 including:
April 2016 The National Diabetes Inpatient Audit (NaDIA) audit team wrote to the Trust to congratulate the staff on the improvements for significant improvements within the National Diabetes Inpatient Audit (NaDIA). The Trust has moved from significantly below national average to significantly above national average, with some results in the top 10% in line with the Trust’s Strategic Direction.
May 2016 End of life care provided by the Trust was named among the best in England, according to a report by the Royal College of Physicians (RCP).
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June 2016 The Trust’s inpatient survey, conducted by Picker, was published with the Trust scoring ‘as expected’ with an overall score of 8.2/10, comparing favourable to neighbouring trusts.
July 2016 A consultant at the Trust became the first British Ear, Nose and Throat (ENT) surgeon to receive visiting professor status at a top medical university in China.
The Trust was awarded silver by Nottinghamshire County Council for ‘Wellbeing at Work’ schemes offered to staff. This follows a bronze award received in October 2015.
August 2016 The Medical School at the University of Sheffield awarded Juan Ballesteros, Consultant in Emergency Medicine, the Clinical Teaching Award after students at the medical school were asked to nominate individuals who provided high quality teaching in a clinical setting and inspired and supported them through their learning.
The Trust’s Trauma Peer Review noted positive progressive since 2015/16’s audit, with concerns found to be low-level and easily resolvable.
Jason Mullarkey, Project Manager and keen cyclist at Doncaster Royal Infirmary, bagged himself a bronze in the ‘Race to Rio,’ a national workplace initiative to get NHS employees active. The Trust also managed to finish the race in third place on the organisation league table. Members of the team racked up 52,873km in total which roughly amounts to 9,000,000 calories burnt and a tremendous 37,000 hours of activity.
September 2016 A team that specialises in protecting patients from pressure ulcers at Doncaster and Bassetlaw Teaching Hospitals won first place at the Tissue Viability Society’s 2016 conference for a unique skin care routine that counteracts the effects of skin damage.
October 2016 A team of research nurses at the Trust were shortlisted for the Nursing Times Clinical Research Nursing award, for making life-changing clinical research easily accessible to all patients.
Following a successful campaign lead by the Health and Wellbeing team, we became the first acute Trust in the country to vaccinate over 75% of our front-line staff against flu.
November 2016 Director of Procurement, Andrea Smith, was nominated for NHS Leadership Academy’s Emerging Leader Award for leading her team to deliver cost-saving measures which will totalled over £2 million by the end of the financial year.
Richard Somerset, Deputy Director of Procurement received a ‘Highly Commended Award’ at the annual Health Care Supply Excellence Awards for his project management of a joint
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The Integrated Discharge Team at Bassetlaw Hospital won Care Team of the Year at the Great East Midlands Care Awards.
December 2016 The Trust was awarded a Bronze Sport and Physical Activity Award by NHS Employers for our commitment to providing healthy work place activities for staff.
NHS Leadership Academy awards the Trust’s Strategy and Improvement directorate Outstanding Non-Clinical Achievement award for cost-saving activities.
January 2017 An innovative and collaborative approach to purchasing medical supplies, which has saved Hospital Trusts in South and Mid Yorkshire, Chesterfield and Bassetlaw more than £1m, was shortlisted for Health Service Journal’s Healthcare Awards.
The British Society of Echocardiography (BSE) accredits the echocardiography service at Doncater Royal Infirmary, which performs cardiac ultrasound scans (echocardiograms) on patients, as being a high quality service and commended the clinical experts who work there.
The Trust becomes Doncaster and Bassetlaw Teaching Hospitals, becoming one of only five to gain this status in Yorkshire.
Doncaster and Bassetlaw Teaching Hospitals’ Knowledge and Library Service awarded a perfect score of 100% for Health Education England’s (HEE) annual NHS library assessment.
February 2017 Holly Ridgeway-Bowyer, Apprentice Clinical Photographer, nominated for Apprentice of the Year award by Health Education England.
The Association of Chartered Certified Accountants (ACCA) awards the Trust Approved Accredited Employer status in recognition of its commitment to providing finance staff with excellent support to ensure that they uphold the highest professional standards.
Dawn Jarvis, former Director of Strategy and Improvement, shortlisted for Finance Innovator of the Year award by the Chartered Institute of Public Finance and Accountancy (CIPFA) for her role in leading the Trust’s Strategy and Improvement team, with particular emphasis on efforts concerned with financial turnaround.
March 2017 Health and Wellbeing Lead, Helen Houghton named ‘Flu Fighter Champion’ at NHS Employer’s annual Flu Fighter Awards, thanks to work leading the Trust’s flu vaccination campaign.
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The Trainee Assistant Practitioner project awarded the 'Partnership of the Year' award at the Talent for Care awards at the Guild Hall in Hull on 10 March. The project is worked in collaboration between DBTH, Sheffield Teaching Hospitals, Barnsley District General Hospitals, St Luke's Hospice, Rotherham District General Hospital, Sheffield Health and Social Care and Sheffield Children's Hospitals.
Social, community and human rights
Communications and Engagement
Having an open and honest approach to keeping patients, the public, GPs, staff, governors and members informed about key news and developments is very important to us. Through a wide variety of mediums, including social media, members’ events and the local press, we look to genuinely engage with people, listen to their views, suggestions and feedback, and work with them to keep improving the care we provide:
Publicising public health messages, key news and developments and pursuing positive working relationships with the media. Throughout 2016/17 the Trust substantially increased its output via traditional and social media to positive effect Consulting with patients, the public and partner organisations about our strategies and developments where appropriate Being honest about mistakes, both with patients/next of kin and with external bodies where appropriate. We have continued to be open and transparent in regards to our financial position, publishing a number of staff bulletins as to our progress as well as placing columns in local media Learning from and responding to feedback, whether it’s provided directly to us or via websites like Patient Opinion and NHS Choices Responding to Freedom of Information (FOI) requests Providing patient and service users with high quality information, for example about health conditions and treatment Keeping key stakeholders, including governors, members, staff and GPs informed through regular briefings, publications and member events Holding our Board of Directors meetings and Board of Governors meetings in public Publicising our complaints procedure.
Our work delivering NHS England’s screening programmes (abdominal aortic aneurism, breast cancer, diabetic eye and cervical cancer) has continued, strengthening our community engagement across South Yorkshire and Bassetlaw, developing relationships with key partners and community leaders in Doncaster, Worksop and wider in South Yorkshire.
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We continue to improve our community engagement through education. Outreach visits to local schools, conducted by the Education Team, have provided school pupils with an understanding of the services provided by the Trust, how they can manage their own health and also to showcase career opportunities within the NHS, which was expanding upon with the Trust’s Ambassador Programme.
Trips from local schools have also been organised, with special educational needs school, Heatherwood, visiting Doncaster Royal Infirmary to understand what services are available and also to address any anxiety that pupils may have when coming into hospital.
In March, the Trust supported Keep Britain Tidy, with team members encouraged to keep their department and area tidy, while senior executive got involved, picking litter around the grounds.
Charity, volunteers and fundraising
The enormous contribution made by volunteers, fundraisers and charitable associations continues to humble us and we are truly grateful for the benefits they offer to our patients and staff.
Volunteers
We have over 250 volunteers in our hospitals who volunteer across a range of services including assisting patients at mealtimes, escorting patients and visitors around the hospital, assisting in clinics and working in our coffee shop. Many more opportunities are available and we strive to expand these opportunities each year.
Volunteers from external agencies including Royal Voluntary Service, the League of Friends, Aurora and the Montagu Hospital Comforts Fund also provide important services that enhance our patients’ hospital experience.
Charitable funds and fundraising
Charitable and legacy funds such as the Montagu Hospital Comforts Fund, the Bassetlaw Hospital League of Friends and the Fred and Ann Green Legacy enable us to provide items or services that benefit patients and staff but which are additional to those that the NHS should reasonably provide.
Countless individuals, many of them patients or their relatives have fundraised for the Trust’s charitable funds or bequeathed legacies. We are very touched by their generosity, and that of the many companies and organisations that have made donations to benefit patient care in 2016/17.
Being green and sustainable
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Our commitments to sustainable environments and energy saving continue to form part of our overall strategy.
The Trust’s combined power engines at both DRI and Montagu Hospitals generate over 1.2 megawatts of energy. This supports both heating and steam generation on site and also the heating provision and sterilisation processes within the hospital’s sterile disinfection unit. The electrical generation that is created is fed back on to the network and provides for nearly half the electrical capacity required on the DRI site.
In addition the Trust has two deep ground boreholes providing primary water supplies to both Doncaster Royal Infirmary and Bassetlaw Hospital. These provide much of the site’s water supplies from a sustainable and natural water aquifer. During the last year the pumps for both systems have been replaced to maintain optimum efficiency from the borehole supplies.
The reportable carbon emission of the Trust has continued to show a downward trend resulting in a reduced carbon reduction commitment cost to the Trust this year.
In terms of the carbon reduction commitment the CHP engines have an annual scrutiny by the Environment Agency.
In addition to reducing our waste streams as far as possible, we also aim to provide the safest possible systems and use the ‘Sharpsmart’ system for the disposal of sharps and needles.
The Trust has committed to developing an ‘active travel plan’ for staff, to improve health and wellbeing and to also reduce the impact on local communities and the environment. The plan, currently open for consultation with staff, means encouraging team members to get more active when working, especially for those with office-based positions, as well as considering how they travel to and from work, or between sites.
Key developments since the end of 2016/17
The Trust said goodbye to two Board members on 31 March 2017. Dawn Jarvis left the organisation on 31 March as Director of Strategy and Improvement after five years at the Trust and David Crowe departed after eight years as a Non-executive Director. David has been replaced on the Board by Neil Rhodes.
The Trust launched its new financial system, SBS, on 3 April 2017.
Principal risks and uncertainties and factors affecting future performance
The principal risks against achievement of the Trust’s strategic objectives are around the delivery of accurate financial reporting, compliance with regulatory standards, ensuring appropriate estates infrastructure is in place and cyber security.
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Ensuring we comply with financial performance aspects of the regulatory framework and deliver accurate financial reporting
The Trust has made significant strides to reduce its deficit through delivering an ambitious deficit reduction and cost improvement programme. In addition, weaknesses in the financial controls of the Trust have been bolstered through regular monitoring of progress through a new Financial Oversight Committee and the enhancement of key roles within the Trust’s finance team.
This resulted in a clean set of accounts for 2015/16, completion of month nine accounts and a consistency of reporting over the year. Although direct regulatory involvement has reduced throughout the year, the Trust nevertheless remains in a position of mandated support in respect of the NHS Improvement Single Oversight Framework and its provider licence. It is also non-compliant for delivery of accurate financial reporting underpinned by effective financial governance.
Over the coming year, the planned introduction of a new financial system, loss of corporate memory and further CIP plans pose significant challenges for the Trust.
Ensuring that appropriate estates infrastructure is in place to deliver services
A significant proportion of the Trust’s estate dates back to the 1960s and requires investment to ensure that we are able to meet our legal requirements and maintain a safe environment in which to care for our patients. An external report in November 2015 highlighted necessary remedial action to ensure the building was compliant with existing regulations and additional surveys have brought the main issues into corporate focus.
In 2016/17 the Trust reinstated its governance framework for overseeing capital works and the estates capital programme for 2016/17 is based upon maintaining and improving the safety of the buildings and their environments and, in so doing, supporting the patient safety agenda. Moving forward, the availability of capital funds to support such improvements remains a challenge.
Failure to achieve compliance with performance and delivery aspects of Single Oversight Framework, CQC and other regulatory standards, triggering regulatory action
The Trust was last inspected by the CQC in April 2015 and received a rating of ‘requires improvement’, with ‘good’ for caring and well-led. Recommendations have been monitored through the Trust’s Clinical Governance Oversight Committee and, at an operational level, through regular monitoring of targets at care group level.
Work is still required to ensure that the recommendations are embedded throughout the organisation. A key challenge remains around recruiting, retaining and developing sufficient nursing and other clinical staff to ensure safe staffing levels. We are using both national and local evidence to define evidence-based staffing levels for an increasingly wide range of staff.
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Governance structures are in place to support the active reduction of our agency spend in- line with the introduction of new price caps and to minimise our reliance on agency and locum.
Ensuring the Trust remains operational in case of cyber security breach
A recent issue at a neighbouring trust has exposed the vulnerability of NHS organisations to cyber security breaches. In response, the Trust is carrying out detailed penetration testing of its systems, ensuring staff are aware of their responsibilities in mitigating the risks and putting in place sufficient staffing capacity and capability.
Working towards Sustainability and Transformation Plans (STP)
The STP, made up of trusts and CCGs within Doncaster, Bassetlaw, Sheffield, Rotherham and Barnsley, is the local approach to delivering the national ‘Five Year Forward View’ plan, as put forward by NHS England. 25 health care partners from across the region are involved in the plan, along with Healthwatch and voluntary sector organisations, and the Trust’s future plans will work in tandem and partnership with the STP.
The estates capital programme for 2017/18 is based upon maintaining and improving the safety of the built environment and in so doing supporting the patient safety agenda.
Going Concern
After making enquiries, the directors have a reasonable expectation that the NHS foundation trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts.
Insert Signature
Accountability Report
Directors Report
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Composition of the Board
During 2016/17, the following persons were members of the Board of Directors:
Name Position Term of Term of office Attendance office from at Board meetings Suzy Brain England Chair of the Board (from 1.1.17) 3 years 1.1 2017 3 of 3 Chris Scholey Chairman (to 31.12.16) 1 year 1.1.2016 9 of 9 Alan Armstrong Non-executive Director 2 years 1.10.2016 12 of 12 (Senior Independent Director from 1.10.16) Geraldine Broderick Non-executive Director (and 2 years 1.4.2014 3 of 3 Senior Independent Director). Both roles to 18.7.16. David Crowe Non-executive Director (to 2 years 1.4.2015 9 of 12 31.3.17) Martin McAreavey Non-executive Director 3 years 1.3.2015 12 of 12 John Parker Non-executive Director 3 years 1.4.2016 11 of 12 (Deputy Chairman to 31.3.17) Linn Phipps Non-executive Director (from 3 years 1.1.2017 3 of 3 1.11.7) Philippe Serna Non-executive Director 3 years 1.7.2015 10 of 12 Mike Pinkerton Chief Executive (to 31.1.17) 9 of 10 Richard Parker Director of Nursing, Midwifery and Quality (to 31.12.16) / 11 of 12 Chief Executive (acting from 1.1.17, substantive from 1.2.17) Karen Barnard Director of People and Organisational Development (from 10 of 11 2.5.2016) Jeremy Cook Interim Director of Finance (to 1.11.2016) 7 of 7 Moira Hardy Acting Director of Nursing, Midwifery and Quality (from 3 of 3 3.1.17) Dawn Jarvis Director of Strategy and Improvement (to 31.3.2017) 11 of 12 David Purdue Chief Operating Officer 12 of 12 Jon Sargeant Director of Finance (from 2.11.2016) 5 of 5 Sewa Singh Medical Director 12 of 12
All Non-executive Directors are considered to be independent, meeting the criteria for independence as laid out in NHS Improvement’s Code of Governance.
Non-executive Directors are appointed and removed by the Board of Governors, while Executive Directors are appointed and removed by the Nominations and Remuneration Committee of the Board.
The outgoing Chairman, Chris Scholey, had no other significant commitments and this position did not change during the year.
The new Chair of the Board Suzy Brain England’s other main commitments are as Chair of Keep Britain Tidy and Derwent Living and as a Lay Representative for Health Education
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England: Yorkshire and Humber. This position did not change since her commencement in post on 1 January 2017.
Balance of the Board Non-executive Directors are appointed to bring particular skills to the Board, ensuring the balance, completeness and appropriateness of the Board membership.
The Board of Directors considers the balance and breadth of skills and experience of its members to be appropriate to the requirements of the Trust. The skill mix of the Board was considered by the Appointments and Remuneration Committee of the Board of Governors during 2016/17 as part of Non-executive Director appointments processes, and the Committee recruited two Non-executive Directors in this period.
Brief details of all Directors who served during 2016/17 are as follows:
Suzy Brain England OBE C.Dir (Joined Trust 1 January 2017) is an experienced board chair, non-executive director, consultant, mentor and counsellor. Suzy is currently the Chair of Derwent Living Housing Association, Chair and Trustee of Keep Britain Tidy, Lay Representative for Health Education England's doctor training and recruitment in Yorkshire, a member of the Institute of Directors' Accreditation and Standards Committee, and founder of Cloud Talking mentoring services. Suzy has a wealth of experience in chairing and serving on boards in a variety of sectors including health, housing, enterprise and finance. She is a former Chair of Kirklees Community Healthcare Services, former Non-executive Director and Acting Chair of Mid-Yorkshire Hospitals NHS Foundation Trust and was a Non- executive Director at Barnsley Hospital NHS Foundation Trust. She was awarded an OBE for her work as Chair of the Department of Work and Pensions Decision Making Standards Committee. Suzy began her career as a journalist and in her executive roles she has been CEO of The Talent Foundation, the Earth Centre in South Yorkshire and a Director in the Central London Training and Enterprise Council.
Chris Scholey (left Trust 31 December 2017) was previously the Managing Director of Renaissance South Yorkshire. He was UK Sales and Marketing Director then UK Managing Director of Rexam Glass from 1988 to 2005. Chris lives in Dinnington and has a physics degree from Liverpool.
Alan Armstrong has spent most of his career working in personnel and human resources in industry. In 1996, he joined NSK Europe Ltd, a Japanese-owned firm that produces bearings for the automotive and general industrial markets, as their Human Resources Manager and rose to Board-level positions. He was their European HR Director from 2010 until May 2013. Alan now runs his own consultancy firm focusing on corporate HR strategy development, talent management, employee engagement and facilitating continuous improvement within organisations. He is also a member of the Institute of Directors and spent two years as a Non-executive Director of Nottinghamshire and Derbyshire Chamber of Commerce.
Geraldine Broderick (left Trust 18 July 2016) has gained a wealth of accountancy and management experience during her career, acting as Managing Director for three companies of the Barlow Group from 1997 to 2001. From 2001 to 2005, she was the
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Managing Director responsible for combining the eight companies into one entity. Geraldine now runs Leah & Broderick Associates, a management consultancy that specialises in interim management and business turnaround, working with organisations to develop strategic plans and implement business excellence frameworks. Geraldine has also been a Non-executive Director for A1 Housing in Bassetlaw.
David Crowe (joined Trust 31 March 2017) lives in Carlton-in-Lindrick, near Worksop, and has a background in human resources management. Over the years, he has worked in printing, home shopping, local government, and engineering. Most recently, he was HR Director for a privately-owned printing group, BGP, with Board-level responsibility for HR strategy and operations. This included handling issues related to the company’s expansion as well as to factory closure. From 2000 to 2006, he was HR Director of the UK’s largest independent print group, Polestar. David is a member of the Leeds Employment Tribunal Panel and of the Central Arbitration Committee.
Martin McAreavey left Northern Ireland when he was 18 to train in Medicine and General Medical Practice in Scotland. In 1999 he moved with his family to Yorkshire to train in Public Health Medicine. Since qualifying as a Consultant in Public Health Medicine in 2005 he has taken on increasingly senior roles in Health Care and Health Care Education, his current role being Deputy Director of the Leeds Institute of Medical Education, this institute responsible for the training of new doctors (approx. 1,400 medical students in total), and Associate Professor at the University of Leeds. He also holds an honorary Consultant contract in Public Health Medicine with Public Health England and an Executive Master of Business Administration degree from the Leeds University Business School.
John Parker was born and brought up in Manton, Worksop and currently lives in Saxilby. He is a qualified accountant and during his career has gained a wealth of financial experience. In addition to senior Civil Service appointments, John has been Finance Director for a number of large public and private sector organisations. John is currently Senior Lecturer in Finance at Sheffield Hallam University Business School and is a partner in a firm of financial management consultants.
Linn Phipps (joined Trust 1 January 2017) has a background in the public sector, originally in public transport and local government director roles. For over 15 years she has held a portfolio of Non-executive Director (NED) and consultancy posts. She has been a Non- executive Director/Chair in NHS primary care and in mental health/learning disability care. Her consultancy and non-executive work focuses on coaching, mediation and facilitation; addressing governance and risk; and reducing health inequalities. She has national roles representing patient and public voice, for example serving on two NICE (National Institute for Health & Care Excellence) committees as a Lay Member, and on NHS England’s Patient Online Programme Board as Chair of its Stakeholder Forum. Previously the Chair of Healthwatch Leeds, she is now Deputy Chair, and until November 2016, served as a Patient and Public Voice representative of NHS England's Clinical Priorities Advisory Group.Linn is particularly interested in how patient and public views influence what happens in health and care.
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Philippe Serna was educated at the University of New South Wales, in Australia and is a qualified chartered accountant with over 25 years’ experience. He has worked through his own company as a senior interim consultant to Blue Chip and smaller companies throughout Europe since 2003. Philippe has expertise in risk management, process design, control and audit along with director level finance and management experience. He also currently serves on the board of an Academy Trust.
Richard Parker was appointed Chief Executive in January 2017. Richard's previous role was Director of Nursing, Midwifery & Quality. Richard began his career as a student nurse, qualifying in 1985. Richard was appointed Deputy Chief Nurse at Sheffield Teaching Hospitals in 2005, Deputy Chief Operating Officer in 2010 and then Chief Operating Officer in 2013. He held that position until joining us in October 2013. Richard has a special interest in ways of ensuring that nurse staffing levels are safe, appropriate and provide high-quality patient care. He gained a MBA (Health and Social Services) in 1997 from Leeds University and the Nuffield Institute for Health and his dissertation was on acuity, patient dependency and safe staffing levels.
Mike Pinkerton (left the Trust 31 January 2017) joined the Trust as Chief Executive in 2013, after holding previous roles within the organisation. Mike’s first degree was in biomedical electronics and his early career was in medical and industrial technologies in the private and public sectors. Mike has an MSc in Public Sector Management and was on the NHS Graduate Training Scheme. He has experience of general and quality management across acute, community and mental health sectors, and was Chief of Business Development at Rotherham NHS Foundation Trust prior to joining us.
Karen Barnard joined the Trust from Sheffield Teaching Hospitals where she was Deputy Director of HR and Organisational Development. Before that she worked at Mid Yorkshire Hospitals as Deputy Director of HR and has experience working for various NHS organisations across Northern Lincolnshire.
Jeremy Cook (left the Trust November 2016) joined the Trust in November 2015 as Interim Director of Finance. A Chartered Accountant with 31 years post postgraduate qualification experience of which the last 22 years have been spent in the NHS. He has worked both in Scotland and in England in small, medium and large acute trusts, large mental health trusts and in primary care. Jeremy has been self-employed covering interim and project work for the last six years. He has spent three years working in Central London and three years within Greater Manchester.
Moira Hardy qualified as a registered general nurse in 1985 from the Sheffield School of Nursing, and become Acting Director of Nursing, Midwifery and Quality in January 2017. She has worked in a number of corporate senior nursing roles at Assistant Chief Nurse level before moving to Doncaster as Deputy Director of Nursing, Midwifery & Quality in July 2014. Moira is a strong advocate for patients and promoting positive patient experience. She gained a BMedSci in Nursing Studies from the University of Sheffield in 2000.
Dawn Jarvis (left the Trust 31 March 2017) has a Masters degree in Human Resource Management and was the Director of People and Change at the Department for Education
31 prior to joining the Trust. Dawn has a background in HR, transformational change, leadership, and efficiency. She left the Trust in March 2017.
David Purdue qualified as a registered general nurse from Nottingham University in 1990 and specialised in cardiac nursing in Nottingham where he set up a number of cardiac nurse- led services, an innovation that won him an award from the National Modernisation Agency. After four years working on the implementation of the National Service Framework for coronary heart disease and then improving access to heart services in the East Midlands, David returned to hospital life in 2004 as clinical nurse manager for cardiothoracics at City Hospital in Nottingham. He joined the Trust in October 2008 as Divisional Nurse Manager for Medicine. David was Associate Director of Performance from 2010. He was Acting Chief Operator Officer from June 2013 until his substantive appointment to the role in July 2013.
Jon Sargeant joined the Trust as Director of Finance in November 2016. Previously Director of Finance at Burton Hospitals NHS Foundation Trust, Jon has over 25 years of experience, working exclusively in the health service. Starting as a Financial Trainee at Heartlands Hospital in 1989, Jon held a number of board level posts, most notably as Director of Finance at Epsom and St Helier University Hospitals, leading a number of reconfiguration projects at the London-based Trust, before moving to Burton Hospitals in 2013.
Sewa Singh graduated from Sheffield University Medical School and trained in Surgery in South Yorkshire and London. He is an enthusiastic trainer and was Director of the Surgical Training Programme in South Yorkshire from 2009 until appointment as Medical Director. He has worked for the Trust as a Consultant Vascular Surgeon since 1996. He was Clinical Director for Surgery in 2004-07, Clinical Director, Division of Surgery 2008-10, and Deputy Medical Director from 2010 until his appointment as Medical Director in April 2012.
Registers of interests All Directors and Governors are required to declare their interests, including company directorships, on taking up appointment and as appropriate at Board of Governors and Board of Directors meetings in order to keep the register up to date.
The Trust can specifically confirm that there are no material conflicts of interest in the Board of Governors or Board of Directors, and Directors and Governors declared no company directorships which may conflict with their management or governance responsibilities. The Register of Directors’ Interests and the Register of Governors’ Interests are available on request from the Foundation Trust Office at Doncaster Royal Infirmary.
Cost allocation and charging
The Trust complied with the cost allocation and charging guidance issued by HM Treasury.
Donations
The Trust made no donations to political parties or other political organisations in 2016/17 and no charitable donations in 2016/17.
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Payments Practice Code
The Trust has adopted the Public Sector Payment Policy, which requires the payment of non-NHS trade creditors in accordance with the CBI prompt payment code and government accounting rules. The target is to pay these creditors within 30 days of receipt of goods or a valid invoice (whichever is the later) unless other payment terms have been agreed with the supplier. The Trust is in receipt of cash support from the Department of Health and therefore the Trust’s cash flow is being proactively managed with the aim of paying outstanding invoices within the Public Sector Payment Policy 30 day target.
Quality governance
The Board of Directors monitors a series of quality measures and objectives on a monthly basis, reported as part of the Business Intelligence Report and Nursing Workforce report. Risks to the quality of care are managed and monitored through robust risk management and assurance processes, which are outlined in our Annual Governance Statement. The sub- committees of the Board, particularly the Clinical Governance Oversight Committee, play a key role in quality governance, receiving reports and using internal audit to test the processes and quality controls in place. This enables rigorous challenge and action to be taken to develop services to enable improvement.
During 2016/17, the Trust underwent an external governance review in accordance with NHS Improvement’s Well Led framework. In addition to examining the Trust’s approach to the four key questions of Well Led, the Trust agreed eight focus areas with NHS Improvement around whistleblowing, internal audit, collaborative working, strategic planning, risk management, the Board’s sub-committees, business planning and Board level mentoring/support.
The review was positive about the Trust’s quality culture, highlighting that the Board had led the response to the financial turnaround internally which had earned the respect of the wider workforce and had been a key factor in the delivery of financial improvements whilst maintaining a focus on quality and performance. In addition, it found that the wider culture of the Trust was clearly focussed around the quality of service provided, with good levels of awareness of the ‘We Care’ values amongst staff. Areas for improvement around quality impact assessments and data quality were highlighted.
The Board gives regular consideration to ensuring service quality in all aspects of its work, including changes to services and cost improvement plans. The Board proactively works to identify and mitigate potential risks to quality. More information on our arrangements to govern service quality can be found in our Annual Governance Statement (page 69) and Quality Report (page 88). There are no material inconsistencies to report between the Annual Governance statement, annual/quarterly board statements, the Board Assurance Framework, Quality Report, Annual Report and CQC reports.
We aim to work with patients and the public to improve our services, including the collection of feedback through the Friends and Family Test comments, patient surveys and involvement in service changes. We also work in partnership with Healthwatch Doncaster
33 and Healthwatch Nottinghamshire and the Trust’s public Governors, to promote patient and public engagement. We have actively been supported by Healthwatch and local Learning Disability patients in undertaking the Patient Led Assessment of the Care Environment (PLACE) this year. Their contribution is very helpful and important in our endeavours to make improvements for patients.
Disclosures to auditors
Each director confirms that, as far as he/she is aware, there is no relevant audit information of which the Trust's auditor is unaware, and that they have taken all the steps they ought to have taken as a director in order to make themselves aware of any relevant audit information and to establish that the Trust’s auditor is aware of that information.
Income disclosures
The directors confirm that, as required by the Health and Social Care Act 2012, the income that the Trust has received from the provision of goods and services for the purposes of the health service in England is greater than its income from the provision of goods and services for any other purposes. The Trust has processes in place to ensure that this statutory requirement will be met in future years, and has amended its constitution to reflect the Board of Governors’ new role in providing oversight of this.
In addition to the above, the directors confirm that the provision of goods and services for any other purposes has not materially impacted on our provision of goods and services for the purposes of the health service in England.
Remuneration report
Annual Statement on Remuneration
The Nominations and Remuneration Committee aims to set executive remuneration at an appropriate level to ensure good value for money while enabling the Trust to attract and retain high quality executives.
Having frozen executive remuneration in 2015/16, the Committee took the view that it was necessary to increase executive remuneration by 1% and, for the Chief Operating Officer and Director of Nursing, Midwifery and Quality by an additional £5k.
This was offered on the basis of achievement of objectives in the year, was in line with the pay increase awarded to staff nationally and took account of a 1% rise in executive salaries over the past three years. Doncaster and Bassetlaw Teaching Hospitals were also outliers in respect of executive remuneration, in that our team is generally paid less when compared with neighbouring trusts.
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The additional uplifts for the two named officers were awarded as a means of securing their continued employment and implemented following advice from an external Board Advisor appointed by NHS Improvement to work with the Trust.
Insert signature
Suzy Brain England OBE Chair of the Board
Remuneration policy – Executive Directors
It is the policy of the Nominations and Remuneration Committee to consider all reviews and proposals regarding executive remuneration on their own merits. This means that the recruitment market will be taken into account when seeking to appoint new directors, and salaries are set so as to ensure that the Trust is able to recruit and retain individuals with the required competencies and skills to support delivery of the Trust’s strategy.
Executive directors do not have any performance related components within their remuneration, and do not receive a bonus.
The committee does not routinely apply annual inflationary uplifts or increases, and only applies uplifts of any kind where this is thought to be justified by the context. The primary aim of the committee is to ensure that executive remuneration is set at an appropriate level to ensure good value for money while enabling the Trust to attract and retain high quality executives.
The committee considers the pay and conditions of other employees when setting the remuneration policy, but does not actively consult with employees. The committee also considers the remuneration information published annually by NHS Providers when making decisions regarding appropriate remuneration levels.
One Executive director earns more than £142,500, and the Nominations and Remuneration Committee has given detailed consideration to the context of this salary and the performance of the individual in order to satisfy itself that this remuneration is reasonable.
Remuneration policy – Senior managers 1
As at 31 March 2017 senior managers other than the Executive directors are not remunerated according to Agenda for Change Terms and Conditions of service.
As part of the appraisal process, the remuneration of these managers may reduce or increase on the basis of performance, including delivery of personal objectives and CIP targets. The starting salary for these managers is generally market based, within the pay strategy set by the Trust. With the exception of remuneration, all other Agenda for Change Terms and Conditions, including those relating to payment for loss of office, are applied to these managers.
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All other managers are remunerated in accordance with either the Agenda for Change or Terms and Conditions of service. Approval to pay remuneration outside of Agenda for Change Terms and Conditions may only be granted by the Director or Deputy Director of People and Organisational Development.
For managers who are paid according to Agenda for Change Terms and Conditions, the Trust is under an obligation to pay increments and uplifts in accordance with national pay agreements. The Trust does not propose to introduce any new obligation which could give rise to, or impact on, remuneration payments or payments for loss of office.
The Trust intends to maintain this remuneration policy for 2017/18.
NOTE: 1 This section of the report discusses the wider remuneration policy applied to senior managers not paid in accordance with Agenda for Change Terms and Conditions, but it should be noted that these employees do not meet the NHS Improvement definition of a ‘senior manager’, and have therefore not been included in the remuneration tables .
Remuneration policy - Other employees
Other than the senior managers and Executive directors referred to above, all employees are paid according to either the Agenda for Change or Terms and Conditions of service.
Nominations and Remuneration Committee of the Board of Directors
The Nominations and Remuneration Committee of the Board of Directors is responsible for the appointment and remuneration of Executive directors.
The membership of the committee in 2016/17 consisted of the Chairman and Non-executive Directors. The Chief Executive, the Director of People and Organisational Development (both of whom withdraw if their own remuneration or appointment is considered) and the Trust Board Secretary attend by invitation in order to assist and advise the committee. The committee was convened on six occasions during the year to discuss appointments and the remuneration of Executive Directors.
Name Role Attendance Suzy Brain England Chair of the Board (from 2 of 2 OBE 1.1.17) Chris Scholey Chair of the Board (to 4 of 4 31.12.16) Alan Armstrong Non-executive Director 6 of 6 (Senior Independent Director from 1.10.16) Geraldine Broderick Non-executive Director (to 1 of 1 18.7.16)
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David Crowe Non-executive Director (to 3 of 6 31.3.17) Martin McAreavey Non-executive Director 6 of 6 John Parker Non-executive Director 6 of 6 (Deputy Chair of the Board to 31.3.17) Linn Phipps Non-executive Director (from 2 of 2 1.1.17) Philippe Serna Non-executive Director 4 of 6
Fair pay comparison
At 31 March 2017, the ratio of the annual salary of the highest-paid director (the Chief Executive) to the median salary of Trust staff was 7.72:1 (7.27:1 on 31 March 2015). The median figure was £21,692 (31 March 2016 was £20,368).
Expenses
2016/17 2015/16 No. No. No. in Expenses No. in Expenses receiving receiving office Paid (£) office Paid (£) expenses expenses Non-executive 9 9 £10,209.24 7 6 £7,234.43 directors Executive directors 9 5 1,980.43 6 4 £2,423.20 Governors 35 8 £2,242.80 39 10 £4,086.72
Senior Managers Service Contracts
All directors have a notice period of six months.
Name Position Date of contract Unexpired (date term as at commenced in 31 March post as senior 2017 manager) Suzy Brain England Chair of the Board (from 1.1.17) 1.1.2017 2 years 9 OBE months Chris Scholey Chairman (to 31.12.16) 1.1.2009 n/a Alan Armstrong Non-executive Director (Senior 1.10.2013 1 year 6 Independent Director from 1.10.16) months
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Geraldine Non-executive Director (and Senior 1.4.2009 n/a Broderick Independent Director). Both roles to 18.7.16. David Crowe Non-executive Director (to 31.3.17) 1.4.2009 n/a Martin McAreavey Non-executive Director 1.3.2015 11 months John Parker Non-executive Director (and Deputy 1.4.2010 1 year Chair of the Board to 31.3.17) Linn Phipps Non-executive Director (from 1.1.17) 1.1.2017 2 years 9 months Philippe Serna Non-executive Director 1.7.2015 1 year 4 months Mike Pinkerton Chief Executive (to 31.1.17) 11.6.2012 n/a Richard Parker Director of Nursing, Midwifery & Quality 14.10.2013 n/a (to 31.12.16) / Chief Executive (acting from 1.1.17, substantive from 1.2.17) Karen Barnard Director of People and Organisational 2.5.2016 n/a Development (from 2.5.16) Jeremy Cook Interim Director of Finance (to 1.11.16) n/a n/a Moira Hardy Acting Director of Nursing, 3.1.2017 n/a Midwifery and Quality (from 3.1.17) Dawn Jarvis Director of Strategy & Improvement (to 11.6.2012 n/a 31.3.2017) David Purdue Chief Operating Officer 10.7.2013 n/a Jon Sargeant Director of Finance (from 2.11.16) 2.10.2016 n/a Sewa Singh Medical Director 1.4.2012 n/a
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Name and Title 2016-17 2015-16 Salary and Taxable Annual Long Term Pension Other Total Salary and Taxable Annual Long Pension Other Total fees benefits Perform- Perform- Related Remuner (bands fees benefits Perform- Term Related Remuner (bands of (bands of Rounded ance ance benefit -ation of £5000) (bands of Rounded ance Perform- benefit -ation £5000) £5000) to related related (bands of (bands of £5000) to related ance (bands of (bands of the bonus bonus £2500) £5000) the bonus related £2500) £5000) nearest (bands of (bands of nearest (bands of bonus £100 £5000) £2500) £100 £5000) (bands of £2500)
Suzy Brain England 10-15 10-15 n/a n/a OBE – Chair of the Board (from 1 January 2017) Chris Scholey – 30-35 30-35 40-45 40-45 Chairman (to 31 December 2016) Alan Armstrong 10-15 10-15 10-15 10-15 Non-executive Director Geraldine Broderick 0-5 0-5 10-15 10-15 Non-executive Director (to 18 July 2016) David Crowe 10-15 10-15 10-15 10-15 Non-executive Director (to end March 2017) John Parker 10-15 10-15 10-15 10-15 Non-executive Director Martin McAreavey 10-15 10-15 10-15 10-15 Non-executive Director Linn Phipps 0-5 0-5 n/a n/a Non-executive Director Philippe Serna 10-15 10-15 5-10 5-10 Non-executive Director Mike Pinkerton 140-145 110- 250-255 165-170 85-87.5 250-255 Chief Executive (to 31 112.5 January 2016) Sewa Singh(Note 1) 215-220 210-215 85-87.5 300-305
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Medical Director Jeremy Cook(Note 2)- 155-160 155-160 Interim Director of Finance (to 1.11.16) Dawn Jarvis - Director 120-125 45-47.5 165-170 120-125 40-42.5 160-165 of Strategy and Improvement (to 31 March 2017) David Purdue 110-115 70-72.5 180-185 115-120 37.5-40.0 150-155 Chief Operating Officer Richard Parker - 125-130 125- 250-255 115-120 15-17.5 130-135 Director of Nursing, 127.5 Midwifery & Quality (to 31.12.16) / Chief Executive (acting from 1.1.17, substantive from 1.2.17) Jon Sargeant – Director 55-60 30-32.5 85-90 n/a n/a n/a of Finance (from 2.11.16) Karen Barnard – 95-100 22.5-25 115-120 n/a n/a n/a Director of People and Organisational Development (from 2 May 2016) Moira Hardy – Acting 20-25 n/a n/a n/a Director of Nursing, Midwifery and Quality (from 3 January 2017)
* Salary at appointment band 165-170. For 2014/15 a voluntary reduction applied Note 1 - Includes remuneration related to clinical duties Note 2 - Payment to third party including VAT, left organisation November 2016
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The remuneration report table above has been prepared in line with 2015/16 ARM for Foundation Trusts. The basis of calculation for pension related benefits shows the pension accrued in year multiplied by a factor of 20, this has resulted in large pension related benefits being shown in the remuneration report table above.
The basis of calculation for pension related benefits is in line with section 7.69 of the ARM, and follows the ‘HMRC method’ which is derived from the Finance Act 2004 and modified by Statutory Instrument 2013/1981. The calculation required is: Pension benefit increase = ((20 x PE) + LSE) - ((20 x PB) + LSB))
PE is the annual rate of pension that would be payable to the director if they became entitled to it at the end of the financial year; PB is the annual rate of pension, adjusted for inflation, that would be payable to the director if they became entitled to it at the beginning of the financial year; LSE is the amount of lump sum that would be payable to the director if they became entitled to it at the end of the financial year; and LSB is the amount of lump sum, adjusted for inflation, that would be payable to the director if they became entitled to it at the beginning of the financial year.
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Pension benefits Salary and pension entitlements of senior managers
Name and Title Pension Pension Real increase/ Real Total accrued Cash Equivalent Cash Real increase/ Employers benefit at benefit at (decrease) in increase/(decrease) pension and Transfer Value at Equivalent (decrease) in Contribution March 2017 March 2016 Pension Benefit in pension and related lump sum 31 March 2017 Transfer Cash to Stakeholder (Bands of (Bands of (Bands of £2500) related lump sum at at age 60 at 31 £000 Value at 31 Equivalent Pension £5000) £000 £5000) £000 £000 age 60 March 2017 March 2016 Transfer To nearest (Bands of £2500) (Bands of £2500) £000 Value £100 £000 £000 £000
Mike Pinkerton 60 -65 55.0-60.0 5 – 7.5 15.0 – 17.5 247.5 – 250.0 Nil 1,118 - - Chief Executive (to date 31.1.17) note 1 Sewa Singh 75 - 80 70-75 2.5 -5.0 7.5 – 10.0 310 – 312.5 1774 1,654 120 - Medical Director Jon Sergeant 40 - 45 40 -45 2.5 – 5.0 2.5 – 5.0 165 – 167.5 778 735 43 Director of Finance (from 2.11.16) Karen Barnard 40 - 45 40 - 45 0 – 2.5 2.5 – 5.0 167.5 - 170 848 824 24 Director of People and Organisational Development Dawn Jarvis - Director of 10 - 15 5.0-10.0 0 – 2.5 - 10.0 – 12.5 109 83 26 - Strategy and Improvement (to 31.3.17) David Purdue 40 - 45 35-40 2.5 – 5.0 2.5 – 5.0 160.0 – 162.5 714 652 62 - Chief Operating Officer Richard Parker – Director of 45 - 50 40.0-45.0 5.0 – 7.5 15 – 17.5 187.5 – 190.0 905 779 126 - Nursing, Midwifery and Quality Chief Executive (acting from 1.1.17, substantive from 1.2.17)
Note 1 – Variance due to retirement and therefore taking pension
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Cash Equivalent Transfer Value (CETV)
The CETV is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member's accrued benefits and any contingent spouse's pension payable from the scheme. A CETV is a payment made by a pension scheme, or arrangement to secure pension benefits in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits that the individual has accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity to which the disclosure applies.
The CETV figures, and from 2004/05 the other pension details, include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS pension scheme. They also include any additional benefit accrued to the member as a result of their purchasing additional years of pension service in the scheme at their own cost. CETV's are calculated within the guidelines and framework prescribed by the Institute and faculty of Actuaries.
Real increase in CETV
This reflects the increase in CETV effectively funded by the employer. It takes account of the increase in accrued pension due to inflation, contributions paid by the employee (including the value of any benefits transferred from another pension scheme or arrangement) and uses common market valuation factors for the start and end of the period. On 1 October 2008, there was a change in the factors used to calculate CETVs as a result of the Occupational Pension Scheme (Transfer Value Amendment) regulations. These placed responsibility for the calculation method for CETVs (following actuarial advice) on Scheme Managers or Trustees. Further regulations from the Department for Work and Pensions to determine CETV from Public Sector Pension Schemes came into force on 13 October 2008.
In his budget of 22 June 2010 the Chancellor announced that the uprating (annual increase) of public sector pensions would change from the Retail Prices Index (RPI) to the Consumer Prices Index (CPI) with the change expected from April 2011. As a result the Government Actuaries Department undertook a review of all transfers factors. The new CETV factors have been used in the above calculations and are lower than the previous factors we used. As a result the value of the CETVs for some members has fallen since 31 March 2010.
Our staff
We can only realise our vision as a Trust through the enthusiasm, innovation, hard work, engagement and behaviours of our staff. How they feel about working here and their commitment to the patients, the Trust and the NHS are all vital to providing outstanding care to our patients. It is absolutely crucial that we recruit and retain the right people, support their health and wellbeing, enable them to maintain the highest level of knowledge and skill,
43 and support them in doing their jobs. We believe that this is a Trust with great people providing great care every day, but we also know that we can continually improve, aiming to be the best in our class in everything we do.
Keeping staff informed and engaged
We engage with our staff in a range of ways, from formal consultation with staff side representatives through collective agreements, to open feedback forums regarding planned changes. Our monthly Staff Brief keeps people informed about key news and developments, including the Trust’s performance and how staff can contribute towards improvement. This follows the monthly Board of Directors meeting that takes place a few days earlier and ensures information is cascaded quickly throughout the organisation. Members of the executive team brief members of staff at each site, encouraging engagement and informal questions. The Staff Brief documents are also cascaded through the organisation by managers and team leaders and are made available on the intranet.
The weekly DBTH Buzz staff newsletter, which communicates key information, celebrates individual and team achievements and explains what different people’s jobs involve to highlight how every member of staff has an important role to play in our success as an organisation, continues to be well received across the organisation.
In line with our cost saving efforts this year, we introduced a separate, monthly, bulletin called the Monthly Turnaround. This one page missive kept staff up-to-date on all things cost improvement, simply communicating this information in a number of small boxes contained with snippets of information such as our performance against monthly cost saving targets, overachievement and overarching goal.
The Ask the Boss facility also allows staff to put their questions and suggestions to the Chief Executive, receiving a direct response if they have provided their contact details. Full responses to staff questions are also published on the staff intranet.
We have also branched into different mediums of communication. In 2017 we introduced a staff Facebook ‘group’. With over 1,200 members, this closed network is hosted by Facebook and administrated by the Communications Team, only open to members of the Trust. This new platform gives staff an informal forum in which to communicate, as well as giving the organisation the opportunity to share news with those harder to reach groups of staff.
Reward and recognition
It is important that we encourage and recognise good performance by our staff so our staff awards scheme called DBTH Stars (Staff Awards and Recognition Scheme) enables any employee to nominate colleagues who deserve recognition for the work they do. Once a month a panel of staff and managers review the nominations and select the winning ‘Star’. The winner receives gift vouchers and a place on our ‘wall of stars’; all nominees receive a certificate.
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In September 2016, we held the annual DBTH Stars event celebration at Doncaster’s Keepmoat Stadium. The event, organised in partnership with the Doncaster Free Press, and hosted by Look North’s Harry Gration, was a resounding success with staff and sponsors and we are already organising the 2017 event.
Health and Wellbeing
A healthy workforce is a vital element in providing high-quality care to our patients. The Health and Wellbeing strategy has picked up pace with an increase in staff engagement of healthy lifestyle activities. A new Lifestyle Assessment Service for staff has been launched, along with a range of exercise opportunities including a walking programme. A team of over 50 health champions from within existing staff have been recruited and trained and are available to support staff with leading a healthier lifestyle.
Our 2016 Staff Survey results show a slight increase in staff experiencing work related stress and we aim to improve on this in the coming year, with a range of opportunities for staff including training and mindfulness.
We have achieved the Nottinghamshire Wellbeing at Work Award at Silver level and we are working towards Gold. We are also working towards achieving the National Workplace Health Charter. We achieved the National Sport and Physical Activity Bronze Award and are working towards the Silver Award. We also came third in a national NHS physical activity challenge.
Our Health and Wellbeing team supports people returning to work after illness and this year with cross-organisational support ran another very successful flu vaccination programme that resulted in 75% of frontline staff being immunised by 30 October 2016 and receiving the accolade of being the first Trust in the Country to vaccinate 75% of frontline workers.
Health and safety
During the past year, we have continued to encourage staff to report issues, and have seen a decrease of 8.9% in the number of issues reported in comparison to the last financial year. This reduction can be attributed to different ways of working, such as the Enhanced Care Team which ensures vulnerable patients have supervision when on the ward.
This financial year has seen an increase in the number of correctly reported staff incidents to Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) reporting to the Health and Safety Executive (HSE), attributable to a variety of causes. While there have been a small number of incidents that have been submitted erroneously, the rest remain correctly reported, an encouraging development, with further awareness training scheduled for 2017.
It has been identified through HSE and regional reports that the Trust has been under- reporting for Sharps, with the number of related injuries lower that other Trusts locally. Throughout the past 12 months there has been a drive to ensure that Sharps injuries are not
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only reported to Occupational Health or Emergency Departments but are reported on Datix. There is a 16.3% increase in reported sharps injuries compared to the last financial year (121 incidents compared to 104). This is encouraging, and further work is scheduled for 2017 within this reporting field.
Our approach to Statutory and Essential to role Training (SET) continues to improve, with the Trust achieving 74.23% compliance for 2016/17 based upon 6,330 Trust employees. Action plans have been developed and are in place to support areas specifically around access to and support with e-Learning, with a number of bespoke education sessions trialled recently for the identified staff groups with positive outcomes evidenced. This will help to increase the compliance statistics further in the coming year.
Education and training
As part of our promise to staff to Develop Belong Thrive Here we are committed to the training of our staff to enable them to provide an excellent service for our patients. Our Education and Training department facilitates this process by providing a wide range of courses offering personal and professional development, as well as Statutory and Essential for Role Training.
Our formal recognition as a Teaching Hospital is reflected in our commitment to developing our staff to enable them to provide an excellent service to our patients. Our Education and Training department facilitates this process by providing a wide range of educational opportunities, study events and courses offering personal and professional development, as well as Statutory and Essential for Role Training.
Care Group Education leads support the Training and Education Department to align the Care Group structure with bespoke training within the service.
All three hospital sites have newly refurbished training rooms with eLearning suites to support learning close to the work place. There will be many new opportunities over the next year with the introduction of the apprenticeship levy.
Workforce statistics as at 31 March 2017
(excl. bank and locum) Headcount (Perm) FTE Headcount (Other) FTE Total staff employed as at 6,174 5,128.39 670 394.90 31 March 2017 Clinical Support 1,334 1096 37 36.27
Other Healthcare 684 607.48 14 13.09 Professionals Medical and Dental 327 311.26 189 180.04 Nursing and Midwifery 1,833 1,580.17 30 26.67
Non Clinical (Admin & Clerical 1,996 1532 171 132.08 and Estates & Ancillary)
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2016/17 2016/17 Actual Benchmarking data Target 2015/16 rate was 4.16% Staff Sickness Absence Rate 4.46% 3.50% In 2015/16 the regional average was 5%
Equality and diversity
We have a richly diverse workforce (see our workforce statistics below), with staff from across the globe working alongside those born and bred in South Yorkshire and Bassetlaw. Respect for each other’s unique skills, experience and strengths is an integral element in effective team-working and our Fair Treatment for All policy sets out the standards we expect.
This includes equality of opportunity for job applicants, where we anonymise applications before shortlisting. We are a now recognised as Level 2 on the Disability Confident Scheme (replaced the Disability Two Ticks framework) focused on retention as well as recruitment. To support this work we have policies and guidelines in place to support the recruitment of people with disabilities. We also make reasonable adjustments to enable us to retain staff who become ill or develop disabilities with support from our Occupational Health Team.
Details of our equality priorities and some of the actions we take can be found on the Equality and Diversity page of the Trust website www.DBTH.nhs.uk, where we also publish information to comply with our obligations under the Equality Act.
Equality Information as at 31 March 2017 – Directors
Gender (Directors Only) Headcount Headcount % Female 3 43% Male 4 57%
Note: All staff meeting the NHS Improvement criteria to be considered a ‘senior manager’ are directors.
Senior Managers
Gender Headcount Headcount % Female 116 68% Male 54 32%
Equality Information as at 31 December 2016
Gender Headcount FTE Headcount % Female 5,512 4,439.13 82.3
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Male 1,183 1,068.18 17.7
Age Headcount FTE Headcount % 16 - 20 45 33.24 0.67 21 - 25 485 446.35 7.24 26 - 30 697 613.13 10.41 31 - 35 712 583.47 10.63 36 - 40 667 547.02 9.96 41 - 45 835 693.86 12.47 46 - 50 971 816.88 14.50 51 - 55 1,059 871.96 15.82 56 - 60 801 614.32 11.96 61 - 65 351 242.77 5.24 66 - 70 61 37.35 0.91 71 & above 11 6.96 0.16
Ethnicity Headcount FTE Headcount % Any Other 45 42.09 0.67% Asian 309 281.64 5.32% Black 96 83.66 1.50% Chinese 20 19.39 0.35% Mixed 58 50.51 0.98% White 6,102 4,890.36 88.79% Not Disclosed 179 139.66 2.38%
Disability Headcount FTE Headcount % No 4,989 4,118.91 74.5 Yes 225 180.19 3.4 Not Disclosed 92 78.58 1.4 Unspecified 1,389 1,129.62 20.7
Sexual Orientation Headcount FTE Headcount % Bisexual 9 7.24 0.13 Gay 15 14.36 0.22 Heterosexual 2,574 2,134.91 38.45 Lesbian 15 12.75 0.22 Not Disclosed 3,174 2,596.62 47.41 Unspecified 908 741.43 13.56
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Our Trust values set out in the strategic direction, embeds our desire to eliminate all forms of discrimination, promote equality of opportunity, value diversity and foster good relations. We are firmly committed to fair and equitable treatment for all and by truly valuing the diversity everyone brings, create the best possible services for our patients and working environment for our staff.
Our Fair Treatment for all policy explicitly sets out our expectations of all staff that we will not tolerate any form of discrimination, victimisation, harassment, bullying or unfair treatment on the grounds of a person’s age, disability, gender re-assignment, marriage and civil partnership, pregnancy and maternity, race including nationality and ethnic origin, religion or belief, gender or sexual orientation.
Slavery and Human Trafficking Statement 2016/17
Slavery and human trafficking remains a hidden blight on society. We all have a responsibly to be alert to the risks in our business and in the wider supply chain. Employees are expected to report concerns and management are expected to act upon them.
Organisation’s Structure and Principal Activities
As well as being an acute foundation trust with one of the busiest emergency services in the country, we are Teaching Hospital, supported by Sheffield University and Sheffield Hallam University and have strong links with the Yorkshire and Humber Deanery.
We are fully licensed by NHS Improvement and fully registered (i.e. without conditions) by the Care Quality Commission (CQC) to provide the following regulated activities and healthcare services:
Treatment of disease, disorder or injury Nursing care Surgical procedures Maternity and midwifery services Diagnostic and screening procedures Family planning Termination of pregnancies Transport services, triage and medical advice provided remotely Assessment or medical treatment for persons detained under the Mental Health Act 1983.
We serve a population of more than 420,000 across south Yorkshire, north Nottinghamshire and the surrounding areas and we run three hospitals: Doncaster Royal Infirmary, Bassetlaw Hospital and Montagu Hospital.
Our Supply Chains
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Our supply chains include the sourcing of all products and services necessary for the provision of high quality care to our service users.
Our Policies on Slavery and Human Trafficking
We are committed to ensuring that there is no modern slavery or human trafficking in our supply chains or in any part of our business.
Due Diligence Processes for Slavery and Human Trafficking
We expect that our supply chains have suitable anti-slavery and human trafficking policies and processes. Most of our purchases are against existing supply contracts or frameworks which have been negotiated under the NHS Standard Terms and Conditions of Contract which have the requirement for suppliers to have in place suitable anti-slavery and human trafficking policies and processes.
We expect each entity in the supply chain to, at least, adopt ‘one-up’ due diligence on the next link in the chain as it is not always possible for us (and every other participant in the chain) to have a direct relationship with all links in the supply chain.
Our standard ITT documentation includes a standard question asking whether suppliers are compliant with section 54 (Transparency in supply chains etc.) of the Modern Slavery Act 2015. If they are, they are required to provide evidence. If they are not, they are required to provide an explanation as to why not. In addition, our standard contract contains the following provisions:
The Supplier warrants and undertakes that:
It will comply with all relevant Law and Guidance and shall use Good Industry Practice to ensure that there is no slavery or human trafficking in its supply chains; and (ii) notify the Authority immediately if it becomes aware of any actual or suspected incidents of slavery or human trafficking in its supply chains;
10.1.29 it shall at all times conduct its business in a manner that is consistent with any anti- slavery Policy of the Authority and shall provide to the Authority any reports or other information that the Authority may request as evidence of the Supplier’s compliance with this Clause 10.1.29 and/or as may be requested or otherwise required by the Authority in accordance with its anti-slavery policy.
Supplier Adherence to Our Values
We have zero tolerance to slavery and human trafficking. We expect all those in our supply chain and contractors to comply with our values. The Trust will not support or deal with any business knowingly involved in slavery or human trafficking.
Training
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Senior staff within our Procurement Team are duly qualified as Fellows of the Chartered Institute of Procurement and Supply and have passed the Ethical Procurement and Supply Final Test.
This statement is made pursuant to section 54 (1) of the Modern Slavery Act 2015 and constitutes the Trust’s slavery and human trafficking statement for the current financial year.
Staff Survey
Our performance on staff satisfaction is benchmarked against other similar trusts once a year in the NHS National Staff Survey. In most trusts this is done by surveying a randomly- selected representative sample of staff. Our first census survey was in 2012 and we have continued with that approach each year, surveying every substantive employee (i.e. those on long-term or permanent contracts).
In 2016 we continued with an online survey for all staff, and saw our response rates again increase. This gives us confidence in the validity of the data and the ability to drill down. We will continue to work with leaders across the Trust to achieve further improvements in response rates. However, there was a notable decrease in engagement levels reflecting broader staff concerns described below.
Summary of Performance
Results show a disappointing picture overall, with a downturn across areas, returning broadly to the results achieved prior to last year’s considerable improvement and the upward trajectory since our first census survey in 2012. Our overall score for staff engagement was 3.66 which is a decrease against 3.78 in 2015, and below the average of 3.81 for all acute trusts. We have made increasing levels of engagement across DBTH one of the key priorities for 2017.
Response rate and overall staff engagement
2015 2016 Trust improvement/deterioration Trust Trust Benchmarking Increase/decrease in Group (all percentage points Acute Trusts) average Response rate 44% 47% 43% An improved response rate, greater than the 2% increase for all acute trusts. Staff engagement 3.77 3.66 3.81 Our rate has decreased compared to an increase of 0.6% for all acute trusts for the same period.
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Top 5 Ranking scores 2015 2016 Trust improvement/deterioration Trust Trust Benchmarking Group (all Acute Trusts) average KF16. Percentage of A statistically significant staff working extra 72 69 72 decrease in this Key Factor hours KF20. Percentage of No statistically significant staff experiencing increase in this Key Finding. discrimination at 8 9 11 This was one of our five work in the last 12 highest last year also months KF25. Percentage of staff experiencing harassment, bullying No statistically significant or abuse from change in this Key Finding. 26 27 patients, 26 This was one of our five relatives or the highest last year also public in last 12 months KF26. Percentage of staff experiencing No statistically significant harassment, bullying 23 change in this Key Finding 24 25 or abuse from staff This was one of our five in last highest last year also 12 months KF28. Percentage of staff witnessing potentially harmful errors, near misses 30 30 31 No statistically significant or change in this Key Finding incidents in last month
Bottom 5 Ranking Scores 2015 2016 Trust improvement/deterioration Trust Trust Benchmarking Group (all Acute Trusts) average KF7: Percentage of A statistically significant staff able to contribute decrease in this Key Factor. towards improvements 66 63 70 One of our five lowest last at work year also.
KF9: Effective Team A statistically significant 3.6 3.75 Working decrease in this Key Factor.
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3.68 One of our five lowest last year also.
KF8. Staff satisfaction A statistically significant with level of 3.88 3.83 3.92 decrease in this Key Factor. responsibility and involvement KF10. Support from A statistically significant 3.68 3.61 3.73 immediate managers decrease in this Key Factor. KF1. Staff recommendation of A statistically significant the organisation as a 3.72 3.55 3.76 decrease in this Key Factor. place to work or receive treatment
Future priorities and targets:
From our results it is clear that as we went through the period of Turnaround last year it negatively impacted on our staff. Generally overall experience of being part of team DBTH was worse than in previous surveys and whilst there are a lot of areas for improvement there was also some really positive feedback highlighted by the survey. Low levels of staff reported witnessing potentially harmful errors at work and the levels of harassment, discriminations and bullying experienced by staff, from patients and other staff, are amongst some of the lowest in the country.
We saw statistically significant decreases in 14 of the 27 Key Factors compared to the 2015 survey. The corporate priorities to address these will be determined following a series of listening events instigated by the Chief Executive soon after his recent appointment.
We continue to use a range of local systems to monitor progress, in addition to quarterly surveys from the Staff Friends & Family Test and the next Annual Staff Survey.
Countering fraud, bribery and corruption
Fraud costs the NHS millions of pounds a year that could have been spent on patient care, so everyone has a duty to help prevent it. The Trust is committed to deterring and detecting all instances of fraud, bribery and corruption. Our aim is to make sure that losses are reduced to an absolute minimum, therefore ensuring that valuable public resources are used for their intended purpose.
NHS fraud may be committed by anyone, including staff, patients and suppliers of goods/services to the NHS. To ensure we have the right culture and that our staff are able to recognise and report fraud, we require all employees to receive fraud awareness training as part of our Statutory and Essential Training (SET) program. To amplify our efforts, we held a Fraud Awareness Month in November 2016 and we were pleased to be an official supporter of International Fraud Awareness Week in the same month.
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We have a well-publicised system in place for staff to raise concerns if they identify or suspect fraud. They can do this via our Local Counter Fraud Specialist (LCFS), the Director of Finance or via the NHS Fraud and Corruption reporting line (0800 028 40 60 or online at www.reportnhsfraud.nhs.uk) and our whistleblowing procedures. Patients and visitors can also refer suspicions of NHS fraud to the Trust via the same channels.
The Director of Finance is nominated to lead counter fraud work and is supported by our resident LCFS. The Trust has a robust Fraud, Bribery and Corruption Policy and Response Plan which provides a framework for responding to suspicions of fraud and provides advice and information on various aspects of fraud investigations. The Trust also has a Standards of Business Conduct and Employees Declarations of Interest Policy which clearly sets out the expectations we have of all our staff where probity is concerned. To reinforce this, the Chief Executive has recently issued an updated and publically available statement setting out our position to ensuring our organisation is free from bribery and corruption. There are references to counter fraud measures and reporting processes in various other Trust policies and procedures.
We have maintained our collaborative counter fraud arrangement with two other local acute NHS trusts. This arrangement allows us to have a LCFS permanently on site, supported by a small team of counter fraud specialists dedicated to dealing with fraud in a secondary care setting. An annual work plan, approved by the Director of Finance with oversight from the Trust’s Audit and Non-Clinical Risk Sub-Committee, has been in place over the last year. The key aims are to seek to proactively create an anti-fraud culture, implement appropriate deterrents and preventative controls and ensure that allegations of fraud are appropriately and professionally investigated to a criminal standard and to this end successful prosecutions have taken place. Progress reports on all aspects of counter fraud work and details of investigations are received at each meeting of the Trust’s Audit and Non-Clinical Risk Sub-Committee.
The Trust follows the guidance contained in the NHS Provider Standards and ensures our contractual obligations with our local Clinical Commissioning Groups are adhered to. NHS Protect provide the national framework through which NHS trusts seek to minimise losses through fraud and annually we submit our assessment to NHS Protect setting out our position in relation to these standards. For the past four years we have maintained an overall ‘Green’ level of compliance, which we affirm by benchmarking our activity with other Trusts.
Expenditure on consultancy
The Trust incurred expenditure of £1,371,715 of which £221,839.91 was related solely to Capital Projects.
Staff exit packages 73 As part of the Trust wide Turnaround projects we introduced a limited Mutually Agreed Resignation Scheme (MARS), running from October 2016 to March 2017. This voluntary scheme enabled nine employees, in agreement with the Trust, to leave their employment
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voluntarily in March in return for a payment. The Scheme was only available to members of staff with permanent contracts of employment with two years or more continuous service with the Trust.
2016/17
Exit package cost Number of Number of other Total number of exit band compulsory departures agreed packages by cost redundancies band <£10,000 4 28,587 £10,001 - £25,000 2 36,853 £25,001 - £50,000 1 3 146,412 £50,001 - £100,000 £100,001+ Total number of exit 1 9 211,852 packages by type
Agreement Number Total value of Agreement Voluntary redundancies including early retirement contractual costs Mutually agreed resignations (MARS) 9 £169,731 contractual costs Early retirements in the efficiency of the service contractual costs Contractual payments in lieu of notice Exit payments requiring HMT approval Total 9 £169,731
High paid and off pay-roll arrangements
For all off-payroll engagements as of 31 March 2016, for more than £220 per day and that last for longer than six months:
No. of existing engagements as of 31 March 2017 1 Of which: Number that have existed for less than one year at the time of reporting Number that have existed for between one and two years at the time of reporting 2 Number that have existed for between two and three years at the time of reporting
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Number that have existed for between three and four years at the time of reporting Number that have existed for four or more years at the time of reporting
The Trust undertakes a risk based assessment on new and existing off-payroll engagements, to seek assurance that each individual is paying the right amount of tax.
For all new off-payroll engagements, or those that reached six months in duration, between 1 April 2016 and 31 March 2017, for more than £220 per day and that last for longer than six months:
Number of new engagements, or those that reached six months in duration between 1 April 2016 and 31 March 2017 Number of the above which include contractual clauses giving the trust the right to request assurance in relation to income tax and national insurance obligations Number for whom assurance has been requested Of which: Number for whom assurance has been received Number for whom assurance has not been received * Number that have been terminated as a result of assurance not being received
All off-payroll contracts are required to allow the trust to seek assurance as to their tax obligations as part of their engagement.
Off-payroll engagements of board members, and/or, senior officials with significant financial responsibility, between 1 April 2015 and 31 March 2017:
Number of off-payroll engagements of board members, and/or, senior officials with significant financial responsibility, during the financial year. 2*
Number of individuals that have been deemed ‘board members and/or senior officials with significant financial responsibility’ during the financial year. This 18 figure must include both off-payroll and on-payroll engagements.
* (a) Jeremy Cook was employed on an interim basis from November 2015 to November 2016, until the appointment of a substantive Finance Director. (b) Martin McAreavey is a non-executive director, and the Trust pays his remuneration (£12k per annum) to his main employer, Leeds University, in exchange for the time he spends on his duties as a member of the Board of Directors. Martin McAreavey is not paid through a personal service company,
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Governance Report
Responsibility for preparing this annual report and ensuring its accuracy sits with the Board of Directors. The principal responsibilities and decisions of the Board of Directors and Board of Governors are as shown below. The process for resolution of conflict between the Board of Directors and Board of Governors is detailed in the Trust Constitution.
The respective roles of the Board of Directors and Board of Governors are as follows:
Board of Directors Board of Governors Operational management Hold the Non-executive Directors to account for Strategic development the performance of the Board of Directors. Capital development Appoint and determine the remuneration of the Business planning chairman and Non-executive Directors Financial, quality and service Appoint the auditors performance Promote membership, and governorship, of the Trust-wide policies Trust Risk assurance and governance Establish links and communicating with members Strategic direction of the Trust and stakeholders (taking account of the views of Seek the views and represent the interests of the Board of Governors). members and stakeholders Approve significant transactions, mergers, acquisitions, separations, dissolutions, and increases in non-NHS income of over 5%.
Board of Directors
Although the Board remains accountable for all its functions, it delegates to management the implementation of Trust policies, plans and procedures and receives sufficient information to enable it to monitor performance.
In addition to the responsibilities listed above, the powers of each body, and those delegated to specific officers, are detailed in the Trust’s Reservation of Powers to the Board and Delegation of Powers.
Performance evaluation of directors
The Chair conducts the performance appraisals of the Non-executive Directors. The Senior Independent Director and Vice Chairman conduct the performance appraisal of the Chair. The Board of Governors approves the objectives of the Chair and Non-executive Directors, and all governors and directors feed into the appraisal process by providing commentary regarding the performance of the Chair and Non-executive Directors.
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The performance review of Executive directors is carried out by the Chief Executive, with input from Non-executive Directors.
Performance evaluation of the Board and its sub-committees
The Board and its sub-committees conduct regular self-assessments of its performance. In 2016/17, the Board’s self-assessment was carried out as part of the external governance review undertaken by Deloitte LLP under NHS Improvement’s Well Led Framework. The reviewer was chosen following a competitive tendering exercise and had no previous connection with the Trust. The next external governance review will take place in 2019.
During the year both the Audit and Non-clinical Risk Committee and Clinical Governance Oversight Committee conducted self-assessments of their performance and are now implementing the action plans from those reviews.
Audit and Non-clinical Risk Committee
The committee’s remit is to make sure that effective internal control and systems are in place and in compliance with law, guidance and codes of conduct. The Committee has three members – all Non-executive Directors, including the Chair of the Committee. One member has recent and relevant financial experience.
Name Role Meeting attendance Philippe Serna – Chair Non-executive Director 4 of 5 David Crowe Non-executive Director 4 of 5 Martin McAreavey Non-executive Director 5 of 5
The Audit and Non-clinical Risk Committee has, on behalf of the Board:
Reviewed internal control and systems, including the Board Assurance Framework Reviewed standards of financial reporting Approved the internal and external audit plans each year and associated costs Received summaries of internal audits Received the External Auditors’ opinion on the financial statements, Annual Audit Plan and Report Examined the circumstances when Standing Orders were waived Reviewed schedules of losses and compensations Reviewed the standards of business conducted by and for the Board, with the aim of ensuring high standards of probity.
The Trust has an internal audit function, and the internal auditors attend all meetings of the Audit and Non-clinical Risk Committee to report on progress against the annual audit plan and present summary reports of all internal audits conducted. The internal audit function in 2016/17 was carried out by KPMG. Internal audit’s main functions are to provide
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Reviewing the Trust’s internal control system Undertaking investigations into particular aspects of the Trust’s operations Examining relevant financial and operating information Undertaking VFM audits Reviewing compliance by the Trust with particular laws or regulations Identifying, assessing and controlling significant risks to the Trust.
External auditors review the accuracy of the Annual Accounts and may carry out various reviews in accordance with the Audit Code for NHS Foundation Trusts. Directors made the auditors aware of all the information that they require to carry out their audit responsibilities in accordance with the Audit Code.
During 2016/17, the committee considered a range of issues including matters raised through internal audit, compliance with CQC standards, corporate risk, security, and compliance with standing orders. The committee maintains a formal work plan and action log to ensure that areas of concerns are followed up and addressed by the executive team.
The Trust began 2016/17 with PricewaterhouseCoopers (PWC) as its external auditing firm. Following consideration of a report by the Board of Governors in June 2017, PWC were replaced as the Trust’s external auditors.
A sub-committee made up of three Governors supported by the Chair of Audit and Non- clinical Risk Committee, the Interim Deputy Director of Finance, Head of Procurement and Trust Board Secretary conducted the tender exercise. EY were appointed as the Trust’s new external auditors by Governors in September 2016 for an initial term of three years.
For 2016/17, the Trust paid audit fees (Statutory Audit and Assurance on the Quality Report) to the external auditor of £91,000 (inc. VAT) in addition to £61,495 (inc. VAT) for the Charitable Fund Statutory Audit.
Board of Governors
During 2016/17 the Board of Governors met on five occasions. Board of Governors meetings are held in public. The composition of the Board of Governors, including attendance at Board of Governors meetings is shown below:
Name Constituency / Partner Organisation Meeting attendance Michael Addenbrooke Public – Doncaster (Vice Chairman) 4 of 5 Dr Utpal Barua Public – Bassetlaw (to 31.3.17) 4 of 5 Philip Beavers Public – Doncaster 4 of 5 Dennis Benfold Public – Doncaster (to 17.8.16) 0 of 2
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Shelley Brailsford Public – Doncaster 5 of 5 Hazel Brand Public – Bassetlaw 3 of 5 Anwar-ul-aq Choudhry Public – Doncaster (from 18.8.16) 1 of 3 David Cuckson Public – Rest of England & Wales 4 of 5 Dev Das Public - Doncaster 4 of 5 Eddie Dobbs Public - Doncaster 5 of 5 Nicky Hogarth Public - Doncaster 5 of 5 Peter Husselbee Public – Bassetlaw 3 of 5 Bev Marshall Public – Doncaster 4 of 5 Susan Overend Public – Bassetlaw 5 of 5 John Plant Public - Doncaster 5 of 5 Patricia Ricketts Public – Doncaster 4 of 5 Denise Strydom Public – Bassetlaw (to 1.2.17) 2 of 5 George Webb Public - Doncaster (Lead Governor) 5 of 5 Maureen Young Public - Doncaster 4 of 5 Dr Vivek Desai Staff - Medical and Dental 4 of 5 Lynn Goy Staff - Nurses and Midwives 4 of 5 Shahida Khalele Staff – Other Healthcare Professionals 2 of 5 Lorraine Robinson Staff - Nurses and Midwives 5 of 5 Andrew Swift Staff - Non-Clinical (to 29.9.16) 3 of 3 Roy Underwood Staff - Non-Clinical 4 of 5 Prof Ruth Allarton Partner - Sheffield Hallam University 3 of 5 Dr Oliver Bandmann Partner - Sheffield University 0 of 5 Lisa Bromley Partner - Bassetlaw CCG 2 of 5 Pat Knight Partner - Doncaster MBC 4 of 5 Ainsley MacDonnell Partner - Nottinghamshire County Council 4 of 5 Jackie Pederson Partner - Doncaster CCG (to 17.7.2016) 0 of 2 Anthony Fitzgerald Partner – Doncaster CCG (from 18.7.2016) 3 of 3 Susan Shaw Partner – Bassetlaw District Council 4 of 5 Rupert Suckling Partner - Doncaster MBC 3 of 5 Clive Tattley Partner - Bassetlaw and Doncaster CVS 4 of 5
Our public and staff governors are elected by the members of their constituencies, while our partner governors are appointed by the partner organisations named in our constitution.
In addition to the Chair of the Board, all directors attend Board of Governors meetings to listen to governors’ views and to brief and advise governors on the business of the Trust.
Director Role Board of Governors meeting
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attendance Suzy Brain England Chair of the Board (from 1.1.17) 1 of 1 OBE Chris Scholey Chairman (to 31.12.16) 4 of 4 Non-executive Director (Senior Independent Director Alan Armstrong 4 of 5 from 1.10.16) Non-executive Director (and Senior Independent Geraldine Broderick 1 of 2 Director). Both to 18.7.16. Jeremy Cook Interim Director of Finance (to 1.11.16) 3 of 3 David Crowe Non-executive Director (to 31.3.17) 4 of 5 Acting Director of Nursing, Midwifery and Quality (from Moira Hardy 1 of 1 3.1.17) Dawn Jarvis Director of Strategy & Improvement (to 31.3.17) 3 of 5 Martin McAreavey Non-executive Director 5 of 5 John Parker Non-executive Director (Deputy Chairman to 31.3.17) 4 of 5 Linn Phipps Non-executive Director (from 1.1.17) 1 of 1 Director of Nursing, Midwifery & Quality (to Richard Parker 31.12.16) / Chief Executive (acting from 1.1.17; 4 of 5 substantive from 1.2.17) Mike Pinkerton Chief Executive (to 31.1.17) 4 of 5 Director of People and Organisational Karen Barnard 2 of 4 Development (from 2.5.16) David Purdue Chief Operating Officer 4 of 5 Jon Sargeant Director of Finance (from 2.11.16) 1 of 2 Philippe Serna Non-executive Director 1 of 5 Sewa Singh Medical Director 3 of 5
Appointments and Remuneration Committee of the Board of Governors
Non-executive Directors, including the Chairman, are appointed for a term of office of up to three years, and may be removed by the Board of Governors. The Board of Governors delegates the recruitment and selection of candidates to its Appointments and Remuneration Sub-committee.
During 2016/17, the Appointments and Remuneration Sub-committee of the Board of Governors was convened to discuss the recruitment of the Chair of the Board, Non- executive Director appointments and objective setting and performance evaluation for the Chair and Non-executives. The committee recommended the following appointments, all of which were approved by the Board of Governors:
. Suzy Brain England OBE, appointed as Chair for a term of three years commencing 1 January 2017 . Alan Armstrong, reappointed Non-executive Director for a term of two years commencing 1 October 2016
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. Linn Phipps, appointed Non-executive Director for a term of three years commencing 1 January 2017 . Neil Rhodes, appointed Non-executive Director for a term of three years commencing 1 April 2017.
The committee was convened on six occasions during the year.
Open advertisement is used for all new appointments. The committee has not traditionally used open advertisement for reappointments of existing directors unless the Non-executive Director in question has served more than six years, or there are concerns regarding the Non-executive Director’s performance.
The membership of the Appointments and Remuneration Committee during the year consisted of:
Name Role Attendance Suzy Brain England OBE Chair of the Board 2 of 2 Chris Scholey Chairman 3 of 3 Geraldine Broderick Senior Independent Director (Chair of the 1 of 1 committee in respect of the Chair’s appointment) Alan Armstrong Senior Independent Director (Chair of the 1 of 1 committee in respect of the Chair’s objective setting) Ruth Allarton Partner Governor 4 of 6 David Cuckson Public Governor, Rest of England & Wales 6 of 6 Peter Husselbee Public Governor, Bassetlaw 2 of 6 John Plant Public Governor, Doncaster 3 of 6 Rupert Suckling Partner Governor 1 of 4 Clive Tattley Partner Governor 2 of 2 George Webb Public Governor, Doncaster 5 of 6 Roy Underwood Staff Governor 5 of 6
Governor elections and terms of office
Governors serve for a three year term of office and are eligible to stand for re-election or re- appointment at the end of that period.
During the year ending 31 March 2017, no elections for governor positions were held.
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Membership
The trust has two categories of members:
Public members - people who live within the areas covered by either of the three public constituencies: o Bassetlaw District o Doncaster Metropolitan Borough o Rest of England and Wales.
Staff members - Trust staff automatically become members unless they decide to ‘opt-out’. There are four staff classes: o Medical and Dental o Nurses and Midwives o Other healthcare professionals o Non-clinical.
At 31 March 2017, there are 16,172 members overall. An analysis of our current membership body is provided below:
Number of members at 31 March 2017 Public Constituency 9,517 Doncaster 5,750 Bassetlaw 2,566 Rest of England & Wales 1,201 Staff Constituency 16,172 Nurses and Midwives 2,215 Non-clinical 2,167 Other healthcare professionals 1,660 Medical and Dental 613 TOTAL 16,172
The Trust’s current membership strategy is to improve the quality and quantity of member engagement with a focus on underrepresented groups rather than increasing the overall membership numbers.
No member events took place in 2016/17 but one was scheduled for the first month of 2017/18 on Medical Imaging and Oncology. The Trust also held an Annual Members’ Meeting, where our staff put on health related displays and stalls.
We work to engage with our members, and support Governors to seek the views of members, in a number of ways, including:
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Continuing to communicate directly with individual members and keeping them informed regarding governors activities via the member magazine, Foundations for Health. Inviting feedback from members through the Foundation Trust Office. Holding member events on the topics that our members are interested in, and seeking their feedback on the services discussed. Governor attendance at local community events, targeting events at schools and colleges in order to recruit and engage with young people. Continuing to regularly inform the membership of the Trust’s plans and activities through the member magazine, Foundations for Health. Working to ensure contested Governor elections and improved member participation in the election process. Working to recruit and engage young members, who are currently under- represented, through engagement with local schools. Publicising the governor role and the ‘Governor Patient Experience Pledge’ through the use of posters and cards.
Members who wish to contact directors or Governors may do so via the Foundation Trust Office on [email protected] or 01302 644157, or by post to: Trust Board Secretary, Doncaster Royal Infirmary, Armthorpe Road, Doncaster, DN2 5LT.
Steps that Board members have taken to understand the views of governors and members Executive and Non-executive Directors attend Board of Governors meetings to offer their knowledge on their areas of expertise and to listen to the views of Governors. Other steps that directors have taken to understand the views of Governors and members are:
Attendance at governors’ quarterly ‘time out’ sessions Attendance at Board of Governors’ sub-committee meetings where appropriate Giving governors opportunities to raise queries and concerns directly with directors Regular meetings and briefings between the Board of Governors, Chief Executive and Chair of the Board Accessibility of the Chair of the Board, Trust Board Secretary, Senior Independent Director, and Foundation Trust Office Nominated governor observers are invited to observe or sit on committees with directors, including the Clinical Governance Oversight Committee, Audit and Non- clinical Risk Committee, Financial Oversight Committee and Fred and Ann Green Legacy Advisory Group Governor participation in Ward Quality Assurance Toolkit inspections Governor sponsorship of wards consultation sessions with governors regarding the development of Trust forward plans Governor views are sought as part of the process for appraising the performance of the Chair of the Board and Non-executive Directors Sharing information, such as Board minutes, Governors’ Brief, reports and briefing papers and Foundations for Health, the members’ magazine.
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NHS Foundation Trust Code of Governance
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust has applied the principles of the NHS Foundation Trust Code of Governance on a comply or explain basis. The NHS Foundation Trust Code of Governance, most recently revised in July 2014, is based on the principles of the UK Corporate Governance Code issued in 2012.
For the year ending 31 March 2017, the Board considers that it was fully compliant with the provisions of the NHS Foundation Trust Code of Governance.
The Board of Directors is committed to high standards of corporate governance, understanding the importance of transparency and accountability and the impact of Board effectiveness on organisational performance. The Trust carries out an ongoing programme of work to ensure that its governance procedures are in line with the principles of the Code, including:
supporting governors to appoint Non-executive Directors and external auditors with appropriate skills and experience ensuring a tailored and in-depth induction programme for the new Chair, Non- executive directors and Governors facilitating an external review of the Trust’s governance arrangements working with governors in ‘time out’ sessions, briefings and enabling governors to attend meetings of the governance sub-committees of the Board, to improve the ways in which governors engage with and hold the Board to account ongoing review of compliance with the Code of Governance by the Board of Governors and Board of Directors when making decisions which impact on governance arrangements.
For details on the disclosures required by the Code of Governance, see below:
Ref. Requirement Disclosure A.1.1 This statement should also describe how any disagreements See Governance Report (p.). between the council of governors and the board of directors will be resolved. The annual report should include this schedule of matters or a summary statement of how the board of directors and the council of governors operate, including a summary of the types of decisions to be taken by each of the boards and which are delegated to the executive management of the board of directors. A.1.2 The annual report should identify the chairperson, the See Accountability Report deputy chairperson (where there is one), the chief (p.); Remuneration Report executive, the senior independent director (see A.4.1) and (p.); and Audit Committee the chairperson and members of the nominations, audit section (p.); and remuneration committees. It should also set out the number of meetings of the board and those committees and individual attendance by directors.
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A.5.3 The annual report should identify the members of the See Board of Governors council of governors, including a description of the section (p.) constituency or organisation that they represent, whether they were elected or appointed, and the duration of their appointments. The annual report should also identify the nominated lead governor. B.1.1 The board of directors should identify in the annual report See Accountability Report each non-executive director it considers to be independent, (p.) with reasons where necessary. B.1.4 The board of directors should include in its annual report a See Accountability Report description of each director’s skills, expertise and (p.) experience. Alongside this, in the annual report, the board should make a clear statement about its own balance, completeness and appropriateness to the requirements of the NHS foundation trust. B.2.10 A separate section of the annual report should describe the See Remuneration Report work of the nominations committee(s), including the and Board of Governors process it has used in relation to board appointments. section (p.) B.3.1 A chairperson’s other significant commitments should be See Governance Report (p.) disclosed to the council of governors before appointment and included in the annual report. Changes to such commitments should be reported to the council of governors as they arise, and included in the next annual report. B.5.6 Governors should canvass the opinion of the trust’s See membership section members and the public, and for appointed governors the (p.) body they represent, on the NHS foundation trust’s forward plan, including its objectives, priorities and strategy, and their views should be communicated to the board of directors. The annual report should contain a statement as to how this requirement has been undertaken and satisfied. B.6.1 The board of directors should state in the annual report See Governance Report (p.) how performance evaluation of the board, its committees, and its directors, including the chairperson, has been conducted. B.6.2 Where an external facilitator is used for reviews of See the Annual Governance governance, they should be identified and a statement Statement (p.) and made as to whether they have any other connection with Auditor’s report (p.) the trust. C.1.1 The directors should explain in the annual report their See the Annual Governance responsibility for preparing the annual report and accounts, Statement (p.) and and state that they consider the annual report and Auditor’s report (p.) accounts, taken as a whole, are fair, balanced and understandable and provide the information necessary for patients, regulators and other stakeholders to assess the NHS foundation trust’s performance, business model and strategy. There should be a statement by the external
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auditor about their reporting responsibilities. Directors should also explain their approach to quality governance in the Annual Governance Statement (within the annual report). C.2.1 The annual report should contain a statement that the See the Annual Governance board has conducted a review of the effectiveness of its Statement (p.) system of internal controls. C.2.2 A trust should disclose in the annual report: See Audit Committee (a) if it has an internal audit function, how the function is section (p.) structured and what role it performs; or (b) if it does not have an internal audit function, that fact and the processes it employs for evaluating and continually improving the effectiveness of its risk management and internal control processes. C.3.5 If the council of governors does not accept the audit This has not occurred (See committee’s recommendation on the appointment, Audit Committee section on reappointment or removal of an external auditor, the board p.) of directors should include in the annual report a statement from the audit committee explaining the recommendation and should set out reasons why the council of governors has taken a different position. C.3.9 A separate section of the annual report should describe the See Audit Committee work of the audit committee in discharging its section (p.) responsibilities. The report should include: the significant issues that the committee considered in relation to financial statements, operations and compliance, and how these issues were addressed; an explanation of how it has assessed the effectiveness of the external audit process and the approach taken to the appointment or re-appointment of the external auditor, the value of external audit services and information on the length of tenure of the current audit firm and when a tender was last conducted; and if the external auditor provides non-audit services, the value of the non-audit services provided and an explanation of how auditor objectivity and independence are safeguarded. D.1.3 Where an NHS Foundation Trust releases an Executive This has not occurred (see Director, for example to serve as a Non-executive Director Remuneration Report on elsewhere, the remuneration disclosures of the annual page 33) report should include a statement of whether or not the director will retain such earnings. E.1.5 The board of directors should state in the annual report the See Board of Governors steps they have taken to ensure that the members of the section (p.) board, and in particular the non-executive directors, develop an understanding of the views of governors and members about the NHS foundation trust, for example
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through attendance at meetings of the council of governors, direct face-to-face contact, surveys of members’ opinions and consultations. E.1.6 The board of directors should monitor how representative See membership section (p. the NHS foundation trust's membership is and the level and ) effectiveness of member engagement and report on this in the annual report.
Single Oversight Framework
NHS Improvement’s Single Oversight Framework provides the framework for overseeing providers and identifying potential support needs. The framework looks at five themes:
Quality of care Finance and use of resources Operational performance Strategic change Leadership and improvement capability (well-led)
Based on information from these themes, providers are segmented from 1 to 4, where ‘4’ reflects providers receiving the most support, and ‘1’ reflects providers with maximum autonomy. A foundation trust will only be in segments 3 or 4 where it has been found to be in breach or suspected breach of its licence.
The Single Oversight Framework applied from Quarter 3 of 2016/17. Prior to this, NHS Improvement’s Risk Assessment Framework (RAF) was in place. Information for the prior year and first two quarters relating to the RAF has not been presented as the basis of accountability was different. This is in line with NHS Improvement’s guidance for annual reports.
Segmentation
The Trust is currently in segment 3 (mandated support) which reflects the breach of licence notified on 24 February 2016. The Trust has an additional condition on its licence that it has in place sufficient and effective board, management and clinical leadership capacity and capability as well as appropriate governance systems and processes. On 29 February 2016, the Trust provided, and NHS Improvement accepted, a series of undertakings to ensure that the breaches do not continue or reoccur. These related to:
Sustainability Financial governance Distressed Financing and Sustainability and Transformation Fund General undertakings
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The undertakings provided have largely been discharged and progress is reported on a quarterly basis to Board of Directors.
This segmentation information is the Trust’s position as at 31 March 2017. Current segmentation information for NHS trusts and foundation trusts is published on the NHS Improvement website.
Finance and use of resources
The finance and use of resources theme is based on the scoring of five measures from ‘1’ to ‘4’, where ‘1’ reflects the strongest performance. These scores are then weighted to give an overall score. Given that finance and use of resources is only one of the five themes feeding into the Single Oversight Framework, the segmentation of the Trust disclosed above might not be the same as the overall finance score here.
Area Metric 2016/17 Q3 score Q4 score Financial sustainability Capital service capacity 4 4 Liquidity 4 2
Financial efficiency I&E margin 4 4
Distance from financial plan Agency spend 1 2 Financial controls 2
Overall scoring 3 3
Statement of Accounting Officer’s responsibilities
The NHS Act 2006 states that the Chief Executive is the Accounting Officer of the NHS Foundation Trust. The relevant responsibilities of the Accounting Officer, including their responsibility for the propriety and regularity of public finances for which they are answerable, and for the keeping of proper accounts, are set out in the NHS Foundation Trust Accounting Officer Memorandum issued by NHS Improvement.
Under the NHS Act 2006, NHS Improvement has directed Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust to prepare for each financial year a statement of accounts in the form and on the basis set out in the Accounts Direction. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of Doncaster and Bassetlaw Hospitals NHS Foundation Trust and of its income and expenditure, total recognised gains and losses and cash flows for the financial year.
In preparing the accounts, the Accounting Officer is required to comply with the requirements of the NHS Foundation Trust Annual Reporting Manual and in particular to:
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Observe the Accounts Direction issued by NHS Improvement, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis Make judgements and estimates on a reasonable basis State whether applicable accounting standards as set out in the NHS Foundation Trust Annual Reporting Manual have been followed, and disclose and explain any material departures in the financial statements Ensure that the use of public funds complies with the relevant legislation, delegated authorities and guidance and Prepare the financial statements on a going concern basis.
The Accounting Officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the NHS Foundation Trust and to enable him/her to ensure that the accounts comply with requirements outlined in the above mentioned Act. The Accounting Officer is also responsible for safeguarding the assets of the NHS foundation trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities.
The financial reporting matters which affected the Trust during the year are outlined further in the Annual Governance Statement.
To the best of my knowledge and belief, I have properly discharged the responsibilities set out in NHS Improvement’s NHS Foundation Trust Accounting Officer Memorandum.
Signed……………….. Richard Parker Date: 08 May 2017 Chief Executive
Annual governance statement
Scope of responsibility
As Accounting Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the Trust’s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the NHS Foundation Trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum.
The purpose of the system of internal control
The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal
70 control is based on an ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place in Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, for the year ended 31 March 2017 and up to the date of approval of the annual report and accounts.
Capacity to handle risk
The Chief Executive has overall accountability and responsibility for risk management, while the Executive Directors are responsible for those risks which are relevant to their areas of responsibility. In particular, the Medical Director and Director of Nursing, Midwifery and Quality are responsible for risk to the safety and quality of patient care, and the Director of Finance is responsible for financial risk. The allocation of risks to individual directors is outlined in both the Assurance Framework and Corporate Risk Register. The Trust Board Secretary, on behalf of the Chief Executive, is responsible for the Board Assurance Framework and Corporate Risk Register.
Risk policies are reviewed annually, in light of current best practice advice, to assess whether changes are required.
Care Group directors and directorate managers are responsible for the risk registers for their departments. In addition, management of risk is a fundamental duty of all employees whatever their grade, role or status. The Trust uses the Datixweb integrated risk management system, and an associated training programme has been undertaken with staff at all levels, including Care Group management teams, to ensure that they are aware of current good practice in relation to risk management. Local risk management training needs are discussed with the risk management department and tailored accordingly, and the Trust Board Secretary’s office may be contacted to provide guidance to staff on application of the relevant policies.
The risk and control framework
The Board assures itself of the validity of its corporate governance statement through reviews of its governance processes which are routinely undertaken by internal audit but this year formed part of the external governance review under the Well Led Framework. Other assurance comes from committee effectiveness reviews, Board and committee inspection of key performance metrics, consideration of the board assurance framework and corporate risk register, reviews of key governance documents such as the constitution, SFIs and standing orders and involvement in a range of processes geared towards maintaining focus on quality such as ward walkabouts and quality impact assessments.
The Board is responsible for determining the organisation’s risk appetite, ensuring that robust systems of internal control and management are in place and that risks to the achievement of organisational objectives are being appropriately managed. During 2016/17 this responsibility has been supported through the assurance sub-committees of the Board:
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Audit and Non-clinical Risk Committee – responsible for non-clinical risk, including financial governance, information governance and corporate governance Clinical Governance Oversight Committee – responsible for clinical risk, including clinical and quality governance Financial Oversight Committee – responsible for undertaking scrutiny of financial reporting and progress against turnaround and cost reduction plans.
The primary role of these committees in respect of risk management is to review the assurance framework on a quarterly basis, and to satisfy the Board of Directors that there are satisfactory review arrangements in place for the Trust’s internal control and risk management systems. The arrangements for clinical (quality) risks and non-clinical risks are otherwise the same. The Board receives a quarterly report highlighting gaps in control and assurance as well as any proposed changes to the assurance framework.
In addition to the above, the committees receive assurance regarding compliance with Care Quality Commission (CQC) registration and information governance requirements. Data quality forms part of the internal audit annual work plan. Risks to data security are managed and controlled through application of the Information Governance Policy and assessment of compliance with the requirements in the Information Governance Toolkit.
As part of the Board’s commitment to improving risk management, the Trust’s Corporate Risk Register and Assurance Framework underwent ongoing review and amendment during 2016/17 and both are subject to further enhancement in 2017/18.
The Trust’s Risk Management Strategy covers risk identification, evaluation, recording, escalation, control, review and assurance. It also defines the structures for the management and ownership of risk.
The Management Board is responsible for monitoring and reviewing the Corporate Risk Register, which is linked with the assurance framework, on a monthly basis. Each Care Group and department is responsible for maintaining its own risk register, which is a standing agenda item on the Care Group management team meeting. Any risk identified as ‘Extreme’ is escalated to the Management Board for consideration regarding action required.
To mitigate the risk of planned savings programmes adversely impacting on quality of care, all plans are reviewed and signed off by the Medical Director and Director of Nursing, Midwifery and Quality before being approved.
The principal risks to compliance with licence condition FT4 are:
o Risks to the provision of accurate, comprehensive, timely and up to date financial information to support board decision-making and oversight o Risk of failure to maintain sound financial governance and control processes o Failure to maintain fit for purpose board assurance and governance processes.
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The Trust undertakes a variety of work in order to mitigate corporate governance risks, including regular audits and reviews of governance processes each year including reviews of its constitution and standing orders and the reporting lines between Board, committees and other decision-making bodies. Significant risks to achievement of governance standards are included within the assurance framework and corporate risk register, and therefore reviewed in line with the processes outlined above.
The Trust has ended 2016/17 in full compliance with the code of governance. The Board commissioned an external review of its governance arrangements in Q3 2016/17. In addition to the four key strands of NHS Improvement’s Well Led framework, the reviewers also assessed the Trust’s position in relation to eight key areas of focus agreed with the regulator. The review made a total of 18 recommendations, including around strengthening the risk and board assurance processes, which are being taken forward through a working group of the Board of Directors.
The Business Intelligence Report, Nursing Workforce Report and Finance Report are the key method through which operational performance data is reported to the board for oversight and assurance purposes. This report is kept under continuous review and its format is amended regularly in order to ensure it meets the needs of the board and supports rigorous oversight and decision making.
The most significant risks/challenges currently facing the Trust are:
Failure to achieve compliance with financial performance aspects of the Single Oversight Framework and provider license, triggering regulatory action Failure to deliver accurate financial reporting underpinned by effective financial governance Failure to ensure that appropriate estates infrastructure is in place Failure to achieve compliance with performance and delivery aspects of Single Oversight Framework, CQC and other regulatory standards, triggering regulatory action Risk that Trust becomes non-operational due to cyber attack.
This list is not exhaustive and more details can be found in the Corporate Risk Register, where mitigating actions and outcomes are detailed. These risks will be managed through the governance and assurance processes outlined above. Outcomes will be assessed through the Trust’s management reporting systems.
The Trust has an effective structure in place for public stakeholder involvement, predominantly through the Board of Governors. The Trust’s assurance framework has been informed by partnership working and a variety of external contacts, including:
. Collaborative working between governors and directors. The Board of Governors reviews updates from executive directors on performance, quality, and finance and associated risks at its quarterly meetings and through new monthly briefings . Consistent engagement with commissioners through contract review meetings and other contacts, and in relation to key shared risks
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. Governor observers in attendance at the Clinical Governance Oversight Committee, Audit and Non-clinical Risk Committee and Financial Oversight Committee.
Public stakeholders are involved in managing risks through involvement in patient safety review group and patient experience committee as well as a range of patient safety campaigns such as Gina’s Story, Carol’s Story, John’s Campaign and Sign Up to Safety.
The foundation trust is fully compliant with the registration requirements of the Care Quality Commission.
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. This includes ensuring that deductions from salary, employer’s contributions and payments into the Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations.
Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with.
The foundation trust has undertaken risk assessments and Carbon Reduction Delivery Plans are in place in accordance with emergency preparedness and civil contingency requirements, as based on UKCIP 2009 weather projects, to ensure that this organisation’s obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with.
Review of the economy, efficient and effectiveness of the use of resources
The following policies and processes are in place to ensure that resources are used economically, efficiently and effectively:
Scheme of Delegation and Reservation of Powers to the Board Standing Financial Instructions and Standing Orders Competitive processes used for procuring non-staff expenditure items Use of materials management and other best practice approaches to hold appropriate stock levels and minimise wastage Cost improvement plans and turnaround work-streams, managed by the Strategy and Improvement directorate and designed to not impinge on effective delivery of quality patient care Strategy and Improvement processes to drive turnaround and cost reduction programmes Grip and control work, including tight controls on vacancy management, non- permanent staffing and recruitment.
The Board gains assurance regarding financial and budgetary management from a monthly finance report. The Audit and Non-Clinical Risk Committee receives reports regarding losses
74 and compensations and waiver of standing orders, among others, while the Financial Oversight Committee receives detailed reports on progress in delivering CIPs. Risks to the Trust’s financial objectives are subject to regular review and monitoring in the same way as other risks.
A range of internal and external audits that provide further assurance on economy, efficiency and effectiveness have been conducted during the year and reported to the Audit and Non-clinical Risk Committee.
The Head of Internal Audit is required to provide an annual opinion in accordance with Public Sector Internal Audit Standards, based upon and limited to the work performed, on the overall adequacy and effectiveness of the organisation’s risk management, control and governance processes (i.e. the system of internal control). This is achieved through a risk- based programme of work, agreed with Management and approved by the Audit and Non- Clinical Risk Committee, which can provide assurance, subject to the inherent limitations described below. The opinion covers the period 1 April 2016 to 31 March 2017 inclusive, and is based on the 21 audits that were completed in this period.
For the period 1 April 2016 to 31 March 2017, Internal Audit found that significant assurance with minor improvement opportunities can be given on the overall adequacy and effectiveness of the organisation’s framework of governance, risk management and control. Overall the review found that the Assurance framework in place was founded on a systematic risk management process and did provide appropriate assurance to the Board. The Assurance Framework reflected the organisation’s key objectives and risks and was reviewed on a quarterly basis by the Board. In 2016/17 the Trust reviewed the content and format of the Assurance Framework to ensure it remains relevant and fit for purpose.
Internal audit issued one ‘significant assurance’ and eight ‘significant assurance with minor improvement opportunities’ and these included core reviews of financial reporting month end checklists, Reference Costs, Independent Project Assurance over the outsourcing of financial systems, IG Toolkit, Payroll and Finance Team Structure and Patient Safety & Infection Control reviews.
They issued eleven ‘partial assurance with significant improvements required’ opinions in respect of our 2016-17 assignments. These reviews related to Core Financial Systems, financial reporting month end checklist –Month 3, Performance Indicators, IT Capability, Booking Management, CQC Compliance, Medicines Management, Incident Reporting, Investigation and Learning, Duty of Candour, Recruitment Strategy and E-rostering.
As part of these audits we raised 7 high risk recommendation relating to:
Performance Indicators -ensuring data quality processes are fully understood and that correct data is reported within the Audiology Department; IT Capability -the absence of an Information Management and Technology Strategy and capacity within the IT department;.
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Medicines Management and CQC Compliance -the safe and secure storage of medicines and Intra Venous fluids.
The annual external audit review by EY, as stated in their ISA 260 report, provides ….
The Trust’s 2016 reference cost index is 96, which means that costs are 4% below average.
Information governance
There have been no serious incidents relating to information governance, including data loss or confidentiality breach. Internal audit carried out an audit of the information governance toolkit in 2016/17 and gave it an assurance rating of green (significant).
Annual quality report
The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended) to prepare Quality Accounts for each financial year. NHSI has issued guidance to NHS foundation trust boards on the form and content of annual Quality Reports which incorporate the above legal requirements in the NHS Foundation Trust Annual Reporting Manual.
The formulation of the Trust’s Quality Report is led by the Director of Nursing, Midwifery and Quality, with the support of the Board of Directors and the Board of Governors. The Board of Directors monitors the key measures and objectives in the Quality Account on a monthly basis throughout the year. Significant risks to achievement of quality priorities are included within the assurance framework and corporate risk register, and therefore reviewed in line with the processes outlined above.
Data in relation to the measures in the Quality Report is collected and reported alongside the data in relation to other performance and quality metrics, including NHSI compliance targets. The quality of this data is audited through regular internal audit reviews.
In line with information governance requirements, the Trust carries out a rolling annual audit programme of specialty based inpatient waiting times data. 18 weeks data quality is a high priority, with a comprehensive rolling programme of routine validation. In addition, external validation of waiting lists undertaken by EY at the end of the year has demonstrated excellent levels of data accuracy. This ensures we have high quality data to maintain the accuracy of waiting times to enable us to treat patients in chronological order for the same clinical priority, support demand and capacity modelling and ensure accurate performance reporting. The results are reported to the Data Quality Group, which reports to the Information Governance Group, and results are used to inform action planning and targeted training. Additionally, we undertake quarterly reviews of all planned inpatient waiters and the results are shared with our main commissioner, Doncaster Clinical Commissioning Group.
The CQC last conducted a full inspection across all of the Trust’s sites in April 2015, and gave the Trust an overall rating of ‘requires improvement’, with a rating of ‘good’ for the Caring
76 and Well-Led domains. 74% of areas assessed were rated ‘good’, and no areas were rated ‘inadequate’, placing the Trust in the top 20% of trusts inspected nationally. The full results of the inspection, which provide an external view of the risks presented by the Trust, were reported to the Board. An action plan was developed in response to all recommendations made following the inspection, and the Trust has implemented all recommendations within agreed timescales.
Compliance with CQC standards is monitored by the Clinical Governance Oversight Committee, and performance against CQUIN and other quality targets is monitored by the Board of Directors. The data quality behind quality and performance reports is subject to internal audit, the results of which are reported to the Audit and Non-clinical Risk Committee.
Quality governance is subject to rigorous challenge through Non-executive Director and Governor engagement, and Non-executive chairmanship of the Audit and Non-clinical Risk and Clinical Governance Oversight Committees. Non-executive Directors and Governors also actively engage with staff and patients on quality by regularly visiting wards and departments.
Review of effectiveness
As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal control.
My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, clinical audit and executive managers and clinical leads within the NHS Foundation Trust who have responsibility for the development and maintenance of the internal control framework. I have drawn on the content of the quality report attached to this Annual Report and other performance information available to me. My review is also informed by comments made by the external auditors in their management letter and other reports. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Board, the Audit and Non-clinical Risk, Clinical Governance Oversight and Financial Oversight Committees and plans to address any weaknesses and ensure continuous improvement of the system are in place.
A number of the ways in which the Board and I have received assurance regarding the effectiveness of the Board’s system of controls have been outlined above.
Following the financial misreporting in 2015/16, the Trust has worked hard to implement all the changes required to both reduce its deficit and deliver improvements in financial governance. The recommendations from the KPMG investigation into financial misreporting have largely been implemented and the achievement of an £6.7m end-of-year deficit and £11.9m of cost improvements, both reported to Financial Oversight Committee and Board in April 2017, whilst still maintaining appropriate levels of quality, is a testament to the hard work and dedication of all staff.
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In Quarter three, the Trust employed Deloitte to carry out an external review of its governance processes as part of our undertakings to NHS Improvement. In addition to examining the Trust’s approach to the entire Well Led framework, the Trust agreed eight key areas of focus with NHS Improvement to provide additional assurance around whistleblowing, internal audit, collaborative working, strategic planning, risk management, the Board’s sub-committees, business planning and Board level mentoring/support. The review made 18 recommendations which the Trust is now taking forward through an action plan, monitored by a Board-level working group.
The year has been one of change at Board level with our experienced Chair and Chief Executive both departing the Trust towards the end of the year. A new Chair, Chief Executive, Director of Finance and Non-executive Directors have committed to bring a pace and dynamism to the Trust’s work.
In quality and performance terms, the Board remains assured that governance processes are effective. During 2016/17, the Trust managed effective improvements in pathways, due to the hard work of the staff in medical imaging department, ensured the overall Trust position achieved 98.8%.
This year we achieved the 62 day wait for first treatment, coming in at 93.5%. We also achieved our two week referral rates when cancer is not suspected, however we narrowly missed out on suspected cases, achieving 92.8% instead of the required 93%. All 31 day targets were achieved.
We narrowly missed the target of 92% for the singular target of complete pathways for 2016/17, achieving 90.5%. There were eight speciality pathways not achieving at the end of the year, mainly due to increasing levels of referrals in the year. These were General Surgery, Urology, Trauma and Orthopaedics, ENT, Ophthalmology, Pain Services, gynaecology and cardiology.
Although we failed to achieve the four hour access target, 2016/17 saw the Trust outperform many neighbouring trusts and we were amongst the best performing organisations in the country. The Trust managed to stay above 90% ten months out of the year, with Bassetlaw Hospital’s Emergency Department achieving over 95% for six separate months, routinely being in the top ten of best performing departments, despite high attendance.
NHS Improvement’s new Single Oversight Framework placed the Trust in segment 3 (mandated support) due to the breach of its licence position. However, the Trust is working with NHS Improvement to explore the potential for coming out of breach with its licence sometime during 2017/18.
The Trust recognises the need for ongoing development and continuous improvement of its systems of control and assurance to ensure the assurance framework and risk register remain fit for purpose.
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The systems for clinical and non-clinical risk management and governance are aligned, with robust processes in place for the monitoring of risks and controls. As part of our work to ensure continuous improvement, the format and structure of both the corporate risk register and assurance framework are subject to ongoing revision and amendment during the year in response to feedback from directors and recommendations regarding best practice.
Conclusion
Following my review, my opinion is that Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust has a sound system of internal control that supports the achievement of its policies, aims and objectives.
Signed……………….. Richard Parker Chief Executive
24 May 2017
Independent auditor’s report to the Board of Governors
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Chief Executive’s statement
Despite the challenges we have faced as a Trust over the past 12 months, and the changes we had to make at a pace consistent with our Turnaround plans, we have succeeded in making improvements in the quality of the care offered to our patients. Ensuring the organisation is on a sustainable financial footing would be no achievement if we did not continue to make efforts to maintain our commitment to patient safety, while ensuring the continual improvement of the care we offer to patients, and I am proud to say we have not slipped in this regard.
This year we have made good progress in a number of areas. In line with one of our improvement priorities from last year, we have achieved a lower than expected performance on C.Diff infection achieving an 18.75% improvement on our performance in 2015/16, with a similar improvement in the number of cases resulting in a possibly preventable cause. Furthermore, only four of the 26 reported cases were classified as potentially avoidable.
This commitment to infection prevention and control was also evidenced in our extremely good performance in vaccinating our staff against flu. Thanks to the efforts of our Health and Wellbeing Team, we became the first acute Trust nationally to vaccinate over 75% of our front line staff, successfully delivering the vaccination to over 3,500 doctors and nurses in just two months. Achieving such a high standard protects not only staff, but patients in their charge.
We have also seen a reduction of 14% in repeated falls, and falls with harm caused, as well as serious harm from falls. This is due in large part to a number of initiatives such as our Enhanced Care Team and our Falls Champions which have ensured that our most vulnerable patients are well supervised and supported during their care.
Also in line with last year’s priorities, we have seen continued progress with our Hospital Standardised Mortality Ratio (HSMR), reducing by 4.54 points from 95.62 last year to 91.08 this year. This is lower the expected range of 100 for the 12 month period. The Standardised Hospital Mortality Indicator (SHMI), which also includes deaths following discharge from hospital, has also improved, reducing 3.7 points from 105.7 to 102. Although this is now within the expected range we will look to continue the improvement and move to less than 100 in the coming year.
Like many NHS providers, this year we have continued to face considerable challenges in regards to staffing, an issue that is not just local to our Trust. In January it became apparent that we did not have the capacity to sufficiently and safely staff Bassetlaw Hospital’s Children’s Ward. Together with our partners at NHS Bassetlaw Clinical Commissioning Group (CCG), we took the decision to close the ward overnight with children needing to be admitted for a prolonged period of time transferred to Doncaster Royal Infirmary. We recognise that this decision has caused concern for the local communities and will maintain our efforts to fill the medical and nursing vacancies that led to the change in our paediatric services.
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In order to address the ongoing staffing challenges, we are investigating schemes to fill any workforce gaps we encounter. One of our focuses for the next year and beyond will be to ensure that we are looking at how we can change and refresh our workforce plans to make the best use of the skills and expertise we have available in South Yorkshire and Bassetlaw. We are committed to working closely with our local and regional partners, looking towards strengthening partnerships with commissioners, primary care and other health and social care providers to support clinically-led change which improves the outcomes of care for patients.
In January 2017, we became Doncaster and Bassetlaw Teaching Hospital. Amongst other improvements, this means that the Trust is projecting to train 25% of medical students in the region, which adds to the fact that we are already training 30% of other healthcare professional students. I firmly believe that this achievement will help the Trust to recruit high calibre staff and in the training and retention of the skills and expertise needed to ensure we sustain high quality services for the people of Doncaster, Bassetlaw and beyond.
Over the year we have worked closely with our South Yorkshire and Bassetlaw partners to strengthen our working relationships as part of the Working Together Vanguard to develop new care models and address wider issues. We are also an integral partner of the South Yorkshire and Bassetlaw Sustainability and Transformation Plan (STP) which is set to become a first wave Accountable Care System. 2016/17 marks the penultimate 12 months of our five year strategic direction ‘Looking Forward to our Future’ and as we refresh this vision, we will emphasise the need for our future direction to fit with the needs of the wider health and social care community to deliver the local, regional and national priorities and improvements.
As we look forward to the year ahead, we recognise that there is more to be done, to eliminate Never Events, further reduce infection risks from MRSA bacteraemia and improve our patient safety indicators further to achieve the Sign up to Safety target of a 50% reduction in avoidable harm over three years, ending in 2018 and these reflect in our priorities for improvement in 2017/18.
To the best of my knowledge, the information in this Quality Report is accurate.
Richard Parker Chief Executive 8 May 2017
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Looking forward to our priorities for improvement in 2017/18
The Trust has reviewed its performance against the quality priorities for 2016/17 and reviewed the risk profile of patient safety, experience and clinical effectiveness, reaching a blend of indicators from 2016/17 being carried forward and an introduction of indicators new for this year.
These indicators will be reported to the Board or the Clinical Governance and Quality Committee on a quarterly basis or more frequently if required. Delivering harm free care and improving patient experience continues to be the Trust’s focus for 2017/18 and the table below identifies those indicators which are our highest priorities:
Patient safety quality improvement targets Target Actual 2017/18 2016/17 1. Take a zero tolerance approach to Never Events 0 1 2. Reduce the number of healthcare associated 0 3 infections (MRSA bacteraemia) 3. Maintain low levels or reduce healthcare associated 40 26 infections (C.Diff) 4. Increase reliability of Sepsis management on End of year admission to hospital* data not <90% available yet
Clinical effectiveness quality improvement targets Target Actual 2017/18 2016/17 5. Reduce the number of deaths which may have been 91.08 preventable - Hospital Standardised Mortality Ratio <95 (Jan 16 – (HSMR) Dec 16) 6. Reduce the number of deaths which may have been 102 preventable - Summary Hospital-level Mortality <100 (Dec 15 – Indicator (SHMI) Nov 16) 7. Reduce avoidable Re-admissions (30 days – SRR <99 SRR 99.2 Standardised Readmission Ratio) 8. Increase reliability of fluid balance chart completion*
Patient experience quality improvement targets Target Actual 2017/18 2016/17 9. Reduce the number of complaints 517 570 10. Demonstrate increased Patient Engagement activities 100% of Not in each Care Group. Care measured Groups 11. Reduce the number of complaints relating to staff 10% 129
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attitude and behaviour reduction 12. Reduce the number of complaints issues about 10% 169 communication.* reduction
* Governor selection to be determined
In identifying the priorities for improvement for 2017/18, the Trust has taken into account the views of:
Patients and their care outcomes: Via patient surveys and complaints monitoring Staff: Reports on clinical outcomes and incident reporting Commissioners: Via quality meetings and contractual arrangements Service users: Via the work of the Patient Experience and Engagement Committee and priorities identified in analysis of key themes.
Over the coming year, the Trust aims to develop strategies to improve patient engagement and listening activities. This will strengthen the patients and public voice in how we prioritise quality improvement initiatives.
Looking back on our priorities for improvement in 2016/17
Over the last year we have made substantial improvements in delivering harm free care. The following tables provide an overview of our achievements against the quality improvement targets we set for 2016/17.
Key
= target achieved = close to target = behind plan
Patient safety quality improvement targets Target Actual Progress 2016/17 2016/17 1. Take a zero tolerance approach to “never 0 1 < events” 2. Reduce the number of healthcare associated 0 3 < infections - MRSA bacteraemia 3. Maintain or reduce the number of healthcare 40 26 associated infections - C difficile
Clinical effectiveness quality improvement targets Target Actual Progress 2016/17 2016/17 4. Reduce the number of deaths which may have <100 91.08 been preventable - Hospital Standardised (Jan 16 – Dec
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Mortality Ratio (HSMR) 16)
5. Reduce the number of deaths which may have <100 102 been preventable - Summary Hospital-level (Dec 15 – Mortality Indicator (SHMI) Nov 16) 6. Reduce avoidable Re-admissions 5.4% 6.34%
Patient experience quality improvement targets Target Actual Progress 2016/17 2016/17 7. Reduce the number of complaints 535 574 8. Reduce the number of complaints issues about 170.1 169 communication. 9. Improve response rates for Friends & Family 6.9% < 4.2% Test – Accident & Emergency 10. Reduce the number of complaints relating to 130 129 staff attitude and behaviour
Statements of assurance
Review of services
During 2016/17, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust provided and or sub-contracted 49 relevant health services.
Doncaster and Bassetlaw Hospitals NHS Foundation Trust has reviewed all the data available on the quality of care in all 49 of these relevant health services.
The income generated by the relevant health services reviewed in 2016/17 represents 100% of the total income generated from the provision of relevant health services by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust for 2016/17.
Participation in clinical audits
During 2016/17, [data not yet available] national clinical audits and [data not yet available] national confidential enquiries covered relevant health services that Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust provides.
During that period, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust participated in [data not yet available] national clinical audits and [data not yet available] national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in.
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The national clinical audits and national confidential enquiries that Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust was eligible to participate in during 2016/17 are as follows: (see table below – ineligible audits stated to be N/A)
The national clinical audits and national confidential enquiries that Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust participated in, and for which data collection was completed during 2016/17, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of the audit or enquiry.
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Trust Data collection participation completed during % of cases submitted in audits 2016/17 Acute Coronary Syndrome or Acute Myocardial Infarction (MINAP) Yes Yes Adult Asthma Yes Yes Adult Cardiac Surgery NA NA Asthma (paediatric and adult) care in emergency departments Yes Yes - DRI only Bowel Cancer (NBOCAP) Yes Yes Cardiac Rhythm Management (CRM) Yes Yes Case Mix Programme (CMP) Yes Yes Child Health Clinical Outcome Review Programme Yes Yes Chronic Kidney Disease in primary care NA NA Congenital Heart Disease (CHD) NA NA Coronary Angioplasty/National Audit of Percutaneous Coronary Interventions (PCI) NA NA Diabetes (Paediatric) (NPDA) Yes Yes Elective Surgery (National PROMs Programme) Yes Yes Endocrine and Thyroid National Audit No No Falls and Fragility Fractures Audit programme (FFFAP) Yes Yes Head and Neck Cancer Audit No No Inflammatory Bowel Disease (IBD) programme Yes Yes Learning Disability Mortality Review Programme Major Trauma Audit Yes Yes Maternal, Newborn and Infant Clinical Outcome Review Programme Yes Yes Medical & Surgical Clinical Outcome Review Programme Yes Yes Mental Health Clinical Outcome Review Yes Yes National Audit of Dementia Yes Yes National Audit of Pulmonary Hypertension NA NA
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National Cardiac Arrest Audit (NCAA) Yes Yes National Chronic Obstructive Pulmonary Disease (COPD) Audit Yes Yes National Comparative Audit of Blood Transfusion - Audit of Patient Blood Management in Yes Yes
Scheduled Surgery National Diabetes Audit -Adults No No National Emergency Laparotomy Audit (NELA) Yes Yes National Heart Failure Audit Yes Yes National Joint Registry (NJR) Yes Yes National Lung Cancer Audit (NLCA) Yes Yes National Neurosurgery Audit Programme NA NA National Ophthalmology Audit No No National Prostate Cancer Audit Yes Yes National Vascular Registry Yes Yes Neonatal Intensive and Special Care (NNAP) Yes Yes Nephrectomy audit NA NA Oesophago-gastric Cancer (NAOGC) Yes Yes Paediatric Intensive Care (PICANet) NA NA Paediatric Pneumonia Yes Yes Percutaneous Nephrolithotomy (PCNL) Yes Prescribing Observatory for Mental Health (POMH-UK) NA NA Radical Prostatectomy Audit NA NA Renal Replacement Therapy (Renal Registry) Yes Yes Rheumatoid and Early Inflammatory Arthritis NA NA Sentinel Stroke National Audit programme (SSNAP) Yes Yes Severe Sepsis and Septic Shock – care in emergency departments Yes Yes - DRI only Specialist rehabilitation for patients with complex needs Stress Urinary Incontinence Audit Yes Yes UK Cystic Fibrosis Registry NA NA
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The reports of [data not yet available] national clinical audits were reviewed by the Trust in 2016/17 and Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided:
The Trust will undertake any actions which were found necessary to improve the quality of healthcare.
The reports of 140 local clinical audits were reviewed in 2016/17 and we intend to take the following actions to improve the quality of healthcare:
- The Trust will ensure all actions are taken forward through the clinical governance arrangements at specialist and Care Group level.
We have listed below three examples of improvements which have been made as a result of audits undertaken throughout 2016/17:
Audit into the prescribing of tetanus immunoglobulin in Emergency Department at Doncaster Royal Infirmary
It was noticed that the usage and expenditure of tetanus immunoglobulin had significantly increased right across the Emergency Care Group in this financial year. It was acknowledged that a change in practice may have contributed to this, so this audit was undertaken to assess the appropriateness of the treatment. Not all wounds require the tetanus immunoglobulin even if they are tetanus-prone and this is outlined in the ‘Green Book’.
Not all wounds that are tetanus-prone are high risk and therefore will not require tetanus immunoglobulin. High risk means they are heavily contaminated with soil or manure where tetanus spores may exist, so lightly soiled or clean wounds that do not meet the above criteria are not classed as such.
Methodology: All patients who received any tetanus product between the 15 October and 15 November 2016 were retrieved using the Symphony clinical system. All patient records were accessed and the auditor made an independent assessment of the nature of the tetanus product that the patient should receive (if any) and then compared this decision with the actual product prescribed.
Standards: 100% of patients who receive tetanus immunoglobulin should fulfil the criteria for a (contaminated) tetanus-prone wound 100% of patients who receive the Diptheria/Tetanus/Pertussis (DTP) vaccine should meet the criteria outlined in the Green Book 100% of patients who were prescribed tetanus immunoglobulin should have been given a DTP vaccine (as appropriate) at the same time.
Results (of the 40 patients which were audited):
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Standard 1 was not met. Of the patients that received the immunoglobulin only 33.3% (2/6) of patients met the criteria of a contaminated tetanus-prone wound, based on the information recorded on Symphony Standard 2 was not met. Of the patients that were prescribed DTP vaccine, 91% (31/34) met the criteria for vaccination Standard 3 was not met. Three patients who were prescribed tetanus immunoglobulin (whether or not this was inappropriate) who should have also received a DTP vaccine based on the guidance did not receive the vaccine based on the vaccination history recorded on Symphony 50% of the patient records had no mention of vaccination status Batch numbers of the vaccines/immunoglobulins did not seem to be recorded on Symphony.
Conclusion: The usage of tetanus immunoglobulin does not reflect the prescription numbers during the same month, which leads the auditor to believe that whilst the prescribing is broadly appropriate there may have been an administration error whereby the DTP vaccine has been prescribed but the immunoglobulin given in error Knowledge gaps have been identified in some areas Incidentally, it appears that the batch numbers of the vaccines/immunoglobulins have not been recorded after administration The PGD’s that legislate for ENP’s to administer these products need updating and clarifying Some additional training is required both for medical and nursing staff in the Emergency Department.
Audit on Consultant Sign-off
In December 2010 the Royal College of Emergency Medicine published a standard for ‘Consultant sign-off’. The Department of Health subsequently adopted ‘Consultant sign-off’ as a quality indicator for Emergency Departments in England. This topic is on the RCEM national audit programme. The aim of this audit is to identify current levels of compliance against the RCEM standards, raise awareness of the standards and improve the standard of care and increase patient safety.
Actions: Display Consultant sign-off conditions in Triage and Doctor workplace Educate junior doctors and ENPs about consultant sign-off.
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Audit of compliance with documentation – notes audit, 100% compliance with criteria in notes audit on Ward 16
The aim of this audit is to determine ward performance against completion of criteria in notes. To understand compliance position at ward level, identify areas of concern and where necessary implement change.
Results: 100% compliance in five out of 16 criteria All criteria consistently over 70% compliance Overall improvement in all criteria from start of audit.
Actions Plan: Continue regular monitoring of documentation Feedback to both qualified therapy staff and therapy assistants – preferred method to be agreed with staff Redesign of audit tool Refresher training on ‘Notes guidelines’ and ‘Legal implications of accurate documentation’ Repeat audit three months after original to assess improvement.
Participation in clinical research
The number of patients receiving relevant health services provided or sub-contracted by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust in 2016/17 that were recruited during that period to participate in research approved by a research ethics committee 3606. Of these, 1,416 participants were recruited onto studies adopted onto the National Institute for Health Research Portfolio, exceeding our annual target of 1,000.
During 2016/17, 57 additional studies were approved to commence within the Trust, which include Clinical Trials of Investigational Medicinal Products (CTIMPs) and Medical Device trials. The Trust supports research in differing roles, either as a sponsoring organisation, a participating organisation or as a participant identification centre. The department of Research and Development is continuing to expand to reflect both the increasing level of research activity and also to support the continuing advancement of research within the Trust, with the Research team providing comprehensive support to researchers during the planning, set-up and delivery phases of research.
Participation in clinical research demonstrates the Trust’s commitment to improving the quality of care we offer to patients and to making our contribution to wider health improvements. Our clinical staff members stay abreast of the latest possible treatment options and active participation in research leads to successful patient outcomes. Our engagement with clinical research demonstrates our commitment to testing and offering the latest medical treatments and techniques.
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We have delivered successfully to almost all of our Key Performance Indicator (KPI) listed in the Research and Development strategy and have set the last two years of KPIs.
Within this last year we have been particularly focussed on delivery to the Collaborations for Leadership in Applied Health Research and Care (CLAHRC) programme. This has included the twelve-month appointment of a Research Fellow, who will be taking forward specific elements of our strategy over the next year.
Use of the Commissioning for Quality and Innovation (CQUIN) payment framework
A proportion of Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust income in 2016/17 was conditional on achieving quality improvement and innovation goals agreed between Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust and any person or body they entered into a contract, agreement or arrangement with for the provision of relevant health services, through the Commissioning for Quality and Innovation payment framework.
Further details of the agreed goals for 2016/17 and for the following 12 month period are available electronically at:
[updated link will be inserted]
The monetary total in 2016/17, conditional upon achieving quality improvement and innovation goals, was £6.46m. The total associated payment in 2016/17 was £6.23m.
We have worked with our local commissioners to ensure that the CQUIN scheme was aligned with local commissioning strategies and our own strategic direction and core values.
Working together the CQUIN income has been used to incentivise and accelerate quality and innovation improvements above the baseline requirements set out in the standard contract.
Although challenging, the Trust successfully achieved the majority of improvements and innovations which had been agreed.
Statements from the Care Quality Commision (CQC)
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust is required to register with the Care Quality Commission (CQC) and its current registration status is FULL Registration compliance with no conditions on registration.
The CQC Commission has not taken enforcement action against Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust during 2016/17.
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust has not participated in any special reviews or investigations by the CQC during the reporting period.
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Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust has undergone a Comprehensive Inspection by the CQC in April 2015. The subsequent findings were that the Trust overall outcome was ‘Requires Improvement’. Doncaster Royal Infirmary, Bassetlaw Hospital and Retford Hospital were given outcome of ‘Requires Improvement’, with Montagu Hospital being as assessed as ‘Good’.
Positively noted in the assessment was that there were no services or components of core pathways identified as ‘Inadequate’, with a total of 74% of services and their component parts being assessed as ‘Good’.
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The action plan that was developed in response to the Comprehensive Inspection report in October 2015 has been delivered and reported through the Clinical Governance and Quality Committee and the Audit and Non-Clinical Risk Committee. Internal audit have followed up including mock inspection. This has identified further recommendations to sustain improvements and remedy findings from the mock inspection.
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust has participated in the Joint OFSTED and CQC targeted inspection for Special Educational Needs and Disability (SEND) for Nottinghamshire in June 2016. There were no recommendations specific to the Trust. Data quality
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust submitted records during 2016/17 to the Secondary Uses Services for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data:
Including the patient’s valid NHS number:
99.6% for admitted patient care – national position 99.3 % 99.7% for outpatient care – national position 99.5% 97.7% for accident and emergency care – national position 96.7%.
Including the patients valid General Medical Practice Code:
100% for admitted patient care – national position 99.9% 100% for outpatient care – national position 99.8% 99.9% for accident and emergency care – national position 99%.
Information governance toolkit attainment 2016/17
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust Information Governance Assessment Report overall score for 2016/17 of 75% and was graded as Satisfactory. Clinical coding error rate
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust was not subject to the Payment by Results clinical coding audit during the reporting period by the Audit Commission. In line with Information Governance Requirements the Trust had external inpatient clinical coding audits, (diagnoses and procedure coding) undertaken during 2016/17 which resulted in the Trust maintaining IG level three. The combined results of the audits were:
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Primary diagnoses incorrect - 97% Secondary diagnoses incorrect – 97.6% Primary procedures incorrect – 95% Secondary procedures incorrect – 99%.
The results should not be extrapolated further than the actual sample audit as some of the issues raised may only relate to the speciality selected and will not apply to other specialities. Extrapolating the overall results would not provide an accurate position in relation to performance. The audit consisted of 303 finished consultant episodes split over two audits covering a wide variety of specialties. Additionally during 2016/17 work was undertaken with an external company to improve the accuracy and depth of clinical coding, which also included clinical documentation. The learning from this project will be taken into 2017/18 by the Trust. Work continues to ensure we are using the Clinical Coding Encoder system to its full potential.
The Trust recognises the importance of high quality information as a fundamental requirement for the prompt, safe and effective treatment of patients. High quality information is critical to the delivery of high quality care to patients and in meeting the needs of clinical governance, management information, accountability, financial control, health planning and service agreements.
High quality business information supports decision making as well as ensuring that the Trust reports its performance accurately both internally and externally including Commissioners, NHS England, NHS Improvement, the Department of Health and the Care Quality Commission.
Achievement of CQUIN, accurate charging for income, through robust data collection and reporting, is also reliant on high quality data. It also provides commissioner confidence and assurance.
Maintaining and driving improvements in data quality continued to be an area of high priority and focus for the Trust, during 2016/17 and this will continue in 2017/18 and beyond. The Trust continues to invest in data quality resources.
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust will be taking the following actions to improve data quality:
In October 2016, the Trust implemented a modern Patient Administration System (PAS), which alongside other benefits, has provided opportunities for long term improved data quality. As with all major new system implementations, there continues to be some data quality challenges, and focused work continues to address these challenges Nationally, data quality is measured by the Secondary Uses Service (SUS) Data Quality Dashboards. For 2016/17 to month 10 (latest published data) the Trust had a composite score of 99.6% across a range of indicators which cover inpatients, outpatient and Emergency Department, against a national comparative score of 96.5%. The Trust is consistently above the national average and is fourth within
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Yorkshire and Humberside. This is a significant achievement for the Trust and demonstrates a strong commitment to high quality data 18 Weeks data quality continues to be of high priority for the Trust with routine validation firmly embedded within the Trust. During 2016/17 there was a specific data quality improvement plan on 18 Weeks, which was agreed with commissioners and further work and extended scope are planned for 2017/18. This ensures we have high quality data to maintain the accuracy of waiting times to support treating patients in chronological order for the same clinical priority, support demand and capacity modelling and ensure accurate performance reporting Key priority packages of work were agreed and delivered in line with the requirements laid down within the Data Quality Improvement Plan for 2016/17 within the NHS Standard Contract with commissioners. The PAS Replacement data quality work continued to be the area of highest priority We continue to provide focus on key data quality performance areas through the Trust Data Quality Group. The group identifies key work streams to address areas of concern and then monitors and review progress against improvement targets. The Data Quality Group reports to the Trust Information Governance Group We continue to undertake key regular data quality audits, both to fulfil Information Governance and local requirements. We promote the principle of ‘Right First Time’ in respect of recording patient information. This also links into the Trust’s financial Turnaround projects and focused work will continue in 2017/18 through specific task to finish groups For all Trust system implementations, data quality is a key element within the project, including potential risks along with mitigating strategies and actions.
Achievements against quality improvement priorities 2016/17
Quality improvement 1 – patient safety Take a zero tolerance approach to “never events”
Why = these are largely preventable patient safety incidents that should not occur if preventative measures have been implemented within the Trust Outcome = 1 case, close to target.
During 2016/17 the Trust reported one never event against a target of zero. Never Events are defined by the National Patient Safety Agency (NPSA) as ‘serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers.’
Year Number of incidents reported* Per 1000 occupied bed days 2012/13 2 0.0062 2013/14 3 0.0092 2014/15 1 0.0030 2015/16 2 0.0063 2016/17 1 0.0034
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Details of the Trust’s reported never event during 2016/17 are as follows:
Retained wire following emergency admission and indication for life saving treatment.
The incident has not caused any long term physical harm to the patient, but has provided a valuable learning opportunity that has been introduced into local and regional medical staff training for the technique of chest drain insertion using a guidewire. The guidewire was successfully removed and the patient has been informed of the incident and findings of the investigation.
Progress, Monitoring & Reporting: The learning from root cause analysis which follows any such events, is shared Trust-wide to ensure that the learning from the never event does not happen again in the future. Reporting to the Board of Directors takes place monthly.
The Trust has an incident reporting system that specifically enables any member of staff to highlight never events or serious incidents, so that any potential case can be reviewed rapidly. This provides a culture of openness and the duty of candour to our patients.
*It should be noted that year on year figures are not directly comparable as the original ‘Never Events’ definition as set out by NPSA in April 2009 was expanded for 2011/12 and then expanded further in 2012/13, and revised again in 2014/15.
Data Source: Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust internal systems. This data is governed by: National definitions
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Quality improvement 2 – patient safety To reduce levels of hospital acquired MRSA bacteraemia
Why = the Trust wishes to ensure the safest possible care for patients by reducing the number of healthcare acquired infections.
Outcome = Trust not achieved trajectory with three cases reported during 2016/17, this is a slight increase on the number of cases reported during 2015/16.
Year Number of reported cases Per 1000 occupied bed days 2012/13 2 0.0062 2013/14 2 0.0061 2014/15 2 0.0061 2015/16 2 0.0063 2016/17 3 0.0102
The Trust had three MRSA bacteraemia against a zero tolerance to avoidable infection in 2016/17 financial year:
The first case was a patient who screened negative for MRSA, but later colonised MRSA, that was identified on subsequent screening. The patient had complex care needs and was difficult to take blood cultures from. The outcome at the post infection review was that it was a blood culture contaminant The second case was in a complex patient who had been found to be colonised with MRSA, and a peripheral cannula was inserted for intravenous antibiotic due to urosepsis and left in without documentation of visual infusion phlebitis (VIP) score completed daily. The post infection review concluded that the cannula was the source of infection The third was a patient who had multiple negative screens for MRSA, and was admitted into a side room due to Clostridium difficile infection. They acquired MRSA colonisation while in hospital; although no cross infection could be identified from other patients. The blood culture isolate was considered to be contaminant as it was not in keeping with clinical findings and patient had not required treatment on discharge.
There are policies, procedures and training in place to reduce the risk of MRSA bacteraemia, and other infections, with surveillance monitoring systems in place to monitor the reliability of the processes that mitigate risks. In addition to impressing upon staff that the compliance to policies and procedures is required, the following learning have been identified:
Patients who are colonised with MRSA are at a greater risk of MRSA infection, so avoiding when possible: invasive devices, such as urinary catheters, central venous access, IV cannulas, use of IV routes when possible with antibiotics Documentation of VIP scores is to be monitored more frequently to determine levels of compliance Use of decolonisation treatments proactively for higher risk patients.
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Progress, Monitoring & Reporting: Dashboards are completed for the monitoring and reporting of HCAI’s. Reporting to the Board of Directors takes place monthly.
Data Source: Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust internal systems This data is governed by: National definitions
Quality improvement 3 – patient safety To reduce levels of hospital acquired C-diff
Why = the Trust wishes to ensure the safest possible care for patients by reducing the number of healthcare acquired infections.
Outcome = Trust trajectory achieved with 26 cases reported during 2016/17, which demonstrates a 18.75% reduction on the number of cases reported during 2015/16.
Year Number of reported cases Per 1000 occupied bed days 2012/13 67 0.1988 2013/14 41 0.1269 2014/15 44 0.1353 2015/16 32 0.1023 2016/17 26 0.0891
We recorded 26 cases attributed to the Trust with four of these showing lapses in care due to antibiotic use outside Trust guidelines. We met our trajectory for Clostridium difficile infection for 2016/17, and further improved by approximately 18.75% from 2015/16 financial year achievement.
There was no evidence of cross-infection as different ribotypes, confirmed through suspected samples being sent for testing at the reference centre.
The lapses in care for the four cases have been addressed through local action, with antibiotic stewardship being the focus for trust wide learning. This means using the correct antibiotic for the presenting need and keeping course lengths within recommended use.
Progress, Monitoring & Reporting: Dashboards are completed for the monitoring and reporting of HCAI’s. Reporting to the Board of Directors takes place monthly.
Data Source: Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust internal systems This data is governed by: National definitions
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Quality improvement 4 & 5 – clinical effectiveness Reduce the number of deaths which may have been preventable
Why = Implementing a system for continuous review of HSMR and SHMI will support achievement of no avoidable deaths and no avoidable harm to patients.
Outcome = Target achieved HSMR: 91.08 (Jan 16 – Dec 16) SHMI 102 (Dec 15 – Nov 16).
Year HSMR SHMI 2013 111.12 (Jan 13 – Dec 13) 108.47 (Oct 12 – Sep 13) 2014 108.68 (Jan 14 – Dec 14) 112.88 (Oct 13 – Sep 14) 2015 95.62 (Jan 15 – Dec 15) 105.7 (Oct 14 – Sep 15) 2016 91.08 (Jan 16 – Dec 16) 102 (Dec 15 – Nov 16)
Both the HSMR and the SHMI continue to show a steady improving picture reflecting the work that the Trust has put in in recent years in re-engineering emergency pathways, improved depth of coding and 7/7 working as well as undertaking reviews of deaths and undertaking thematic analysis for the purpose of learning.
The difference in the values reflects that the SHMI also takes account of deaths within 30 days of discharge and not just in hospital deaths.
Progress, Monitoring & Reporting: Monitoring of the Trust HSMR and SHMI continues through the Mortality Monitoring Group. Reporting to the Board of Directors takes place monthly.
Data Source: HED This data is governed by: National definitions
Quality improvement 6 – clinical effectiveness Reduce the number of avoidable re-admissions
Why = Avoidable emergency re-admissions are a symptom of poor planning and support for patients when going home. This can also identify pathways of care that are prematurely discharging patients before they are well enough to cope at home.
Outcome = 3.8% reduction achieved based on the readmissions rates reported in Q1 2016/17 & Q4 2016/17, however, the overall Trust target readmission rate of 5.4% has not been achieved.
Benchmarking data illustrates that there is slightly better than average rates of emergency readmissions, however the reduction target has not been achieved this year.
Readmission Rate Readmission Rate Difference Difference % Q1(Jan – Mar) Q4(Oct – Dec) 2014 6.39% 6.01% 0.38 5.9 2015 6.18% 5.73% 0.45 7.3
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2016 6.41% 6.17% 0.24 3.8
Progress, Monitoring & Reporting: Establish a process to review re-admissions. Monitoring through the CQUIN working groups and reporting to the board on the Readmission rate in the Business Intelligence report.
Data Source: Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust internal systems This data is governed by: National definitions
Quality improvement 7 – patient experience Reduce the number of complaints
Why = learning from complaints is taken forward through actions to improve services in line with the needs of the patients.
Outcome = 570 complaints have been reported during 2016/17 this demonstrates a slight increase on the number reported during 2015/16. Target not achieved.
An increased rate of complaints in quarter two and quarter four has resulted in not achieving the intended reduction in complaints this year. The intention is to pursue achieving a higher number of concerns being dealt with before they become complaints, so promoting local resolution of issues at ward and department level is key to helping patients have an improved experience.
80 70 60 50 Complaint 40 Average month rate 2015/16 30 Average month rate 2016/17 20 10 Target 2016/17 0 Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec Feb 201520152015201520152016201620162016201620162017
Progress, Monitoring & Reporting: Internal Audit review of actions. Audit of high risk and Parliamentary Health Service Ombudsman investigations. Reporting to the Patient Experience and Engagement Committee.
Data Source: Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust internal systems. This data is governed by: National & Local definitions
Quality improvement 8 – patient experience Reduce the number of complaints issues about communication
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Why = Communication issues are identified in more complaints than any other issue and are often a contribution to other concerns raised with the Trust.
Outcome = 169 – reduction achieved.
The Trust set an objective of reducing the number of complaints about communication for the quality account for 2016/17, to reduce by 10%. The chart below illustrates that this has been achieved. The total number of communication complaints in 2015/16 was 189 and in 2016/17 it was 169 (10.58%). There has been a challenge to all teams to improve communication and examples of changes made in services have proved to be effective in reducing issues in several areas. However, there continues to be issues and although there is improvement greater than the target was set, there is an intent to continue to tackle communication issues across all staff groups and improve patient experience in that regard.
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20
15 Month rate
10 Average 2015/16 Average 2016/17 5 Target 2016/17
0
Jul2016 Jul2015
Jan2016 Jan2017
Jun2015 Jun2016
Oct Oct 2015 Oct 2016
Apr 2015 Apr 2016
Sep2015 Feb2016 Sep2016 Feb2017
Dec2015 Dec2016
Aug2015 Aug2016
Nov 2015 Nov 2016 Nov
Mar 2016 Mar 2017 May2016 May2015
Progress, Monitoring & Reporting: Internal Audit review of actions. Audit of high risk and Parliamentary Health Service Ombudsman investigations. Reporting to the Patient Experience and Engagement Committee.
Data Source: Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust internal systems. This data is governed by: National & Local definitions
Quality improvement 9 – patient experience Improve response rates for the Friends and Family Test in the Emergency Department
Why = The Trust believes that every patient should feel that they matter and are at the heart of everything we do.
Outcome = 4.2% - not achieved
The FFT rate of completion in A&E has not been achieved, although slightly improved on the rate from 2015/16. On analysing the reasons for this, there is a small window of opportunity
111 to capture patients who are discharged from the Emergency Department, in part because they want to leave as soon as they can and the cards given to patients are often discarded on the way out of the department. There are an average of 488 FFT scores obtained each month, providing comments and an average positive score of 91%, which is higher than the regional and national rate.
With other data for the FFT test for inpatients, there is a similar to national and regional average recommended rate and a higher rate of response.
Emergency Department Completion Rates
2013/2014 25.1% 2014/2015 6.9% 2015/2016 3.4% 2016/2017 4.2%
Progress, Monitoring & Reporting: Monthly monitoring of A&E and inpatient FFT completion rates. Monthly reporting to the Board of Directors. Monthly benchmarking against national reporting.
Data Source: Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust internal systems. This data is governed by: National definitions
Quality improvement 10 – patient experience Reduce the number of complaints relating to staff attitude and behaviour
Why = The good attitudes and behaviour of staff is paramount to providing a good quality service and patient experience. This also relates to the families and visitors of patients, who should be afforded the appropriate good quality customer service skills.
Outcome = 129, target achieved.
The Trust set an objective of reducing the number of complaints about staff attitude and behavior for the quality account for 2016/17, to reduce by 10%. The chart below illustrates that this has been achieved. The total number of staff attitude and behavior complaints in 2015/16 was 145 and in 2016/17 it was 129 (11.03%).
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20 18 16 14 12 Monthly rate 10 8 Average 2015/16 6 Average 2016/17 4 Target 2016/17 2
0
Jul 2015Jul 2016Jul
Jan2016 Jan2017
Jun 2015 Jun Jun2016
Oct 2015 Oct 2016
Apr 2015 Apr 2016
Sep2015 Feb2016 Sep2016 Feb2017
Dec2015 Dec2016
Aug2015 Aug2016
Nov 2016 Nov Nov 2015 Nov
Mar 2016 Mar 2017 May2016 May2015
Progress, Monitoring & Reporting: Monthly monitoring of Emergency Department and inpatient FFT completion rates. Monthly reporting to the Board of Directors. Monthly benchmarking against national reporting.
Data Source: Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust internal systems This data is governed by: National definitions
Review of Quality Performance 2016/17
The national and local Commissioning for Quality and Innovation (CQUIN) targets have been met on the whole. There was full achievement across all but some aspects of the Sepsis screening and treatment and monitoring of antibiotics, which were partially achieved. A particularly positive achievement in the CQUIN’s over the last year are the flu vaccination of staff, with the Trust being the first to reach the target nationally, with the Helen Houghton, Health and Wellbeing Lead, being awarded Flu Fighter Champion by NHS Employers. Helen graciously accepted the award on behalf of the wider team involving the occupational health and the senior nursing team.
The local CQUIN initiatives have continued from previous activities over the last year, with collaborative working with community partners in the management of discharge processes and end of life care. These measures have resulted in closer working relationships and tackled issues that have been exposed to benefit patients care and access to the right services. We acknowledge the contribution made from our provider colleagues in the health community and the support of the clinical commissioners in taking these initiatives forward.
The schemes for 2016/17 are shown below:
Local CQUINs o Patient safety – sign up to safety plan o Discharge multi-disciplinary review
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o End of Life multi-disciplinary review o Pressure ulcer reduction National CQUINs o National Health and Well Being improvement plan o National Health and Well Being healthy food o National Health and Well Being frontline flu o National Sepsis ED o National Sepsis Wards o National Cancer 62 day performance o National Cancer RCA for >104 day cases o National Antibiotic consumption o National Empiric review NHS England CQUINs o NHSE Critical care discharge o NHSE specialty schemes
The Trust uses a range of quality measurements to assess the services that we provide, including accreditation for nutrition, infection prevention and control, patient safety, effective, responsive and patient experience. Much of this information is relevant to each clinical area, so have driven quality improvement through use of triangulated measurements and annual assessments by Heads of Nursing and Midwifery and Deputy Directors in the Nursing Directorate. When issues are identified then the Deputy Directors take forward interventions with the relevant Head of Nursing or Midwifery and their leadership team to tackle performance and provide support. We have taken a harder line with expected standards, improving on each ward’s historical performance, to contribute to the Quality Assurance Tool outcomes so that we can continue to build on the progress of previous years.
The indicators below are included to demonstrate the Trust’s performance against additional mandatory quality initiatives.
National National targets and regulatory target or requirements 2013/14 2014/15 2015/16 2016/17 trajectory 2016/17
All cancers: 62-day wait for first treatment from: 89.4% 87.8% 85.5% 86.5% 85%
Urgent GP referral for suspected cancer
All cancers: 62-day wait for first treatment 94.7% 94.4% 92.7% 93.5% 90% from:
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NHS Cancer Screening Service referral
18 week maximum wait from referral to treatment (patients on an incomplete pathway) 92.8% 93% 92.1% 90.5% 92% Data Source: Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust internal systems
Maximum waiting time of four hours in A&E from arrival to admission, transfer or Discharge 95.5% 92.9% 94.51% 91.4% 95% Data Source: Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust internal systems
Definitions used by audited indicators
Indicator Definition Maximum waiting time Numerator of four hours in The total number of patients who have a total time in Emergency Emergency Department of four hours or less from arrival to Department from admission, transfer or discharge. Calculated as: arrival to admission, (Total number of unplanned Emergency Department transfer or discharge attendances) – (Total number of patients who have a total time in Emergency Department over 4 hours from arrival to admission, transfer or discharge) Denominator The total number of unplanned Emergency Department attendances
Detailed rules and guidance for measuring Emergency Department attendances and emergency admissions can be found at https://www.england.nhs.uk/statistics/wp- content/uploads/sites/2/2013/03/AE-Attendances- Emergency-Definitions-v2.0-Final.pdf
18 week maximum Numerator wait from referral to The number of patients on an incomplete pathway at the end treatment (patients on of the reporting period who have been waiting no more than an incomplete 18 weeks pathway) Denominator The total number of patients on an incomplete pathway at the
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end of the reporting period
Detailed rules and guidance for measuring referral to treatment (RTT) standards can be found at http://www.england.nhs.uk/statistics/statistical-work- areas/rtt-waiting-times/rtt-guidance/
Reduce the number of (a) where the time period between discharge from the initial avoidable re- admission and the readmission is equal to or less than 30 days admissions (b) which has an emergency admission method code37 of 21- 25, 2A, 2B, 2C or 2D (or 28 if the provider has not implemented CDS 6.2) (c) which has a national tariff (d) irrespective of whether the initial admission has a national tariff (e) irrespective of whether it is to the same provider (f) irrespective of whether it is non-contract activity (paragraph 936) (g) irrespective of whether the initial admission or readmission occurs in the NHS or independent sector. https://www.gov.uk/government/uploads/system/uploads/att achment_data/file/214902/PbR-Guidance-2013-14.pdf
The completeness and accuracy of the data used in the indicator calculation is dependent on the completeness and accuracy of the data capture at source. To the best of our knowledge and belief the information used to calculate indicators is complete, accurate and relates to the reporting period.
2017/18 Quality Improvement Priorities comparative data
The table below shows comparative data to provide additional context.
Target 2016/17 2015/16 2014/15 2017/18 Patient safety quality improvement targets 13. Take a zero tolerance approach to 0 1 2 1 “never events” 14. Reduce the number of healthcare 0 3 2 2 associated infections - MRSA bacteraemia 15. Maintain or reduce low levels the 40 26 32 44 number of healthcare associated infections (C.Diff) Clinical effectiveness quality improvement targets
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16. Reduce the number of deaths which <95 91.08 95.62 may have been preventable - Hospital (Jan16 – (Jan 15 – 108.68 Standardised Mortality Ratio (HSMR) Dec 16) Dec15) 17. Reduce the number of deaths which <100 102 105.7 may have been preventable - Summary (Dec 15- (Oct 14 – 112.88 Hospital-level Mortality Indicator (SHMI) Nov 16) Sep15) 18. Reduce avoidable Re-admissions SRR <99 Patient experience quality improvement targets 19. Reduce the number of complaints 517 570 563 640 20. Demonstrate increased Patient 100% of Not Not Not Engagement activities in each Care Care measured measured measured Group Groups 21. Reduce the number of complaints 116 129 144 143 relating to staff attitude and behaviour
Tenth indicator is to be determined through Governor selection and will be added to the relevant section above.
Comments on the 2016/17 Quality Account were received by:
Healthwatch Nottingham
As the independent watchdog for health and social care in the county, we work to ensure that patient and carer voices are heard by providers and commissioners. We are grateful to be given the opportunity to view and comment on the Quality Report. We specifically reviewed it in response to the issues that have been bought to the attention of Healthwatch.
Healthwatch Nottinghamshire would like to highlight a number of recognised successes presented in the Account and to seek assurance and guidance from the Trust in addressing under performance and the areas of concern that remain.
Successes
Over the past 12 months the Trust appears to have made some significant positive shifts in a number of patient safety areas.
Reduction of the number of falls Reduction of reported Never Events Continued reduction of patients with C.Diff (Clostridium difficile infection) Reduction of number of deaths which may have been preventable.
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In addition to these improvements, we congratulate Helen Houghton and the Health and Wellbeing Team who were recognised nationally for their efforts in vaccinating over 75% of Trust staff, the first in the country to do so.
In addition to the above, Healthwatch Nottinghamshire is pleased that the Trust received 10% fewer complaints relating to staff communication and acknowledges the efforts of all departments in doing so. However, staff communication is still the second most prevalent negative theme reported to Healthwatch Nottinghamshire, so we welcome the Trust’s intent to continue to improve in this area.
Healthwatch Nottinghamshire has welcomed a closer working relationship with the Trust over the past year, with our Chair and Chief Executive meeting regularly with senior staff at the Trust. Whilst observing the different roles both organisations have, it is acknowledged that both have a joint objective of ensuring high quality services for patients. Healthwatch Nottinghamshire has in particular used these opportunities to scrutinise how the decisions to move services from Bassetlaw Hospital to Doncaster Royal Infirmary affects patients.
Healthwatch Nottinghamshire has also been involved in conversations with seldom-heard groups in the Bassetlaw area as part of the consultation process for the South Yorkshire & Bassetlaw Sustainability and Transformation Plan.
Improvement / Concerns
Healthwatch Nottinghamshire recognises the increased demands on Emergency and Urgent Care Services and is therefore aware of the intense pressure to maintain the target admitting, transferring or discharging patients within four hours of arrival at Emergency Department .These increased pressures are reflected in the fall of patients being seen in four hours from 94.5% to 91.4% year-on-year.
We are disappointed that the Trust was not able to reduce the number of complaints from members of the public, one of their quality improvement objectives for 2016/17, although we welcome the Trust’s commitment to resolve issues at ward and department level as a means to preventing complaints.
The draft of the Quality Account we saw would benefit from some more explanation and contextual information, particularly for members of the public who may not have the background knowledge of NHS systems and terminology.
Comments received by Healthwatch Nottinghamshire
Between April 2016 and March 2017, we collected 85 experiences about the Trust. Over this period only 42% of the comments Healthwatch Nottinghamshire received were positive, a fall from 57% in 2015/16. Over one fifth of patients (21%) with negative comments talked about waiting times for services, which is reflected in the increase of patients not being seen within the four hour target at Emergency Department. The most prevalent positive trend patients spoke about was the compassionate care shown by staff, with 26% talking about
118 this. An informatics breakdown of patient experiences at the Trust is displayed on the following page.
Actions / Recommendations
Healthwatch Nottinghamshire seeks clarification on the following:
1. Opportunities for Healthwatch Nottinghamshire to engage with the Trust in identifying opportunities to ensure continuing improvements across communications and patient feedback/complaints 2. How the Trust plans to increase the percentage of patients seen within four hours of arrival at the Emergency Department.
Healthwatch Nottinghamshire welcomes improvements in a number of the priority areas set for 2016/17, but we also recognise the challenges still faced by the Trust. We look forward to seeing further improvements in 2017/18. We will continue to work with the Trust, to monitor any issues which arise, and ensure that we represent the views of local people.
Healthwatch Doncaster
INSERT
NHS Bassetlaw Clinical Commissioning Group (CCG)
On Behalf of Denise Nightingale, Chair of the Bassetlaw CCG Quality and Patient Safety Committee
Thank you for the opportunity to comment on Doncaster and Bassetlaw Hospitals NHS Foundation Trust Quality Account for 2016/17.
Firstly, I should like to commend the Trust for its open and constructive approach to engaging with its commissioners in the planning, delivery and monitoring of services. We concur with the priorities that have been focussed on, and assess this report is an accurate record of progress towards their achievement. Progress regarding patient safety and a reduction in avoidable harms remains excellent and has now been improving for a number of years.
We encourage the Trust to further focus upon the following: A focus on improving patient experience and in particular a reduction in negative experience relating to staff attitude and behaviour A focus on staff wellbeing which is key to the delivery of high quality services and can be measured in part through staff retention rates A continuation of work to address avoidable mortality and morbidity with an increase in system wide reviews in partnership with other agencies
We look forward to further discussions ensuring there are sustainable and safe services for our area
Denise Nightingale Executive Lead for Quality and Safety, Chief Nurse NHS Bassetlaw CCG
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NHS Doncaster Clinical Commissioning Group (CCG)
INSERT
Statement of Directors’ responsibilities in respect of the Quality Account/Report
The directors are requires under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 to prepare Quality Account for each financial year.
NHS Improvement has issued guidance to NHS foundation trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that foundation trust boards should put in place to support the data quality for the preparation for the quality report.
In preparing the quality report, directors are required to take steps to satisfy themselves that: The content of the quality report meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual The content of the quality report is not inconsistent with internal and external sources of information including: o Board minutes and papers for the period April 2016 to April 2017 (draft minutes for April 2016) o Papers relating to Quality reported to the Board over the period April 2016 to March 2017; o Feedback from Doncaster Clinical Commissioning Group dated INSERT and from Bassetlaw Clinical Commissioning Group dated 16 May 2017 o Feedback from Healthwatch Nottinghamshire dated 16 May 2017 and from Healthwatch Doncaster dated INSERT o The Trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated 25 April 2017 o The latest national patient survey dated February 2017 o The latest national staff survey dated 7 March 2017 o The Head of Internal Audit’s annual opinion over the Trust’s control environment dated INSERT The Quality Report presents a balanced picture of the NHS foundation trust’s performance over the period covered The performance information reported in the quality report is reliable and accurate There are proper internal controls over the collection and reporting of the measures of performance included in the Quality Report, and these controls are subject to review to confirm that they are working effectively in practice; The data underpinning the measure of performance reported in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review; and the Quality Report has been prepared in accordance with NHS Improvement’s annual reporting guidance.
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The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Report.
By order of the Board
INSERT SIGNATURE
Independent Auditor’s Report to the Board of Governors of Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust on the Annual Quality Report
Summary of Financial Statements
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Title Annual Accounts 2016/17
Report to: Board of Directors Date: 23 May 2017
Author: Jonathan Sargeant, Director of Finance
For: Recommendation to ANCR Purpose of Paper: Executive Summary containing key messages and issues Attached are the unaudited accounts for the financial year end dated 31st March 2017, as submitted to NHSI and EY (the Trust’s auditors) on the 26th April 2017.
The audit is currently taking place and as of the time of writing there are no changes that impact upon the bottom line, identified changes being presentational in nature. The draft audit letter will be sent to board members when it is received, although initial findings will be presented to the ANCR on the 26th May 2017. The deadline for submission of the accounts, with a final opinion, is the 31st May 2017.
Board has already delegated final sign off of the annual accounts to ANCR, which meets on 26 May 2017.
Recommendation
Board considers and make any comments on the draft annual accounts, prior to sign off by ANCR.
Related Strategic Objectives
Provide the safest, most effective care possible Control and reduce the cost of healthcare Focus on innovation for improvement Develop responsibly, delivering the right services with the right staff
Data entered below will be used throughout the workbook:
Trust name: Doncaster and Bassetlaw Hospitals NHS Foundation Trust This year 2016/17 Last year 2015/16 This year ended 31 March 2017 Last year ended 31 March 2016 This year commencing: 1 April 2016
Intro Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
FOREWORD TO THE ACCOUNTS
DONCASTER AND BASSETLAW HOSPITALS NHS FOUNDATION TRUST
These accounts for the year ended 31 March 2017 have been prepared by the Doncaster and Bassetlaw Hospitals NHS Foundation Trust in accordance with paragraphs 24 and 25, schedule 7 of the National Health Service Act 2006 in the form Monitor has, with the approval of the Treasury, directed.
Richard Parker Chief Executive --- May 2017
Foreword Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
CONSOLIDATED STATEMENT OF COMPREHENSIVE INCOME FOR THE YEAR ENDED 31 March 2017 Group Foundation Trust
2016/17 2015/16 2016/17 2015/16 Note £000 £000 £000 £000
Operating income 4 387,347 360,035 385,647 359,572 Operating expenses 6 (390,106) (402,471) (387,352) (400,830) Operating deficit (2,759) (42,436) (1,705) (41,258) Finance costs: Finance income 12 325 384 38 42 Finance costs 13 (1,762) (857) (1,762) (857) Public dividend capital dividends payable (3,232) (4,666) (3,232) (4,666) Net finance costs (4,669) (5,139) (4,956) (5,481)
Deficit for the year (7,428) (47,575) (6,662) (46,739)
Other comprehensive expense \ income Revaluation (losses) \ gains on investment assets (1,039) - - Revaluation gains on property, plant and equipment 3,959 - 3,959 - Impairments on property, plant and equipment (5,778) (5,778) Other reserve movements 259 - 259 - Total comprehensive expense for the year (3,210) (54,392) (2,444) (52,517)
Deficit adjusted for Impairments
Retained (deficit) for the year (7,428) (47,575) (6,662) (46,739) Add back ; Impairments 2,248 12,365 2,248 12,365 Reversal of Impairment (1,462) (1,983) (1,462) (1,983)
Net Impairment 786 10,382 786 10,382
Retained (Deficit) for the Year before Impairments (6,642) (37,193) (5,876) (36,357)
The notes on pages 5 to 41 form part of these accounts.
All activities relate to continuing operations.
1 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
CONSOLIDATED STATEMENT OF FINANCIAL POSITION AS AT
31 March 2017 Group Foundation Trust 31 March 31 March 31 March 31 March 2017 2016 2017 2016 Note £000 £000 £000 £000 Non-current assets Intangible assets 14 6,453 2,937 6,453 2,937 Property, plant and equipment 15 188,921 188,652 188,921 188,652 Charitable fund investments 16 8,016 9,732 - - Trade and other receivables 19 1,533 1,592 1,533 1,592 Total non-current assets 204,923 202,913 196,907 193,181
Current assets Inventories 18 4,584 5,474 4,584 5,474 Trade and other receivables 19 26,459 15,302 26,241 15,676 Cash and cash equivalents 27 3,187 2,626 2,396 2,169 34,230 23,402 33,222 23,319
Non-current assets held for sale 20 - 300 - 300
Total current assets and non-current assets 34,230 23,702 33,222 23,619 held for sale
Total assets 239,153 226,615 230,129 216,800
Current liabilities Trade and other payables 21 (27,555) (28,046) (27,072) (27,274) Borrowings 23 (3,027) (2,775) (3,027) (2,775) Provisions 24 (583) (524) (583) (524) Tax payable 22 (5) (4,199) - (4,199) Other liabilities 25 (1,096) (556) (1,096) (556) Total current liabilities (32,266) (36,100) (31,778) (35,328)
Total assets less current liabilities 206,887 190,515 198,351 181,472
Non-current liabilities Borrowings 23 (77,143) (59,037) (77,143) (59,037) Provisions 24 (2,204) (728) (2,204) (728) Total non-current liabilities (79,347) (59,765) (79,347) (59,765)
Total assets employed 127,540 130,750 119,004 121,707
Financed by Taxpayers' equity Public dividend capital 128,780 128,780 128,780 128,780 Revaluation reserve 26 33,094 29,939 33,094 29,939 Income and expenditure reserve (43,233) (37,375) (42,870) (37,012) Charitable fund reserve 35 8,899 9,406 - - Total taxpayers' equity 127,540 130,750 119,004 121,707
The accounts on pages 1 to 40 were approved by the Board of Directors on XX XXX 2017and signed on its behalf by:
Richard Parker Chief Executive
2 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
CONSOLIDATED STATEMENT OF CHANGES IN TAXPAYERS' EQUITY FOR THE YEAR ENDED 31 March 2017 Group Public dividend Revaluation Income and Charitable fund Total Taxpayers capital (PDC) reserve expenditure reserve Equity reserve Notes £000 £000 £000 £000 £000 Balance at 1 April 2016 128,780 29,939 (37,375) 9,406 130,750
Changes in equity for 2016/17 (Deficit) \ Surplus for the year - - (6,662) (507) (7,169) Impairments on property, plant and equipment 15.1 & 17 - - - - - Transfers to the income and expenditure account in respect - (804) 804 - - of assets disposed of Transfer of the excess of current cost depreciation over - - - - - Revaluation losses on investment assets - - - - - Revaluations - property, plant and equipment - 3,959 - 3,959 New PDC received - - - - -
Balance at 31 March 2017 128,780 33,094 (43,233) 8,899 127,540
Balance at 1 April 2015 128,755 36,353 9,091 11,433 185,632
Changes in equity for 2015/16 Deficit for the year - - (47,252) (1,292) (48,544) Impairments on property, plant and equipment 15.1 & 17 - (5,778) - - (5,778) Transfers to the income and expenditure account in respect of assets disposed of - (636) 636 - - Consolidation Reserves Transfer - - 150 (150) - Revaluation losses on investment assets (585) (585) New PDC received 25 - - - 25 Balance at 31 March 2016 128,780 29,939 (37,375) 9,406 130,750
Foundation Trust Public dividend Revaluation Income and Charitable fund Total Taxpayers capital (PDC) reserve expenditure reserve Equity reserve Notes £000 £000 £000 £000 £000 Balance at 1 April 2016 128,780 29,939 (37,012) 121,707
Changes in equity for 2015/16 Deficit for the year - - (6,662) (6,662) Impairments on property, plant and equipment 15.1 & 17 - - - - Transfers to the income and expenditure account in respect - (804) 804 - of assets disposed of Revaluations - property, plant and equipment - 3,959 - 3,959 Balance at 31 March 2017 128,780 - 33,094 - (42,870) - 119,004
Balance at 1 April 2015 128,755 36,353 9,091 174,199
Changes in equity for 2015/16 - Impairments on property, plant and equipment (5,778) (5,778) Transfers to the income and expenditure account in respect of assets disposed of (636) 636 - Consolidation Reserves Transfer - Deficit for the year - - (46,739) (46,739) New PDC received 25 - - 25 Balance at 31 March 2016 128,780 29,939 (37,012) 121,707
3 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
CONSOLIDATED STATEMENT OF CASH FLOWS FOR THE YEAR ENDED
31 March 2017 Group Foundation Trust
2016/17 2015/16 2016/17 2015/16 Note £000 £000 £000 £000 Cash flows from operating activities Operating deficit (2,759) (42,436) (1,705) (41,258) Depreciation and amortisation 8,827 9,302 8,827 9,281 Impairments 2,249 12,365 2,249 12,365 Reversal of impairments (1,463) (1,983) (1,463) (1,983) Other non cash movements 946 - - - (Gain) on disposal - - - (18) Income recognised in respect of capital donations (2,077) 907 (2,077) (342) Decrease \ (Increase) in inventories 890 2 890 2 (Increase) in trade and other receivables (12,676) 853 (12,396) 700 (Decrease) \ Increase in trade and other payables (4,236) (12,515) (3,992) (12,273) (Decrease) in tax payable - - - - Increase in other current liabilities 540 530 540 530 Increase \ (Decrease) in provisions 24 1,535 220 1,535 220 Other movements in operating cash flows 417 (986) 23 - Net cash (outflow) \ inflow from operating activities (7,807) (33,741) (7,569) (32,776)
Cash flows from investing activities Interest received 38 42 38 42 Purchase of investment assets - - - - Disposal of investment assets - - - - Purchase of intangible assets 14 (731) (739) (731) (739) Purchase of property, plant and equipment 15 (9,442) (14,169) (9,386) (14,169) Receipts from disposal of plant, property and equipment 982 942 982 942 Receipt of cash donations to purchase fixed assets 2,077 - - - NHS Charitable funds - net cash flows from investing activities 287 342 2,077 - Net cash outflow from investing activities (6,789) (13,582) (7,020) (13,924)
Net cash outflow before financing (14,596) (47,323) (14,589) (46,700)
Cash flows from financing activities Public dividend capital received - 25 - 25 Loans received 61,134 46,352 61,134 46,352 Loans repaid (42,752) (2,435) (42,752) (2,435) Other loans repaid (22) (50) (22) (50) Interest paid (1,734) (693) (1,734) (693) Public Dividend Capital dividends paid (1,810) (6,036) (1,810) (6,036) Net cash inflow from financing 14,816 37,163 14,816 37,163
Net decrease in cash and cash equivalents 220 (10,160) 227 (9,537) Cash and cash equivalents at 1 April 2,967 13,127 2,169 11,706 Cash and cash equivalents at 31 March 27 3,187 2,967 2,396 2,169
4 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS
1. Accounting policies and other information
Basis of Preparation
NHS Improvement, in exercising the statutory functions conferred on Monitor, is responsible for issuing an accounts direction to NHS foundation trusts under the NHS Act 2006. NHS Improvement has directed that the financial statements of NHS foundation trusts shall meet the accounting requirements of the Department of Health Group Accounting Manual (DH GAM) which shall be agreed with the Secretary of State. Consequently, the following financial statements have been prepared in accordance with the DH GAM 2016/17 issued by the Department of Health. The accounting policies contained in that manual follow IFRS and HM Treasury’s FReM to the extent that they are meaningful and appropriate to NHS foundation trusts. The accounting policies have been applied consistently in dealing with items considered material in relation to the accounts.
Accounting convention These accounts have been prepared under the historical cost convention modified to account for the revaluation of property, plant and equipment, intangible assets, inventories and certain financial assets and financial liabilities.
Going Concern Uncertainty These accounts have been prepared on a going concern basis. International Accounting Standard (IAS) 1 requires the management of all entities to assess, as part of the accounts preparation process, the bodies’ ability to continue as a going concern. This is further enforced by Department of Health requirements to review the trust’s going concern basis on an annual basis, the going concern principle being the assumption that an entity will remain in business for the foreseeable future.
This is to facilitate the accounting basis to be used in the preparation of the Trust’s annual accounts. Should an assessment be made that an entity is not a going concern then the year end balance sheet should be prepared on a ‘disposals’ basis i.e. items valued at their likely sale value. In many cases this would propose significantly lower values than the usual valuations based on ongoing trading (e.g. stocks) and require the inclusion of other ‘winding up costs’ (e.g. redundancies). Therefore, to support the assessment of the trust as a going concern the following is noted :
1. There is continuing support from local commissioners – the trust currently has two year contracts in place to 31st March 2019. 2.Within the proposals for the local STP the Trust is expecting to play a significant role in the provision of urgent and emergency services in South Yorkshire and Bassetlaw with the potential for inward investment to support the additional services once final decisions are made e.g. Stroke services as per the recent public consultation carried out by CCG’s. 3. The Trust recently transferred its working capital repayable on demand ‘overdraft’ type loan to a structured loan with agreed repayment dates. This new converted loan was for £40m all repayable on 18th January 2020. 4. Whilst no formal undertaking has been received from NHSI to continue to provide additional liquidity on an ongoing basis all planning assumptions that the trust operates under imply this will be forthcoming. 5. The trust has delivered a year end financial outcome well ahead of its agreed control total for 2016/17 (£17.3m compared with £24.7m) and plans to achieve the lower target assigned for 2017/18 (£16m). Therefore it is considered appropriate for the trust to continue to prepare its financial statements on a going concern basis
1.1 Consolidation
The NHS foundation trust is the corporate trustee to Doncaster and Bassetlaw NHS charitable fund. The foundation trust has assessed its relationship to the charitable fund and determined it to be a subsidiary because the foundation trust is exposed to, or has rights to, variable returns and other benefits for itself, patients and staff from its involvement with the charitable fund and has the ability to affect those returns and other benefits through its power over the fund.
The charitable fund’s statutory accounts are prepared to 31 March in accordance with the UK Charities Statement of Recommended Practice (SORP) which is based on UK Financial Reporting Standard (FRS) 102. On consolidation, necessary adjustments are made to the charity’s assets, liabilities and transactions to:
• recognise and measure them in accordance with the foundation trust’s accounting policies and • eliminate intra-group transactions, balances, gains and losses.
Where the Foundation Trust and Group balances differ these are displayed separately, otherwise a single set of results is reported.
1.2 Income
Income in respect of services provided is recognised when, and to the extent that, performance occurs and is measured at the fair value of the consideration receivable. The main source of income for the Foundation Trust is contracts with commissioners in respect of healthcare services.
Under the terms of the Foundation Trust’s contracts, once a patient is admitted and treatment begins then the income for that treatment or spell can start to be recognised. Income relating to those spells, which are partially completed at the year end, is apportioned across the financial years on a pro rata basis, based on the costs incurred.
Where income is received for a specific activity, which is to be delivered in the following financial year, that income is deferred.
Income from the sale of non-current assets is recognised only when all material conditions of sale have been met and is measured as the sums due under the sale contract.
5 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
1. Accounting policies and other information (continued)
1.3 Expenditure on employee benefits
Short-term employee benefits
Salaries, wages and employment-related payments are recognised in the financial year in which the service is received from employees. The cost of annual leave entitlement earned but not taken by employees at the end of the financial year is recognised in the accounts to the extent that employees are permitted to carry-forward leave into the following financial period.
Pension costs NHS Pension Scheme Past and present employees are covered by the provisions of the NHS Pensions Scheme. The scheme is an unfunded, defined benefit scheme that covers NHS employers, general practices and other bodies, allowed under the direction of Secretary of State, in England and Wales. It is not possible for the Foundation Trust to identify its share of the underlying scheme liabilities. Therefore, the scheme is accounted for as a defined contribution scheme.
Employers pension cost contributions are charged to operating expenses as and when they become due.
Additional pension liabilities arising from early retirements are not funded by the scheme except where the retirement is due to ill-health. The full amount of the liability for the additional costs is charged to the operating expenses at the time the Foundation Trust commits itself to the retirement, regardless of the method of payment.
1.4 Expenditure on other goods and services
Expenditure on goods and services is recognised when, and to the extent that, they have been received and is measured at the fair value of those goods and services. Expenditure is recognised in operating expenses except where it results in the creation of a non-current asset such as property, plant and equipment.
1.5 Property, plant and equipment
Recognition
Property, plant and equipment is capitalised where: • it is held for use in delivering services or for administrative purposes; • it is probable that future economic benefits will flow to, or service potential be provided to, the Foundation Trust; • it is expected to be used for more than one financial year; • the cost of the item can be measured reliably; and • individually has a cost of at least £5,000; or • forms a group of assets which individually have a cost of more than £250, collectively have a cost of at least £5,000, where the assets are functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under single managerial control; or • form part of the initial equipping and setting-up cost of a new building or refurbishment of a ward or unit irrespective of their individual or collective cost.
Where a large asset includes a number of components with significantly different asset lives then these components are treated as separate assets and depreciated over their own useful economic lives.
6 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
1. Accounting policies and other information (continued)
1.5 Property, plant and equipment (continued)
Measurement
Valuation
All property, plant and equipment assets are measured initially at cost, representing the costs directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the manner intended by management.
All assets are measured subsequently at fair value. All land and buildings are revalued using professional valuations when management determine there to be a material difference between carrying value and fair value as defined by International Accounting Standard (IAS) 16 'Property, Plant and Equipment'. All other assets are valued at net current replacement cost as a proxy for fair value, with management checking a number of high value items each year to ensure this is still reasonable and no material differences found.
An item of property, plant and equipment which is surplus with no plan to bring it back into use is valued at fair value under IFRS 13, if it does not meet the requirements of IAS 40 of IFRS 5.
Subsequent expenditure Subsequent expenditure relating to an item of property, plant and equipment is recognised as an increase in the carrying amount of the asset when it is probable that additional future economic benefits or service potential deriving from the cost incurred to replace a component of such item will flow to the enterprise and the cost of the item can be determined reliably. Where a component of an asset is replaced, the cost of the replacement is capitalised if it meets the criteria for recognition above. The carrying amount of the part replaced is de-recognised. Other expenditure that does not generate additional future economic benefits or service potential, such as repairs and maintenance, is charged to the Statement of Comprehensive Income in the period in which it is incurred.
Depreciation
Items of property, plant and equipment are depreciated over their remaining useful economic lives in a manner consistent with the consumption of economic or service delivery benefits. Freehold land is considered to have an infinite life and is not depreciated.
Property, plant and equipment which has been reclassified as ‘held for sale’ ceases to be depreciated upon the reclassification. Assets in the course of construction and residual interests in off-Statement of Financial Position PFI contract assets are not depreciated until the asset is brought into use or reverts to the trust, respectively.
Useful Economic lives of property, plant and equipment
Useful economic lives reflect the total life of an asset and not the remaining life of an asset. The range of useful economic lives are shown in the table below: 2016/17 2015/16 Years Years Buildings excluding dwellings 11 to 87 11 to 90 Dwellings 45 to 53 26 to 54 Plant and machinery 7 to 15 1 to 10 Transport equipment 5 to 7 2 to 7 Information technology 1 to 5 1 to 10 Furniture and fittings 1 to 7 1 to 7
Finance-leased assets (including land) are depreciated over the shorter of the useful economic life or the lease term, unless the FT expects to acquire the asset at the end of the lease term in which case the assets are depreciated in the same manner as owned assets above.
Revaluation gains and losses
Revaluation gains are recognised in the revaluation reserve, except where, and to the extent that, they reverse a revaluation decrease that has previously been recognised in operating expenses, in which case they are recognised in operating income.
Revaluation losses are charged to the revaluation reserve to the extent that there is an available balance for the asset concerned and thereafter are charged to operating expenses.
Gains and losses recognised in the revaluation reserve are reported in the Statement of Comprehensive Income as an item of ‘other comprehensive income’.
7 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
1. Accounting policies and other information (continued)
1.5 Property, plant and equipment (continued)
Impairments
In accordance with the DH GAM, impairments that arise from a clear consumption of economic benefits or service potential in the asset are charged to operating expenses. A compensating transfer is made from the revaluation reserve to the income and expenditure reserve of an amount equal to the lower of the impairment charged to operating expenses and the balance in the revaluation reserve attributable to that asset before the impairment.
An impairment that arises from a clear consumption of economic benefit or service potential is reversed when, and to the extent that, the circumstances that gave rise to the loss is reversed. Reversals are recognised in operating income to the extent that the asset is restored to the carrying amount it would have had if the impairment had never been recognised. Any remaining reversal is recognised in the revaluation reserve. Where, at the time of the original impairment, a transfer was made from the revaluation reserve to the income and expenditure reserve, an amount is transferred back to the revaluation reserve when the impairment reversal is recognised.
Other impairments are treated as revaluation losses. Reversals of 'other impairments' are treated as revaluation gains.
De-recognition
Assets intended for disposal are reclassified as ‘Held for Sale’ once all of the following criteria are met: • the asset is available for immediate sale in its present condition subject only to terms which are usual and customary for such sales; • the sale must be highly probable i.e.: - management are committed to a plan to sell the asset; - an active programme has begun to find a buyer and complete the sale; - the asset is being actively marketed at a reasonable price; - the sale is expected to be completed within 12 months of the date of classification as ‘Held for Sale’; and - the actions needed to complete the plan indicate it is unlikely that the plan will be dropped or significant changes made to it.
Following reclassification, the assets are measured at the lower of their existing carrying amount and their ‘fair value less costs to sell’. Depreciation ceases to be charged and the assets are not revalued, except where the ‘fair value less costs to sell’ falls below the carrying amount. Assets are de-recognised when all material sale contract conditions have been met.
Property, plant and equipment which is to be scrapped or demolished does not qualify for recognition as ‘Held for Sale’ and instead is retained as an operational asset and the asset’s economic life is adjusted. The asset is de-recognised when scrapping or demolition occurs.
Donated and government grant funded assets
Donated and grant funded property, plant and equipment assets are capitalised at their fair value on receipt. The donation or grant is credited to income at the same time, unless the donor has imposed a condition that the future economic benefits embodied in the grant are to be consumed in a manner specified by the donor, in which case the donation or grant is deferred within liabilities and is carried forward to future financial years to the extent that the condition has not yet been met.
The donated and grant funded assets are subsequently accounted for in the same manner as other items of property, plant and equipment.
8 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
1. Accounting policies and other information (continued)
1.6 Intangible assets
Recognition
Intangible assets are non-monetary assets without physical substance which are capable of being sold separately from the rest of the Foundation Trust’s business or which arise from contractual or other legal rights. They are recognised only where it is probable that future economic benefits will flow, or service potential be provided, to the Foundation Trust and where the cost of the asset can be measured reliably.
Internally generated intangible assets Internally generated goodwill, brands, mastheads, publishing titles, customer lists and similar items are not capitalised as intangible assets.
Expenditure on research is not capitalised.
Expenditure on development is capitalised only where all of the following can be demonstrated:
• the project is technically feasible to the point of completion and will result in an intangible asset for sale or use • the trust intends to complete the asset and sell or use it • the trust has the ability to sell or use the asset • how the intangible asset will generate probable future economic or service delivery benefits, eg, the presence of a market for it or its output, or where it is to be used for internal use, the usefulness of the asset; • adequate financial, technical and other resources are available to the trust to complete the development and sell or use the asset and • the trust can measure reliably the expenses attributable to the asset during development.
Computer software
Computer software which is integral to the operation of hardware e.g. an operating system, is capitalised as part of the relevant item of property, plant and equipment. Computer software which is not integral to the operation of hardware e.g. application software, is capitalised as an intangible asset.
EU emissions trading scheme allowances
EU Emission Trading Scheme allowances are accounted for as government grant funded intangible assets if they are not expected to be realised within twelve months.
Measurement
Intangible assets are recognised initially at cost, comprising all directly attributable costs needed to create, produce and prepare the asset to the point that it is capable of operating in the manner intended by management.
Subsequently intangible assets are measured at current value in existing use. Where no active market exists, intangible assets are valued at the lower of depreciated replacement cost and the value in use where the asset is income generating. Revaluations gains and losses and impairments are treated in the same manner as for property, plant and equipment. An intangible asset which is surplus with no plan to bring it back into use is valued at fair value under IFRS 13, if it does not meet the requirements of IAS 40 of IFRS 5.
Intangible assets held for sale are measured at the lower of their carrying amount or ‘fair value less costs to sell’.
Amortisation
Intangible assets are amortised over their expected useful economic lives in a manner consistent with the consumption of economic or service delivery benefits.
1.7 Revenue government and other grants
Government grants are grants from Government bodies other than income from primary care trusts or NHS Trusts for the provision of services. Where a grant is used to fund revenue expenditure it is taken to the Statement of Comprehensive Income to match that expenditure.
1.8 Inventories
Inventories are valued at the lower of cost and net realisable value. The cost of inventories are measured using the First In, First Out (FIFO) method with the exception of drugs which are measured using the weighted average cost method.
9 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
1. Accounting policies and other information (continued)
1.9 Financial instruments
Recognition
Financial assets and financial liabilities which arise from contracts for the purchase or sale of non-financial items (such as goods or services), which are entered into in accordance with the Foundation Trust’s normal purchase, sale or usage requirements, are recognised when, and to the extent which, performance occurs i.e. when receipt or delivery of the goods or services is made.
All other financial assets and financial liabilities are recognised when the Foundation Trust becomes a party to the contractual provisions of the instrument.
De-recognition
All financial assets are de-recognised when the rights to receive cash flows from the assets have expired or the Foundation Trust has transferred substantially all of the risks and rewards of ownership.
Financial liabilities are de-recognised when the obligation is discharged, cancelled or expires.
Classification and measurement
Financial assets are categorised as Loans and receivables.
Financial liabilities are classified as Financial liabilities measured at amortised cost.
Financial assets and financial liabilities at “fair value through income and expenditure”
Financial assets and financial liabilities at “fair value through income and expenditure” are financial assets or financial liabilities held for trading. A financial asset or financial liability is classified in this category if acquired principally for the purpose of selling in the short-term. Derivatives are also categorised as held for trading unless they are designated as hedges.
These financial assets and financial liabilities are recognised initially at fair value, with transaction costs expensed in the income and expenditure account. Subsequent movements in the fair value are recognised as gains or losses in the Statement of Comprehensive Income.
Loans and receivables
Loans and receivables are non-derivative financial assets with fixed or determinable payments with are not quoted in an active market. They are included in current assets.
The Foundation Trust’s loans and receivables comprise: cash and cash equivalents, NHS receivables, accrued income and other receivables.
Loans and receivables are recognised initially at fair value, net of transactions costs and are measured subsequently at amortised cost, using the effective interest method. The effective interest rate is the rate that discounts exactly estimated future cash receipts through the expected life of the financial asset or, when appropriate, a shorter period, to the net carrying amount of the financial asset.
Interest on loans and receivables is calculated using the effective interest method and credited to the Statement of Comprehensive Income.
Held-to-maturity investments
Held-to-maturity investments comprise listed fixed asset investments. All the investments are measured at their fair value at the reporting date (see note 1.20). They are included in non-current assets.
Available-for-sale financial assets Available-for-sale financial assets (see note 1.20) are non-derivative financial assets which are either designated in this category or not classified in any of the other categories. They are included in long-term assets unless the trust intends to dispose of them within 12 months of the Statement of Financial Position date.
Available-for-sale financial assets are recognised initially at fair value, including transaction costs, and measured subsequently at fair value, with gains or losses recognised in reserves and reported in the Statement of Comprehensive Income as an item of “other comprehensive income”. When items classified as “available-for-sale” are sold or impaired, the accumulated fair value adjustments recognised are transferred from reserves and recognised in “finance costs” in the Statement of Comprehensive Income.
10 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
1. Accounting policies and other information (continued)
1.9 Financial instruments (continued)
Financial liabilities measured at amortised cost
Financial liabilities measured at amortised costs are recognised initially at fair value, net of transaction costs incurred, and measured subsequently at amortised cost using the effective interest method. The effective interest rate is the rate that discounts exactly estimated future cash payments through the expected life of the financial liability or, when appropriate, a shorter period, to the net carrying amount of the financial liability.
They are included in current liabilities except for amounts payable more than 12 months after the Statement of Financial Position date, which are classified as non-current liabilities.
Interest on financial liabilities carried at amortised cost is calculated using the effective interest method and charged to Finance Costs. Interest on financial liabilities taken out to finance property, plant and equipment or intangible assets is not capitalised as part of the cost of those assets.
Impairment of financial assets
At the Statement of Financial Position date, the Foundation Trust assesses whether any financial assets are impaired. Financial assets are impaired and impairment losses are recognised if, and only if, there is objective evidence of impairment as a result of one or more events which occurred after the initial recognition of the asset and which has an impact on the estimated future cash flows of the asset.
For financial assets carried at amortised cost, the amount of the impairment loss is measured as the difference between the asset’s carrying amount and the present value of the revised future cash flows discounted at the asset’s original effective interest rate. The loss is recognised in the Statement of Comprehensive Income and the carrying amount of the asset is reduced indirectly through the use of a bad debt provision, until such time as the debt is considered to be no longer recoverable.
1.10 Leases
Finance leases Where substantially all risks and rewards of ownership of a leased asset are borne by the NHS foundation trust, the asset is recorded as property, plant and equipment and a corresponding liability is recorded. The value at which both are recognised is the lower of the fair value of the asset or the present value of the minimum lease payments, discounted using the interest rate implicit in the lease.
The asset and liability are recognised at the commencement of the lease. Thereafter the asset is accounted for an item of property plant and equipment.
The annual rental is split between the repayment of the liability and a finance cost so as to achieve a constant rate of finance over the life of the lease. The annual finance cost is charged to Finance Costs in the Statement of Comprehensive Income. The lease liability is de-recognised when the liability is discharged, cancelled or expires.
Operating leases Other leases are regarded as operating leases and the rentals are charged to operating expenses on a straight-line basis over the term of the lease. Operating lease incentives received are added to the lease rentals and charged to operating expenses over the life of the lease.
Leases of land and buildings Where a lease is for land and buildings, the land component is separated from the building component and the classification for each is assessed separately.
1.11 Provisions
The NHS foundation trust recognises a provision where it has a present legal or constructive obligation of uncertain timing or amount; for which it is probable that there will be a future outflow of cash or other resources; and a reliable estimate can be made of the amount. The amount recognised in the Statement of Financial Position is the best estimate of the resources required to settle the obligation. Where the effect of the time value of money is significant, the estimated risk-adjusted cash flows are discounted using the discount rates published and mandated by HM Treasury.
11 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
1. Accounting policies and other information (continued)
1.11 Provisions (continued)
Clinical negligence costs
The NHS Litigation Authority (NHSLA) operates a risk pooling scheme under which the Foundation Trust pays an annual contribution. The NHSLA, in return, settles all clinical negligence claims. Although the NHSLA is administratively responsible for all clinical negligence cases, the legal liability remains with the Foundation Trust. The total value of clinical negligence provisions carried by the NHSLA on behalf of the Foundation Trust is disclosed at note 24.
Non-clinical risk pooling
The Foundation Trust participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the Foundation Trust pays an annual contribution to the NHS Litigation Authority and in return receives assistance with the costs of claims arising. The annual membership contributions and any ‘excesses’ payable in respect of particular claims are charged to operating expenses when the liability arises.
Pay provisions
The Foundation Trust provides for legal or constructive obligations that are of uncertain timing or amount arising as a consequence of implementing medical career reform, restructuring and appeals in relation to employment tribunals and equal pay.
1.12 Contingencies
Contingent assets (that is, assets arising from past events whose existence will only be confirmed by one or more future events not wholly within the entity’s control) are not recognised as assets, but are disclosed in note 31 where an inflow of economic benefits is probable. Contingent liabilities are not recognised, but are disclosed in note 31, unless the probability of a transfer of economic benefits is remote.
Contingent liabilities are defined as:
• possible obligations arising from past events whose existence will be confirmed only by the occurrence of one or more uncertain future events not wholly within the entity’s control; or
• present obligations arising from past events but for which it is not probable that a transfer of economic benefits will arise or for which the amount of the obligation cannot be measured with sufficient reliability. • possible obligations arising from past events whose existence will be confirmed only by the occurrence of one or more uncertain future events not wholly within the entity’s control; or • present obligations arising from past events but for which it is not probable that a transfer of economic benefits will arise or for which the amount of the obligation cannot be measured with sufficient reliability.
1.13 Public dividend capital
Public dividend capital (PDC) is a type of public sector equity finance based on the excess of assets over liabilities at the time of establishment of the predecessor NHS trust. HM Treasury has determined that PDC is not a financial instrument within the meaning of IAS 32.
A charge, reflecting the cost of capital utilised by the NHS foundation trust, is payable as public dividend capital dividend. The charge is calculated at the rate set by HM Treasury (currently 3.5%) on the average relevant net assets of the NHS foundation trust during the financial year. Relevant net assets are calculated as the value of all assets less the value of all liabilities, except for (i) donated assets (including lottery funded assets), (ii) average daily cash balances held with the Government Banking Services (GBS) and National Loans Fund (NLF) deposits, excluding cash balances held in GBS accounts that relate to a short-term working capital facility, and (iii) any PDC dividend balance receivable or payable. In accordance with the requirements laid down by the Department of Health (as the issuer of PDC), the dividend for the year is calculated on the actual average relevant net assets as set out in the “pre-audit” version of the annual accounts. The dividend thus calculated is not revised should any adjustment to net assets occur as a result the audit of the annual accounts.
1.14 Value Added Tax
Most of the activities of the Foundation Trust are outside the scope of VAT and, in general, output tax does not apply and input tax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of non-current assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT.
12 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
1. Accounting policies and other information (continued)
1.15 Corporation tax
Most of the activities of the Foundation Trust are outside the scope of corporation tax. For those activities which fall within the scope the Foundation Trust employs a three-stage test to determine whether or not an activity is likely to be taxable: • Is the activity an authorised activity related to the provision of core healthcare; • Is the activity actually or potentially in competition with the private sector or is it clearly ancillary to the Foundation Trust’s core healthcare objectives and not entrepreneurial in nature; and • Are the annual profits in excess of £50,000
The Foundation Trust has determined that it is has no corporation tax liability.
Note 1.16 Foreign Exchange
The functional and presentational currencies of the trust are sterling.
A transaction which is denominated in a foreign currency is translated into the functional currency at the spot exchange rate on the date of the transaction.
Where the trust has assets or liabilities denominated in a foreign currency at the Statement of Financial Position date:
• monetary items (other than financial instruments measured at “fair value through income and expenditure”) are translated at the spot exchange rate on 31 March • non-monetary assets and liabilities measured at historical cost are translated using the spot exchange rate at the date of the transaction and • non-monetary assets and liabilities measured at fair value are translated using the spot exchange rate at the date the fair value was determined.
Exchange gains or losses on monetary items (arising on settlement of the transaction or on re-translation at the Statement of Financial Position date) are recognised in income or expense in the period in which they arise.
Exchange gains or losses on non-monetary assets and liabilities are recognised in the same manner as other gains and losses on these items.
1.17 Third party assets
Assets belonging to third parties (such as money held on behalf of patients) are not recognised in the accounts since the Foundation Trust has no beneficial interest in them. However, they are disclosed in a separate note to the accounts in accordance with the requirements of HM Treasury’s Financial Reporting Manual.
1.18 Losses and special payments
Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way that individual cases are handled. Losses and special payments are charged to the relevant functional headings in expenditure on an accruals basis, including losses which would have been made good through insurance cover had NHS trusts not been bearing their own risks (with insurance premiums then being included as normal revenue expenditure).
However the losses and special payments note is compiled directly from the losses and compensations register which reports on an accrual basis with the exception of provisions for future losses.
1.18 EU emissions trading scheme
EU Emission Trading Scheme allowances were accounted for as government grant funded intangible assets if they are not expected to be realised within twelve months and otherwise as other current assets. They were valued at open market value. As this phase of the scheme has now finished the remaining allowances are held until they are sold at a future date.
1.19 Operating segments
Operating segments are reported in a manner consistent with the internal reporting provided to the chief operating decision-maker. The chief operating decision-maker, who is responsible for allocating resources and assessing performance of the operating segments, has been identified as the Foundation Trust Board.
13 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
1. Accounting policies and other information (continued)
1.20 Charitable fund investments
Investments are stated at market value as at the Statement of Financial Position date. The Statement of Comprehensive Income includes the net gains and losses arising on revaluation and disposals throughout the year.
All gains and losses are taken to the Statement of Comprehensive Income as they arise. Realised gains and losses on investments are calculated as the difference between sales proceeds and opening market value (purchase date if later). Unrealised gains and losses are calculated as the difference between market value at the year end and opening market value (or purchase date if later).
1.21 Accounting standards that have been issued but have not yet been adopted
The Treasury FReM does not require the following Standards and Interpretations to be applied in 2016/17. The application of the Standards as revised would not have a material impact on the accounts for 2016/17, were they applied in that year:
IFRS 9 Financial Instruments - Application required for accounting periods beginning on or after 1 January 2018, but not yet adopted by the FReM: early adoption is not therefore permitted. IFRS 14 Regulatory Deferral Accounts - Not yet EU-endorsed.* Applies to first time adopters of IFRS after 1 January 2016. Therefore not applicable to DH group bodies. IFRS 15 Revenue from Contracts with Customers - Application required for accounting periods beginning on or after 1 January 2018, but not yet adopted by the FReM: early adoption is not therefore permitted. IFRS 16 Leases - Application required for accounting periods beginning on or after 1 January 2019, but not yet adopted by the FReM: early adoption is not therefore permitted.
Note 1.22 Early adoption of standards, amendments and interpretations No new accounting standards or revisions to existing standards have been early adopted in 2016/17.
2. Critical accounting estimates and judgements
The preparation of the accounts requires management to make judgements, estimates and assumptions that affect the application of policies and reported amounts of assets and liabilities, income and expenses. The estimates and associated assumptions are based on historical experience and various other factors that are believed to be reasonable under the circumstances, the results of which form the basis of judgements about carrying values of assets and liabilities that are not readily apparent from other sources. Actual results may differ from these estimates.
The estimates and underlying assumptions are reviewed on an ongoing basis. Revisions to accounting estimates are recognised in the financial year in which the estimate is revised if the revision affects only that financial year, or in the financial year of the revision, and future financial years, if the revision affects both current and future financial years.
The estimates and judgements that have had a significant effect on the amounts recognised in the accounts are outlined below.
Income estimates
In measuring income for the year, management have taken account of all available information. Income estimates that have been made have been based on actual information related to the financial year.
14 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
2. Critical accounting estimates and judgements (continued)
Included in the income figure is an estimate for open spells, patients undergoing treatment that is only partially complete at twelve midnight on 31 March. The number of open spells for each specialty is taken and multiplied by the average specialty price and adjusted for the proportion of the spell which belongs to the current year.
Injury compensation scheme income is also included to the extent that it is estimated it will be received in future years. It is recorded in the current year as this is the year in which it was earned. However as cash is not received until future periods, when the claims have been settled, an estimation must be made as to the collectability.
Expense accruals
In estimating expenses that have not yet been charged for, management have made a realistic assessment based on costs actually incurred in the year to date, with a view to ensuring that no material items have been omitted.
Impairment of property, plant and equipment
Specialised property has been valued at depreciated replacement cost on a modern equivalent asset basis in line with Royal Institute of Chartered Surveyors standards. Land has been valued having regard to the cost of purchasing notional replacement sites in the same locality as the existing sites.
Recoverability of receivables
In accordance with the stated policy on impairment of financial assets, management have assessed the impairment of receivables and made appropriate adjustments to the existing allowance account for credit losses.
Provisions
In accordance with the stated policy on provisions, management have used best estimates of the expenditure required to settle the obligations concerned, applying HM Treasury’s discount rate as stated, as appropriate. Management have also taken into account all available information for disputes and possible outcomes.
3. Operating segments
The Foundation Trust manages the delivery of healthcare services across 6 care groups of which contain 41 specialities. There are also 9 corporate units that support the care groups. Performance is reported at care group level to the Foundation Trust Board, however this is not the primary way in which financial matters are considered.
The Foundation Trust has applied the aggregation criteria from IFRS 8 Operating Segments because the care groups provide similar services, have homogenous customers, common production processes and a common regulatory environment. On this basis the Foundation Trust believes that there is one segment.
The overall deficit reported to the Foundation Trust Board under the care group based reporting structure was £6,662,000 (2015/16 £46,739,000 deficit), which is the same as the deficit reported in the Statement of Comprehensive Income.
The Foundation Trust's NHS charitable fund has a reported deficit of £507,000 (2015/16 £2,027,000 deficit) before taking into account intra group transactions.
15 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
4. Operating income Group Foundation Trust 2016/17 2015/16 2016/17 2015/16 £000 £000 £000 £000 Income from patient care activities by activity Elective income 56,557 55,710 56,557 55,710 Non elective income 81,962 76,752 81,962 76,752 Outpatient income 50,895 50,384 50,895 50,384 A&E income 18,277 17,676 18,277 17,676 Other types of activity 116,355 120,489 116,355 120,489 Total income from commissioner requested services 324,045 321,011 324,045 321,011 Private patients 654 1,338 654 1,338 Other non-commissioner requested clinical income 2,704 1,891 2,704 1,891 Total income from non-commissioner requested services 3,358 3,229 3,358 3,229
Total income from patient care activities 327,403 324,240 327,403 324,240
Other operating income Education, training and research 10,987 9,275 10,987 9,275 Charitable and other contributions to expenditure 3,458 - 2,639 513 Non-patient care services to other bodies 14,084 15,370 14,084 15,370 Sustainability and Transformation Fund income 22,124 - 22,124 - Profit on disposal of investments 881 478 - - Profit on disposal of land and buildings - 18 - 18 Reversal of impairments of property, plant and equipment - 1,983 - 1,983 Rental revenue from operating leases 453 504 453 504 Staff recharges 33 3,397 33 3,397 Other income 7,924 4,770 7,924 4,272 Total other operating income 59,944 35,795 58,244 35,332
Total operating income 387,347 360,035 385,647 359,572
The Terms of Authorisation set out the mandatory goods and services that the Foundation Trust is required to provide (commissioner requested services). The majority of the income from patient care activities shown above is derived from the provision of commissioner requested services except other non-commissioner requested clinical income and private patient income.
In other operating income the "other income" is mainly income from internal generation, the largest sources were the Foundation Trust's catering outlets, car parking charges and staff accommodation.
5. Income from patient care activities by source Group and Foundation Trust
2016/17 2015/16 £000 £000
NHS England 54,029 30,023 Clinical Commissioning Groups (CCGs) 266,035 287,505 NHS other 257 60 Local authorities 3,724 3,417 Private patients 654 1,338 Other non-protected clinical income (non NHS): Overseas patients (non-reciprocal) 326 29 Injury costs recovery 2,378 1,575 Other non-NHS clinical income - 293 327,403 324,240
The income from CCGs for activity covered by 'Payment by Results' is charged at national tariff, subject to a market forces factor adjustment.
Injury costs recovery income is subject to a provision for doubtful debts of 22.94% (2015/16 21.99%) to reflect expected rates of collection.
5.2 Overseas visitors Group and Foundation Trust 2016/17 2015/16 £000 £000 Income from Overseas visitors 326 29 Cash payments received in year 37 16 Amounts added to the provision for impairment of receivables 211 91 Amounts written off in year 46 -
16 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
6. Operating expenses Group Foundation Trust 2016/17 2015/16 2016/17 2015/16 £000 £000 £000 £000
Services from Foundation Trusts 5,269 4,149 5,269 4,149 Services from NHS Trusts 247 128 247 128 Services from other NHS bodies 3,929 2,094 3,929 2,094 Purchase of healthcare from non NHS bodies 9,014 13,334 9,014 13,334 Employee Expenses - Executive directors 1,088 922 1,088 922 Employee Expenses - Non-executive directors 124 111 124 111 Employee Expenses - Staff 249,606 249,800 249,606 249,800 NHS Charitable funds - employee expenses 70 107 - - Drug costs 37,823 39,843 37,823 39,843 Supplies and services - clinical 27,248 28,855 27,248 28,855 Supplies and services - general 4,997 5,178 4,997 5,178 Establishment 1,764 2,075 1,764 2,075 Transport 515 542 515 542 Premises 13,378 11,569 13,378 11,569 Rentals under operating leases 611 660 611 660 Depreciation on property, plant and equipment 8,087 8,601 8,087 8,601 Amortisation on intangible assets 740 680 740 680 Impairments of property, plant and equipment 786 12,315 786 12,315 Impairments of assets held for sale - 50 - 50 Provision for impairment of receivables 930 435 930 435 Increase in other provision 853 78 853 78 Audit fees 125 84 125 84 Audit fees - charitable funds 6 6 - - Internal Audit fees 137 154 137 154 Other auditors' remuneration - 9 - 9 Clinical negligence 16,080 14,993 16,080 14,993 Loss on disposal of property, plant and equipment 13 - 13 - Legal fees 391 156 391 156 Consultancy costs 1,663 882 1,663 882 Training, courses and conferences 518 769 518 769 Patient travel 18 23 18 23 Security 473 486 473 486 Redundancy (not included in employee expenses) 463 749 463 749 Redundancy (included in employee expenses) - 159 - 159 Early retirement (including movements on provisions) - 366 - 366 Insurance 334 338 334 338 Other services - - - - Losses, ex gratia & special payments 82 82 82 6 Other 46 237 46 237 Other - NHS charitable fund 2,678 1,528 - - 390,106 402,547 387,352 400,830
The values disclosed above in respect of provisions for impairment of receivables are net of any credits for reversals of previous impairments.
17 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
7. Operating leases
7.1 Operating lease income
The Foundation Trust has a number of leasing arrangements for the use of land and buildings, mainly with other NHS organisations. The only significant leasing arrangement not with another NHS organisation is with Parkhill Hospital at Doncaster Royal Infirmary.
Group and Foundation Trust Rental income 2016/17 2015/16 £000 £000 Rents recognised as income 453 504
Total future minimum lease payments due 2016/17 2015/16 £000 £000 Receivable: Not later than one year 453 517 Between one and five years 655 1,183 Total 1,108 1,700
7.2 Operating lease expenditure
The Foundation Trust has a number of leasing arrangements with other NHS bodies in respect of the use of their buildings. The minimum lease payments were £374,000 (2015/16 £374,000).
In addition to this the Foundation Trust also has leasing arrangements in respect of medical equipment and vehicles. The minimum lease payments were £237,000 (2015/16 £286,000).
Group and Foundation Trust Payments recognised as an expense 2016/17 2015/16 £000 £000 Minimum lease payments 611 660
Total future minimum lease payments 2016/17 2015/16 £000 £000 Payable: Not later than one year 424 635 Between one and five years 948 1,135 After 5 years 39 277 Total 1,411 2,047
18 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
8. Employee costs and numbers
8.1 Employee costs 2016/17 2015/16 Total Permanently Other Total Permanently Other Group Employed Employed £000 £000 £000 £000 £000 £000 Salaries and wages 211,941 187,602 24,339 215,640 183,493 32,147 Social security costs 16,744 16,744 - 13,025 13,025 - Employer contributions to NHS pension scheme 21,986 21,986 - 21,944 21,944 - Employer contributions to Other pension schemes ------Other employment benefits ------Redundancy and early retirements 23 23 - - - - Employee benefits expense 250,694 226,355 24,339 250,609 218,462 32,147
2016/17 2015/16 Total Permanently Other Total Permanently Other Foundation Trust Employed Employed £000 £000 £000 £000 £000 £000
Salaries and wages 215,912 187,602 24,339 215,912 183,386 32,147 Social security costs 13,025 16,744 - 13,025 13,025 - Employer contributions to NHS pension scheme 21,944 21,986 - 21,944 21,944 - Employer contributions to Other pension schemes 9.2 ------Other employment benefits ------Redundancy and early retirements - 23 - - - - Employee benefits expense 250,881 226,355 24,339 250,881 218,355 32,147
8.2 Monthly average number of people employed (whole time equivalents) 2016/17 2015/16 Total Permanently Other Total Permanently Other Group Employed Employed Wte Wte Wte Wte Wte Wte
Medical and dental 647 583 64 642 556 86 Administration and estates 1,044 1,044 - 1,110 1,105 5 Healthcare assistants and other support staff 733 725 8 673 648 25 Nursing, midwifery and health visiting staff 2,567 2,541 26 2,515 2,483 32 Scientific, therapeutic and technical staff* 461 459 2 398 397 1 Healthcare science staff* 406 392 14 475 475 - Other - - - - - Total 5,858 5,744 115 5,813 5,664 149
2016/17 2015/16 Total Permanently Other Total Permanently Other Foundation Trust Employed Employed Wte Wte Wte Wte Wte Wte
Medical and dental 647 583 64 642 556 86 Administration and estates 1,043 1,043 - 1,109 1,104 5 Healthcare assistants and other support staff 733 725 8 673 648 25 Nursing, midwifery and health visiting staff 2,567 2,541 26 2,515 2,483 32 Scientific, therapeutic and technical staff* 461 459 2 398 397 1 Healthcare science staff* - - 475 475 - Total 5,857 5,743 114 5,812 5,663 149
19 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
9. Pension costs
9.1 NHS Pension costs Past and present employees are covered by the provisions of the two NHS Pension Schemes. Details of the benefits payable and rules of the Schemes can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions. Both are unfunded defined benefit schemes that cover NHS employers, GP practices and other bodies, allowed under the direction of the Secretary of State in England and Wales. They are not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, each scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS body of participating in each scheme is taken as equal to the contributions payable to that scheme for the accounting period. In order that the defined benefit obligations recognised in the financial statements do not differ materially from those that would be determined at the reporting date by a formal actuarial valuation, the FReM requires that “the period between formal valuations shall be four years, with approximate assessments in intervening years”. An outline of these follows:
Additional pension liabilities arising from early retirements are not funded by the scheme except where the retirement is due to ill-health. The full amount of the liability for the additional costs is charged to the operating expenses at the time the Foundation Trust commits itself to the retirement, regardless of the method of payment. a) Accounting valuation A valuation of scheme liability is carried out annually by the scheme actuary (currently the Government Actuary’s Department) as at the end of the reporting period. This utilises an actuarial assessment for the previous accounting period in conjunction with updated membership and financial data for the current reporting period, and are accepted as providing suitably robust figures for financial reporting purposes. The valuation of scheme liability as at 31 March 2017, is based on valuation data as 31 March 2016, updated to 31 March 2017 with summary global member and accounting data. In undertaking this actuarial assessment, the methodology prescribed in IAS 19, relevant FReM interpretations, and the discount rate prescribed by HM Treasury have also been used.
The latest assessment of the liabilities of the scheme is contained in the scheme actuary report, which forms part of the annual NHS Pension Scheme (England and Wales) Pension Accounts. These accounts can be viewed on the NHS Pensions website and are published annually. Copies can also be obtained from The Stationery Office.
b) Full actuarial (funding) valuation The purpose of this valuation is to assess the level of liability in respect of the benefits due under the schemes (taking into account their recent demographic experience), and to recommend contribution rates payable by employees and employers. The last published actuarial valuation undertaken for the NHS Pension Scheme was completed for the year ending 31 March 2012. The Scheme Regulations allow for the level of contribution rates to be changed by the Secretary of State for Health, with the consent of HM Treasury, and consideration of the advice of the Scheme Actuary and appropriate employee and employer representatives as deemed appropriate. The next actuarial valuation is to be carried out as at 31 March 2016. This will set the employer contribution rate payable from April 2019 and will consider the cost of the Scheme relative to the employer cost cap. There are provisions in the Public Service Pension Act 2013 to adjust member benefits or contribution rates if the cost of the Scheme changes by more than 2% of pay. Subject to this ‘employer cost cap’ assessment, any required revisions to member benefits or contribution rates will be determined by the Secretary of State for Health after consultation with the relevant stakeholders.
c) Scheme provisions The NHS Pension Scheme provided defined benefits, which are summarised below. This list is an illustrative guide only, and is not intended to detail all the benefits provided by the Scheme or the specific conditions that must be met before these benefits can be obtained:
21 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
8. Employee costs and numbers (continued)
8.3 Employee exit packages Group and Foundation Trust 2016/17 2015/16 Number of Number of Total Number of Number of other Total Compulsory other agreed Compulsory agreed Exit package cost band Redundancies departures Redundancies departures
<£10,000 - 6 6 - 12 12 £10,000 - £25,000 - 6 6 - 5 5 £25,001 - £50,000 1 3 4 - 7 7 £50,001 - £100,000 - - - - 6 6 £100,001 - £150,000 - - - - 1 1 Total number of packages 1 15 16 - 31 31
Total cost of packages (£000) 42 232 274 - 908 908
During the year the Foundation Trust made 1 member of staff (2015/16 0 staff) compulsorily redundant as a consequence of department restructurings and 15 (2015/16 31) other agreed departures.
8.4 Exit packages: non compulsory departure payments 2016/17 2015/16 Total Value of Total Value of Agreements Agreements Agreements Agreements Number £000 Number £000 Voluntary redundancies including early retirement contractual costs - - 1 101 Mutually agreed resignations (MARS) 9 169 30 807 Contractual payments in lieu of notice - - - - Exit payments following employment tribunals or court orders 6 63 - - Total 15 232 31 908
8.5 Directors' emoluments Group and Foundation Trust 2016/17 2015/16 £000 £000 Aggregated emoluments 839 931 Compensation for loss of office - - 839 931
During the year, 7 (2015/16 6) directors accrued retirement benefits under the NHS pension scheme which is classed as a defined benefit scheme.
2016/17 2015/16 Highest paid director Emoluments (Mid Point) 181 168 Employer contributions to NHS pension scheme 21 22 Defined benefit scheme: Accrued pension at the end of the year 905 1,118
The highest paid director is the Chief Executive.
20 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
9. Pension costs (continued)
9.1 NHS Pension costs (continued)
The Scheme is a “final salary” scheme. Annual pensions are normally based on 1/80th for the 1995 section and of the best of the last three years pensionable pay for each year of service, and 1/60th for the 2008 section of reckonable pay per year of membership. Members who are practitioners as defined by the Scheme Regulations have their annual pensions based upon total pensionable earnings over the relevant pensionable service.
With effect from 1 April 2008 members can choose to give up some of their annual pension for an additional tax free lump sum, up to a maximum amount permitted under HMRC rules. This new provision is known as “pension commutation”.
Annual increases are applied to pension payments at rates defined by the Pensions (Increase) Act 1971, and are based on changes in retail prices in the twelve months ending 30 September in the previous calendar year. From 2011-12 the Consumer Price Index (CPI) has been used and replaced the Retail Prices Index (RPI).
Early payment of a pension, with enhancement, is available to members of the scheme who are permanently incapable of fulfilling their duties effectively through illness or infirmity. A death gratuity of twice final year’s pensionable pay for death in service, and five times their annual pension for death after retirement is payable.
For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the liability for the additional costs is charged to the employer.
Members can purchase additional service in the NHS Scheme and contribute to money purchase AVC’s run by the Scheme’s approved providers or by other Free Standing Additional Voluntary Contributions (FSAVC) providers.
9.2 NEST Pension costs
The Foundation Trust is a member of the National Employment Savings Trust (NEST) pension scheme which operates as a defined contribution plan.
Under a defined contribution plan, the Foundation Trust pays fixed contributions into a fund but has no legal or constructive obligation to make further payments if the fund does not have sufficient assets to pay all of the employees' entitlements to post-employment benefits. The Foundation Trust's obligation is therefore effectively limited to the amount it agrees to contribute to the fund and effectively place actuarial and investment risk on the employee. The Foundation Trust expects its level of contributions in 2016/17 to be broadly inline with 2015/16.
The amount recognised in the period is the contribution payable in exchange for service rendered by employees during the period.
10. Retirements due to ill-health
During 2016/17 there were 6 (2015/16 6) early retirements from the Foundation Trust agreed on the grounds of ill-health. The estimated additional pension liabilities of these ill-health retirements will be £409,000 (2015/16 £200,000), based on information supplied by NHS Pensions. The cost of these ill- health retirements will be borne by the NHS Business Services Authority - Pensions Division.
22 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
11. Auditors' remuneration Group Foundation Trust 2016/17 2015/16 2016/17 2015/16 £000 £000 £000 £000 Audit fees: audit services- statutory audit 70 57 70 52 audit services- statutory audit - 2015/16 additional costs - 33 - 32 Other auditors remuneration: further assurance services - quality accounts 55 9 55 9 Total 125 99 125 93
The statutory audit fee does not include work on the Quality Report as required under Monitor's Audit Code for NHS Foundation Trusts. This is shown under further assurance services.
Limitation on the external auditors' liability is set at £2,000,000.
Group Foundation Trust 12. Finance income 2016/17 2015/16 2016/17 2015/16 £000 £000 £000 £000
Bank accounts 38 42 38 42 Investments listed on Stock Exchange 287 342 - - Investments in a Common Investment Fund - - - - Total 325 384 38 42
Group and Foundation Trust 13. Finance costs 2016/17 2015/16 £000 £000
Interest on loans from the Independent Trust Financing Facility (ITFF) 559 528 Working capital loans from the Department of Health 1,202 190 Other Interest - 54 Interest on late payment of commercial debt 2 85 Unwinding of discount on provisions (note 24) - - Total 1,762 857
23 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
14. Intangible assets Group and Foundation Trust Computer EU emissions Assets under Total software - trading scheme construction 14.1 Intangible assets 2016/17: purchased allowances £000 £000 £000 £000 Gross cost at 1 April 2016 7,795 27 324 8,146 Additions purchased 731 - - 731 Reclassifications p 3,850 - (324) 3,526
Gross cost at 31 March 2017 12,376 27 - 12,403
Accumulated amortisation at 1 April 2016 5,209 - - 5,209 Charged during the year 740 - - 740 Accumulated amortisation at 31 March 2017 5,949 - - 5,949
Net book value Purchased 6,386 1 - 6,387 Donated 41 - - 41 Government granted - 26 - 26 Total at 31 March 2017 6,427 27 - 6,454
Prior year: Group and Foundation Trust Computer EU emissions Assets under Total software - trading scheme construction 14.2 Intangible assets 2015/16: purchased allowances £000 £000 £000 £000 Gross cost at 1 April 2015 7,056 27 324 7,407 Additions purchased 739 - 739 Revaluation losses - - - - Gross cost at 31 March 2016 7,795 27 324 8,146
Accumulated amortisation at 1 April 2015 4,529 - - 4,529 Charged during the year 680 - - 680 Accumulated amortisation at 31 March 2016 5,209 - - 5,209
Net book value Purchased 2,537 1 324 2,862 Donated 49 - - 49 Government granted - 26 - 26 Total at 31 March 2016 2,586 27 324 2,937
14.3 Economic life of intangible assets Min Life Max Life Years Years Computer software licences (straight line basis) 1 5 EU emissions allowances 1 7 Assets under construction 1 5
24 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
15. Property, plant and equipment Group and Foundation Trust Land Buildings Dwellings Assets under Plant and Transport Information Furniture Total excluding construction machinery equipment technology and fittings dwellings 15.1 Property, plant and equipment 2016/17: £000 £000 £000 £000 £000 £000 £000 £000 £000
Cost or valuation at 1 April 2016 8,035 150,717 4,167 6,499 48,502 410 21,824 5,497 245,651 Additions purchased 3,102 2,525 846 864 7,337 Additions donated 1,591 368 30 88 2,077 Additions government granted - Revaluation Depreciation Reversal (3,697) (91) (3,788) Reclassifications 2,974 (6,499) (3,525) Reclassified as held for sale - Disposals (39) (677) (70) - - - (786) Revaluation (losses)/gains 39 3,920 3,959 Impairments charged to operating expenses - Impairments charged to revaluation reserve - Reversal of Impairments crediting income - Cost or valuation at 31 March 2017 8,035 158,607 3,399 - 51,325 410 22,700 6,449 250,925
Accumulated depreciation at 1 April 2016 - - - - 36,750 327 15,876 4,046 56,999 Reclassifications ------Reclassified as held for sale - Disposals - - (11) - (69) - - - (80) Revaluation gains ------Impairments charged to operating expenses - 2,248 ------2,248 Reversal of Impairments crediting income - (1,462) ------(1,462) Charged during the year - 2,911 102 - 2,880 5 1,600 589 8,087 Revaluation Depreciation Reversal - (3,697) (91) - - - - - (3,788) Accumulated depreciation at 31 March 2017 - - - - 39,561 332 17,476 4,635 62,004
Net book value Purchased 8,035 151,595 3,399 - 10,644 78 5,153 1,741 180,645 Donated - 5,730 - - 979 - 63 73 6,845 Government granted - 1,282 - - 141 - 8 - 1,431 Total 31 March 2017 8,035 158,607 3,399 - 11,764 78 5,224 1,814 188,921
There are no restrictions or conditions imposed by the donor on the donated additions. The cash donated equals the fair value of the donated asset additions. All of the asset disposals related to unprotected assets and therefore did not impact on the Foundation Trust's ability to provide its Commissioner Requested Services.
25 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
15. Property, plant and equipment (continued)
Prior year: Group and Foundation Trust Land Buildings Dwellings Assets Plant and Transport Information Furniture Total excluding under machinery equipment technology and dwellings constructio fittings 15.2 Property, plant and equipment 2015/16: n £000 £000 £000 £000 £000 £000 £000 £000 £000 Cost or valuation at 1 April 2016 11,565 164,320 5,452 2,287 47,723 357 20,807 5,410 257,921 Additions purchased - 4,917 13 4,212 1,596 53 1,126 118 12,035 Additions donated ------Additions government granted ------Revaluation Depreciation Reversal - (6,057) (226) - - - - - (6,283) Disposals - - (955) - (817) - (109) (31) (1,912) Revaluation (losses)/gains ------Impairments charged to operating expenses - (12,315) ------(12,315) Impairments charged to revaluation reserve (3,530) (1,905) (343) - - - - - (5,778) Reversal of Impairments crediting income - 1,757 226 - - - - - 1,983
Cost or valuation at 31 March 2017 8,035 150,717 4,167 6,499 48,502 410 21,824 5,497 245,651 Accumulated depreciation at 1 April 2016 - 2,955 134 - 34,330 309 14,358 3,583 55,669 Reclassified as held for sale - Disposals - - (38) - (811) - (108) (31) (988) Charged during the year - 3,102 130 - 3,231 18 1,626 494 8,601 Revaluation Depreciation Reversal - (6,057) (226) - - - - - (6,283)
Accumulated depreciation at 31 March 2017 - - - - 36,750 327 15,876 4,046 56,999
Net book value Purchased 8,035 145,562 4,167 6,499 10,639 83 5,876 1,451 182,312 Donated - 3,890 - - 926 - 48 - 4,864 Government granted - 1,265 - - 187 - 24 - 1,476 Total 31 March 2017 8,035 150,717 4,167 6,499 11,752 83 5,948 1,451 188,652
26 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
15. Property, plant and equipment (continued)
15.3 Land, buildings and dwellings held at revalued amounts
Valuations are carried out by professionally qualified valuers in accordance with the Royal Institution of Chartered Surveyors (RICS) Appraisal and Valuation Manual. During the year the Trust undertook a full revaluation of the site.
15.4 Land, buildings and dwellings held at open market value
The totals at 31 March 2017 include land, buildings and dwellings valued at open market value of:
Group and Foundation Trust 31 March 31 March 2017 2016 £000 £000 Buildings, excluding dwellings 350 881 Dwellings 1,289 1,969 TOTAL 1,639 2,850
15.5 Land, buildings and dwellings by holding
The net book values at 31 March 2017 include land, buildings and dwellings which comprise:
Group and Foundation Trust 31 March 31 March Protected Unprotected 2017 2016 £000 £000 £000 £000 Freehold 159,953 3,000 162,953 162,919 Short leasehold - - - TOTAL 159,953 3,000 162,953 162,919
15.6 Property, plant and equipment leased to third parties
The Foundation Trust is the lessor of a number of property assets provided under operating leases, however they are not all discrete assets in their own right, but areas within the Foundation Trust's existing buildings. The additional details below only cover those assets which are discrete and/or material.
Group and Foundation Trust 31 March 31 March 2017 2016 £000 £000 Gross carrying amount 4,024 5,083 Depreciation charge for the financial year (48) - Revaluation gain/(impairment losses) recognised for the financial year 827 (302)
27 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
15. Property, plant and equipment (continued)
15.7 Economic life of property, plant and equipment Group and Foundation Trust 31 March 31 March 2017 2016 Years Years Buildings excluding dwellings 11 to 87 3 to 91 Dwellings 45 to 53 5 to 57 Plant & Machinery 7 to 15 1 to 25 Transport Equipment 5 to 7 2 to 7 Information Technology 1 to 5 1 to 10 Furniture & Fittings 1 to 7 1 to 7
16. Charitable fund investments
16.1 Analysis of investments Group 31 March 31 March 2017 2016 £000 £000
Market value at 1 April 9,732 12,453 Less: Disposals at carrying value (3,272) (2,621) Add: Acquisitions at cost 1,297 1,075 Unrealised gains on revaluation 259 (1,063) Audit adjustment to bid price valuation (112) Market value at 31 March 8,016 9,732
Historic cost at 31 March 6,155 8,475
16.2 Market Value at 31 March Group 31 March 31 March 2017 2016 £000 £000 Investments listed on Stock Exchange Fixed Interest Investments 811 1,108 UK Equities 5,844 4,777 Overseas Equities 157 2,269 Other Investments 1,150 1,578 7,962 9,732 Investments in a Common Investment Fund - - Cash & Accrued Intetest held as part of the portfolio 54 341 8,016 10,073
The asset allocations set out in the investment portfolio Fixed Interest 10-20%, UK Equity 40-60%, Overseas Equity 10-30%, Property 10-20% and Cash 0-10%
The Foundation Trust does not knowingly invest the Charity's assets where core business (>20% of turnover) is tobacco or alcohol.
There are no direct investments made outside of the UK.
There are two holdings which each represent more than 5% of the total portfolio market value, these are: £000 Charities Prop Property Fund 587 CCLA Investment Ma Property Inc 563
28 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
16. Charitable fund investments (continued)
16.3 Reconciliation of gains on revaluation and disposal
Group 31 March 31 March 2017 2016 £000 £000 Sale proceeds 4,236 3,099 Disposals at carrying value (3,354) (2,645) Realised (losses) \ gains on disposal 882 454 Unrealised (losses) \ gains on revaluation 259 (1,039) Total (losses) \ gains on investments 1,141 (585)
17. Impairments Group and Foundation Trust 31 March 31 March 2017 2016 £000 £000 Impairment of assets due to: Changes in market price 259 1,039 Impairments charged to: Operating expenses - new and increases to impairments 2,249 - Operating income - reversal of impairments previously (1,463) - charged 786 - Revaluation reserve - - 786 -
18. Inventories Group and Foundation Trust 31 March 31 March 18.1 Inventories 2017 2016 £000 £000
Drugs 1,586 2,312 Theatre consumables 1,096 1,545 Building and engineering consumables 211 162 Other consumables 1,691 1,455 Total 4,584 5,474
Group and Foundation Trust 31 March 31 March 18.2 Inventories recognised in expenses 2017 2016 £000 £000
Inventories recognised as an expense in the financial year 38,318 41,278
29 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
19. Trade and other receivables Group Foundation Trust 19.1 Trade and other receivables 31 March 31 March 31 March 31 March 2017 2016 2017 2016 £000 £000 £000 £000 Current NHS receivables 5,717 8,290 5,717 8,290 Accrued income 16,544 998 16,356 1,144 Provision for the impairment of receivables - Non NHS (1,040) (757) (1,040) (757) Prepayments 1,310 1,541 1,310 1,541 VAT receivable 765 973 765 973 PDC dividend receivable - 1,370 - 1,370 Other receivables 3,135 2,873 3,135 3,115 NHS charitable funds 28 14 - - Total 26,459 15,302 26,243 15,676
Non-current Provision for the impairment of receivables (835) (449) (835) (449) Other receivables 2,368 2,041 2,368 2,041 Total 1,533 1,592 1,533 1,592
Total 27,992 16,894 27,776 17,268
The great majority of trade was with NHS England and Clinical Commissioning Groups, as commissioners for NHS patient care services. As they were funded by government to buy NHS patient care services, no credit scoring of them was considered necessary.
Group Foundation Trust 19.2 Provision for impairment of receivables 31 March 31 March 31 March 31 March 2017 2016 2017 2016 £000 £000 £000 £000 Balance at 1 April 1,206 771 1,206 771 Arising during the year 930 435 930 435 Utilised during the year (261) - (261) - Reversed unused - - Balance at 31 March 1,875 1,206 1,875 1,206
Group Foundation Trust 19.3 Ageing of impaired receivables past their due date 31 March 31 March 31 March 31 March 2017 2016 2017 2016 £000 £000 £000 £000 By up to three months 1,595 1,884 1,595 1,884 By three to six months 541 546 541 546 By more than six months 1,356 1,263 1,356 1,263 Total 3,492 3,693 3,492 3,693
Group Foundation Trust 19.4 Ageing of non-impaired receivables past their due date 31 March 31 March 31 March 31 March 2017 2016 2017 2016 £000 £000 £000 £000 By up to three months 1,865 1,865 1,515 1,865 By three to six months 538 538 500 538 By more than six months 855 855 954 855 Total 3,258 3,258 2,969 3,258
30 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
20. Non-current assets held for sale Group and Foundation Trust 31 March 31 March 2017 2016 £000 £000 Net book value at 1 April 300 350 Plus assets classified as available for sale in the year - - Less assets sold in year (300) - Less revaluation loss on assets held for sale (50) Less assets no longer classified as held for sale - - Net book value at 31 March 2016 - 300
At 31 March 2016 Barrowby House is held for sale.
21. Trade and other payables Group Foundation Trust
31 March 31 March 31 March 31 March 2017 2016 2017 2016 £000 £000 £000 £000 Current Interest payable - 176 204 176 NHS and related bodies payables 3,777 7,253 3,776 7,253 PDC dividend payable 52 - 52 - Other trade payables - capital 1,026 1,054 1,190 1,054 Other trade payables - revenue 7,756 9,083 7,932 9,083 Other payables 2,957 - 2,962 - Accruals 11,688 9,449 10,954 9,449 VAT payable - 259 - 259 NHS Charitable funds 299 772 - - Total 27,555 28,046 27,070 27,274
22. Tax payable Group and Foundation Trust
31 March 31 March 2017 2016 £000 £000
Tax and social security costs 5 4,199
31 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
23. Borrowings Group and Foundation Trust 31 March 31 March 2017 2016 £000 £000 Current Loans from Independent Trust Financing Facility (ITFF) 3,027 2,753 Other - Salix Finance - Energy efficiency loan scheme - 22 Total 3,027 2,775
Non-current Loans from Independent Trust Financing Facility (ITFF) 22,957 25,985 Working capital loans from Department of Health 54,186 33,052 Other - Salix Finance - Energy efficiency loan scheme - - Total 77,143 59,037
Total 80,170 61,812
Loans outstanding as at 31 March 2017 - repayment of principal falling due:
ITFF Other Total £000 £000 £000 within one year 3,027 - 3,027 within one to two years 62,242 - 62,242 between two and five years 5,399 - 5,399 after five years 9,502 - 9,502 Total 80,170 - 80,170
32 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
24. Provisions Group and Foundation Trust Current Non-current Total 31 March 31 March 31 March 31 March 31 March 31 March 2017 2016 2017 2016 2017 2016 £000 £000 £000 £000 £000 £000 Early retirement pensions 101 158 1,065 365 1,166 523 Legal claims 329 229 - - 329 229 Injury benefits (NHS Pensions) 77 77 1,139 363 1,216 440 Mutually Agreed Redundancy Scheme 76 60 - - 76 60 Total 583 524 2,204 728 2,787 1,252
Early Legal Redundacy Other pay Total retirement claims items pensions £000 £000 £000 £000 £000 At 1 April 2016 523 229 60 440 1,252 Change in discount rate - - - - - Arising during the year 799 177 65 853 1,894 Used during the year (156) (77) (49) (77) (359) At 31 March 2017 1,166 329 76 1,216 2,787
Expected timing of cash flows: Within one year 101 329 76 77 583 Between one and five years 402 - - 307 709 After five years 663 - - 832 1,495 1,166 329 76 1,216 2,787
33 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
24. Provisions (continued)
Pensions costs relating to the early retirements of employees are not funded by the NHS Pension Scheme, the full amount of the liability for the additional costs is charged to the income and expenditure account at the time the Foundation Trust commits itself to the retirement, regardless of the method or timing of payment.
Legal claims (not clinical negligence) include personal injury claims made against the Foundation Trust. These claims are covered under the Foundation Trust's commercial insurance policies, for incidents arising pre 1 April 2000, or the NHSLA Pooling Arrangement Scheme, for incidents post 1 April 2000.
Other provisions include those made for the cost of injury benefits based on information provided by the NHS Pension Agency and did include provisions for the cost of back pay as a consequence of implementing medical career reform, restructuring and appeals in relation to equal pay which were settled in the 2015/16 financial year.
The timing of payments in relation to any of these is unclear, however, it is expected that the vast majority of the personal injury claims will be completed in the 2016/17 financial year with pension and injury benefit provisions being settled over the next few years. At 31 March 2017 the NHS Litigation Authority included provisions in their accounts of £162,500,000 (31 March 2016 £143,676,000) in respect of clinical negligence liabilities of the Foundation Trust.
25. Other liabilities Group and Foundation Trust 31 March 31 March 2017 2016 £000 £000 Current Deferred income Health Education England 340 309 Deferred income - local government - 17 Deferred income - grants - - Deferred income - other 756 230 Total 1,096 556
Non-current Deferred Income - - Total - -
Total 1,096 26
26. Revaluation reserves Group and Foundation Trust Non- Property, current plant and Total assets held equipment for sale £000 £000 £000
Balance at 1 April 2016 29,639 300 29,939
Changes in equity for 2016/17 Revaluation gains 3,959 - 3,959 Transfers to the income and expenditure account in res (677) (127) (804)
Balance at 31 March 2017 32,921 173 33,094
Balance at 1 April 2015 36,003 350 36,353 - Changes in equity for 2015/16 (6,364) (50) (6,414) - Balance at 31 March 2016 29,639 300 29,939
34 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
Group Foundation Trust 31 March 31 March 31 March 31 March 27. Cash and cash equivalents 2017 2016 2017 2016 £000 £000 £000 £000 Balance at 1 April 2,967 12,033 2,169 11,706 Net change in year 220 (9,066) 227 (9,537) Balance at 31 March 3,187 2,967 2,396 2,169
Made up of Commercial banks and cash in hand 2,289 224 107 224 Cash with the Government Banking Service 898 2,743 2,289 1,945 Cash and cash equivalents as in statement of financial position 3,187 2,967 2,396 2,169
Cash and cash equivalents as in statement of cash flows 3,187 2,967 2,396 2,169
The Foundation Trust accounts as part of the Government Banking Service have transferred to a sole Natwest account from the 1st March 2016. The Citibank and RBS accounts have now ceased and no netting off is now required.
28. Financial Instruments Group Foundation Trust 31 March 31 March 31 March 31 March 28.1 Financial assets 2017 2016 2017 2016 £000 £000 £000 £000 Held-to-maturity investments Listed fixed interest investments 811 1,107 - - Available-for-sale financial assets Listed securities 7,151 8,649 - - Loans and receivables Receivables 24,104 12,795 24,104 12,795 Cash & Accrued Interest (investment portfolio) 54 345 - - Cash at bank and in hand 3,187 2,967 2,396 2,169 Total 27,345 16,107 26,500 14,964
28.2 Financial liabilities Group Foundation Trust
31 March 31 March 31 March 31 March 2017 2016 2017 2016 Financial liabilities measured at amortised costs £000 £000 £000 £000 Payables - 27,261 - 31,962 Borrowings - 80,170 - 61,812 Provisions - - 556 Total - 107,431 - 94,330
Expected timing of cash flows: Within one year - 30,288 - 35,293 Between one and five years - 67,641 - 45,648 After five years - 9,502 - 13,389 - 107,431 - 94,330
28.3 Financial risk management
Financial reporting standard IFRS 7 'Financial Instruments: Disclosures' requires disclosure of the role that financial instruments have had during the financial year in creating or changing the risks a body faces in undertaking its activities. Because of the continuing service provider relationship that the Foundation Trust has with Clinical Commissioning Groups (CCGs) and the way those bodies are financed, the Foundation Trust is not exposed to the degree of financial risk faced by business entities. Also financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which the financial reporting standards mainly apply. The Foundation Trust has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the Foundation Trust in undertaking its activities. The only exception to this from a group perspective is the NHS charitable fund investment portfolio.
35 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
28. Financial Instruments (continued)
28.3 Financial risk management (continued)
The investment portfolio is managed on a day-to-day basis by an external investment manager with delegated authority to act on behalf of the Foundation Trust within formally defined parameters.
The Foundation Trust’s treasury management operations are carried out by the finance department, within parameters defined formally by the Foundation Trust’s standing financial instructions and policies agreed by the Foundation Trust Board. Treasury activity is subject to review by the Foundation Trust’s internal auditors.
Market risk IFRS 7 defines three components of Market Risk; Currency risk, Interest Rate Risk, and Price Risk. The Foundation Trust's assessment of its exposure to these risks is as follows;
Currency risk This is the risk that the Foundation Trust's income and expenditure could be affected materially by foreign exchange rate gains and losses.
The Foundation Trust is principally a domestic organisation with the great majority of transactions, assets and liabilities being in the UK and sterling based. The Foundation Trust has no overseas operations. The Foundation Trust therefore has low exposure to currency rate fluctuations.
Interest rate risk This is the risk that the Foundation Trust's income and expenditure could be affected materially by changes in interest rates on financial liabilities (e.g. Borrowings).
The Foundation Trust borrows from government for capital expenditure. The borrowings are for 1 – 25 years, in line with the life of the associated assets, and interest is charged at the National Loans Fund rate, fixed for the life of the loan. The Foundation Trust therefore has low exposure to interest rate fluctuations.
Price risk
Price risk arises on financial instruments as a result of changes in, for example, commodity or equity prices. The Foundation Trust is exposed to price risk of its listed securities and fixed interest investments. The Foundation Trust manages those risks by its appointed investment manager monitoring the markets closely and through the spread of investments in line with its investment policy: Fixed Interest 10-20%, UK Equity 40-60%, Overseas Equity 10-30%, Property 10-20% and Cash 0-10%. Price volatility in 2016/17 led to unrealised gain across the portfolio of £259,000 (2015/16 -£585,000 loss).
Credit risk This is the risk that other parties may not pay amounts due from them to the Foundation Trust. The principle sources of credit risk are trade and other receivables and cash investments.
To minimise the risk in respect of cash investments the Foundation Trust maintains a risk averse stance to investing surplus operating cash, keeping balances in its Government Banking Service accounts.
Because the majority of the Foundation Trust’s income comes from contracts with other public sector bodies, the Foundation Trust has low exposure to credit risk. Amounts receivable from NHS Foundation Trusts and other NHS bodies are statutorily backed by the Secretary of State for Health. Consequently the risk of non- receipt of such sums is low The maximum exposures as at 31 March 2017 are in receivables from customers, as disclosed in the Trade and other receivables note, which can be found in Note 19.
None of the Group's financial assets are secured by collateral or other credit enhancements.
36 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
28. Financial Instruments (continued)
28.3 Financial risk management (continued)
Liquidity risk The majority of the Foundation Trust’s operating costs are incurred under contracts with NHS England and Clinical Commissioning Groups, which are financed from resources voted annually by Parliament . The Foundation Trust funds its capital expenditure from government. The Foundation Trust is not therefore exposed to significant liquidity risks.
28.4 Fair Values
Fair value is defined as the amount for which an asset could be exchanged, or a liability settled,between knowledgeable, willing parties in an arm's length transaction. For the investments held a quoted price in an active market is available, the fair value and book value are based on the quoted price at the end of the reporting year. For other financial assets and liabilities as at 31 March 2017 fair values are the same as the book values.
29. Capital commitments
Contracted capital commitments at 31 March not otherwise included in these accounts:
Group and Foundation Trust 31 March 31 March 2017 2016 £000 £000 Property, plant and equipment 668 2,831 Intangible assets 30 87 Total 698 2,918
The commitments at 31 March 2017 relate to mainly for Fire Schemes (£363k), Medical Equipment and Imaging Equipment (£306k) and IT and software for £30k.
30. Events after the financial year
There are no events after the reporting date which the Foundation Trust is aware which should be reported within the Group or Foundation Trust accounts.
31. Contingencies Group and Foundation Trust Contingent liabilities 31 March 31 March 2017 2016 £000 £000 Legal claims 191 124 Total 191 124
The contingent liability relates to personal injury claims made against the Foundation Trust which are covered under the NHSLA Pooling Arrangement Scheme, but for which no provision has been made due to the low probability of settlement.
37 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
32. Related party transactions
Doncaster and Bassetlaw Hospitals NHS Foundation Trust is a public benefit corporation which was established under the granting of Authority by the Independent Regulator for NHS Foundation Trusts, Monitor.
During the year none of the Governors, Board Members or Management Board Members or parties related to them; or entities controlled, jointly controlled or significantly influenced by them or a close family member has undertaken any material transactions with the Foundation Trust.
Other than the figures contained in the remuneration report no other payments were made to directors
Other NHS and Government bodies are also regarded as a related party. During the year the Foundation Trust had transactions as follows:
Group and Foundation Trust Income Expenditure Receivables Payables £000 £000 £000 £000 Department of Health Group 369,035 30,837 20,832 5,429 Other Government Bodies 3,724 47,930 871 2,962 372,759 78,767 21,703 8,391
During the year the Foundation Trust has had a significant number of material transactions with the following: Income Expenditure Receivables Payables £000 £000 £000 £000 Doncaster CCG 189,168 - - 152 Bassetlaw CCG 62,784 - 478 9 NHS England 54,029 1,670 15,096 - Barnsley CCG 6,376 - - 144 Rotherham CCG 10,252 - - - Sheffield Teaching Hospitals NHS Foundation Trust 10,789 7,516 2,210 2,711 Health Education England 10,072 - - 340 Hardwick CCG 3,623 - - 118 Newark & Sherwood CCG 3,107 - 231 - North Derbyshire CCG 855 - 44 - Southern Derbyshire CCG 120 - - - Wakefield District CCG 3,073 - - - North Lincolnshire CCG 3,337 - - - Doncaster Met Borough Council 2,504 1,572 - - Nottinghamshire Healthcare NHS Foundation Trust 1,640 - 181 - The Rotherham NHS Foundation Trust 1,271 652 816 224 Rotherham, Doncaster and South Humber Mental Health NFT 1,097 2,091 284 359 East Riding CCG 1,708 - - - NHS Lincolnshire East CCG 104 - - - United Licolnshire Hospitals NHS Trust 140 - - - NHS Lincolnshire West CCG 1,030 - - - Nottingham County Council 996 - - - Barnsley Hospital Foundation Trust 333 - 145 - Mansfield & Ashfield CCG 610 - - - Chesterfield Royal Hospital Foundation Trust 130 - - - Sheffield CCG 406 - - - Vale of York CCG 222 - - - York Teaching Hospital NHS Foundation Trust - 100 - - Leeds Teaching Hospitals NHS Trust - 153 - - Northern Lincs & Goole Hosps NHS Foundation Trust 121 108 - - Sheffield Children's Hospital NHS Foundation Trust 150 1,633 173 589 NHS Pension Services - 21,986 - - HMRC - 16,744 - 2,962 Care Quality Commission - 196 - - NHS Litigation Authority - 16,080 - - Bassetlaw County Council - 1,220 - - National Blood Authority - 1,741 - - NHS Property Services - 103 - - Public Health England (PHE) 110 - - - Northumbria Healthcare NHS Foundation Trust - - - - Department of Health 239 - - - 370,396 73,565 19,658 7,608
38 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
33. Third Party Assets
The Foundation Trust held £500 cash and cash equivalents at 31 March 2017 (31 March 2016 £2,000) which relates to monies held by the Foundation Trust on behalf of patients. This has been excluded from the cash and cash equivalents figure reported in the accounts.
34. Losses and Special Payments Group and Foundation Trust 31 March 2017 31 March 2016 Number £000 Number £000 Special payments: Ex-gratia payments 259 291 43 120 Less reimbursements from NHS Litigation Authority - - - (29) Severance Payments - - - - Total 259 291 43 91
Total losses and special payments 259 291 43 91
None of the cases exceeded £300,000. These amounts are reported on an accruals basis but excluding provisions for future losses.
35. Charitable fund reserve Group 31 March 31 March 2017 2016 £000 £000 Reserve by fund classification Unrestricted 2,966 2,021 Restricted 5,933 7,385 Endowment - - 8,899 9,406
Restricted funds are funds which are to be used in accordance with specific restrictions imposed by the donor. Where the restriction requires the gift to be invested to produce income but the Corporate Trustee has the power to spend the capital, it is classed as expendable endowment and the income is classed as unrestricted funds.
Unrestricted income funds comprise those funds which the Corporate Trustee is free to use for and purpose in furtherance of the charitable objects. Unrestricted funds include designated funds, where the donor has made known their non binding wishes or where the Corporate Trustee, as its discretion, has created a fund for a specific purpose.
39 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
NOTES TO THE ACCOUNTS (continued)
36. NHS charitable fund
The Foundation Trust is the Corporate Trustee of the Doncaster and Bassetlaw Hospitals NHS Foundation Trust Charitable Fund (registered charity number 1057917). The object is for funds to be used “for any purpose or purposes relating to the National Health Service wholly or mainly for the service provided by Doncaster and Bassetlaw Hospitals NHS Foundation Trust”.
Included in the Foundation Trust's accounts as at 31 March 2017 are net receivables of £391,000 (31 March 2016 £58,000) and contributions towards operating expenses and capital expenditure of £2,077,000 (2015/16 £171,000). These transactions and balances are eliminated in full on consolidation into the Group accounts.
Copies of the audited annual report and accounts of the charitable fund are available separately by contacting the Foundation Trust's Finance Department.
36.1 Summary statement of financial activities 2016/17 2015/16 Unrestricted Restricted Total Total Funds Funds Funds Funds £000 £000 £000 £000
Incoming resources 779 40 819 443 Resources expended 409 (3,163) (2,754) (2,226) Net outgoing resources 1,188 (3,123) (1,935) (1,783) Investment Income 72 215 287 341 Transfers between funds (600) 600 - - (Losses) \ Gains on revaluation and 285 856 1,141 (585) disposal of investment assets Net movement in funds 945 (1,452) (507) (2,027) Fund balances 1 April 2,021 7,385 9,406 11,433 Fund balances 31 March 2,966 5,933 8,899 9,406 33.3%
31 March 31 March 2017 2016 Unrestricted Restricted Total Total Funds Funds Funds Funds £000 £000 £000 £000
Investment assets 2,645 5,371 8,016 9,732 Current assets 129 262 391 58 Cash 261 530 791 798 Current liabilities (69) (230) (298) (1,182) Total net assets 2,966 5,933 8,900 9,406
Charitable fund 2,966 5,933 8,899 9,406
40 Doncaster and Bassetlaw Hospitals NHS Foundation Trust - Annual Report and Accounts 2016/17
41
Title NHS Improvement Self-certification
Report to: Board of Directors Date: 23 May 2017
Author: Richard Parker, Chief Executive
For: Approval Purpose of Paper: Executive Summary containing key messages and issues
NHS foundation trusts are required to self-certify whether or not they have complied with the conditions of the NHS provider licence (which itself includes requirements to comply with the National Health Service Act 2006, the Health and Social Care Act 2008, the Health Act 2009, and the Health and Social Care Act 2012, and have regard to the NHS Constitution). They are also required to confirm they have the required resources available if providing commissioner requested services, and that they have complied with governance requirements.
The Trust is required to self-certify against the following licence conditions:
The purpose of self-certification is to carry out assurance that the Trust continues to comply with its licence conditions. It is down to the Trust how it decides to do this but templates have been provided. The Trust’s response is given as an appendix.
It is for the Board to sign off the self-certification having regard to the views of Governors. A presentation on the self-certification process will be given to Governors on 23 May, on the evening of Board. Accordingly the recommendation to Board is “subject to” any further comments from Governors. The deadline for submission is 31 May 2017 for FT4 and 30 June for G6/COS7.
Recommendation
To approve the self-certification documents attached as appendices for onward submission to NHSI by the deadline dates, subject to any comments from governors.
Related Strategic Objectives
Provide the safest, most effective care possible Control and reduce the cost of healthcare Focus on innovation for improvement Develop responsibly, delivering the right services with the right staff
Analysis of risks
Key risks against the licence conditions are highlighted within the completed templates.
Self-Certification Template - Condition FT4 Doncaster and Bassetlaw Hospitals NHS Foundation Trust
Foundation Trusts and NHS trusts are required to make the following declarations to NHS Improvement:
Corporate Governance Statement - in accordance with Foundation Trust condition 4 (Foundations Trusts and NHS trusts) Certification on training of Governors - in accordance with s151(5) of the Health and Social Care Act (Foundation Trusts only)
These Declarations are set out in this template.
How to use this template 1) Save this file to your Local Network or Computer. 2) Enter responses and information into the yellow data-entry cells as appropriate. 3) Once the data has been entered, add signatures to the document. Worksheet "FT4 declaration"
Corporate Governance Statement (FTs and NHS trusts)
The Board are required to respond "Confirmed" or "Not confirmed" to the following statements, setting out any risks and mitigating actions planned for each one
1 Corporate Governance Statement Response Risks and Mitigating actions Please complete A new chair, chief executive, DoF and two new NEDs joined the Board in 2016/17 1 The Board is satisfied that the Licensee applies those principles, systems and standards of good corporate Confirmed both Risks and which gave rise to risks of adequate continuity at a senior leadership level. Key governance which reasonably would be regarded as appropriate for a supplier of health care services to the Please complete Risks and Mitigating actions Migitating actions NHS. mitigations are in place including a structured induction programme, board development and objective setting/appraisal processes. & Explanatory Please complete Risks and Mitigating actions p 2 The Board has regard to such guidance on good corporate governance as may be issued by NHS Improvement Confirmed Risk of non-compliance mitigated through Secretary attending NHS Providers Trust both Risks and Secs Network. New guidance is presented through CEO's report to Board. Please complete Risks and Mitigating actions from time to time Migitating actions Please complete Risks and Mitigating actions
3 The Board is satisfied that the Licensee has established and implements: Confirmed Risk of not having a fit-for-purpose committee structure mitigated through the Please complete Trust's scheme of delegation and standing orders. The Trust commissioned an (a) Effective board and committee structures; both Risks and (b) Clear responsibilities for its Board, for committees reporting to the Board and for staff reporting to the external governance review and committee effectiveness reviews in 2016/17 which have resulted in revisions to terms of reference and formulation of new committee Please complete Risks and Mitigating actions Migitating actions Board and those committees; and structure. Clear terms of reference exist for committees below Board level. Staff & Explanatory (c) Clear reporting lines and accountabilities throughout its organisation. accountability structures are set out within individual job descriptions. Information Please complete Risks and Mitigating actions
4 The Board is satisfied that the Licensee has established and effectively implements systems and/or processes: Confirmed The risk that the Trust's systems and processes are not adeqaute are mitigated in a number of ways. The committee architecture gives assurance to the Board that the (a) To ensure compliance with the Licensee’s duty to operate efficiently, economically and effectively; Trust is operating effectively. The committees scrutinise areas of performance around finance, operations, quality and workforce and escalate appropriately. The (b) For timely and effective scrutiny and oversight by the Board of the Licensee’s operations; CGOC reviews a range of quality metrics and montiors progress against the CQC (c) To ensure compliance with health care standards binding on the Licensee including but not restricted to action plan while other committees focus on patient safety and experience. Quality standards specified by the Secretary of State, the Care Quality Commission, the NHS Commissioning Board and impact is montiored through Management Board. The Trust has developed its statutory regulators of health care professions; quality account for 2016/17 highlighting quality improvements made during the (d) For effective financial decision-making, management and control (including but not restricted to period and outlining priorities for 2017/18. The Trust has clear SFIs and a Delegation Scheme that determines the framework for financial decision-making, appropriate systems and/or processes to ensure the Licensee’s ability to continue as a going concern); management and control. Systems of internal control are subject to regular audit Please complete Risks and Mitigating actions (e) To obtain and disseminate accurate, comprehensive, timely and up to date information for Board and and the Financial Oversight Committee has provided independent oversight and Committee decision-making; challenge. There are robust accountable systems in place to monitor CIP schemes. (f) To identify and manage (including but not restricted to manage through forward plans) material risks to The Board committee calendar ensures up-to-date information is provided to compliance with the Conditions of its Licence; meetings for scrutiny and assurance. The Trust has a Risk Policy in place and the (g) To generate and monitor delivery of business plans (including any changes to such plans) and to receive Board Assurance Framework and Corporate Risk Register provide the framework through which high-level risks are considered. The Board and committees receive Please complete internal and where appropriate external assurance on such plans and their delivery; and the BAF and CRR on a quarterly basis. The Trust has an annual planning process both Risks and (h) To ensure compliance with all applicable legal requirements. that ensures business plans are developed and supported. The governance, risk Migitating actions and control processes in place ensure the Trust remains compliant. & Explanatory Information Please complete Risks and Mitigating actions
Please complete both Risks and Migitating actions & Explanatory Information Please complete Risks and Mitigating actions 5 The Board is satisfied that the systems and/or processes referred to in paragraph 4 (above) should include but Confirmed The risk that the Trust's systems and processes are not adequate is mitigated in a not be restricted to systems and/or processes to ensure: number of ways. There is an effective objective setting and performance review process in place for board members, portfolios are reviewed on an annual basis and a range of development opportunities are available. There is a robust quality (a) That there is sufficient capability at Board level to provide effective organisational leadership on the quality impact assessment process in place which is monitored by two senior clinicians of care provided; from the Executive Team. A regular business intelligence report is brought to Board (b) That the Board’s planning and decision-making processes take timely and appropriate account of quality of and a range of other quality mertrics are reported to Clinical Governance Oversight care considerations; Committee. The quality improvement strategy is reviewed on a regular basis. (c) The collection of accurate, comprehensive, timely and up to date information on quality of care; Board members are actively involved in quality initiatives including ward walkabouts and through being members of operational committees. One non-executive has (d) That the Board receives and takes into account accurate, comprehensive, timely and up to date Please complete Risks and Mitigating actions taken on responsibility as a Freedom to Speak Up Guardian. Clear escalation information on quality of care; routes are in place to ensure matters are referred up to Board committees. Those (e) That the Licensee, including its Board, actively engages on quality of care with patients, staff and other board committees also have a standing item on each agenda allowing them to relevant stakeholders and takes into account as appropriate views and information from these sources; and escalate to the Board. Please complete (f) That there is clear accountability for quality of care throughout the Licensee including but not restricted to both Risks and systems and/or processes for escalating and resolving quality issues including escalating them to the Board Migitating actions where appropriate. & Explanatory Information Please complete Risks and Mitigating actions
Please complete both Risks and Migitating actions & Explanatory Information Please complete Risks and Mitigating actions 6 The Board is satisfied that there are systems to ensure that the Licensee has in place personnel on the Board, Confirmed Risk of failing to ensure appropriate capacity on the Board is mitigated through Please complete reporting to the Board and within the rest of the organisation who are sufficient in number and appropriately regular reviews of NED composition when considering new NED appointments by both Risks and Please complete Risks and Mitigating actions qualified to ensure compliance with the conditions of its NHS provider licence. the Appts & Rems Committee. Executive capacity is reviewed by the CEO and any Migitating actions proposals for change taken through the Noms & Rems Committee. & Explanatory Please complete Risks and Mitigating actions
Signed on behalf of the Board of directors, and, in the case of Foundation Trusts, having regard to the views of the governors
Signature Signature
Name Richard Parker, Chief Executive Name Suzy Brain England, Chair
Further explanatory information should be provided below where the Board has been unable to confirm declarations under FT4.
A Not applicable.
OK Worksheet "Training of governors"
Certification on training of governors (FTs only)
The Board are required to respond "Confirmed" or "Not confirmed" to the following statements. Explanatory information should be provided where required.
2 Training of Governors
1 The Board is satisfied that during the financial year most recently ended the Licensee has provided the Confirmed necessary training to its Governors, as required in s151(5) of the Health and Social Care Act, to ensure OK they are equipped with the skills and knowledge they need to undertake their role.
Signed on behalf of the Board of directors, and, in the case of Foundation Trusts, having regard to the views of the governors
Signature Signature
Name Richard Parker Name Suzy Brain England
Capacity Chief Executive Capacity Chair of the Board
Date 23 May 2017 Date 23 May 2017 Further explanatory information should be provided below where the Board has been unable to confirm declarations under s151(5) of the Health and Social Care Act
A Not applicable. Worksheet "G6 & CoS7"
Declarations required by General condition 6 and Continuity of Service condition 7 of the NHS provider licence
The board are required to respond "Confirmed" or "Not confirmed" to the following statements (please select 'not confirmed' if confirming another option). Explanatory information should be provided where required.
1 & 2 General condition 6 - Systems for compliance with license conditions (FTs and NHS trusts)
1 Following a review for the purpose of paragraph 2(b) of licence condition G6, the Directors of the Licensee are Confirmed satisfied that, in the Financial Year most recently ended, the Licensee took all such precautions as were necessary in order to comply with the conditions of the licence, any requirements imposed on it under the NHS OK Acts and have had regard to the NHS Constitution.
3 Continuity of services condition 7 - Availability of Resources (FTs designated CRS only) EITHER: 3a After making enquiries the Directors of the Licensee have a reasonable expectation that the Licensee will have Confirmed the Required Resources available to it after taking account distributions which might reasonably be expected Please fill details in cell E22 to be declared or paid for the period of 12 months referred to in this certificate. OR 3b After making enquiries the Directors of the Licensee have a reasonable expectation, subject to what is explained below, that the Licensee will have the Required Resources available to it after taking into account in particular (but without limitation) any distribution which might reasonably be expected to be declared or paid for Please Respond the period of 12 months referred to in this certificate. However, they would like to draw attention to the following factors (as described in the text box below) which may cast doubt on the ability of the Licensee to provide Commissioner Requested Services. OR 3c In the opinion of the Directors of the Licensee, the Licensee will not have the Required Resources available to Please Respond it for the period of 12 months referred to in this certificate.
Statement of main factors taken into account in making the above declaration In making the above declaration, the main factors which have been taken into account by the Board of Directors are as follows: • Continuing support from local commissioners – the trust currently has two year contracts in place to 31st March 2019. • Within the proposals for the local STP the Trust is expecting to play a significant role in the provision of urgent and emergency services in South Yorkshire and Bassetlaw with the potential for inward investment to support the additional services once final decisions are made. • The Trust recently transferred its Working capital repayable on demand ‘overdraft’ type loan to a structured loan with agreed repayment dates. • The trust has delivered a year end financial outcome well ahead of its agreed control total for 2016/17.
Signed on behalf of the board of directors, and, in the case of Foundation Trusts, having regard to the views of the governors
Signature Signature
Name Richard Parker Name Suzy Brain England
Capacity Chief Executive Capacity Chair of the Board
Date 23 May 2017 Date 23 May 2017
Further explanatory information should be provided below where the Board has been unable to confirm declarations under G6.
A N/A
Title Review of Committee Structure
Report Board of Directors Date: 23 May 2017 to:
Author: Matthew Kane, Trust Board Secretary
For: Approval Purpose of Paper: Executive Summary containing key messages and issues
To propose a new structure for Board-level committees, including new memberships, terms of reference and meeting cycles in order to align with NHSI’s Single Oversight Framework and the Trust’s emerging strategic direction.
Recommendation
Board is asked to:
(1) Disestablish the existing Clinical Oversight Committee and Financial Oversight Committee.
(2) Establish the new committee structure as set out in the attached report with the terms of reference attached as Appendix A, with effect from 1 June 2017.
(3) Agree to update the Board’s standing orders in accordance with the new structure.
(4) Approve the committee membership set out in the report.
(5) Note the separate piece of work on the charities committee structure.
(6) Seek expressions of interest from governors to sit on the new committees as observers.
Related Strategic Objectives
Provide the safest, most effective care possible Control and reduce the cost of healthcare Focus on innovation for improvement Develop responsibly, delivering the right services with the right staff
Analysis of risks There is a risk that the new committees will take time to adjust to new ways of working which may impact on level of assurance they are able to give Board, particularly in the early stages.
Whilst a period of adjustment is inevitable with any new structure, the Trust has sought to mitigate the degree of change by not proposing significant amendments to Audit and Non-clinical Risk Committee at this time.
Board Assurance Framework The report relates to all risks on the Board Assurance Framework.
Review of Board Committees
The Board commenced a review of its committee structure in February 2017, where it sought to incorporate the recommendations from the Well Led review and the committee effectiveness reviews undertaken by Internal Audit into Audit and Non-clinical Risk Committee and Clinical Governance Oversight Committee.
During the review process it was felt that a more radical redesign of the Board’s committees was required, linking them to the key themes within NHSI’s Single Oversight Framework and the emerging strategic direction. The key requirements for the new committee structure were as follows:
The committees should seek to provide assurance to Board on reports concerning finance, performance and workforce.
The committees should include both executive as well as non-executive directors in voting capacities, reflecting the nature of the wider unitary board.
The number of committees should not increase although it was acknowledged that the frequency of individual committees may need to change.
The committees should take place on a single day, prior to Board meetings, to enable other conversations and meetings to take place involving non-executives.
The new structure, highlighted below, is based on two new committees known as Finance and Performance Committee and Quality and Effectiveness Committee. They replace the former Financial Oversight Committee and Clinical Oversight Committee and are intended to be broader in scope and activity. They will also have responsibility for monitoring delivery against core enabling strategies within the strategic plan. The draft terms of reference and work-plans have been worked up with committee chairs and lead officers and are attached as Appendix A. Audit and Non-clinical Risk Committee will remain largely unchanged with the exception of inclusion of an executive director within the membership.
Board of Directors
Quality & Effectiveness Finance & Performance Nominations & Charitable Funds Committee Committee Remuneration Committee Committee
Fred and Ann Green governance Audit & Non-clinical Risk Committee
structures
As part of the annual objective setting process, the Chair has agreed with non-executives who will sit on and chair each committee. This is as follows:
Non-executives Executives Audit & Non-clinical Risk Philippe Serna Director of Finance (vice chair) (four members) (chair) John Parker Linn Phipps Finance & Performance Neil Rhodes (chair) Chief Operating Officer (six members) Martin McAreavey Director of Finance (vice chair) Philippe Serna Director of People and OD (Director of Strategy & Improvement in attendance) Quality & Effectiveness Linn Phipps (chair) Medical Director (vice chair) (six members) Alan Armstrong Director of Nursing, Midwifery & Quality Martin McAreavey Director of People and OD Nominations and Suzy Brain England None Remuneration (chair) (Chief Executive and Director of People (seven members) All NEDs and OD in attendance)
The proposed number of members on each Board committee is in line with the Walker Review which stated that the optimum size of a committee is between five and nine members. Legally, the Board can only delegate its functions to an executive director or a committee of directors which means a committee of executive or non-executive directors. Corporate directors and other staff may attend Board committees but would have no voting rights, same as on the Board.
It is proposed to continue offering governors the opportunity to attend and observe committee meetings in line with their role at Board meetings. Since the new committees have a slightly different focus from those that exist at present, it is proposed to seek new expressions of interest from Governors for these roles.
It is proposed that the new structure will come into effect from 1 June. A revised timetable showing ‘committee days’ taking place roughly a week before Board is attached as Appendix B. From 2018, it is proposed that ‘committee days’ will take place on the same day of each month (e.g. the Tuesday before Board). This has not been possible this year due to committee chairs’ other commitments. New ‘Board days’ will comprise the Board meeting and a development activity or charitable committee.
In addition to the new structure outlined above, the Director of Finance is leading some work on revising the committee structure for charities. This report makes no changes to that structure but the new governance arrangements are likely to see a revised Charitable Funds Committee comprising all the NEDs, three executives and the executor of the Fred and Ann Green estate together with the Fred and Ann Green advisory group. Finance and Performance Committee
Terms of Reference
Name Finance and Performance Committee (“the committee”)
Purpose The committee will carry out its duties as an assurance committee of the Board in reviewing systems of control and governance specifically in relation to operational performance and financial planning and reporting. It is supported by the Audit and Non-clinical Risk Committee which provides the oversight arm of the Board, reviewing adequacy and effectiveness of controls.
Responsible to Board of Directors. The chair of the committee is responsible for reporting assurance to the Board on those matters covered by these terms of reference through a regular written report. The minutes of the committee shall also be submitted to the Board of Directors. The Chair of the committee shall draw to the attention of the Board of Directors any issues that require disclosure to the Board of Governors, or may require executive action. The committee will present a written annual report to the Board summarising the work carried out during the financial year and outlining its work plan for the future year.
Relationship to The committee will receive information and assurances from the Trust’s other committees internal management and operational committees as required. This includes Corporate Investment Committee and Capital Monitoring Group. However the only committee that will formally report into Finance and Performance will be the Cash Committee.
Board of Directors
Audit & Non-clinical Risk Finance & Performance Quality & Effectiveness
Cash Committee (to be established)
It is important that the committee minimises areas of overlap with the Audit and Non-clinical Risk Committee. Therefore, the following specific areas of responsibility will be excluded from the Finance and Performance Committee agenda:
1
Audit – external and internal; Standing Financial Instructions and Scheme of Delegation oversight; Local Counter Fraud Specialist work.
Delegated The committee is a committee of the Board and holds those powers authority specifically delegated to it by the Board and set out in these terms of reference.
The committee is authorised to investigate any activity within its terms of reference. It is further authorised to seek any information it requires from any employee of the Trust and all employees are directed to co-operate with any request made by the committee.
The committee may make a request to the executive for legal or independent professional advice and request the attendance of external advisers with relevant experience and expertise if it considers this necessary.
The committee will operate at a strategic level as the executive is responsible for the day to day operational financial delivery and performance management of the Trust.
Duties and work (1) To review reports relevant to the Committee that relate to the programme following matters:
- current financial and operational performance and reporting, - financial forecasts, budgets and plans in light of trends and operational expectations, - plans and processes for the implementation of Effectiveness and Efficiency Improvement Plans, - the Trust’s financial strategy, in relation to both revenue and capital, - sensitivity and scenario analysis to support financial planning, - major Trust investment plans, maintaining oversight of investments, - any innovative, commercial or investment activity e.g. proposed joint ventures, - any specific risks in the Board Assurance Framework relevant to the committee,
and provide assurance to the Board in respect of their delivery.
(2) To review the following strategies on behalf of the Board:
- the Estates and Facilities Strategy; 2 - IT and Information Strategy; - Finance and Commercial Strategy.
(3) To consider and agree on behalf of the Board:
- appropriate measurements to review to provide assurance by which operational performance is managed in line with the Single Oversight Framework and strategic objectives of the Trust; - appropriate targets and tolerances by which measurements can be assessed, including updated forecasts where necessary, in order to monitor performance in line with the Single Oversight Framework and stated objectives of the Trust; - the Trust’s Investment Policy and Procurement Strategy; - any significant variations to the Trust’s existing procurement methodology in accordance with the Standing Orders; - NHSI quarterly declarations.
(4) To receive, consider and make recommendations to the Board for the final decision on proposals and their respective funding sources for significant transactions which would:
- materially change the Trust’s service provision; - seek to merge or partner with another organisation(s) which would change the Trust’s independent status; - be transactions that extend beyond the levels of delegation of the CEO.
(5) To make arrangements as necessary to:
- ensure that all members of the Board and senior officers of the Trust maintain an appropriate level of knowledge and understanding of key financial issues; - undertake a review of the Committee’s effectiveness on an annual basis.
(6) To approve terms of reference and membership of reporting sub- committees and oversee the work of those sub-committees.
Chairing The chair will be nominated from among the non-executive members of the arrangements committee. The vice-chair will be the Director of Finance.
3 Membership Three NEDs Director of Finance Chief Operating Officer Director of People and Organisational Development
In attendance Director of Strategy and Improvement (non-voting) Governor observer Secretary Trust Board Secretary Voting Matters will generally be decided by way of consensus. Where it is necessary to decide matters by a vote then each member will have one vote. The Chair will have a casting vote. Quorum Three members, including the chair or vice-chair Frequency of Monthly, with other meetings convened as necessary. meetings Papers Papers will be distributed three clear days in advance of the meeting. Permanency This is a permanent sub-committee of the Board. Reporting None. committees Circulation of Board of Directors minutes Sub-committees Cash Committee Date approved by the committee: Date approved by Board of Directors: Review date: Annually
4 Quality and Effectiveness Committee
Terms of Reference
Name Quality and Effectiveness Committee (“the committee”)
Purpose The committee will carry out its duties as an assurance committee of the Board in reviewing systems of control and governance specifically in relation to clinical quality and governance and organisational effectiveness. It is supported by the Audit and Non-clinical Risk Committee which provides the oversight arm of the Board, reviewing adequacy and effectiveness of controls.
Responsible to Board of Directors. The Chair of the committee is responsible for reporting assurance to the Board on those matters covered by these terms of reference through a regular written report. The minutes of the committee shall also be submitted to the Board of Directors. The Chair of the committee shall draw to the attention of the Board of Directors any issues that require disclosure to the Board of Governors, or may require executive action. The committee will present a written annual report to the Board summarising the work carried out during the financial year and outlining its work plan for the future year.
Relationship The Committee will receive information and assurances from the Trust’s to other internal management and operational committees as required. This includes committees Clinical Governance and Quality Committee, Patient Experience Committee and Workforce and Education Committee as shown below.
Board of Directors
Finance & Perfoamnce Quality & Effectiveness Audit & Non-clinical Risk
Clinical Gov & Quality Patient Experience Workforce & Education
Delegated The committee is a committee of the Board and holds those powers authority specifically delegated to it by the Board and set out in these terms of reference.
The committee is authorised to investigate any activity within its terms of reference. It is further authorised to seek any information it requires from any employee of the Trust and all employees are directed to co-operate with any request made by the committee.
Page 1 of 4 DRAFT: April 2017 The committee may make a request to the executive for legal or independent professional advice and request the attendance of external advisers with relevant experience and expertise if it considers this necessary.
The committee will operate at a strategic level as the executive is responsible for the day to day delivery of Trust services and management of its workforce.
Duties and (1) To review reports relevant to the Committee that relate to the work following matters: programme - the effectiveness of clinical governance, clinical risk management and clinical control, - the Trust wide quality objectives as part of the Quality Improvement Strategy, - promoting an honest and open reporting culture, - disclosure statements (in particular the Quality Report and Declarations of Compliance made to NHSI), prior to endorsement by the Board, - the CQC Essential Standards of Quality and Safety as part of the internal assurance process, - compliance with licensing standards of the Care Quality Commission, - the clinical risk management framework and any controls and assurances against relevant clinical risks on the Board Assurance Framework, - any improvement reviews/notices from the Care Quality Commission and other external assessors, - clinical data and patient identifiable information to ensure that it is in accordance with the Caldicott Guidelines and relevant legislation and guidance, - adverse clinical incidents, complaints and litigation and examples of good practice and learning, - the QPIA process for Efficiency and Effectiveness Improvement Plans, - comments, compliments and complaints, - workforce matters including workforce planning, staff engagement, training, education and development, staff wellbeing, equality and diversity, employee relations and HR and OD systems and processes,
and provide assurance to the Board in respect of their delivery.
(2) To review the following strategies and policies on behalf of the Board:
- Site Development Strategy, - Patient Experience and Person Centred Care Strategy, - Clinical Quality and Governance Strategy, - Research and Development Strategy, - Quality Improvement and Innovation Strategy, - People and Workforce Development Strategy, - Communications and Engagement Strategy,
Page 2 of 4 DRAFT: April 2017 - Clinical Audit Strategy, - Risk Identification Policy, - Disaster Recovery Plans, - Safeguarding Children Plans
and any annual reports relevant to the committee.
(3) Through the Clinical Governance & Quality Committee, the committee will obtain assurance that clinical governance strategies and plans are embedded and that the clinical governance function is adequately resourced and has appropriate staffing.
(4) To undertake thematic reviews and deep dives into quality, governance and workforce related issues.
(5) To ensure that the Trust has reliable, up-to-date information about what it is like being a patient experiencing care administered by the Trust.
(6) To approve terms of reference and membership of reporting sub- committees and oversee the work of those sub-committees.
Chairing The chair will be nominated from among the non-executive members of the arrangements committee. The vice-chair will be the Medical Director. Membership Three members, appointed by the Board of Directors from amongst the Non-executive Directors (other than the Chairman of the Trust). Medical Director Director of Nursing, Midwifery and Quality Director of People and Organisational Development
In attendance Clinical Commissioning Group Representative Two governors
Secretary Trust Board Secretary Voting Matters will generally be decided by way of consensus. Where it is necessary to decide matters by a vote then each member will have one vote. The Chair will have a casting vote. Quorum Three members, including the chair or vice-chair. Frequency of Once every two months. meetings Papers Papers will be distributed a minimum of three clear working days in advance of the meeting, but ideally a week before.
Permanency The committee is a permanent committee.
Page 3 of 4 DRAFT: April 2017 Sub- Clinical Governance & Quality Committee committees Patient experience Committee Workforce and Education Committee Date approved by the committee: Date approved by the Board of Directors: Review date:
Page 4 of 4 DRAFT: April 2017
Audit and Non-clinical Risk Committee Terms of Reference
Name Audit and Non-clinical Risk Committee (“the committee”)
Purpose To provide the Board of Directors (“the Board”) with a means of independent and objective review of internal controls and risk management arrangements relating to:
Financial systems The financial information used by the Trust Non clinical controls and assurance systems, including information to governors Non clinical risk management arrangements Compliance with law, guidance and codes of conduct Counter fraud activity Responsible to Board of Directors. The Chair of the committee is responsible for reporting assurance to the Board on those assurance matters covered by these Terms of Reference. The minutes of the committee shall be submitted to the Board of Directors. The Chair of the committee will report to the Board after each meeting and shall draw to the attention of the Board any issues that require disclosure to the Board of Governors, or require executive action. The committee will present a written annual report to the Board summarising the work carried out during the financial year and outlining its work plan for the future year.
Delegated The committee is a non-executive committee and holds no executive powers authority other than those specifically delegated in these Terms of Reference.
Board of Directors
Finance & Performance Audit & Non-clinical Risk Quality & Effectiveness
Health & Safety Group Information Governance Group
The committee is authorised to investigate any activity within its Terms of Reference. It is further authorised to seek any information it requires from any employee of the Trust and all employees are directed to co-operate with any request made by the committee.
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The committee is authorised by the Board to secure legal or independent professional advice, or to request the attendance of external advisers with relevant experience and expertise if it considers this necessary.
Duties and 1 Integrated Governance, Risk Management and Control work programme 1.1 The committee shall review the effectiveness of the system of integrated governance, risk management and internal controls, to satisfy the Board that its approach to integrated governance remains effective. For the avoidance of doubt the committee will not review specific clinical governance, clinical risk management or clinical controls - this is the role of the Clinical Governance Oversight Committee.
1.2 Determine the actions, controls and audits/reviews required to provide non-executives and the Board with robust assurance regarding the reported financial position going forward; and to maintain the confidence of governors, regulators and the public. Undertake ongoing review of the implementation and effectiveness of these.
1.3 The committee will review the adequacy of:
i. all non clinical risk and control related disclosure statements (in particular the Annual Governance Statement and Declarations of Compliance made to Monitor) together with any accompanying Head of Internal Audit statement, external audit opinions or other appropriate independent assurance, prior to endorsement by the Board; ii. the underlying assurance processes that include the degree of achievement of corporate objectives, the effectiveness of the management of principal risks and the appropriateness of related disclosure statements; iii. the policies and procedures for ensuring compliance with relevant regulatory, legal and code of conduct requirements; and iv. the policies and procedures for all work related to fraud and corruption (but shall not be responsible for the conduct of individual investigations); and v. The operating of, and proposed changes to, the Board of Directors standing orders, standing financial instructions, the constitution, codes of conduct, scheme of delegation and standards of business conduct.
1.4 In carrying out this work the committee will primarily utilise the work of Internal Audit, External Audit and other assurance functions, but will not be limited to these audit functions. It will also seek reports and assurance from executive directors and managers as appropriate, concentrating on the overarching systems of integrated governance, risk management and internal control, together with indicators of their effectiveness.
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2 Internal Audit
2.1 The committee shall monitor the effectiveness of the internal audit function established by management that meets mandatory Public Sector Internal Audit Standards and provides appropriate independent assurance to the committee, Chief Executive and Board. This will be achieved by: i. consideration of the provision of the Internal Audit service, the cost of the audit and any questions of resignation and dismissal; ii. review and approval of the Internal Audit strategy, operational plan and more detailed programme of work, ensuring that this is consistent with the audit needs of the organisation as identified in the Assurance Framework; iii. consideration of the major findings of internal audit work (and management’s response), and ensure co-ordination between the Internal and External Auditors to optimise audit resources; iv. oversee the effective implementation of internal and external audit recommendations; v. ensuring that the Internal Audit function is adequately resourced and have appropriate standing within the organisation; and vi. annual review of the effectiveness of Internal Audit.
3 External Audit
3.1 The committee shall review the work and findings of the External Auditor appointed by the Board of Governors and consider the implications of and management’s responses to their work. This will be achieved by:
i. consideration of the appointment and performance of the External Auditor in accordance with the Trust specification for an External Audit Service, informed by Monitor’s Audit Code for NHS Foundation Trusts;
ii. discussion and agreement with the External Auditor, before the audit commences, of the nature and scope of the audit as set out in the Annual Plan ensuring co-ordination, as appropriate, with other External Auditors in the local health economy;
iii. discussion with the External Auditors of their local evaluation of audit risk and assessment of the Trust and associated impact on the audit fee;
iv. review of all External Audit reports, including agreement of the annual audit letter, before submission to the Board and review of any work carried outside the annual audit plan, together with the appropriateness of management responses; and
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v. review of the annual audit letter and the audit representation letter before consideration by the Board.
4 Other Assurance Functions
4.1 The committee shall review the findings of other significant assurance functions, both internal and external to the organisation, and consider their implications to the governance of the organisation. These will include, but will not be limited to: any reviews by Department of Health Arms Length Bodies or Regulators/Inspectors (e.g. Care Quality Commission, NHS Litigation Authority, Health and Safety etc.); professional bodies with responsibility for the performance of staff; or functions (e.g. accreditation bodies, etc.) relevant to the Terms of Reference of this committee.
4.2 In addition, the committee will review the work of the other committees within the organisation whose work can provide relevant assurance to the committee’s own scope of work.
5 Management
5.1 The committee shall request and review reports and assurance from directors and managers on the overall arrangements for non clinical governance, risk management and internal control.
5.2 They may also request reports from individual functions from within the organisation as appropriate.
6 Financial Reporting
6.1 The committee shall review the Annual Report and Financial Statements before submission to the Board, focusing particularly on:
i. the wording in the Annual Governance Statement and other disclosures relevant to the Terms of Reference of the Committee; ii. changes in, and compliance with, accounting policies and practices; iii. unadjusted mis-statements in the financial statements; iv. major judgemental areas; v. significant adjustments resulting from the audit; vi. the clarity of disclosures; and vii. the going concern assumption
6.2 The committee should also ensure that the systems for financial reporting to the Board, including those of budgetary control, are subject to review as to completeness and accuracy of the information provided to the Board.
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7 Other areas of work
7.1 Information Governance:- The committee shall receive reports and review assurance from directors and managers on the overall arrangement for compliance with Information Governance Standards.
7.2 Health and safety, fire and security:- The committee shall receive reports from relevant directors and officers, including the Local Security Management Specialist, on the arrangements for compliance with relevant health and safety, fire and security standards.
7.3 Counter fraud:- The committee shall receive quarterly reports from the Local Counter Fraud Specialist on counter fraud arrangements, cases, policies and plans.
7.4 Whistleblowing: responsibilities for ensuring that robust systems and processes are in place to raise concerns throughout the organisation.
8 Special Assignments
8.1 The committee shall commission and review the findings of any special assignments required by the Board.
9 Performance
9.1 The committee shall request and review reports and assurance from directors and managers on the overall arrangements for reporting compliance with:
i. the Trust’s non clinical corporate objectives; ii. Monitor’s governance standards and declarations, including the review of areas of non-compliance in the context of Monitor’s “comply or explain” philosophy; and iii. key non clinical performance objectives.
10 Risk Register
10.1 The committee shall request and review reports and assurance from directors and managers on effects of arrangements to identify and monitor risk. The Board will retain the responsibility for routinely reviewing specific risks.
11 Workplan
11.1 The committee’s annual workplan is an appendix to these Terms of Reference, and is subject to annual review by the committee.
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Policy The Committee has responsibility for approving the following policies: approval - Fraud, Bribery & Corruption Policy and Response Plan - Standards of Business Conduct and Employees Declarations of Interest Policy
Chair A Non-executive Director, appointed by the Board of Directors. The Vice Chair will be the Director of Finance.
Membership Four members including three non-executives and the Director of Finance. One of the non-executives shall have recent and relevant financial experience.
Each non-executive shall normally not serve more than three years as a committee member, unless the requirement for one of the members to have recent and relevant financial experience is compromised.
In attendance Deputy Director of Finance Trust Board Secretary Local Counter Fraud Specialist Appropriate internal and external audit representatives Security Management Specialist Other trust staff as appropriate / requested The Chief Executive, executive directors or other officers will be required to attend at the request of the committee, for issues relevant to their areas of responsibilities. Two public governors, nominated by the Board of Governors, will be invited to attend the committee, as observers.
Secretary Trust Board Secretary Voting Matters will generally be decided by way of consensus. Where it is necessary to decide matters by a vote then each member will have one vote. The Chair will have a casting vote. Quorum Two members, including one non-executive and one executive. Attendance Committee members must attend at least 50% of meetings. requirements
Frequency of No less than quarterly and more frequently as required. meetings The External Auditor and Head of Internal Audit may request a private meeting if they consider that one is necessary. They will also have direct access to the Chair of the committee.
Papers Papers will be distributed a minimum of five clear working days in advance of the meeting.
Permanency The committee is a permanent committee.
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Reporting Health and Safety Committee committees Information Governance Steering Group
Circulation of The Governor observers shall report to the Board of Governors on a quarterly minutes and basis regarding the work of the committee, any matters needing action or other improvement and the corrective actions to be taken. reporting requirements The committee shall report to the Board of Governors and seek its approval regarding the appointment, reappointment, termination of appointment and fees of the External Auditors.
Date approved by the committee: Date approved by the Board of Directors: Review date:
Page 7 of 7 Revised Board and Committee Dates 2017
June
Finance & Performance 23 June 9.00am, DRI Quality & Effectiveness 23 June 2.00pm, DRI Board of Directors 27 June 9.00am, DRI Board Development 27 June 2.00pm, DRI
July
Finance & Performance 20 July 9.00am, DRI Audit & Non-Clinical Risk 20 July 2.00pm, DRI Board of Directors 25 July 9.00am, DRI (moved from Montagu) Board Development 25 July 2.00pm, DRI
August
Finance & Performance 22 August 9.00am, DRI Quality & Effectiveness 22 August 2.00pm, DRI Board of Directors 29 August 9.00am, Bassetlaw Charitable Funds 29 August 2.00pm, Bassetlaw
September
Finance & Performance 19 September 9.00am, DRI Audit & Non-Clinical Risk 19 September 2.00pm, DRI Board of Directors 26 September 9.00am, Montagu
October
Finance & Performance 24 October 9.00am, DRI Quality & Effectiveness 24 October 2.00pm, DRI Board of Directors 31 October 9.00am, DRI Board Development 31 October 2.00pm, DRI
November
Finance & Performance 23 November 9.00am, DRI Audit & Non-Clinical Risk 23 November 2.00pm, DRI Board of Directors 28 November 9.00am, Bassetlaw Charitable Funds 28 November 2.00pm, Bassetlaw
December
Finance & Performance 14 December 9.00am, DRI Quality & Improvement 14 December 2.00pm, DRI Board of Directors 19 December 9.00am, Montagu Board Development 19 December 2.00pm, Montagu
Title Managing Conflicts of Interest in the NHS
Report to: Board of Directors Date: 23 May 2017
Author: Matthew Kane, Trust Board Secretary
For: Information Purpose of Paper: Executive Summary containing key messages and issues
NHS England has published new guidance that applies to NHS foundation trusts on the management of conflicts of interest. It will come into force from 1 June 2017.
The rules introduce consistent principles and rules for managing conflicts of interest as well as providing advice to staff and organisations about what to do in common situations and supporting good judgment about how interests should be approached and managed.
A conflict of interest is defined as: “a set of circumstances by which a reasonable person would consider that an individual’s ability to apply judgment or act, in the context of delivering, commissioning, or assuring taxpayer funded health and care services is, or could be, impaired or influenced by another interest they hold.”
The guidance defines a number of common situations which can give rise to risk of conflicts of interest, including:
Gifts and hospitality Outside employment Shareholdings and other ownership interests Patents Loyalty interests Donations Sponsored events, research and posts Clinical private practice
Current position
DBTH already has procedures within its Standards of Business Conduct for managing various types of interests including receipt of gifts and hospitality, sponsorship and sponsorship agreements and secondary employment.
The declaration of employee interests section of our current guidance relates specifically to instances where an employee, or their close relative or associate, has a controlling and/or significant interest in any business or other activity or pursuit which may compete for an NHS contract as well as personal interests in business ventures or activities that could be perceived to have a connection to healthcare provision or be in any way linked to their main employment at the Trust.
Current procedures require staff to complete a form which is then signed off by their director and held in a ‘probity register’ held by the Director of Finance. Rules for executive and non-executive directors and governors are different in that they register and declare their interests with the Trust Board Secretary.
The new requirements
The new guidance goes beyond what we have already in requiring the following measures:
(1) It defines interests into one of four categories:
Financial interests Non-financial Non-financial Indirect interests professional interests personal interests Where an individual Where an individual Where an individual Where an individual may get direct may obtain a non- may benefit has a close association financial benefit from financial professional personally in ways with another the consequences of a benefit from the which are not directly individual who has a decision they are consequences of a linked to their financial interest, a involved in making. decision they are professional career non-financial involved in making, and do not give rise to professional interest such as increasing a direct financial or a non-financial their professional benefit, because of personal interest who reputation. decisions they are would stand to benefit involved in making in from a decision they their professional are involved in career. making.
(2) All staff should continue to declare material interests within 28 days via a positive declaration to their organisation when they join, when they move into a new role or change responsibilities, at the beginning of a new project or as circumstances change and new interests arise.
(3) There is a new requirement for “decision-making staff” to make an annual declaration and for these declarations to be published on the Trust’s website. Decision making staff are those defined as having a material influence in the use of taxpayers money because of the requirements of their role. It is for the Trust to decide who are decision making staff but the guidance suggests the following groups of people:
Executive and non-executive directors who have decision making roles which involve the spending of taxpayers’ money
Members of advisory groups which contribute to direct or delegated decision making on the commissioning or provision of taxpayer funded services Those at Agenda for Change band 8d and above Administrative and clinical staff who have the power to enter into contracts on behalf of their organisation Administrative and clinical staff involved in decision making concerning the commissioning of services, purchasing of good, medicines, medical devices or equipment, and formulary decisions.
(4) There is also a requirement for the Trust’s “strategic decision making groups” to act in accordance with a number of good governance principles including declaring interests at the start of meetings and ensuring any new interests raised are registered. Strategic decision making groups are meetings that make key strategic decisions around entering into or renewing large scale contracts, awarding grants, making procurement decisions and selection of medicines, equipment and devices. It is for the Trust to identify the relevant strategic decision making groups and ensure that they follow those principles, restricting involvement accordingly depending on the nature of a member’s interests.
What the Trust needs to do to be compliant
The Trust needs to take the following actions in order to be compliant with the new guidance:
Adopt an efficient system for registering and publishing interests as the demands of the new requirements are likely to result in additional bureaucracy in terms of filing, uploading and publishing entries through the current paper based probity register. The corporate secretaries within the Working Together Partnership are exploring joint procurement of an online system that allows users to self-declare and publish. In the meantime it is proposed that staff utilise the template interest forms provided by NHS England which can be easily copied into the new system once it is up and running.
Amend the Standards of Business Conduct and Employee’s Declarations of Interest Policy in line with the model policy for Managing Conflicts in the NHS issued by NHS England. The Local Counter Fraud Specialist has prepared an amended version of the Policy to bring to Audit and Non-clinical Risk Committee in June. This will require some amendments to current financial thresholds to bring them in line with NHS England and actually represents a raising of the limit for declaring gifts and hospitality (from £25 to £50). However it is felt that taking an approach that is consistent with the guidance will be defendable if challenged.
Advise staff of the new requirements through Buzz and encourage them to make a positive declaration where they have material interests.
Identify the key “decision making individuals” that must be prompted to update their declarations of interest or make a nil return on an annual basis which is published online. The register for the Board of Directors and Board of Governors will be published on the Directors’ pages of the website from 1 June.
Identify the ‘strategic decision-making groups’ that make key strategic decisions around entering into or renewing large scale contracts, awarding grants, making procurement decisions and selection of medicines, equipment and devices and ensure their Chairs are aware of the need to operate in line with principles of good governance.
Recommendation
Board is asked to:
(1) NOTE the new requirements regarding conflicts of interest in the NHS.
(2) AGREE to designate the following groups as ‘decision-making individuals’ within the definition given in the guidance:
• Executive and non-executive directors All consultant staff • All corporate and care group directors and assistant directors • All staff on or above Agenda for Change Band 8C • All staff within Pharmacy, IT and Procurement teams
(3) AGREE to designate the following groups as ‘strategic decision-making groups’ within the definition given in the guidance:
Board of Directors and its committees Charitable Funds Committee Fred and Ann Green Legacy Sub-Committee Executive Team Management Board Drug & Therapeutics Committee
(4) NOTE the discussions around joint procurement of an electronic system for making annual declarations.
Title National Cyber Security Issues and Response at DBTH
Report to: Board of Directors Date: 23 May 2017
Author: Simon Marsh, Chief Information Officer
For: Assurance Purpose of Paper: Executive Summary containing key messages and issues
This paper sets out the background to the recent NHS cyber-attack and how DBTH responded, the impact here and at other trusts, the tools and processes in place to manage cyber security at the Trust, the results of recent penetration testing and future key actions.
Recommendation
To note the national cyber security issues and DBTH’s response, for assurance.
Related Strategic Objectives
Provide the safest, most effective care possible Control and reduce the cost of healthcare Focus on innovation for improvement Develop responsibly, delivering the right services with the right staff
Analysis of risks
The risks are set out in the report.
Board Assurance Framework 14a Failure of services due to cyber attack 3 x 5 = 15
National Cyber Security Issues and Response at DBTH Situation
The Trust was informed late afternoon on Friday 12th May 2017 of a national cyber-attack via ransom ware affecting large parts of the NHS. At that time it was unclear the extent of the attack, the delivery method of the ransomware and the impact it would have both on the Trust and the greater NHS.
Initial information was this was being delivered via the N3 network. However, as e-mail is a normal and default delivery method for such attacks, it was decided at Trust level to remove access to external inbound and email and this was taken down at approximately 1430 after discussions with the CEO.
The IT team took normal and appropriate steps to secure the system backups and segregate from the rest of the network. Patch levels of the backup servers were analysed and updated as required.
Over the next few hours the scale of the problem became clearer as NHS Digital, via their CareCert (Cyber Security) department, started to release information concerning the delivery method of the ransomware. It was communicated at around 1630 that the ransomware was exploiting a previously known and recognised weakness within the Microsoft Server Message Block (SMB). This is a standard communications network protocol mainly used for shared access to files and communicating across internal network ports. Microsoft had released a fix for this weakness in their March 2017 security update.
Proactive and reactive actions were taken by the IT infrastructure team in response to the ongoing recommendations from Care Cert.
Email was restored on the evening of Friday May 12thonce the position on the method or attack and the Trust security became clear.
Trust tools, reporting and procedures
Internally the IT department uses a self-developed desktop and laptop imaging and auditing system called FOG (there is no definitive reason for this acronym) as part of the asset (hardware and software) and device management process. This allows for standard image profiles to be developed and deployed to laptops, desktops and virtual machines (VDI), collectively known as End User Computing (EUC). FOG also includes a reporting suite to identify software and patch levels of EUC software, both at system (Microsoft) and application level.
DBH has 4,439 EUC devices including 638 laptops. There are 42 XP desktops and the rest of the estate runs Windows 7. The XP desktops are running clinical applications including pathology. These desktops cannot be upgraded to Windows 7 as the applications are not compatible other than with Windows XP.
The Trust operates EUC infrastructure both within and external to the DBH Domain with both types attached to the Trust internal network. Devices within the Domain are owned by and operated by the Trust and are primarily laptops and desktops. Devices external to the Domain are those that primarily support clinical systems. These could be anything from computers running the pathology system to endoscopy scopes and all services of where a Microsoft device is integral to the medical equipment. Whilst these non-domain devices are attached to the internal network, the Trust has no method of direct management or patch remediation.
Most of the known EUC infrastructure is automatically updated via FOG software deployments. The residual known estate needs manual update due to the complexities of the underlying software build in support of specialised applications.
Follow on activities over the weekend 12-15th May 2017.
Network and EUC
As NHS Digital released more information concerning the ransomware, it became evident that the only attack vector was via the SMB route. SMB is a method of sharing computer files and folders over a network. Some organisations decided to enable such sharing to the Internet and National NHS network which can create a lack of security and control hence the extensive spread of the virus. Without the March 2017 patch, both at the edge of the network and ion the EUC estate, organisations were exposed to the ransom ware attack.
The DBH Trust does not use, and never has used, the SMB approach to sharing files and folders to 3rd parties. Instead, the Trust uses the other recognised standard of a De-Militarised Zone (DMZ) to ensure internal to external network segregation. The Trust does use SMB to connect various network segments on an internal basis.
As of 17th May 2017, FOG reported the March 2017 Microsoft patch to 95% of the Trust EUC infrastructure and also implemented on all edge-of-network devices. As SMB is not used to face off to external networks, the threat and underlying risk to DBH was low to non-existent.
Servers
The patch implementation process at the Server level has also been looked at and refined. The Trust operates two distinct types of servers – those owned, hosted and directly managed by the Trust and those owned and hosted by the Trust but with a managed service contract with application software suppliers.
These managed service arrangements ensure that the supplier is contractually responsible for the full service from database to server to application software. These arrangements are necessary to ensure the applications perform as required. Managed applications include the Fuji PAS, JAC, K2 maternity and EMIS’s CAMIS PAS and the Symphony ED system.
Analysis of the entire server estate showed that patching of both direct and managed servers was not current.
Actions undertaken
While the Trust is secure from the current threat, in response to the underlying concerns raised by NHS Digital and at Trust level, the IT infrastructure team has further enhanced the EUC and Server estate as set out below. The data is current as at 18th May 2017.
The FOG application has been upgraded to produce further granular reporting at device level The 42 XP machines on the domain have been patched with the MS patch released over the weekend.
All Windows 7 estate that have logged onto the network are now patched to the March 2017 security patch. Where laptops have not logged onto the network, they will automatically be updated once they do appear. Reporting is taking place to understand the non domain estate. Once this report is available then the IT team will take steps to resolve any underlying issues identified. This will require a risk analysis on a supplier by supplier basis to avoid unilateral patch implementation having unintended consequences on the underlying medical equipment or appliances With the exception of around 12 servers, all owned and managed servers potentially at risk of being infected by the ransomware have been patched to the latest level. The remaining 12 will be completed over the weekend 20/21 May 2017. Backup servers were patched on Friday evening Managed production service servers are being patched and re-booted following discussions and agreements with suppliers and the affected care groups. JAC Pharmacy, Fuji RIS and K2 have already been completed. There are still 32 servers still to be updated. These include Symphony ED test and productions servers. We are working with third party suppliers to get these upgraded and expect all servers to be completed by 26th May 2017. CareCert provided the digital signature of this particular virus. The Trust Privilege Guard AV software was modified to identify this virus and neutralise and remove any underlying opportunity for it to activate. While the firewall configuration has been analysed and found robust, some of the parameters related to internal SMB traffic have been tightened. This had the effect of taking down email on 15th May for about two hours until the parameters were released slightly to allow internal email traffic. No other adverse impact has been identified All of this work was undertaken by DBH Trust staff with suppliers. No central NHS Digital involvement was required. It should be noted that none of the national NHS Digital services, included NHSMail, Spine or other services were affected.
Impact on other NHS services
Locally, Bassetlaw CCG were affected as were a number of GP surgeries in the Rotherham area. Barnsley Trust had a few PC’s affected. Sheffield and Rotherham Acute Trusts were unaffected. There are no reports of Bassetlaw or Doncaster GP surgeries effected. Most trusts took down external mail access until the attack vector was identified.
NLAG were affected. This is the second time in 8 months that NLAG have had IT virus issues. While it is difficult without a detailed knowledge to identify the root cause of the issues on both occasions, the NLAG environment is both multi site and multi organisation. This exposes NLAG to issues that could appear at the weakest point in the overall infrastructure and then spread.
It is apparent that the reliance on electronic patient records and associated patient care across multiple providers (specifically DBH to STH for cancer pathway) has been effected by STH’s decision to take down their internet service for an extended period. This applies equally to electronic referrals and to electronic discharge at STH. The need for manual procedures and event verification is required as part of robust business continuity planning in the event of failure of one element of what is becoming a very complex technical environment.
Penetration Testing Report
The penetration test conducted in March 2017 by CareCert identified.
Our firewall is appropriately protecting our trusted network from the untrusted Internet and N3 Transition network. This ensured that we were not exposed to the recent ransomware attacks. We operate a DMZ in our environment to provide a ‘buffer’ between the trusted and untrusted networks. Wireless - no concerns. As part of the penetration testing, servers which are exposed to the Internet and N3 networks were tested for relevant patching with critical issues in terms of security patching being required on 4 servers which externally face to the Internet/N3. o These were remediated immediately upon receipt of the CareCert report Access to files and folders on the network were checked for ‘all staff’ access. 7 folders were found to be open and thus were flagged as critical. o These were remediated immediately upon receipt of the CareCert report Our network user accounts were tested for appropriate levels of security with a number of ‘super user’ accounts found to have weak passwords o These were remediated immediately upon receipt of the CareCert report Critical aspects identified on our local workstations include that there were a number of components that were out of date and thus in need of upgrade to the latest version. These include the Adobe Shockwave Player, Sophos Engine and Java. o These were remediated immediately upon receipt of the CareCert report Whilst these crucial issues are being addressed, an increased level of activity and compliance will be possible with the appointment of the new IT Security & Continuity Manager (who is expected to be in post with the next three months).
Risks and identified mitigations
Following this incident which has been at a scale not seen before a review of the risks associated to a cyber attack indicates that the mitigation of the risks requires:
The Trust to maintain an industry standard, internally managed security service that includes technologies at edge, EUC and server level. This needs to be maintained in line with published patches with the underlying infrastructure upgraded once the patches have been tested against the infrastructure and the application estate. Where such patches cannot be deployed across the estate then the IM&T management team will be informed and a risk assessment completed. A patch and risk register will be maintained by IM&T management and reported to ANCR on a quarterly basis. Ensure a skilled and knowledgeable resource to analyse, plan and deploy changes to ensure the technology remains current to manage the underlying risk. Further work needs to be undertaken to ensure that Internal processes concerning upgrades to security patches are improved in respect of managed services provided by third parties. Service Level Agreements need to be developed to include scheduled maintenance windows to allow the IT team to reboot and patch underlying servers in line with latest tested security upgrades. With the plans for digital electronic patient records, and the transfer of digital information between health care providers, future designs of interoperability needs to take account of both
compartmentalisation of networks and transfer of data and the development of business continuity plans in conjunction with such service delivery Penetration testing will be included in the IT work planning on an annual basis. An analysis of non-domain medical equipment estate needs completed and based on the residual risk of operating these systems either using older Windows operating system or with out of date patching risk assessments and business case may be required to update this equipment.
Title DBTH approach to recruitment
Report to: Board of Directors Date: 23 May 2017
Author: Karen Barnard, Director of People & OD
For: Assurance Purpose of Paper: Executive Summary containing key messages and issues
This paper seeks to provide the Board of Directors with details of the Trust’s current vacancy rates, the use of temporary staffing and the approach being taken to fill those gaps against a backdrop of national shortages for certain staff groups and specialties.
Vacancy and turnover rates At month 1 of 2017/18 the Trust had a budgeted establishment of 6012wte with a contracted wte (ie staff in post) of 5570wte with a further 286wte temporary resource during April. This equates to a vacancy rate of 7.3% against a target of 5%. Taking account of the temporary resource this vacancy rate reduced to 2.4%. The paper provides benchmarking data in respect of our turnover which indicates we are not an outlier in comparison to other Trusts.
Actions to address these gaps The Leadership team across the Trust recognises the importance of retaining our current workforce and to maximise their attendance at work and therefore the work detailed within the staff survey action plan and the health and wellbeing action plan are key to this. The paper details the range of activities underway to address recruitment, development of new roles, attracting and retaining the local workforce into both professional training and vocational training leading to employment within their local hospitals. It also describes the work to up-skill our current staff by use of the apprenticeship levy and funding from Health Education England in initiatives such as Trainee Assistant Practitioners.
As we develop the revised Strategic Direction and the Site Services Strategy a workforce plan will be collated taking account of the various streams of work underway across the Trust. This will complement the refreshed People & OD strategy.
Recommendation Members of the Board are asked to note this update.
Delivering the Values – We Care We always put the patient first By focusing on improving staff presence, well-being, engagement and skill level
Everyone counts – we treat each other with courtesy, honesty, respect and dignity By having clear and transparent processes and policies and by living our values
Committed to quality and continuously improving patient experience
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By ensuring we are continuously improving against our KPIs and objectives
Always caring and compassionate By recruiting, retaining and engaging the right staff who demonstrate our values
Responsible and accountable for our actions – taking pride in our work By having clear objectives and actions to improve our performance and quality
Encouraging and valuing our diverse staff and rewarding ability and innovation By ensuring the right people with the right skills are involved in delivering our progress
Related Strategic Objectives Provide the safest, most effective care possible Control and reduce the cost of healthcare Focus on innovation for improvement Develop responsibly, delivering the right services with the right staff Analysis of risks
There are three Trust wide risks on the Corporate Risk Register and the Board Assurance Framework that will be directly improved or mitigated by the initiatives described within this paper.
Board Assurance Framework 7 Risk of failing to address the effects of the medical agency cap, leading to gaps in medical rotas 4x4=16 8 Failure to engage and communicate with staff and representatives in relation to immediate 3x4=12 challenges and strategic development 13 Inability to recruit right staff and ensure staff have the right skills to meet operational needs 4x3=12
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Retention and recruitment initiatives across Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust
As Board members will be aware there are national shortages for key staff groups which coupled with opportunities for staff to retire and return on reduced hours is impacting on our workforce. This paper seeks to describe our current staffing levels and then the various programmes of work we have underway to bridge that gap.
1. Vacancy rates
Across the Trust we have a budgeted establishment of 6012 wte in month 1 for 2017/18; this figure is broken down into the following staff groups: Qualified nursing: 1733wte Nursing support: 891wte Medical and dental: 670wte Admin and Clerical: 1022wte Allied Health Professions/Scientific & Professional: 854wte Estates and ancillary: 680wte
From month 1 data we have the following vacancies identified by comparing the number of staff currently employed (contracted wte) with budgeted establishment (please note that as we have moved to the new finance system there is some tidying up required regarding classification of staff groups): Qualified nursing: c 112wte equating to 6.46% Nursing support: c 52wte equating to 5.8% Medical and dental: c 106wte equating to 15.8% * Admin and Clerical: 68wte equating to 6.6% Allied Health Professions/Scientific & Professional: 0.2% - vacancy rates vary across the various professions (some budgeted establishment is currently sat against the nursing staff group) Estates and ancillary: 100wte equating to 14.7% (NB not all these staff sit within Estates and Facilities)
Overall Trust vacancy rate: 7.3% against a target of 5%.
However as the Board of Directors will be aware we do make significant use of temporary staffing such that during month 1 the overall Trust vacancy rate reduced to 2.4% when this resource was taken account of. Temporary staffing ranges from employed staff working extra hours, bank and agency staff. The net difference equated to an additional 286wte for the month of April. The key areas for this temporary staffing were: Qualified nursing: equivalent to 59wte – covering vacancies (approx. 50%) and sickness (36%) Nursing support: equivalent to 111wte - covering vacancies (unqualified and qualified - approx. 32%), sickness (approx. 25%) and specialling (approx. 26%) Admin and clerical: equivalent to 37wte – some vacancies are deliberately being held or covered on a temporary basis pending changes to service provision in order that we can minimise the impact on staff
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Estates and ancillary: equivalent to 67wte – vacancies are currently being recruited to following the introduction of the new service model at DRI; therefore we expect to see a reduction in vacancies and a reduction in the use of temporary staff Medical and dental: during week ending 7 May 2017 there was the equivalent of 97wte hours worked comprising 32wte as extra hours worked by our own medical staff and 65wte agency staff. Work is underway to review the use of medical agency staff to explore how best to fill vacancies on a substantive basis and what alternative roles could be introduced.
2. Turnover
We have a target of 10% or less voluntary turnover. During 2016/17 the following turnover was recorded, however these figures include movement within the Trust. Work is therefore underway to isolate this information to understand turnover external to the Trust but also to identify the nature of internal turnover – is it part of natural career progression (for example therapy rotations) or due to dissatisfaction within a particular team. P&OD will also undertake more detailed analysis of the exit interview material we receive to determine if there are any themes and there will also be a review of the exit interview process – currently staff are sent a questionnaire after they have left and are offered an interview.
Turnover Rates 2016 017 - Exlcusive of Lead Unit Doctors and Fixed Term Contracts
April May June July Aug Sept Oct Nov Dec Jan Feb March 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 Headcount 6,276 6,244 6,211 6,179 6,153 6,167 6,167 6,152 6,129 6,106 6,137 6,147 FTE 5,183.90 5,161.67 5,136.77 5,110.93 5,092.14 5,102.04 5,111.86 5,098.46 5,084.07 5,065.89 5,086.15 5,095.92 Leavers Headcount 50 79 50 74 67 66 79 56 61 63 50 62 Leavers FTE 39.62 62.97 37.82 59.01 55.55 54.92 61.05 45.23 45.26 52.14 38.65 46.33 Starters Headcount 63 23 34 23 45 80 76 32 31 54 43 58 Starters FTE 49.35 18.69 27.65 19.97 40.15 68.72 65.34 28.09 25.93 45.47 38.10 49.25 Turnover Rate (Headcount) 0.80% 1.27% 0.81% 1.20% 1.09% 1.07% 1.28% 0.91% 1.00% 1.03% 0.81% 1.01% Turnover Rate (FTE) 0.76% 1.22% 0.74% 1.15% 1.09% 1.08% 1.19% 0.89% 0.89% 1.03% 0.76% 0.91% Leavers (12m) 720 726 710 727 731 716 746 748 763 784 794 757 Turnover Rate (12m) 11.50% 11.59% 11.33% 11.60% 11.67% 11.45% 11.95% 12.00% 12.27% 12.64% 12.84% 12.26% Leavers FTE (12m) 564.72 571.29 557.51 569.46 574.67 573.19 596.12 596.53 605.81 624.18 629.48 598.55 Turnover Rate FTE (12m) 10.93% 11.05% 10.77% 11.00% 11.10% 11.09% 11.54% 11.57% 11.77% 12.16% 12.29% 11.71%
The leavers over the last 12 months can be categorised as follows: Dismissal (including redundancy): 47 End of fixed term contract: 120 Volunary resignation: 491 Flexi retirement/Retirement: 51/102
The tables below include all turnover – the spike seen in August is due to the main junior doctor changeover. As can be seen from the benchmarking data our figure of 15.02% (as at February 2017 due to the timelag in national reporting) is in the range of other Acute Trusts across Yorkshire and Humber (ranging from 11.49% - Barnsley Hospital to 18.39% - Bradford Teaching Hospitals) so it is pleasing to note that we are not a significant outlier.
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Benchmarking - Monthly Turnover*
However we recognise the need to retain staff and maximise the number of staff who are at work and the activities described in previous reports related to staff engagement and health and wellbeing are key to this.
3. Approaches to fill the gaps identified above
3.1 Recruitment activity
Medical and dental Doctors in training A review of anticipated rota gaps for junior medical staff for August 2017 currently indicates 24 gaps out of 211 places, the majority of which are within the GP training scheme (8 out of 42, of which 6 are in ED), Obs/Gynae ST 1-9 (7 out of 20) and Paediatrics ST1-3 (3 out of 8). There are some
3 specialities where we have yet to receive the rotation details but these are low numbers of places. Adverts are being placed for the expected gaps. The Trust continues to explore the opportunities that Advanced Nurse Practitioners and Physicians Associates can provide to replace junior doctors. Cohorts of students of both staff groups are due to qualify next year and discussions are underway with Care Groups to understand the most appropriate areas for these staff to work.
Consultant posts
Current recruitment activity is as follows:
Anaesthetics – 2 posts currently advertised, recently appointed to a 3rd post. Intensivists are particularly hard to recruit to – approach to recruitment being reviewed Ophthalmology – 3 posts currently advertised, these are re-advertisements. It is anticipated that a networked approach will be required. Histopathology – 4 posts currently advertised. This is a shortage specialty; it is anticipated that technological solutions will required moving forward. Vascular surgery – 2 locums have recently been appointed Care of the Elderly – Recent appointment made Obstetrics & Gynaecology – advert currently on NHS Jobs. Trauma & Orthopaedics – recent appointment made Paediatrics – 5 posts advertised Emergency Department – 2 recent appointments made; a further advert due out with anticipated applicants. Ongoing successful recruitment to CESR programme. Recent improvements in attracting candidates Respiratory Medicine – recent appointment made Gastroenterology – recent appointment made Acute Medicine – interview scheduled for 23 May 2017
Nursing and midwifery A recent recruitment campaign has enabled us to offer 47 posts to students nurses due to qualify in September for adult roles across the range of in-patient services. Offers have been made to paediatric students due to qualify in October which would fill our current paediatric vacancies. Applicants for our midwifery vacancies are curently being shortlisted with 80 applications for 22wte posts. Members will be sighted on the fact that many students apply across the local patch and therefore we will continue to remain in contact with all of these students to maximise take up of these offers. Discussions have also being taking place regarding international recruitment with Health Education England. We continue to be able to recruit Healthcare Assistants and will be moving them onto a new apprenticeship framework going forward.
3.2 Development of new roles
Recognising the gaps in both medical and nursing posts as a Trust we have been collaborating with education providers and neighbouring Trusts to develop and access training programmes for roles such as Advanced Nurse/Clinical Practitioners, Trainee Assistant Practitioners (Band 4) and Physician’s Associates. The Local Workforce Action Board which supports the STP and is co-chaired by Kevan Taylor, Chief Executive of Sheffield Health and Social Care Trust and Mike Curtis, Local
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Director for Health Education England is key to collaboration across South Yorkshire and Bassetlaw – our representative on the LWAB is Dr Alasdair Strachan, Director of Education and I am about to join the group as a representative of the HR Directors. The key areas of focus for the group are the Faculty of Advanced Practice which is being expanded to cover South Yorkshire, the South Yorkshire Regional Excellence Centre whose focus is Bands 1-4 support staff, developing a sustainable primary care workforce and enhancing and retaining skills of exisiting staff. The newest of roles is that of Physician’s Associates – we have had trainees from Sheffield on placement with us and they are due to graduate in February – therefore we have identified the need to gain a better understanding of how these roles can be used as they currently cannot prescribe. We know from those who have been on placement with us that there is some in interest in returning to work here. A workshop is therefore being planned to enable clinicians and Care Groups to better understand all the various roles and how they support the delivery of services. There is commitment from across South Yorkshire and Bassetlaw to standardise terms and conditions to avoid any potential leapfrogging of pay rates and to minimise transfers across the patch. Discussions are also taking place across Doncaster and Bassetlaw Place Plans to ensure we have the right workforce across health and care to provide the necessary care and to avoid duplication. Following the review of the Board committees and the transition from turnaround to transformation the role of the Workforce and Education Committee has also been reviewed. Members of that committee (and colleagues currnetly not on that committee) have agreed that its remit should include a co-ordinating role in terms of the various workforce programmes in place and the development of the overarching Trust workforce plan, which will take account of the various staff group specific plans. The development of those plans will follow on from the discussions due to take place at Management Board in relation to the site services strategy. Tools that will be used include a workforce planning framework and the Calderdale framework. In addition Health Education England have recently introduced a workforce transformation tool (the STAR) which has 5 points namely supply, up-skilling, new roles, new ways of working and leadership which we plan to adopt in the development of our workforce plan.
3.3 Work with training providers
The Training and Education team have been working with our local HEI providers of pre-registration nursing programmes to focus new student nurses on seeing Doncaster as their home placement from the initial recruitment (from September 2017) through all their clinical placements to final employment as qualified nurses (September 2020). A different approach with each of the HEIs has been developed.
With Sheffield Hallam University we have embarked on an initiative to increase the number of applicants in the Doncaster region and therefore selecting DBTH as their primary placement choice. As part of this campaign we hosted a careers event ‘your future in healthcare’ on the 11th May 2017. We showcased the different career opportunities specifically linked to the SHU pre-registration provision; this event was well attended and well supported from across the Trust.
In partnership with the University of Sheffield we have directly commissioned 10 pre-registration student nurse places, all of whom will have their 3 year placements within the Doncaster locality with the intention of recruiting the individuals into registered nursing positions.
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And with a new private University, BPP we are working closely with RDash to provide clinical placements and clinical expertise for the teaching provision of a newly validated pre-registration nursing programme due to commence in September 2017. This newly developed programme will allow us to ‘test’ a new approach and organisation to determine the impact on local recruitment.
To complement all the above we are building on our regional reputation of an organisation which provides high quality placements (our health professional student feedback has been extremely positive: 98%). Our inductions, support for students e.g. escalation of concerns pathway, student clinics and multidisciplinary educational infrastructure all receive positive feedback. We have recently starting using social media to further communicate the opportunities available at DBTH to our learners.
We have also started working more closely with Doncaster College in relation to aspiring existing students to remain in the region, upskilling our current health care workforce and developing opportunities to support our local population to see healthcare as a career option. We aim to pilot some traineeships and internships later in the year.
3.4 Recruitment
The development of the new website will enable us to refresh our external facing recruitment site and create a new approach to on-boarding; this is planned to go live in July. The communications and recruitment teams (in conjunction with training and education) are reviewing our recruitment campaign material to ensure we highlight our Teaching Hospital status and the benefits of coming to work in Doncaster and Bassetlaw. We are increasingly making use of social media to raise our profile as an employer. P&OD is also working with key individuals across the organisation (using nursing as a pilot) to develop a USP recruitment campaign which will be complemented by our new website. During 2016/17 we placed almost 900 adverts; however we need to ensure that we review all requests for re-adverts to ensure we take account of timing to place adverts and how we advertise taking account of the different generational expectations.
Apprenticeships
As previously reported the value of our apprenticeship levy is £1.2m. We have established an apprenticeship group to ensure we maximise the Trust’s use of this levy; however many of the higher level frameworks will not come on stream until later in the year and so our focus is currently on those areas where we have previous experience of apprenticeship roles and beginning the preparatory work for the next stage. We very much see this initiative as applying to both new recruits and as a means of developing existing staff.
Work experience
We have recently developed a work experience framework to ensure that those who come on placement are governed appropriately and that we have a co-ordinated approach. This is an expanding area; one new area we are exploring is working with the Prince’s Trust. We are currently exploring with Doncaster College the opportunity for learners with a learning disability to have placements within our hospitals. As a Trust we recognise the importance of gaining the interest of the local population in roles within our hospitals and anticipate this will expand over time.
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Examples of recruitment campaigns
Newly qualified nurses – following a recent campaign where students on placement were interviewed internally (17) and assessment centres run for the others (30) we have offered 47 students employment with us (out of 51 applicants) – the vast majority were able to be offered their first choice of specialty with the remainder being offered their second choice. Preferences were across the full range of adult in-patient areas including gynaecology, frailty, Emergency Medicine, MSK, Specialist Medicine and Surgical / Specialist Surgery. The approach sees the involvement of ward/department sisters, the recruitment team and educators. There are often discussions about timing of recruitment campaigns for newly qualified nurses; however experience shows us that students apply to most Trusts across the patch and the key factor is whether their first preference can be accommodated and where they want to live. This is one of the reasons for our current focus on maximising recruitment into nurse training from Doncaster and Bassetlaw residents and having much of their placements undertaken within our hospitals.
Cohort service assistant recruitment – once the new model was given the go ahead a number of assessment centres have been run with the next one due at the end of the month to which 40 applicants have been invited. Through the joint working between Facilities and Recruitment we now only have 16 vacancies once the current offers have completed clearances.
Cohort HCA recruitment – we run regular campaigns, the next being in June for which shortlisting is currently underway having received 158 applications. We have a small waiting list of candidates who we unfortunately have not yet been able to match with a vacancy. The intention will be to build up this waiting list so that we can accommodate a likely increased demand in winter. We also work in collaboration with NHS Professionals who run an HCA development programme.
Overseas recruitment – Board members will recall the previous recruitment campaign from the Philippines which unfortunately did not generate the volume of new starters we had expected due to changes in immigration requirements. Those nurses who have joined us are a valuable resource to us. We are therefore exploring what other options are open to us including working with Health Education England with a possible campaign in India.
Preceptorship - We run a well-established preceptorship programme for our newly qualified nurses, midwives and therapists with specific pastoral care and clear progression pathway in midwifery resulting in the retention of 22 of 22 midwives remaining with us from Sept 2016. The HCA extended induction (which will continue and be embedded within an apprenticeship) is also well received and ensures completion of the care certificate.
4. Conclusion
Whilst the Trust clearly has higher vacancy levels and a higher use of temporary workforce than we would wish to have, this paper seeks to demonstrate the variety of approaches being used to recruit to the gaps thereby reducing our reliance on temporary staff and the associated cost of that temporary workforce. A key piece of work over the coming months will be to understand our workforce model going forward to support the Trust’s site services strategy and to review service models in light of restrictions in workforce supply in certain specialties. We continue to work with education providers and partner employers across the STP to maximise our opportunities to have a full complement of staff. Progress against the workforce plan will be monitored through our committee structure. 7
Title Strategy and Improvement Update
Report to: Board of Directors Date: 23 May 2017
Author: Marie Purdue – Acting Director of Strategy and Improvement
For: Assurance and Approval of the Strategic Aims Purpose of Paper: Executive Summary containing key messages and issues This paper seeks to provide:- a) CIP Programme 17/18 progress – paragraph 2 b) Update on NHSI revised grip & control measures – paragraph 3 c) Strategic planning process led by the Directorate of Strategy and Improvement - paragraph 4 d) Quality Improvement and Innovation – paragraph 5 Recommendation Board is asked to receive the contents of the update FOR ASSURANCE. Delivering the Values – We Care (how the values are exemplified by the work in this paper) We always put the patient first By focusing on efficiency and financial stability to deliver care going forward Everyone counts – we treat each other with courtesy, honesty, respect and dignity By having clear and transparent processes and policies and by living our values Committed to quality and continuously improving patient experience By ensuring we are continuously improving our financial position Always caring and compassionate By protecting the future of the Trust by caring about how we become more efficient Responsible and accountable for our actions – taking pride in our work By having clear objectives and actions to improve our financial performance Encouraging and valuing our diverse staff and rewarding ability and innovation By ensuring everyone’s ideas count and everyone’s views are heard Related Strategic Objectives Provide the safest, most effective care possible Control and reduce the cost of healthcare Focus on innovation for improvement Develop responsibly, delivering the right services with the right staff Analysis of risks The main risk of not moving to a new way of working is that we will not have a credible and supported plan to deliver the savings necessary to reduce the financial deficit of the Trust. As a subset of this our key stakeholders and partners may lose faith in our ability to manage our own response to this issue and will take more direct ownership and control. Board Assurance Framework 1 Failure to achieve compliance with Monitor Risk Assessment Framework, CQC 5x4 = 20 and other regulatory standards, triggering regulatory action. 3 Failure to deliver financial plan. 5x5 = 25 4 Failure to deliver cost improvement plans 4x5 = 20 5 Failure to deliver turnaround/cost reduction programme 4x5 = 20
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1 Introduction
1.1. This paper seeks to provide:- a) Efficiency & Effectiveness Improvement Programme 17/18 progress – paragraph 2 b) Update on NHSI revised grip & control measures – paragraph 3 c) Strategic planning process led by the Directorate of Strategy and Improvement - paragraph 4 d) Quality Improvement and Innovation
2 17/18 Efficiency & Effectiveness Improvement Programme – Month 1
2.1 Month 1 – April 2017 Annex 1
The planned delivery for the Improvement Programme for FY17/18 is £14.5m, with a reported actual delivery at M1 of £340k against a forecast delivery to NHSI of £489k. This is behind plan by £149k mainly as a result of underperformance in the procurement and local work streams: o The procurement performance is linked to locum agency costs and has been impacted by changes to IR35. There have also been changes to the original phasing of the plan and it is anticipated that much of this will recover in year with the inclusion of new schemes. o The local workstream contains efficiency plans identified as “in the pipeline” but these are not yet implemented – the PMO are actively following these up.
2.2 Ideas Generation
To date £8.252m of the £14.5m remains unidentified, although it is expected that there will be £2.5m of non-recurrent grip and control savings. There are in excess of 30 potential new projects in the pipeline list being evaluated to help to bridge this gap. Care Group and corporate department meetings are underway with the PMO and Finance to sign off implementation of identified schemes and discuss any new ideas. Each SRO has reviewed the opportunity available in the workstream they are leading to generate new ideas and these continue to be worked through to assess feasibility and potential contribution to efficiency and effectiveness plans.
3 Grip and Control
3.1 In December 15, Monitor (now NHSI), developed a checklist of 161 Grip and Control actions for NHS organisations to embed and evidence they have robust processes and procedures in place. The actions have been reviewed and categorised as either – ‘Business as Usual’, ‘Complete’, or ‘now contained within a Work stream’. Fourteen of the actions on the 161 list are still classed as red and these have been included in work streams to ensure implementation is fully completed.
3.2 In March 17, NHSI shared a Financial Improvement Programme (FIP) Financial Grip and Control checklist (241 actions), which has been created from both the learning events held with FIP
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Phase 1 participants and suppliers and learning from other financial improvement projects that NHSI included.
3.3 An initial review of the 241 actions has been completed to highlight those which are full/partially included in the 161 actions, and those which were ‘new’ actions for 2017/18. All actions have been attributed to a lead CG/Directorate. Many of the “new” actions are already being undertaken but didn’t appear on the 161 list.
4 Strategic Planning Process
4.1 A draft strategic vision has been submitted in line with our undertakings to NHSI. This continues to be a work in progress and engagement continues with meetings arranged with various stakeholders.
4.2 Work on enabling strategies continues to enable further development of a three year plan to support the vision. Timescales for completion have been agreed with the various stakeholders.
4.3 The final is on track to be completed by July 2017 as agreed with NHSI. This will be shared with the Board for agreement prior to submission.
5 Quality Improvement & Innovation
5.1 Work continues on the Quality Improvement & Innovation (Qii) strategy which will set out our vision and our aims to embed Qii into our culture. It is an evolving strategy that will be regularly updated and reviewed (using Qii methodologies to do so) and we intend to engage with as many staff as possible in its implementation and evaluation. The strategy is based on the principle that all staff, along with our patients, carers, residents, governors, and partner organisations have all the ideas and experience to contribute towards improving the quality, safety, effectiveness and efficiency of our services, and to create solutions for the way we design and provide our future services.
5.2 The strategy and its associated action plan will focus on a number of key areas including the model for improvement and our methodology (“DBTH Qii way”) and the approach we will take for implementation, including: developing practical tools and resources; enhancing the knowledge, confidence and capability of our staff in Qii; how we engage for ideas for improvement; celebrating success and sharing ideas. This will be underpinned by significant focus on the culture of Qii within the organisation particularly including values and behaviours and leadership of Qii.
5.3 Engagement with all Care Groups and corporate teams is underway to identify key priority areas for Qii focus for 2017/18, as well as identifying high impact Qii workstreams to support the efficiency and effectiveness work. This will ensure Qii principles are embedded into all transformation work going forward.
5.4 An early draft of the strategy will be shared and discussed with Board. Progress on implementation and outcomes will be shared through active engagement on an on-going basis.
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6 Summary
6.1 Progress with development of the strategy continues and is supported by the Qii approach, however, identification of the required amount of effectiveness and efficiency saving for 17/18 continues to present a significant challenge.
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Improvement Programme Forecast Out turn 2016/17 – M12 position
Improvement Programme FY17/18 as at April 2017
New Plan in Actual in Variance to Plan YTD Actual Variance to Forecast Forecast RAG RAG schemes for Month Month Plan in YTD Plan YTD CYE (17/18) FYE (Recurrent YTD Year End 2017/18 Month of New 17/18 Forecast schemes)
£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Analysis by Workstream Theatres 500 0 0 0 0 0 0 500 1,000 3 3 Medical Productivity 461 0 2 2 0 2 2 254 811 3 1 Non Medical Clinical 68 6 0 -6 6 0 -6 55 68 1 1 Management & Corporate Services Review 727 59 76 17 59 76 17 994 1,067 4 4 Bed Plan / LOS 873 0 0 0 0 0 0 764 1,310 3 3 Procurement 1,858 154 36 -117 154 36 -117 1,509 1,622 1 2 Clinical Admin & outpatients 790 8 0 -8 8 0 -8 782 1,112 3 3 Infrastructure 396 6 0 -6 6 0 -6 261 790 1 1 Commercial 0 0 0 0 0 0 0 300 375 3 3 Care Group & Corporate - Local 575 48 17 -31 48 17 -31 295 306 1 1 Grip & Control / Unidentified 8,252 208 208 0 208 208 0 2,500 0 1 1 TOTAL 14,500 489 340 -148 489 340 -148 8,213 8,460 1 1
Rec 12,000 281 132 -149 281 132 -149 5,713 8,460 Non rec 2,500 208 208 0 208 208 0 2,500 0 14,500 489 340 -149 489 340 -149 8,213 8,460 Year End Position at Month 12 –March 2017
The planned delivery for the Improvement Programme for FY16/17 is £11.0m, with an internal stretch target to £13.0m, and a reported delivery assumption at M1 of £12.415m against a reported forecast delivery to NHSI of £12.380m. Actual delivery in M12 was £1.833m, ahead of plan in month by £516k YTD delivery £11.893m. This is ahead of plan by £894k, and behind forecast delivery to NHSI by £487k
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Title Financial Performance – April 2017
Report to: Board of Directors Date: 23rd May 2017
Author: Jon Sargeant - Director of Finance
For: Assurance Purpose of Paper: Executive Summary containing key messages and issues
To update the Board on the financial position for the month of April 2017.
Recommendation(s)
The Board is asked to NOTE that the reported financial position is a deficit of £3.9m, which is £39k ahead of the planned position after month 1.
Delivering the Values – We Care Not applicable Related Strategic Objectives
Provide the safest, most effective care possible Control and reduce the cost of healthcare Focus on innovation for improvement Develop responsibly, delivering the right services with the right staff
Analysis of risks
Due to the deficit the Trust is in breach of its license with Monitor
Board Assurance Framework 1 Failure to comply with the Monitor Risk Assessment Framework, CQC 5 x 4 = 20 and other regulatory standards, triggering regulatory action. 2 Failure to deliver the financial plan 5 x 5 = 25
3 Failure to deliver the cost improvement plan 4 x 5 = 20
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FINANCIAL PERFORMANCE
P1 April 2017
23rd May 2017
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DONCASTER AND BASSETLAW TEACHING HOSPITALS NHS FOUNDATION TRUST FINANCE SCORECARD APRIL 2017
1. Income and Expenditure vs. Forecast 2. CIPs Performance Indicator Monthly Performance YTD Performance Annual Forecast Performance Indicator Monthly Performance YTD Performance Annual Forecast Actual Variance Actual Variance Plan Actual Variance Actual Variance Plan £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 I&E Perf Exc Impairments 3,900 (39) F 3,900 (39) F 16,489 16,489 Employee Expenses 89 (248) A 89 (248) A 11,675 Income (28,279) 207 A (28,279) 207 A (361,214) (361,214) Drugs 0 0 F 0 0 A 65 STF Incentive (577) 0 A (577) 0 A (11,547) (11,547) Clinical Supplies 25 (63) A 25 (63) A 1,156 Expenditure 31,677 (300) F 31,677 (300) F 376,414 376,414 Non Clinical Supplies 0 0 A 0 0 A 10 Pay 21,134 413 A 21,134 413 A 248,673 248,673 Non Pay Operating Expenses 7 (27) A 7 (27) A 1,224 Non Pay 10,543 (713) F 10,543 (713) F 127,741 127,741 Income 11 (20) A 11 (20) A 369 F = Favourable A = Adverse Other 208 208 F 208 208 F Financial Sustainability Risk Rating Plan Actual UOR 4 3 CoSRR 1 2 Total 340 (149) A 340 (149) A 14,500
3. Statement of Financial Position 4. Other All figures £m Opening Current Movement Performance Indicator Monthly Performance YTD Performance Annual Forecast Balance Balance in Plan Actual Plan Actual Plan 01.04.17 30.04.17 year £'000 £'000 £'000 £'000 £'000 £'000 Non Current Assets 196.9 194.0 (2.9) Cash Balance 1,900 10,259 1,900 10,259 1,900 1,900 Current Assets 33.2 67.8 34.6 Current Liabilities (31.8) (70.3) (38.5) Non Current liabilities (79.3) (76.6) 2.8 5. Workforce Total Assets Employed 119.0 115.0 (4.0) Funded Actual Bank Agency Total in Under / Total Tax Payers Equity 119.0 115.0 (4.0) WTE WTE WTE WTE Post WTE (over)
Current Month 6,049 5,301 194 60 5,555 494 Previous Month 5,982 5,591 158 100 5,849 133 Movement (67) 290 0 (36) 40 0 294 361
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1. Context/Background
The month 1 position for 2017/18 is a deficit of £3,900k, which is £39k ahead of the planned deficit of £3,939k. Income levels and CIP achievement are both lower than planned levels, but vacancies and non pay underspends have counterbalanced these pressures, allowing achievement of the bottom line position.
2. Executive Summary
I&E position In Month In Month In Month YTD YTD Actual YTD Budget Actual Variance Budget Variance
1. Income -29,064 -28,856 207 -29,064 -28,856 207 2. Costs 31,977 31,677 -300 31,977 31,677 -300 3.Capital Charges 1,026 1,079 53 1,026 1,079 53 Total Position Before Impairments 3,940 3,900 -39 3,940 3,900 -39
4.Impairments 0 0 0 0 0 0 Total Position After Impairments 3,940 3,900 -39 3,940 3,900 -39
I&E position In Month In Month In Month 2017/18 Plan Actual Variance Plan Position before STF 4,517 4,477 -39 28,036 STF funding -577 -577 0 -11,547 Reported position 3,940 3,900 -39 16,489
During April, income has been £207k lower than expected, largely driven by a reduction in emergency activity levels and case mix, particularly at the Bassetlaw site. Care Group expenditure was £594k higher than budgeted levels, although no agency premium funding has yet been allocated to Care Group positions. £375k of this overspend relates to premium staffing costs.
The income position at the end of Month 1 is £207k adverse.
Income Position Monthly Position Cumulative Position Annual Plan Plan Actual Variance Plan Actual Variance £000 £000 £000 £000 £000 £000 £000 Patient income from CCGs -23,656 -23,547 109 -23,656 -23,547 109 -302,252 STF funding -577 -577 0 -577 -577 0 -11,547 Drugs income from CCGs -1,798 -1,881 -83 -1,798 -1,881 -83 -22,574 CCG Income -26,031 -26,005 26 -26,031 -26,005 26 -336,373 Trading Income -3,032 -2,851 181 -3,032 -2,851 181 -36,387
Total Income Position -29,064 -28,856 207 -29,064 -28,856 207 -372,761
The expenditure position in April was £300k better than budgeted levels.
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Subjective Code In Month In Month In Month YTD YTD Actual YTD Budget Actual Variance Budget Variance
1. Pay 20,722 21,134 413 20,722 21,134 413 2. Non-Pay 9,773 9,769 -5 9,773 9,769 -5 3. Reserves 1,482 774 -708 1,482 774 -708 Total Expenditure Position 31,977 31,677 -300 31,977 31,677 -300
3. Conclusion
Non pay underspends and staff vacancies have allowed delivery of the month 1 financial plan, despite reduced income compared to plan and a lower than target delivery of Cost Improvement Plans.
4. Recommendations
The Board is asked to note the month 1 2016/17 financial position of £3.9million deficit, £39k ahead of plan.
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Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust Board of Directors Meeting Performance - April 2017 - (Month 1)
Sewa Singh Medical Director Moira Hardy Interim Director of Nursing David Purdue Chief Operating Officer Jon Sargeant Director Of Finance Karen Barnard Director of People and Organisational Development Title Business Intelligence Report
Report to: Board of Directors Date: 23.05.2017
Karen Barnard, Director of People and OD Moira Hardy, Director of Nursing, Midwifery and Quality Author David Purdue, Chief Operating Officer Sewa Singh, Medical Director For: Approval
Purpose of Paper: Executive Summary containing key messages and issues
The Business intelligence report highlights the key performance and quality targets required by the Trust to maintain Monitor compliance. The report focuses on the 4 main performance area for Monitor Compliance • Cancer, measured on average quarterly performance • 4hr Access, measured on average quarterly performance • 18 weeks including Diagnostic waits, measured quarterly but on monthly performance against active waiters, performance measured on the worst performing month in the quarter • Infection control against CDiff annual trajectory
The quality report focuses on the key indicators of mortality and gives specific focus into best practice tariffs, complaints and serious incidents.
The report is triangulated against staffing levels for the Trust with a focus on sickness/ absence and staff turnover.
The report reviews the actions being taken to address for all performance and quality indicators.
Recommendation To note Delivering the Values - We Care (how the values are exemplified by the work in this paper) We always put the patient first • By ensuring the correct capacity and pathways are in place to allow for treatment in the right place, first time. To ensure quality care is at the centre of all we do to provide the most efficient service.
Everyone counts – we treat each other with courtesy, honesty, respect and dignity • By ensuring that all parties have contributed to the planning and delivery of services
Committed to quality and continuously improving patient experience • By delivering new ways of working across health and social care to ensure compliance with all quality indicators
Always caring and compassionate • By ensuring staff are committed to working with partners to improve services.
Responsible and accountable for our actions – taking pride in our work • By being accountable for delivery of the efficient and effective services
Encouraging and valuing our diverse staff and rewarding ability and innovation • Engaging with staff to encourage their ideas and working with them to change practice
Related Strategic Objectives • Provide the safest, most effective care possible • Control and reduce the cost of healthcare • Focus on innovation for improvement • Develop responsibly, delivering the right services with the right staff
Analysis of Risk • Resource – Key financial issues related to additional funding streams to support planning for surge capacity. • Governance – The Trust needs to maintain compliance framework with monitor • Equality and Diversity – No known issues or risks. • PR and Communications – Need for continued appropriate communication to ensure ongoing performance • Patient, Public and Member Involvement – Public attendance at System Resilience Groups • Risk Assessment – The risks to the Trust’s performance are very high 2016/17, at this stage especially in relation to 4hr access • NHS Constitution - Rights and Pledges – No known issues or risks.
Board Assurance Framework 1 Failure to achieve performance and compliance targets and processes 4 X 3 = 12 2 Failure to match capacity with demand, particularly during winter 4 X 4 = 16 3 Failure to maintain appropriate organisational corporate governance systems 5 X 4 = 20
Executive summary - Performance - April 2017
The performance report is against operational delivery in February, March and April 2017
Provide the safest, most effective care possible Monitor governance compliance is rated against 3 National targets, 4hr Access, Referral to Treatment, which includes diagnostic waits and Cancer Targets. The targets are all monitored quarterly, both 4hr access and cancer are averaged over the quarter but referral to treatment is monitored each month of the quarter and must be achieved each month. The business intelligence report also highlights key National and local targets which ensure care is being provided effectively and safely by the Trust.
4hr Access The target is based on the number of patients who are treated within 4hrs of arrival into the emergency department and set at 95 and reported quarterly as an average figure. This target is for all urgent care provided by the Trust for any patient who walks in. We have 2 type 1 facilities, ED at BDGH and DRI and 1 type 3 facility at MMH.
April Performance
Trust 90.37%, Including GP attendances 91.46%
The Trust maintained the planned trajectory for quarter 1; performance was maintained over the Easter bank holidays with bed capacity maintained at 90% on both sites as planned. Medical workforce issues were the predominant cause of breaches. A number of locum staff withdrew from planned shifts and these staff are being investigated through their agency with discussions with the BMA for the ones who withdrew due to pay levels.
Doncaster achieved 90.04%. Total attendances 9627
959 patients failed to be treated within 4hrs, 141 more than March. 673 patients were delayed due to internal ED waits, 156 more than March. 70 were delayed due to bed waits, 56 less than March. 151 patients required to wait in the department due to their condition. 11.7% of patients were transferred to the urgent care centre.
Bassetlaw achieved 91.55%. Total attendances 3718
314 patients failed to be treated within 4hrs, 111 more than March 235 patients were delayed due to internal ED waits, 102 more than March. 18 were delayed due to bed waits, 6 more than March and 31 patients were required to wait in the department due to their condition. The second national programme, Action on A&E has been launched which aims to review urgent care across the system. All place areas are expected to work through 9 key elements to improve 4hr access. The outcomes are expected that England achieves 90% by September 2017 and that Trusts are achieving 95% by March 2018.
The 9 elements are:
Front door streaming in all EDs by October 2017, based on the National specification. Though local variance can be agreed, in place at DRI, plans in place for Bassetlaw Patient Flow, National measures to be agreed, potentially : Discharge to Assess Trusted Assessors in place 7 day discharge rates Reduction in DTOCs, Trust completed National Audit and local ongoing reviews Specialist Mental Health, 24/7 services to be in 50% of all EDs by March 2018 NHS 111, interlinking with acute Trusts and target of 30% of patients not transferred to ED GP Access, 50% of patients have access to GPs at weekends by March 2018 and 100% by March 2019 Care Homes, access to clinical contact centres prior to ringing EDs Standardisation of Urgent Care Centres, All centres operate to the same standard to give a consistent message Implementation of ambulance response service, increase percentage in see and treat and hear and treat.
Lynn Simpson is reviewing counting changes and will feedback to give clarity on GP attendances. System wide perfect week planned for the 5th of September being supported by ECIP.
Referral to Treatment
The target is now measured against incomplete pathways only at 92%. Fines for RTT have been lifted for 2016/17.
April 90.4%
Revalidation of the waiting list is maintained at 15 weeks as per the CCG requirements. The focus of the data quality team is now on education within care groups to ensure the access policy is adhered to. The waiting list at a speciality level is reviewed weekly at the PTL meeting, chaired by the deputy COO. Demand and Capacity assumptions are reviewed at the monthly Planned Care board, which is attended by both CCGs. The main areas of non-compliance are ophthalmology, ENT, General Surgery and pain management; these specialities are the responsibility of the Surgical Care Group. The Care Group is now in special measures for their performance and this is being monitored weekly by the chief operating officer. Trajectories have been set for improvement by the end of Quarter 1.
Diagnostic performance 97.4%
Key issue as stated in the April board relates to audiology capacity, locums are now in place but performance in this area is the only 1 of the 13 diagnostic tests not achieving the 99% target. Medical imaging achieved 99.3%.
Cancer Performance
March 62 day performance 86.6%, Q4 86.7%
March 2 week wait 88.5%, Q4 89% New electronic referral system now being used for all 2 week wait bookings. Their continues to be capacity shortfalls within urology and dermatology, which has adversely affected the position for 2 week wait, though patient choice in 78 cases accounted for the breach. In March 23% of 2 week-wait patients had a diagnosis of cancer. A full action plan has been developed for 2 week-wait performance.
Stroke Performance
43 patients were discharged within the month. Only 22 were directly admitted within 4hrs. Of the 21 not admitted 6 were after 10 hrs due to their initial presentation. 8 were due to pathway delays, 4 of these from Bassetlaw. 7 were admitted within 5hrs. CT within 1hr failed for the first time in 5 months predominantly due to access to CT either the scanner being down or being utilised within the Trust. The plans for hyper acute stroke pathway changes continue to be progressed.
David Purdue Chief Operating Officer May 2017
At a Glance -April 2017 (Month 1) Month Standard (Local, Data Quality RAG Month Month Actual Data Quality RAG Page Indicator Current Month Month Actual Page Indicator Current Month Actual National Or Monitor) Rating Actual (DRI) (BDGH) Rating (TRUST) 31 day wait for second or subsequent treatment: surgery 94.0% M 100.0% % of patients achieving Best Practice Tariff Criteria Apr-17 56.7% 55.6% 60.0%
31 day wait for second or subsequent treatment: anti cancer drug treatments 98.0% M 100.0% Best Practice Criteria
31 day wait for second or subsequent treatment: radiotherapy 94.0% M 100.0% 36 hours to surgery Performance 67.5% 62.9% 80.0% 62 day wait for first treatment from urgent GP referral to treatment 85.0% M 85.8% 72 hours to geriatrician assessment Performance 86.4% 88.8% 80.0% 4-5 Mar-17 17 62 day wait for first treatment from consultant screening service referral 90.0% M 93.1% % of patients who underwent a falls assessment Apr-17 100.0% 100.0% 100.0%
31 day wait for diagnosis to first treatment- all cancers 96.0% M 98.7% FracturedofNeckFemur % of patients receiving a bone protection medication assessment 100.0% 100.0% 100.0% Two week wait from referral to date first seen: all urgent cancer referrals (cancer 93.0% M 88.5% Mortality-Deaths within 30 days of procedure 5.40% 7.40% 0.00% suspected) Two week wait from referral to date first seen: symptomatic breast patients (cancer 93.0% M 93.1% not initially suspected)
Standard (Local, Data Quality RAG Page Indicator Current Month Month Actual National Or Monitor) Rating A&E: Maximum waiting time of four hours from arrival / admission / transfer / 6-7 95.0% M Mar-17 92.6% discharge (Trust) 4 Per Month for
19 Infection Control C.Diff Qtr 2 - 45 full M 5 MonitorCompliance Framework year Apr-17 Infection Control MRSA 0 L 1
Maximum time of 18 weeks from point of referral to treatment- incomplete pathway 92.0% M 90.4% 16 HSMR (rolling 12 Months) 100 N Feb-17 93.12
Never Events 0 L Apr-17 0
8-9 Apr-17 Safe VTE 95.0% N Mar-17 95.0%
% of Patients waiting less than 6 weeks from referral for a diagnostics test 99.0% N 97.5% 12 Per Month Pressure Ulcers L 0 144 full Year 19 2 Per Month 23 Total time in A&E: 4 hours (95th percentile) HH:MM 04:00 N 05:05 Falls that result in a serious Fracture L 0 full Year Apr-17 A&E Admitted patients total time in A&E (95th percentile) HH:MM 04:00 N 07:50 Catheter UTI Snap shot audit 1.08% A&E Non-admitted patients total time in A&E (95th percentile) HH:MM 04:00 N 03:59 Mar-17 A&E: Time to treatment decision (median) HH:MM 01:00 N 00:51:00 Data Quality RAG 6-7 A&E unplanned re-attendance rate % 5.0% N 0.4% Page Indicator Current Month Month Actual Rating A&E: Left without being seen % 5.0% N 3.2%
Ambulance Handovers Breaches -Number waited over 15 & Under 30 Minutes 612 A&EPerformance Indicators Complaints received (12 Month Rolling) 562 Ambulance Handovers Breaches-Number waited over 30 & under 60 Minutes N Mar-17 73
Ambulance Handovers Breaches -Number waited over 60 Minutes 10 Concerns Received (12 Month Rolling) 840 Proportion of patients scanned within 1 hour of clock start (Trust) 48.0% N 37.2% Proportion of patients directly admitted to a stroke unit within 4 hours of clock start 90.0% N 51.2% (Trust) Complaints Performance 17.0% Percentage of eligible patients (according to the RCP guideline minimum threshold) 90.0% N 100.0% given thrombolysis (Trust) Proportion of applicable patients receiving a joint health and social care plan on Feb-17 20 Mar-17
90.0% N 74.4% ComplaintsClaims& Clinical Negligence Scheme for Trusts (CNST) 5 10-12 discharge (Trust)
Stroke Percentage of patients treated by a stroke skilled Early Supported Discharge team 40.0% N 69.2% (Trust) Percentage of those patients who are discharged alive who are given a named person 95.0% N 74.4% Liabilities to Third Parties Scheme (LTPS) 2 to contact after discharge (Trust) Implementation of Stroke Strategy - TIA Patients Assessed and Treated within 24 60.0% N Apr-17 59.3% Hours Cancelled Operations 0.8% N 1.1% Claims per 1000 occupied bed days 0.3 Cancelled Operations-28 Day Standard 0 N 0.0%
13 Out Patients: DNA Rate L Apr-17 9.0% Month Data Quality RAG Page Indicator Current Month YTD (Cumulative) Actual Rating L Out Patients: Hospital Cancellation Rate 6.1% TheatresOutpatients & L 23 Sickness 4.1% 4.5%
25 Workforce Appraisals Mar-17 61.3% Emergency Readmissions within 30 days (PbR Methodology) L Feb-17 6.1%
Effective 24 SET Training 69.5% Monitor Compliance Framework: Cancer - March 2017 (Month 12)
Context Cancer targets are reported quarterly as an average position. Guidance for 62 day pathways has been published which clarifies internal transfer as day 38 for classic 62 day pathways. Performance measures are reported a month behind due to validation and National uploads.
Reasons for Success/Failure 2 week wait failed to achieve the target for both CCGs as a consequence, of reduced capacity in urology and dermatology, main cause of breach remains patient choice. Action plan being shared with CCGs 62 day classic performance achieved at 85.8% as a result of improved pathway management from initial 2 week wait appointment.
Actions being taken to address any issues The Trust reports weekly at the PTL all 62 day target performance Electronic system flags delays within the cancer team to raise at key timing points in patient pathways Individual breach reports are discussed with the MDTs to ensure learning is in place Electronic transfer protocols now agreed with STH for transfer. Improved access to diagnostics, KPIs set against a 7 day turnaround plan, new processes for flagging 62 day pathways being launched in Q1 2017/18 Changes to referral systems being reviewed in line with E referral pathways which need to be embedded by April 2018 Process mapping carried out on two week wait administration pathways. Key areas of work continue around capacity on sites. Patients being contacted when they delay their appointment outside of 14 days
Indicator Standard Mar-16 QTR 4 2016-17 Jan-17 Feb-17 Mar-17 31 day wait for second or subsequent treatment: surgery 94.0% 100.0% 97.7% 94.1% 100.0% 100.0% 31 day wait for second or subsequent treatment: anti cancer drug treatments 98.0% 100.0% 100.0% 100.0% 100.0% 100.0% 31 day wait for second or subsequent treatment: radiotherapy 94.0% 100.0% 100.0% 100.0% 100.0% 100.0% Tumour Type Breast 94.1% 100.0% 100.0% 100.0% 100.0% Gynaecological 100.0% 85.3% 90.9% 81.8% 37.5% Haematological 100.0% 85.4% 100.0% 100.0% 80.0% Head & Neck 80.0% 53.7% 50.0% 77.8% Lower Gastrointestinal 100.0% 75.5% 100.0% 90.9% 90.9% 62 day wait for first treatment from urgent GP referral to treatment Lung 85.0% 76.9% 73.8% 75.0% 100.0% 87.5% Other 50.0% 95.2% 100.0% 100.0% Sarcoma 100.0% 66.7% 50.0% 100.0% 0.0% Skin 100.0% 97.4% 100.0% 100.0% 96.4% Upper Gastrointestinal 100.0% 87.6% 100.0% 85.7% 80.0% Urological 72.7% 74.2% 57.1% 65.5% 82.8% All Cancers 90.2% 85.5% 85.2% 86.8% 85.8% Tumour Type Breast 100.0% 98.6% 100.0% 90.0% 100.0% Gynaecological 88.9% 100.0% Haematological 100.0% 100.0% Head & Neck Lower Gastrointestinal 100.0% 68.2% 50.0% 0.0% 62 day wait for first treatment from consultant screening service referral Lung 90.0% Other Sarcoma Skin Upper Gastrointestinal Urological All Cancers 100.0% 94.3% 87.5% 90.0% 93.1% 31 day wait for diagnosis to first treatment- all cancers 96.0% 97.6% 99.3% 99.2% 100.0% 98.7% Two week wait from referral to date first seen: all urgent cancer referrals (cancer suspected) 93.0% 96.6% 89.0% 90.5% 86.5% 88.5% Two week wait from referral to date first seen: symptomatic breast patients (cancer not initially suspected) 93.0% 97.4% 93.3% 93.1% 93.8% 93.1% Monitor Compliance Framework: Cancer - Graphs - March 2017 (Month 12) Monitor Compliance Framework: A&E - April 2017 (Month 1)
Context 4hr access is measured against all patients attending an urgent care facility. DBTH has 3 departments, 2 type 1 and 1 type 3. No GP patients are currently incorporated into the figures as they attend directly to Ambulatory units. GP patients are currently being collected in shadow form to assess the impacts on performance. Reasons for Success/Failure
April Performance 90.37%, with GP 91.46%, April met the trajectory agreed with NHSi to achieve STF Key issue related to internal ED waits, which accounted for 71% of all waits. Plans for workforce improvements are in place but are being impacted by IR35 and the lack of ED medical staff. need to update
Actions being taken to address any issues FDASS reviewed at DRI, good outcomes, discussing with the CCG the potential up banding of staff, negotiations continue to look at urgent care wider as part of the ACP. Streaming piloted at BDGH from the 22nd of February, initial audit results show positive improvements in flow. Capital funding now agreed to support front door streaming. Plan to have system change by October 2017. Workforce reviews being undertaking to support ED with staff from other specialities. DTOC work reviewed for transfer to assess pathways at Bassetlaw and Doncaster Weekend working being reviewed to assess the effectiveness of consultant ward rounds on both main sites and the infrastructure available to support decision making. SMART ER being developed for streaming at BDGH Winter plan strategy group commenced with key actions for each care group. Bed plan to be agreed at June Board.
Indicator Standard Apr-16 Qtr 4 2016-17 Feb-17 Mar-17 Apr-17 A&E: Maximum waiting time of four hours from arrival/ admission/ transfer/ discharge (Trust) 95.1% 88.9% 88.7% 92.6% A&E: Maximum waiting time of four hours from arrival/ admission/ transfer/ discharge (Bassetlaw CCG) 95.7% 92.5% 93.2% 93.9% 95.0% A&E: Maximum waiting time of four hours from arrival/ admission/ transfer/ discharge (Doncaster CCG) 94.2% 86.9% 85.6% 91.0%
Total time in A&E: 4 hours (95th percentile) HH:MM 04:00 04:00 06:20 06:19 05:05 A&E Admitted patients total time in A&E (95th percentile) HH:MM 04:00 07:59 10:55 10:35 07:50 A&E Non-admitted patients total time in A&E (95th percentile) HH:MM 04:00 03:57 04:37 04:30 03:59 A&E: Time to treatment decision (median) MM 01:00 00:52 00:53 00:52 00:51 A&E unplanned re-attendance rate % 5.0% 0.4% 0.3% 0.3% 0.4% A&E: Left without being seen % 5.0% 3.4% 3.0% 3.3% 3.2% Indicator Standard Mar-16 Qtr 4 2016-17 Jan-17 Feb-17 Mar-17 Ambulance Handovers Breaches -Number waited over 15 & Under 30 Minutes 717 2062 723 727 612 Ambulance Handovers Breaches -Number waited over 30 & under 60 Minutes 212 311 130 108 73 Ambulance Handovers Breaches -Number waited over 60 Minutes 57 89 66 13 10
*April A&E Data is currently unavailable due to not being signed off by the service lead. Monitor Compliance Framework: A&E - Graphs - March (Month 12) Monitor Compliance Framework: 18 Weeks & Diagnostics - April 2017 (Month 1)
Context The Trust have changed the way the incomplete pathways snapshot is monitored. • Late Entered Referrals are included • All amendments made to pathways since the end of September will have been reflected in the data. Previously only those flagged on the DQ system with earlier stops would have been removed. • The removal of any late entered clock stops prior to the end of September. Previously only those in the month or flagged on the DQ system would have been removed. • Correction on weeks waiting calculation for incomplete pathways as the calculation previously reported one day extra on each pathway, • Inclusion of ASIs. Please note: From March 2017 a change has been made to exclude pathways which were for 'planned' procedures but CaMIS was incorrectly starting a Referral to Treatment Clock. For March 2017, this change has resulted in the removal of around: 350 Incomplete Pathways and Incomplete Pathways with a decision to admit for treatment, 200 Admitted Clock Stops and 250 New RTT Periods. The affected specialties are Pain Management and Medical Ophthalmology (which fall into 'Others' when reported to Unify). In March this affected RTT performance negatively by 0.1%.
Reasons for Failure (if applicable) Incomplete pathways for April ended at 90.4%. There was one 52wk breach reported in April. Patient TCI is 19th May 2017. Specialties failed to meet 92% in April: - General Surgery - Urology - Respiratory - Cardiology - Ophthalmology - Trauma and Orthopaedics - ENT - Gynaecology
Key issues - Workforce - Theatre capacity and utilisation - Cancellations at a specialty level - Validation below 18 weeks identified 30% removal rate, resultant in worsened RTT position - Patient Administration - quality - Anaesthetic workforce
Diagnostic performance for April: 97.54% Key issues: - Audiology, staffing sickness and vacancies - Cystoscopies, breaking down of equipment (washers) and impact on cancelling patients - Sleep Studies, lack of equipment to accommodate patient referrals
Actions being taken to address any issues Weekly PTL meetings take place with Care Groups where Delivery Plans are discussed to bring performance levels back in line with commissioned activity and meeting RTT. In response to the current RTT position Recovery Plans are regularly reviewed and challenged with each Care Group. Performance is also discussed at the Care Group Accountability Meeting. Main areas of concern; Ophthalomology, General Surgery, ENT and Pain Management . Diagnostics: Audiology and Endoscopy long term sustainability plan.
Improvements - Dermatology has increased performance from 85% to +94% as of May - Urology has increased performance to +91% - Orthopaedics increased performance from 88% back to almost 91% May - Waiting list management across sites and communication - Respiratoey back to +93% May
Actions 18 week pathways - Advanced Monitoring for RTT with Surcical Care Group. Bi-weekly meetings chaired by COO. - Outsourcing action plans agreed with care group for; ENT and Ophthalmology - Intenral action plans agreed with care group for; Pain Management and GI - Collaboration with CCG on referral management and support in managing demand: Planned Care Programme Board and SDIP - Paused validating below 15 weeks to focus on patient adminstration quality improvement. Working Group established and work commenced with Information and Systems Directorate. - Theatre Productivity Plans led by Theatre Workstream
Diagnostics - Audiology, two locums commenced 10/04 and third Locum appointed early April. Trajectory is reduced breaches in May and mitigated by end of June. - Sleep Studies, consultant review of all referred patients to ensure appropriate referral. Faulty equipment replaced. - Endoscopy capacity secured through external supplier to mitigate patient breaches. Provider required up to end of May to manage demand and reduce waiting list. - Endoscopy business case by surgical care group. CIG in May/June
Risks - Cancellations due to beds - Securing out-sourcing capacity in a timely manner and case need - Investment in Endoscopy - Business Case - 52wk breach due to quality of patient information. - Anaesthetist workforce and recruitment
Summary STF target for April is 91%. The Trust failed this at 90.4%. STF Trajectory for Q1 of 2017/18 is 91%. Q2 onwards 92%. The Trust remains focussed on achieving 92% as soon as possible. Current position as of 16/05 is 91%.
Indicator Standard Apr-16 Qtr. 4 2016-17 Feb-17 Mar-17 Apr-17 Expected date to meet standard
Maximum time of 18 weeks from point of referral to treatment- incomplete pathway 92.0% 92.90% 90.4% 90.5% 90.5% 90.4%
Indicator Standard Apr-16 Feb-17 Mar-17 Apr-17 Expected date to meet standard
% of Patients waiting less than 6 weeks from referral for a diagnostics test 99.0% 99.17% 98.93% 97.43% 97.54%
Diagnostics Waits 59 89 228 185 Monitor Compliance Framework: 18 Weeks & Diagnostics - April (Month 1) Stroke -February 2017 (Month 11) Context
Stroke Targets are now reported against the SSNAP data, performance at level A/B across all areas
Reasons for Failure (if applicable) 43 patients were diagnosed at discharge with a stroke. 9 patients were from out of area. Key elements causing not achieving access within 4 hrs were initial presentation and access to beds.
Actions being taken to address any issues The stroke pathway process has been reviewed to improve direct access for CT, escalation agreed with radiology for when CT is queuing Specialist nurses to be based in ED to support the patient pathway The number of direct access beds for hyper acute stroke is being increased across the stroke unit Working with EMAS to ensure patients are correctly identified to give direct access Plans agreed with clinical staff for location of additional CT scanner. Stroke assessment area identified within ED Pathways for the stroke service out of the hospital to MMH and early supported discharge are being reviewed to ensure adequate bed capacity
Indicator Standard Feb-16 Qtr 3 2016-17 Dec-16 Jan-17 Feb-17
Proportion of patients scanned within 1 hour of clock start (Trust) 48.0% 41.7% 52.7% 54.3% 52.9% 37.2% Proportion of patients directly admitted to a stroke unit within 4 hours of clock start 90.0% 62.5% 63.4% 62.9% 49.0% 51.2% (Trust) Percentage of eligible patients (according to the RCP guideline minimum threshold) given 90.0% N/A 100.0% 100.0% 100.0% 100.0% thrombolysis (Trust) Proportion of applicable patients receiving a joint health and social care plan on discharge 90.0% N/A 90.5% 93.1% 73.0% 74.4% (Trust) Percentage of patients treated by a stroke skilled Early Supported Discharge team (Trust) 40.0% N/A 73.3% 70.6% 53.7% 53.7%
Percentage of those patients who are discharged alive who are given a named person to 95.0% N/A 86.1% 79.4% 65.9% 74.4% contact after discharge (Trust)
Indicator Standard Mar-16 Qtr 4 2016-17 Jan-17 Feb-17 Mar-17
Implementation of Stroke Strategy - TIA Patients Assessed and Treated within 24 Hours 60.0% 81.5% 57.3% 61.5% 46.9% 61.5% Stroke - Graphs February 2017 (Month 11)
Proportion of patients admitted to an acute Stroke unit within 4 hours of arrival 1
0.9 #REF! #REF! #REF!
0.8
76.20% Stroke - Graphs South Yorkshire August- November 2016 Theatre & Outpatients - March 2017 (Month 12)
DNA Rate: Benchmarking data taken from Healthcare Evaluation Data (HED) (April 2016 to February 2017)
Qtr 4 Indicator Standard Apr-16 Feb-17 Mar-17 Apr-17 2016-17
Cancelled Operations (Total) 0.8% 1.2% 1.4% 1.3% 1.0% 1.1% Cancelled Operations (Theatre) 1.1% 1.1% 1.0% 0.8% 0.7% Cancelled Operations (Non Theatre) 0.2% 0.3% 0.3% 0.2% 0.3% Cancelled Operations-28 Day Standard 0 0 3 2 0 0 Outpatients: DNA Rate Total (Refreshed Each 8.23% 9.17% 9.07% 8.67% 9.03% Month) Outpatients: DNA Rate First (Refreshed Each 8.63% 9.44% 9.22% 9.12% 9.38% Month) Outpatients: DNA Rate Follow Up (Refreshed Each 8.05% 9.05% 9.00% 8.46% 8.86% Month) Outpatients: Hospital cancellation Rate (Refreshed 17.90% 5.91% 6.62% 5.76% 6.12% Each Month) Outpatients: Patient cancellation Rate (Refreshed 15.08% 10.83% 11.05% 10.12% 9.58% Each Month) Outpatients: Patient died cancellation Rate 0.00% 0.00% 0.00% 0.00% 0.00% (Refreshed Each Month) * Please note cancellation data has changed to reflect cancellations made within 14 days of the appt. Medical Outliers by Specialty - April 17 (Month 1)
Most Sleepers-out in Least Sleepers-out Daily average March 2017 in March 2017 Medicine to Ortho 0 0 0 Medicine to S12 3 5 0 Medicine to Surgery 10 16 3 Medicine to Gynae 3 6 0
Executive summary - Safety & Quality - April 2017 (Month 1)
HSMR: The Trust's overall rolling 12 month HSMR remains in the better than expected range although HSMR for the month of February w as 102.5. Mortality reviews have not identified signiificant lapses in care
Fractured Neck of Femur: Achievement of BPT fell just below 60% because of high non-elective activity levels creating difficulty with access to theatre within 36 hours. Due to maintenance being performed on the National Hip Fracture Database, not all data for the criteria for the 2017-18 Best Practice Tariff is currently available. Figures will be updated next month when maintenance is completed.
Serious Incidents: Overall, the Trust finished 16/17 with 46% reduction in delogged SIs. The reduction in serious falls was 14%, HAPU 53% and c are issues 46%
Executive Lead: Mr S Singh
C.Diff: The target for this year is unchanged. The rate for April is higher than average as we start 2017/18. The investigations s how that antibiotic choice was a factor forthe cases where there were lapses in care. The Director of Infection Prevention and Control is taking steps to ensure that all prescribers are adhering to antimicrobial guidelines, course lengths are as short as clinically appropriate and regular reviews of antibiotics are led by the Consultants.
Fall resulting in significant harm: There are no falls resulting in significant harm in April.
Hospital Acquired Pressure Ulcers: The initial data shows cases that are undergoing investigation, which may change the number of avoidable cases. The 25% reduc tion seen in 2016/17has led to setting a further reduction target of another 10% for 2017/18.
Complaints and concerns: The rate of complaints remains within normal variation. Reply performance shows that timely replies are not achieving the sta ndard, with few cases being referred to the Ombdsman.
Friends & Family Test: The Trust inpatient rate remains similar or better than the national rate and positive scores.The A&E rate remains at a lower e rate than peers.
Hospital Standardised Mortality Ratio (HSMR) - February 2017 (Month 11)
Overall HSMR (Rolling 12 months) HSMR - Non-elective Admission (Rolling 12 months) HSMR - Elective Admission (Rolling 12 months)
100 100 100
90
80 83.86
95 95 70 93.12 60 93.26 50
90 90 40
Jul 15 - Jun 16 Jun - Jul 15
Jul 15 - Jun - 16 15 Jul
Jul 15 - Jun - 16 15 Jul Aug 15 - 16 Jul
Aug 15 - Jul 16 Jul - 15 Aug
Feb 16 - Jan 17 Jan - 16 Feb
Aug 15 - Jul 16 Jul - 15 Aug
Jan 16 - Dec 16 Dec - 16 Jan
Feb 16 - Jan 17 Jan - 16 Feb Oct 15 - Sep 16 Sep - 15 Oct
Apr 15 - - Mar16 15 Apr
Jan Jan Dec - 16 16
Oct 15 - Sep16
Feb 16Feb Jan - 17
Nov 15 - Oct 16
Sep 15 - Aug 16 Aug - 15 Sep
Jan Jan Dec - 16 16
Oct 15 - Sep - 16 Oct15
Nov 15 - Oct 16 15 Oct - Nov
Sep 15 - Aug 16 Aug - 15 Sep
Jun 15 16 May -
Mar 16 - Feb 17 Feb - 16 Mar
Apr Apr - 15 16 Mar
May 15 - Apr 16 - Apr 15 May
Jun 15 - May 16 May - 15 Jun Nov 15 - 15 Oct 16 - Nov
Dec 15 - Nov 16 Nov - 15 Dec
Mar 16 - Feb 17 Feb - 16 Mar
Sep 15 - Aug 16 Aug - 15 Sep
May - 15 May 16 Apr
Apr Apr - 15 16 Mar
Jun 15 - May 16 May - 15 Jun
Dec 15 - Nov 16 Nov - 15 Dec
Mar Feb - 16 Mar 17
Dec 15 - Nov 16 Nov - 15 Dec May - 15 May 16 Apr
HSMR Trend (monthly) Crude Mortality (monthly) - April 2017 (Month 1) (number of deaths/number of patient discharged) Crude Mortality Crude Mortality 0.022 (DRI) 2014 2015 2016 2017 (Trust) 0.019 January 115.45 116.80 99.21 96.09 2.2% 0.016 0.013 February 99.11 99.94 97.73 102.54 2.0% 0.01 March 102.91 90.54 97.37
April 110.49 105.91 88.50 1.8%
Jul-16
Jan-17
Jun-16
Oct-16
Apr-17
Sep-16 Feb-17
Dec-16
Aug-16
Nov-16 Mar-17 May 90.93 101.15 96.60 1.6% May-16 June 113.74 80.27 92.81 1.4% July 109.94 92.56 96.45 Crude Mortality August 120.18 100.27 87.08 1.2% 0.025 (BDGH) September 110.10 90.26 94.04 1.0% 0.015 October 106.58 90.29 88.30
November 106.84 88.98 82.61 0.005
Jul-16
Jan-17
Jun-16
Oct-16
Apr-17 Feb-17
December 115.87 82.30 93.09 Sep-16
Dec-16
Aug-16
Nov-16
Mar-17
May-16
Jul-16
Jan-17
Jun-16
Oct-16
Apr-17
Sep-16 Feb-17
Dec-16
Aug-16
Nov-16
Mar-17 May-16
May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 Trust 1.50% 1.32% 1.47% 1.37% 1.34% 1.38% 1.22% 1.70% 1.96% 1.96% 1.29% 1.38% Doncaster 1.52% 1.37% 1.70% 1.59% 1.53% 1.43% 1.33% 1.68% 2.12% 2.04% 1.43% 1.33% Bassetlaw 1.82% 1.48% 1.22% 1.17% 1.22% 1.47% 1.12% 2.07% 1.87% 2.06% 1.11% 1.82% NHFD Best Practice Pathway Performance - April 2017 (Month 1)
Best Practice Criteria Performance 36 Hours to Surgery Performance MDT Assessment Performance
100% 120% 100%
80% 100% 90% 60% 80% 40% 80%
60%
Jul-16
Jul-16
Jan-17
Jun-16
Oct-16
Apr-16
Sep-16 Feb-17
Dec-16
Jan-17
Aug-16
Jun-16
Nov-16
Oct-16
Apr-17
Mar-17
Sep-16 Feb-17
Dec-16
May-16
Aug-16
Nov-16
Mar-17 May-16 40% Trust DRI BDGH Trust DRI BDGH
20% 72 Hours to Geriatrician Assessment Performance Falls Assessment Performance
0% 100% 100%
80%
Jul-16 90%
Jan-17
Jun-16
Oct-16
Apr-17
Sep-16 Feb-17
Dec-16
Aug-16
Nov-16 Mar-17 May-16 60% % achieving best practice tariff criteria (Trust) 40% 80%
% achieving best practice tariff criteria (DRI)
Jul-16
Jul-16
Jan-17
Jun-16
Oct-16
Jan-17
Apr-17
Sep-16 Feb-17
Jun-16
Dec-16
Oct-16
Aug-16
Apr-17
Sep-16 Feb-17 Nov-16
Dec-16 Mar-17
Aug-16
Nov-16
May-16 Mar-17 % achieving best practice tariff criteria (BDGH) May-16 Trust DRI BDGH Trust DRI BDGH Relative Risk Mortality (HSMR) - Fractured Neck of Femur Bone Protection Medication Assessment Rolling 12 month
100% 140 130 90% 120
80% 110 98.86
100
Jul-16
Jan-17
Jun-16
Oct-16
Apr-17
Sep-16 Feb-17
Dec-16
Aug-16
Nov-16 Mar-17 May-16 90 Trust DRI BDGH 80 70
60
Jul-16
Jan-17
Jun-16
Oct-16
Apr-16
Sep-16 Feb-17 Feb-16
Dec-16
Aug-16
Nov-16
Mar-16 May-16
Trust DRI BDGH Serious Incidents - April 2017 (Month 1) (Data accurate as at 08/05/17) Please note: At the time of producing this report the number of serious incidents reported are prior to the RCA process being completed. Overall Serious Incidents Number Serious Incidents Reported Serious Incidents per 1000 occupied bed days (Trust & Care Group) 0.9 25 0.8 20 0.7 15 0.6 10 0.5
5 0.4 0.3 0
0.2
Jul-16
Jan-17
Jun-16 Oct-16
Apr-17 0.1
Sep-16 Feb-17
Dec-16
Aug-16
Nov-16
Mar-17 May-16 0 Emergency Care Group MSK & Frailty Care Group Surgical Care Group
Children & Family Services Diagnostic & Pharmacy Speciality Services
Jul-16
Jan-17
Jun-16
Oct-16
Apr-17
Sep-16 Feb-17
Dec-16
Aug-16
Nov-16 Mar-17 Chief Operating Officer Number Reported SI's Number Reported SI's - Previous years performance May-16
Current YTD reported SI's (Apr 17) 6 Number reported SI's (Apr 16) 9 Reported Si's per 1000 occupied bed days Reported Si's per 1000 occupied bed days - Previous years performance Current YTD delogged SI's (Apr 17) 1 Number delogged SI's (Apr 16) 2 Themes Serious Falls Care Issues Pressure Ulcers - Category 3 & 4 (HAPU)
0.09 0.14 0.18 0.08 0.12 0.16 0.07 0.14 0.1 0.06 0.12 0.05 0.08 0.1 0.04 0.06 0.08 0.03 0.06 0.04 0.02 0.04 0.01 0.02 0.02
0 0 0
Jul-16
Jul-16
Jul-16
Jan-17
Jun-16
Oct-16
Apr-17
Sep-16 Feb-17
Jan-17
Dec-16
Jun-16
Jan-17
Aug-16
Oct-16
Jun-16
Apr-17
Nov-16
Feb-17 Sep-16
Oct-16
Mar-17
Apr-17
Dec-16
Sep-16 Feb-17
Aug-16
Dec-16
May-16
Nov-16
Aug-16
Mar-17
Nov-16
Mar-17
May-16 May-16
Serious Falls per 1000 occupied bed days Care Issues per 1000 occupied bed days Pressure Ulcers HAPU 3 & 4 per 1000 occupied bed days Monitor Compliance Framework: Infection Control C.Diff - April 2017 (Month 1) (Data accurate as at 13/05/2017)
Standard Apr May Jun Q1 YTD 2017-18 Infection Control - C-diff 40 Full Year 5 5 2016-17 Infection Control - C-diff 40 Full Year 0 0 2017-18 Trust Attributable 12 3 3 2016-17 Trust Attributable 12 0 0
C-diff 2016-17 Trust Attributable C-diff 2016-17 50 15 40 10 30 20 5 10
0 0
Jul
Jul
Jan
Jun
Oct
Apr
Jan
Feb Sep
Jun
Dec
Oct
Aug
Apr
Sep Feb
Nov
Dec
Mar
Aug
Nov
May
Mar May
2017-18 C-diff Cumulative total 2016-17 C-diff Cumulative total Standard 2017-18 Trust Attributable Cumulative Total 2016-17 Trust Attributable Cumulative Total Standard
Pressure Ulcers & Falls that result in a serious fracture - April 2017 (Month 1) (Data accurate as at 13/05/2016)
Falls that result in a serious fracture 15
Standard Apr May Jun Q1 YTD 10 2017-18 Serious Falls 10 Full Year 0 0 2016-17 Serious Falls 19 Full Year 0 0 5 0
Please note: At the time of producing this report the number of serious falls reported
Jul
Jan
Jun
Oct
Apr
Sep Feb
Dec
Aug
Nov Mar are prior to the RCA process being completed. May
2017-18 Falls Cumulative Total 2016-17 Falls Cumulative Total Standard
Pressure Ulcers (Ungradeable, Cat 3 & Cat 4) 90 75 60 45 Standard Apr May Jun Q1 YTD 30 15 2017-18 Pressure Ulcers 34 Full Year 8 8 0
2016-17 Pressure Ulcers 60 Full Year 4 4 Jul
Jan
Jun
Oct
Apr
Sep Feb
Dec
Aug
Nov
Mar May
Please note: At the time of producing this report the number of pressure ulcers reported are prior to the RCA process being completed. 2017-18 Pressure Ulcer Cumulative Total 2016-17 Pressure Ulcer Cumulative Total Standard Complaints & Claims - April 2017 (Month 1) (Data accurate as at 09/05/2017) Complaints Complaints Received Concerns Received 90 120 April 2017 Year to Date 80 100 Complaints Recieved Complaints Recieved 70 Risk Breakdown Risk Breakdown 60 80 50 60 40
30 40 Low Risk Moderate Risk 20 20 10 High Risk
0 0
42583 42614 42675 42705 42795 42826 42552 42644 42736 42767
42552 42583 42614 42644 42675 42705 42736 42767 42795 42826
Jan 2016 Jan
Jun 2016 Jun
Jan 2016 Jan
Oct 2015 Oct
Jun 2016 Jun
Apr 2016 Apr
Feb 2016 Feb
Oct 2015 Oct
Apr 2016 Apr Dec 2015 Dec
Feb 2016 Feb
Dec 2015 Dec Nov 2015 Nov
Mar 2016 Mar
Nov 2015 Nov
Mar 2016 Mar
May 2016 May May 2016 May
Complaints Mean UCL LCL Concerns Mean UCL LCL Complaints - Resolution Perfomance Parlimentary Health Service Ombusdman (PSHO) (% achieved resolution within timescales)
Complaints Resolution Performance Number of cases 40% Month referred for Number Currently Oustanding investigation 35% April 1 9 30%
25% Number referred for Outcomes investigation 20% YTD YTD 15% Fully / Partially Upheld 0 10% Not Upheld 1 2016/17 9 No further Investigation 0 5% Case Withdrawn 0 0% Fully / Partially Upheld Not Upheld 2017/18 1
Jul-16 No further Investigation
Jan-17
Jun-16
Oct-16
Apr-17
Sep-16 Feb-17
Dec-16
Aug-16
Nov-16
Mar-17 May-16 Case Withdrawn Please note: Performance as a percentage is calculated on the cases replied and overdue, compared to the due date. Any current investigations that have not gone over deadlines are excluded data. Claims Number of Claims per 1000 Occupied bed days Current Month Month Actual YTD 0.6 0.5 Clinical Negligence Scheme for Trusts (CNST) Apr-16 5 5 0.4 0.3 Liabilities to Third Parties Scheme (LTPS) Apr-16 2 2 0.2
Please note: At the time of producing this report the number of claims reported are provisional and prior to validation 0.1
0
Jul-16
Jan-17
Jun-16
Oct-16
Apr-17
Sep-16 Feb-17
Dec-16
Aug-16
Nov-16
Mar-17 May-16 Friends & Family - April 2017 (Month 1) (Data accurate as at 17/05/2016) Inpatients
Please note: At the time of producing this report no further benchmarking data is available from NHS England.
Response Rates (%) Likely to recommend (%) 40% 0.975 0.97 30% 0.965 0.96 20% 0.955 10% 0.95 0.945
0% 0.94
Jul-16
Jul-16
Jan-17
Jan-17
Jun-16
Jun-16
Oct-16
Oct-16
Apr-17
Apr-16
Sep-16 Feb-17
Feb-17 Sep-16
Dec-16
Dec-16
Aug-16
Aug-16
Nov-16
Nov-16
Mar-17
Mar-16
May-16 May-16 Trust England Trust England
Accident & Emergency
Please note: At the time of producing this report no further benchmarking data is available from NHS England.
Response Rates (%) Likely to recommend (%) 14% 0.96 12% 0.94 0.92 10% 0.9 8% 0.88 6% 0.86 0.84 4% 0.82 2% 0.8
0% 0.78
Jul-16
Jul-16
Jan-17
Jun-16
Oct-16
Apr-16
Sep-16 Feb-17
Jan-17
Dec-16
Jun-16
Aug-16
Oct-16
Nov-16
Apr-17
Sep-16 Feb-17
Mar-16
Dec-16
Aug-16
May-16
Nov-16
Mar-17 May-16 Trust England Trust England
Executive summary - Workforce - March 2017 (Month 12)
Sickness absence At the time of writing the report month 1 sickness absence data was not available due to the timing of payroll being closed down for payment. As month 12 data was not available last month the report details sickness rates for the end of year 2016/17. We ended the year at 4.46% which represents a slight reduction over the last few months. We benchmark favourably across Yorkshire and Humber. Appraisals Appraisal compliance rates are continuing to deteriorate with the rate being 57.72% at the end of April 2017. Renewed focus will be given to this target over the coming months as part of the revised accountability meetings with particular attention given to all senior managers having their appraisal as close to the start of the financial year as possible and other staff's appraisals being aligned to meet the peaks and troughs of operational demand. In addition there will be work undertaken in order to enhance the quality of appraisals - this will include a review of the paperwork being used (this should not detract from appraisals continuing in the meantime) and local work such as a questionnaire to capture the appraisee's experience and refresher training for appraisers. SET We have seen a slight reduction in compliance with Statutory and Essential Training the rate at the end of April being 68.42%. but generally the upwards trajectory continues. Staff in post At the time of writing the report this data was not available - data for March has been provided. A separate report details the vacancy rates across the Trust.
Workforce: Sickness Absence - March (Month 12)
Sickness Absence Occurences
Abs Rate = 4.46%
Days Lost = 7,586.37
Feb-17 Cumulative Benchmarking - Sickness Absence* February 2017 Days Lost % Rate Days Lost % Rate Doncaster & Bassetlaw NHS FT 6,538.09 4.26% 82,051.87 4.48% Chief Executive Directorate 0.00 0.00% 392.53 4.85% Children & Family Care Group 916.68 5.58% 10,905.96 5.52% Diagnostic & Pharmacy Care Group 621.75 3.69% 6,488.10 3.32% Directorate Of Strategy & Improvement 0.89 0.22% 48.83 0.98% Emergency Care Group 911.83 4.51% 11,885.77 4.99% Estates & Facilities Directorate 952.37 5.98% 13,369.84 6.84% Finance & Healthcare Contracting Directorate 60.57 3.05% 979.71 4.21% IT Information & Telecoms Directorate 81.91 2.69% 1,136.15 3.13% MSK & Frailty Care Group 611.40 2.74% 9,802.43 3.63% Medical Director Directorate 0.00 0.00% 5.60 0.24% Nursing Services Directorate 31.00 2.18% 838.27 4.84% People & Organisational Development Directorate 94.00 3.71% 708.25 2.41% Performance Management Directorate 302.89 5.42% 2,705.65 4.04% Speciality Services Care Group 755.40 4.57% 9,120.39 4.75% Surgical Care Group 1,197.41 4.30% 13,646.90 4.05% Trust Funds (included in Finance) 0.00 0.00% 4.00 0.85%
Top 10 Absence Reasons
Absence Reason Days Lost % S10 Anxiety/stress/depression/other psychiatric illnesses2,340.00 25.49 S13 Cold, Cough, Flu - Influenza 1,047.00 11.41 S12 Other musculoskeletal problems 999.00 10.88 S25 Gastrointestinal problems 793.00 8.64 S11 Back Problems 630.00 6.86 S98 Other known causes - not elsewhere classified 596.00 6.49 S28 Injury, fracture 552.00 6.01 S26 Genitourinary & gynaecological disorders 410.00 4.47 S99 Unknown causes / Not specified 303.00 3.30 S17 Benign and malignant tumours, cancers 286.00 3.12 Workforce: SET Training - March (Month 12)
SET Training
RAG: Below Trust Rate - Above Target - Above Trust Rate SET Training SET Training % Compliance Doncaster & Bassetlaw NHS FT 69.54% Chief Executive Directorate 74.43%
Children & Family Care Group 73.76%
Diagnostic & Pharmacy Care Group 75.47%
Directorate Of Strategy & Improvement 79.55%
Emergency Care Group 65.94%
Estates & Facilities 42.44%
Finance & Healthcare Contracting Directorate 72.60%
IT Information & Telecoms Directorate 79.41%
MSK & Frailty Care Group 80.78%
Medical Director Directorate 73.03%
Nursing Services Directorate 71.55%
People & Organisational Directorate 92.22%
Performance Directorate 32.91%
Speciality Services Care Group 74.13%
Surgical Care Group 75.35% Workforce: Appraisals - March (Month 12)
Appraisal Reviews RAG: Below Trust Rate - Above Target - Above Trust Rate % Completed Doncaster & Bassetlaw NHS FT 57.72 Chief Executive Directorate 35.71 Children & Family Care Group 70.95 Diagnostic & Pharmacy Care Group 77.28 Directorate Of Strategy & Improvement 16.67 Emergency Care Group 53.64 Estates & Facilities 26.94 Finance & Healthcare Contracting Directorate 7.14 IT Information & Telecoms Directorate 38.33 MSK & Frailty Care Group 77.08 Medical Director Directorate 62.50 Nursing Services Directorate 11.29 People & Organisational Directorate 86.73 Performance Directorate 46.00 Speciality Services Care Group 42.22 Surgical Care Group 65.98 Workforce: Staff in post - March (Month 12)
Staff in Post
Title Nursing Workforce Information
Report to: Board of Directors Date: 23 May 2017
Author: Moira Hardy, Acting Director of Nursing, Midwifery & Quality Rick Dickinson, Acting Deputy Director of Nursing, Midwifery & Quality
For: Information Purpose of Paper: Executive Summary containing key messages and issues This paper updates the Board of Directors on key issues relating to the Nursing Workforce, using information from the May 2017 UNIFY return which relates to April 2017 actual and planned hours:
• The workforce data submitted to UNIFY demonstrates the overall planned versus actual hours worked to be 100% for March 2017 Three wards, all at Bassetlaw Hospital, had a deficit in excess of 10% between planned versus actual hours worked. These wards are B6, A2 and Labour Ward and are due to lower occupancy, acuity and dependency of patients on Ward B6 and significant sickness absence on the maternity wards (A2 and Labour ward). Care Hours Per Patient Day (CHPPD) for April 2017 shows a slight increase from March data at 7.6 and this is seen for both registered and non-registered staff. Data held within the Model Hospital portal has not been updated since the previous report. The Trust position regarding safe nurse staffing and efficiency (Agency Capping) from TDA, Monitor, NHSE, CQC and NICE remains within the 3% cap and was at 2.2% for April, a slight increase from the March position. Workforce information and Quality and Safety profile meeting requirements of NHS England (NHSE), including How to ensure the right people, with the right skills, are in the right place at the right time (2013) and Safe staffing for nursing in adult inpatient wards in acute hospitals (2014) relating to Hard Truths demonstrates that no ward was rated Red for Quality in April 2017. • Key issues and actions include: • the continuing work of the Non-Medical workforce utilisation programme as part of DBH Strategy and Improvement programme • Exploring recruitment opportunities for nursing and midwifery
Recommendation The Board of Directors is asked to NOTE the content of this paper and SUPPORT the actions identified to ensure that the risks associated with inappropriate nurse staffing levels are appropriately managed.
Delivering the Values – We Care (how the values are exemplified by the work in this paper) We always put the patient first By delivering safe and effective care by providing staff who can be responsive and well led
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Everyone counts – we treat each other with courtesy, honesty, respect and dignity By listening to staff and patients when developing and evaluating quality and safety of care. Monitoring that care is delivered with compassion Committed to quality and continuously improving patient experience By developing and monitoring safe staffing levels and the quality of care provision Always caring and compassionate By providing staff with the right skills and ensuring that they are in the right place at the right time We monitor care is delivered with compassion Responsible and accountable for our actions – taking pride in our work By assuring ourselves that the quality of care meets the CQC standard. Having escalation processes in place when staffing, safety and quality vary from optimum levels Encouraging and valuing our diverse staff and rewarding ability and innovation By setting up systems and processes that avoid duplication and reward good practice Related Strategic Objectives Provide the safest, most effective care possible Control and reduce the cost of healthcare Focus on innovation for improvement Develop responsibly, delivering the right services with the right staff Analysis of risks Risks associated to the inability to recruit to establishment and develop staff to provide harm free care, delivered with compassion and of appropriate quality.
Risk associated with not meeting regulatory and commissioner requirement.
The risks identified have been mitigated by the use of temporary staffing to provide planned versus actual hours worked at 100% in April. Despite the use of temporary staff to maintain safe staffing levels the Trust has remained within the 3% agency cap. The main risk in relation to staffing continues to be the recruitment to Registered nurse and midwifery vacancies and opportunities to recruit are actively being explored.
Board Assurance Framework 3 Failure to deliver financial plan. 4 x 5 = 20
13 Inability to recruit the right staff and ensure that staff have the right skills to meet 4 x 3 = 12 operational needs.
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1. INTRODUCTION This paper provides the Board of Directors with detailed information relating to the Nursing Workforce; highlighting issues which may impact upon the Trusts ability to provide appropriate staffing levels and skill mixes. It also updates the Board of Directors on the implementation on Care Hours per Patient Day (CHPPD), which has been a required national return since 01 May 2016 and the data submitted to UNIFY.
This report also provides the Board of Directors with the Trust position in relation to the agency and frameworks caps from TDA, Monitor, NHSE, CQC and NICE
2. BACKGROUND This paper provides the DBHFT Board of Directors with the relevant information to consider staffing levels and skill mixes across the Trust. It provides the planned and actual workforce information, along with the Care Hours per Patient Day (CHPPD) for April 2017, which has been submitted to the UNIFY system, with additional information relating to the April Quality Metrics dashboard for each ward, focusing on those areas that require improvement.
3. WORKFORCE INFORMATION The workforce data submitted to UNIFY provides the actual hours worked in April 2017 by registered nurses and health care support workers compared to the planned hours. The Trusts overall planned versus actual hours worked was 100% in April 2017, similar to March.
3a. Actual versus planned staffing levels (based on daily data capture) The actual staffing levels for April were collected manually, mostly contemporaneously, and validated by the Matrons and Heads of Nursing (HoNs) retrospectively. The Matrons based the planned levels on the agreed planned staffing levels in the 2017/2018 funded establishments. The planned hours are adjusted each month to account for the number of days in the month. The fill rate includes shifts used to support escalation and closed beds.
Data collection for the planned staffing levels for intensive care, paediatric and midwifery areas has led to planned staffing levels being based on actual acuity and dependency requirements on a day by day basis to reflect occupancy levels.
The data for April 2017 (Appendix 1) demonstrates that the actual available hours compared to planned hours were: within 5% for 20 Wards (49%), five less than March between 5% – 10% for 16 Wards (39%) seven more than March surpluses over 10% for 2 Wards (5%) same as March deficits over 10% for 3 Wards (12%) two less than March
The wards where there were surpluses in excess of 10% of the planned hours are Gresley and Rehab 2; both wards requiring additional staff to support patients requiring enhanced care.
The wards where there were deficits in excess of 10% of the planned hours are B6, A2 and Labour Ward at Bassetlaw Hospital. The lower than planned staffing levels were due to:
Lower occupancy, acuity and dependency of patients on Ward B6 allowed staff to be safely moved to support other clinical areas. A2 and Labour Ward are due to significant staff sickness absence and vacancies. The service was optimised through the maternity service on call management and use of community staff to ensure safe services.
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3b. Care Hours Per Patient Day (CHPPD) From 01 May 2016, CHPPD has become the principle measure of nursing and healthcare support worker deployment. Utilising actual versus planned staffing data submitted to UNIFY and applying the CHPPD calculation the care hours for April 2017 are shown below, with a slight increase in the overall and registered midwives and nurses:
Care Hours Per Patient Day (CHPPD) – April 2017 Site Name Registered midwives/ nurses Care Staff Overall BASSETLAW HOSPITAL 4.9 3.1 8.4 DONCASTER ROYAL INFIRMARY 4.4 3.3 7.6 MONTAGU HOSPITAL 2.2 2.8 4.9 TRUST 4.3 3.3 7.6
The CHPPD care hours data from May 2016 – April 2017 remain relatively consistent, although April data is slightly higher.
Data held within the Model Hospital portal has not been updated since the previous report.
3c. Safe Staffing and Efficiency A cap of agency expenditure for registered general and specialist nursing staff, midwives and health visitors has been in place since November 2015. The annual ceiling for DBHFT has been set at the lowest level of 3% which is a reflection of the relatively low level of bank and agency usage when compared to
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the national picture. The Registered Nurse rate for April is 2.2%, an increase from March of 0.64%, but within the 3% cap level.
Information relating to the use of off-framework, high cost nursing agency staff continues to be reported to NHSI on a weekly basis, as does the work to eliminate the use of off framework agencies so that the Trust is compliant with the guidance.
3d. Nurse Manager Clinical Time To ensure that the HoNs and Matrons have a visible presence in the clinical areas HoNs have identified that they are aiming to work at least one clinical shift a month in one of their clinical areas, with the Matrons working two clinical shifts a month. This information is collected as part of the monthly Hard Truths returns. In addition senior sisters/charge nurses are expected to have 2 days per week as managerial/supernumerary time and this information is also being recorded monthly.
The Clinical and Supervisory Time in April 2017 was:
Care Group HoN Clinical Time Matrons Clinical Time Ward Supervisory Time Surgical MSK and Frailty Specialty Service Emergency Obstetrics and Gynae Children’s
All HoN’s and the Matrons who have been at work during April have undertaken their clinical time in order to support ward areas clinically, with the exception of Specialties Care Group, as the HoN was on a “phased return” following sick leave.
Approximately half of senior sisters/charge nurses have been unable to completely maintain their 2 days a week supernumerary time as they have been working clinically due to staffing and operational challenges during April.
3e. Quality and Safety Profile The Quality Metrics (appendix 1) for adult wards include 17 indicators that cover each of the five CQC Key Assessment Criteria (safe, effective, caring and responsive, with the overall score illustrating well led). The review of the Metrics has increased from 15 to 17 measures in 2017/18, mainly comprised of data that is collected for other purposes. For metrics that have continued from previous years, there has been a resetting of the baseline to the outturn of 2016/17, revising trajectories for CDI, PU, falls with harm and multiple falls. New measures for this year include the complaint/concern rate, category 2 pressure ulcers and the audit of appropriate fluid balance chart use linked with work to reduce the impact of acute kidney injury.
The quality data for April illustrates no wards being assessed as red for quality:
C2/CCU has a quality summit planned and Ward 25 has been reviewed with the Matron and Head of Nursing.
The quality summit process is a management meeting with the Matron and Head of Nursing for the relevant area, led by the Acting Deputy Director of Quality and Governance.
The 2016/17 end of year position for the Quality Assurance Tool outcomes is being finalised, with a presentation planned for a celebratory event on 26th May 2017.
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4. PLANNED ACTIONS AND KEY RISKS The major issue facing most acute hospitals nationally, and locally, continues to be the challenge of filling qualified vacancies. The actions to mitigate the risks which have been detailed in previous papers are continuing, along with systems and processes to meet the expectations outlined in the safe staffing and efficiency correspondence. These are:
The Trust has put measures in place to reduce use of non-framework agencies and to minimise the breaching of the price cap. Monitoring and use of escalation processes are in place to tightly control use of registered and non-registered agency usage Continue to progress the Non-Medical workforce utilisation programme as part of DBH Strategy and Improvement programme utilising enabling tools e.g. Calderdale Framework, including; • Challenging and reviewing skill mix to make better use of Non-registered staff exploring the development of extended roles • Reviewing the non-ward staff roles and responsibilities • Reviewing the wards with higher usage of specialling Provide further detailed comparison CHPPD data as this becomes available nationally Review the end of year position with QAT assessments and moderation process to determine final end of year classification. Continue to explore recruitment opportunities for nursing and midwifery
5. RECOMMENDATION The Board of Directors is asked to NOTE the content of this paper and SUPPORT the identified actions.
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APPENDIX 1: HARD TRUTHS May 2017 Paper e /Quality/Safety Profiles April 2017 Data
WQAT annual WQAT annual anned v Actu Safe Effective Caring Responsive Well Led Profile assessment 2015/6 assessment 2016/17
No of Quality Care Group Matron Ward Funded Variance Total Total Total Total QM total score Work-force Rating Rating Dashboard Beds
Surgical NS B6 16 71% 0.0 0.0 0.0 1.0 1.0 Jan-16 Jan-17 NS 20 27 106% 0.0 0.0 2.0 1.5 3.5 Dec-15 Nov-16 NS 21 27 96% 0.5 0.0 0.0 1.5 2.0 Jan-16 Feb-17 LM S12 20 95% 0.5 0.0 1.0 1.0 2.5 Apr-16 Mar-17 RF SAW 21 92% 0.5 0.0 1.5 1.0 3.0 Feb-16 Mar-17 LC ITU DRI 20 98% 0.0 0.0 0.5 2.0 2.5 Nov-15 Mar-17 LC ITU BDGH 6 91% 1.0 0.0 0.0 1.0 2.0 Jan-16 Jan-17 95% MSK and Frailty SS A4 24 106% 1.0 1.0 1.0 1.0 4.0 Mar-16 Mar-17 SS B5 30.7 93% 0.0 1.0 3.5 0.5 5.0 Feb-16 Apr-17 AH St Leger 35 107% 0.5 0.0 1.5 1.0 3.0 Mar-16 Mar-17 AH 1&3 23 108% 0.5 0.0 0.5 1.5 2.5 Nov-15 Mar-17 SS Mallard 16 106% 0.0 1.0 1.0 2.0 4.0 Nov-15 Jan-17 SS Gresley 32 113% 0.0 0.0 2.0 1.5 3.5 Feb-16 Mar-17 SS Stirling 16 101% 0.0 0.0 0.5 1.0 1.5 Oct-15 Feb-17 KM Adwick (rehab2) 29 123% 1.0 0.0 0.0 1.5 2.5 Feb-16 Mar-17 KM Wentworth (rehab1) 29 100% 0.0 0.0 0.0 2.0 2.0 Feb-16 Apr-17 106% Specialty Service JP 18 12 100% 0.0 0.0 1.0 1.0 2.0 Nov-15 Mar-17 JP 18 CCU 12 95% 0.5 0.0 0.0 1.5 2.0 Oct-15 Nov-16 AW 32 18 95% 0.5 0.0 2.0 2.0 4.5 Nov-15 Nov-16 AW 16 24 109% 1.0 0.0 1.0 2.0 4.0 Nov-15 Jan-17 RM 17 24 99% 0.5 0.0 3.5 2.5 6.5 Feb-16 Jan-17 JP CCU/C2 18 109% 1.0 0.0 0.0 2.5 3.5 Nov-15 Dec-16 RM S10 20 93% 0.0 0.0 1.0 1.5 2.5 Nov-15 Jan-17 RM S11 19 98% 1.0 0.0 1.0 2.0 4.0 Dec-15 Feb-17 101% Emergency MH ATC 21 96% 1.0 0.0 0.5 1.5 3.0 Dec-15 May-17 SS AMU 40 109% 1.5 0.0 1.0 1.5 4.0 Feb-16 Mar-17 MH A5 16 108% 0.0 0.0 0.5 2.0 2.5 Jan-16 Apr-17 MH C1 24 103% 1.5 0.0 0.0 1.5 3.0 Dec-15 May-17 SC 24 24 100% 1.5 0.0 1.5 1.5 4.5 Nov-15 Mar-17 SC 25 16 105% 1.5 0.0 0.5 2.5 4.5 Nov-15 Mar-17 SC Respiratory unit 56 99% 1.5 0.0 1.5 1.5 4.5 Nov-15 Mar-17 103% Children and Families AB SCBU 8 101% 0.0 0.0 0.0 0.5 0.5 n/a AB NNU 18 99% 0.0 0.0 0.0 2.0 2.0 n/a AB CHW 18 98% 0.0 0.0 0.0 0.5 0.5 n/a AB A3 14 0.0 0.0 1.0 0.0 1.0 n/a AB COU/CSU 21 97% 0.0 0.0 0.0 0.0 0.0 n/a SS G5 24 97% 0.0 0.5 1.5 1.0 3.0 Apr-16 SS M1 26 96% 0.5 1.0 0.0 1.5 3.0 Nov-15 Nov-16 SS M2 18 91% 0.0 0.5 1.0 1.5 3.0 Nov-15 Nov-16 SS CDS 14 91% 0.0 0.0 1.0 1.5 2.5 Oct-15 Jan-17 SS A2 18 89% 0.0 1.0 0.0 2.0 3.0 May-16 SS A2L 6 90% 0.0 0.0 0.0 1.5 1.5 May-16 95%
Trust Position 100%
Footnote: Paediatrics undertake a patient experience survey but will move to utilising FFT Appendix 1. Quality Indicator Metrics Measure Detail Parameters Red Amber Green Blue SI's (excluding pressure ulcers) number (avoidable) any none none Falls resulting in harm number per 1000 bed days per month against trajectory more falls than 2014/5 Same number of falls as last year less falls than last year (by 0.1-9.9%) less than trajectory exceeds 10% improvement and no avoidable Repeated falls number per 1000 bed days per month against trajectory more multiple falls than 2014/15 same number of repeated falls as last year within trajectory exceeds 10% improvement Clostridium Difficile number against trajectory plan exceeds trajectory within trajectory better than trajectory and no avoidable Safety thermometer - pt harms % new harms (new P ulcers, new VTE's and new UTI's) <92% harm free 92-93% harms free 93-95% harm free >95% harm free Pressure ulcers avoidable severe Pressure Ulcers exceeds trajectory within trajectory better than trajectory and no avoidable
Physiological observation audit Productive ward data until Safety Facilitators review <85% 85-94.9% >=95% >=98% FFT INPATIENT FFT net adopter - % positive scores Less than 94% 94% - 95.49% 95.5% - 96.99% 97% and above FFT Unlikely to recommend Greater than 1% 0.5% - 1% 0.1% - 0.5% 0% FFT response rate Less than 23% 23% - 29.49% 29.5% - 35.99% 36% and above FFT MATERNITY TOUCH POINT 1 FFT net adopter - % positive scores Less than 91% 91% - 94.49% 94.5% - 97.99% 98% and above FFT Unlikely to recommend Greater than 2% 1.5% - 2% 1% - 1.49% Less than 1% FFT MATERNITY TOUCH POINT 2 FFT net adopter - % positive scores Less than 93% 93.01 - 95.49% 95.5% - 97.99% 98% and above FFT Unlikely to recommend Greater than 1% 0.5% - 1% 0.1% - 0.5% 0% FFT response rate Less than 38.5% 38.5% - 64.99% 65% - 76.99% 77% and above FFT MATERNITY TOUCH POINT 3 FFT net adopter - % positive scores Less than 86% 86% - 91.49% 91.5% - 96.99% 97% and above FFT Unlikely to recommend 4% and above 2.6% - 3.99% 1.0% - 2.59% Below 1% FFT MATERNITY TOUCH POINT 4 FFT net adopter - % positive scores Less than 80% 80.01% - 89.99% 90% - 98.99% 99% and above FFT Unlikely to recommend 2.0% and above 1.5% - 1.99% 1.0% - 1.49% Below 1%
No red indicators OR 2 Blue Indicators OR 1 amber, 1 green 1 1 Red indicator OR 2 Amber indicators 2 or more blue indicators with 1 green indicator OVERALL RATING 2 or more Red Blue
Patient discharges 35% discharges before 12 noon < 2014 between Trust 2014 result and 35% meet target of 35% Meet 35% target and a 10% improvement on 2014 ward result Length of Stay reduce LOS by 10% based on 2014/5 out-turn > LOS from 2014/5 A longer LOS than Dr foster case mix adjusted LOS but improved by 10% from 2014/5 At the Dr Foster case mix adjusted LOS or less Lower than Dr Foster case mix adjusted LOS by 10%exceeds 10% improvement and no avoidable
Appraisal rolling 12 month appraisal rate <65% 65%-89% >90% >92% Statutory and Essential to Role training rolling SET training rate <65% 65%-89% >90% >92% E roster effective time should be 76% >80% or less than 70% 77-80% or 75-70% 75-77 green for 6 months Complaints attributed to Care Group Care Group rather than ward level > complaints than 2014/5 Same number as 2014/5 less complaints than 2014/5 less complaints than 2014 and exceeds 10% improvement
No avoidable Results in top 10% consistently - 75% of time including 2 months prior to assessment Results above 2014/15 and through assessment period with 50% being in top 20% Results above 2014/15 and through assessment period but not in top 20% results below 2014/5
Title Corporate Risk Register and Board Assurance Framework
Report to: Finance & Performance Committee Date: 22 May 2017 Board of Directors 23 May 2017
Author: Matthew Kane, Trust Board Secretary
For: Noting Purpose of Paper: Executive Summary containing key messages and issues This report presents the Q4 Board Assurance Framework and Corporate Risk Register which is used to inform the Annual Governance Statement.
Recent changes
The attached BAF and risk register were subject to an end of year review with executives at the end of March 2017. Since the Board last received the BAF, it has been reviewed by sub- committees of the Board on 24 March (ANCR) and 18 April (CGOC) with ratings adjusted accordingly. The Corporate Risk Register has also been reviewed by the Management Board each month.
Annual review
With the Trust in the midst of Turnaround, the early part of 2016/17 saw the main risks relating to delivery of finance and Turnaround plans and compliance with the regulatory framework (risks 1-4). With the Trust coming in significantly better than plan, successive audits showing “Significant assurance with minor improvement opportunities” and a return to more business as usual activity a number of these risks began to see ratings reduced (see tables below).
Above: Location of risks April 2016 Above: Location of risks March 2017 * Denotes new risks
At the same time, new risks were escalated. One was around Board transition, arising from the changes to the chair, chief executive, director of finance and non-executive director roles (shown as Risk 16 above). This was largely mitigated through robust selection processes, induction, pre- commencement shadowing and ongoing training and development.
A further risk was around the potential for a cyber-attack which has been realised at national level but from which DBTH remained unaffected due to the current controls in place. Whilst the risk of attack remains high, the report to this Board on controls in place and actions taken from the incident, should give Board assurance that the risk is being managed.
In Q3, the Board Assurance Framework and Corporate Risk Register were subject to a number of recommendations from the Well Led Review. Principally, the Trust’s BAF is atypical with much of the ‘assurance content’ contained within the risk register. Work has already commenced on a new BAF and CRR with a risk mapping exercise planned for Finance and Performance Committee on 22 May looking at:
- the financial and operational performance risks for 2017-18; - inherent and current ratings; - controls, gaps and required actions.
Similar exercises are planned for meetings of ANCR and QEC. This will result in two separate reports to future Board meetings. A remodelled Board Assurance Framework will show the risks to each of the strategic objectives while the corporate risk register will show the key corporate risks managed by each of the Board committees. The risk architecture and escalation flow will be as shown below:
Board of Directors has oversight of BAF and CRR
Board committees manage relevant CRR risks Finance and Performance Quality and Effectiveness
(ANCR checks the policy and system is working)
Management Board
Consider risks escalated from departmental risk registers
and decide whether to include on CRR
Departmental Risk Registers
Recommendation
That Board notes the end of year position and plans for the revamped BAF and CRR.
Related Strategic Objectives
Provide the safest, most effective care possible Control and reduce the cost of healthcare Focus on innovation for improvement Develop responsibly, delivering the right services with the right staff
Board Assurance Framework Summary – As at March 2017
Please note that where assurance is listed as ‘limited’, this may be due to a number of different reasons. Assurance activities may indicate that controls are inadequate, but assurance may also be limited simply by scope or date. The notes column provides further context where required.
Sources and levels of assurance 2016/17 Internal Inherent Residual Risk Overall Notes / context audit plan – future Rating Rating Operational / Internal Other Comm. Management audit independent audits 1 Failure to achieve ANCR 25 16 Limited None None Limited Core financial compliance with financial systems performance aspects of Finance Team Structure the Monitor Risk Review of CIPs Assessment Framework Strategy and and provider licence, Improvement Plans triggering regulatory action 2 Failure to deliver accurate ANCR 25 16 Limited Limited Limited Limited Core financial financial reporting (f) systems underpinned by effective Finance Team Structure financial governance Payroll Systems / Payroll analytics 3 Failure to deliver financial ANCR 25 4 Limited None None Limited Review of CIPs plan Strategy and Improvement Plans 4 Failure to deliver Cost FinOC 25 6 Significant Limited Significant Significant Risk rating revised in Review of CIPs Improvement Plans in this (b) view of 2016/17 Review of the PMO financial year leading to position and Function impact on Turnaround combined with old risk 5 around Failure to deliver turnaround / cost reduction programme.
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Sources and levels of assurance 2016/17 Internal Inherent Residual Risk Overall Notes / context audit plan – future Rating Rating Operational / Internal Other Comm. Management audit independent audits 5 Failure to ensure that ANCR 25 20 Limited Limited Limited Limited Limited due to appropriate estates (a, b) number of high risk infrastructure is in place issues identified. 6 Risk of failing to address CGOC 25 12 Significant Limited None Limited Assurance limited by Workforce Strategy / the effects of the medical scope and reported safer staffing levels / agency cap, leading to breach position. agency staffing and agency cap / gaps in medical rotas. recruitment and retention / absence management E-rostering 7 Failure to engage and ANCR 20 12 Significant Limited Significant Significant Rating revised down communicate with staff (b, f) in view of improved and representatives in staff side relation to immediate relationships. challenges and strategic development 8 Failure to achieve CGOC 25 16 Significant Significa Significant Significant CQC process / compliance with nt (a, b, c, d) compliance performance and delivery DataQuality / performance aspects of Monitor Risk indicators Assessment Framework, CQC and other regulatory standards, triggering regulatory action
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Sources and levels of assurance 2016/17 Internal Inherent Residual Risk Overall Notes / context audit plan – future Rating Rating Operational / Internal Other Comm. Management audit independent audits 9 Failure to sustain a viable CGOC 20 12 Limited None Significant Significant Assurance is specialist and non- (b) significant in relation specialist range of to service quality, services. although there is a high level of uncertainty /risk relating to future service models across the region. 10 Failure to deliver accurate CGOC 16 12 Significant None Significant Significant CaMIS, Medical and timely performance (f) Records information through Management, booking CaMIS system. management Data Quality / performance indicators 11 Breakdown of ANCR 20 12 Significant Limited Significant Significant Internal audit relationship with key (e, g) assurance is limited partners and by scope. stakeholders 12 Inability to recruit right ANCR 20 12 Significant Limited Significant Significant Limited IA assurance Workforce Strategy staff and ensure staff (c, d) due to scope of Education strategy have the right skills to work. meet operational needs 13 Failure to ensure business ANCR 20 8 Limited Limited None Limited continuity / respond appropriately to major incidents 14 Risk of Fraud ANCR 25 6 Limited Limited Significant Significant Core financial (b, g) systems
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Sources and levels of assurance 2016/17 Internal Inherent Residual Risk Overall Notes / context audit plan – future Rating Rating Operational / Internal Other Comm. Management audit independent audits 14 Trust becomes non- ANCR 25 15 None None None None a operational due to cyber attack 15 Risks from board ANCR 20 8 Significant Limited Significant Significant leadership transition (b) including new Chair and Chief Executive, Director of Finance and non- executive directors
Sources of assurance used in ‘Other independent’ column:
(a) Inspections/ reviews by regulators (b) Reviews / inspections / assessments by other external bodies (c) Patient or staff surveys (d) Independent empirical evidence / outcome measures (e) Partnership exercises / peer reviews (f) External audit (g) Other external assurance (e.g. via consultancy support)
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No. Risk Lead Risk Current Risk Existing Controls Gaps in Control Assurance Gaps in Assurance Actions to address gaps Milestones / timescale for Target Risk Previous / Proposed BAF CRR Director Source Rating completion Rating Changes
Potential Actual
DATIX REF. DATIX
StrategicGoals
Q3 Risk Rating Risk Q3
Likelihood Consequence Rating Likelihood Consequence Rating
1 12423 Failure to achieve 1, DF Exec 4 4 16 20 (i) Business and budget planning (i) Difficulty in sourcing - Board finance reports (i) Financial plans for 2016/17 Timescales for the 5 Finalise budget end of 31/03/2017 2 4 8 22/3/2017 - Ratings BAF compliance with 3, CRR Team processes medical staffing will - Quarterly NHSI shared with NHSI. year plan confirmed March and assurance financial 4 (ii) Financial governance policies and impact on providing a declarations with NHSI and whether May 2017 reviewed performance procedures safe and sustainable - NHSI financial (ii) Financial performance to they are aligned with Work with STP to ensure aspects of the (iii) Monthly monitoring of financial service on one or more sustainability risk rating January 2017 shows a favourable the STP. synchronicity with Trust 8/12/2016 - Updates Monitor Risk performance sites and could impact calculation variance against plan of £9.0m. plan to controls and Assessment (iv) Data analysis of trends and action on performance. - Annual report and assurance Framework and to address deterioration accounts (iii) Draft financial plan submitted provider licence, (v) Continued liaison with budget (ii) Paying in excess of - CE Objectives quarterly end of August. 28.07.16 - Control triggering holders to identify risks to delivery cap will have an reports gaps and assurance regulatory action (vi) Demand and capacity planning adverse impact on the - External audit of annual (iv) Revised financial plan for revised to take proccesses financial position. accounts 2017/18 and 2018/19 to be account of changing (vii) Detailed monitoring by Financial - Internal audit submitted by 23 December. situation Oversight Committee and Cash (iii) The Trust is programme Committee undertaking a review - Production of annual 29.03.16 - Risk into an analysis of its budget 2017/18 added to register to long term financial reflect specific position. Until this has financial element of been formulated it is regulatory risk not possibe to confirm 28.07.16 - No whether the Trust is change financially viable in the medium to long term.
2 17 Failure to deliver 2 DF Exec 4 4 16 16 (i) Checklist of control accounts (i) Gaps in capacity - Internal audits by (i) External audit of accounts for (i) Work on (i) Monitoring through the Budget completed by 2 4 8 22/3/2017 - BAF accurate financial CRR Team reviewed by the Financial Oversight within the finance KPMG 2015/16 did not require implementation of the Financial Oversight end of March Assurance reviewed reporting Committee on a monthly basis team which are - External audit by E&Y adjustment as the unadjusted general ledger could Committee and ANCR. underpinned by (ii) Board report reconciled to general reflected in the new as part of 2016/17 differences were not material have a destabilising (ii) Key interims kept within Interim year end audit 8/12/2016 - Updates effective financial ledger on a monthly basis structure. Key posts accounts (ii) Consistency of reported impact on the organisation of EY - March 2017 to controls and governance (iii) All CIPs reported as actioned have are covered by interim results in months 1-10 of department assurance been through budget retraction. staff. 2016/17 do not indicate any risk (ii) Loss of interims may Implementation of SBS - Reconciliation of CIPs still to be (ii) New structure of financial misreporting result in loss of 1 April 2017 28.7.16 - achieved to negative budgets in the signed off by (ii) A risk mitigation strategy to corporate memory Comprehensive ledger Management Board be developed as part of the Final accounts - end of updating and change and being migration timetable to July 2017 in risk rating to implemented. implement the outsourcing to reflect changing Management Accounts SBS situation. element of structure (iv) Governance structure in under review. place to support migration to SBS 29.03.16 - Risk (iii) Increased risk (v) Completion of M9 accounts added to register to through increased reflect specific risk of management focus on failing to improve SBS system financial governance (vi) Gaps in corporate and reporting. memory
3 11 Failure to deliver 2 DF Exec 1 4 4 16 (i) Budgets set on recurrent outturn - Board discussion and Financial performance to January None None 2 4 8 22/3/2017 - Ratings BAF financial plan CRR Team resulting in a more robust financial approval of the 2017/18 2017 shows a favourable and assurance plan. Budget setting process reviwed budgets variance against plan of £9.0m reviewed through the Financial Oversight - Budget setting Committee. principles and process 8/12/2016 - Updates (ii) Budgets signed off by care groups approved by Financial to controls and and corporate departments Oversight Committee assurance (iii) Baseline budgets reviewed by - Monthly Board Finance KPMG as part of the Financial reports 28.07.16 - Risk Improvement Plan work - Minutes of further downgraded (iv) Monthly monitoring at Board and accountability, grip and to 12 based on directorate level control, Turnaround financial (v) Uncommitted general contingency Programme Board and performance for Q2 reserve . Performance Review (vi) Regular financial acountability and meetings with NHSI 29.03.16 - Risk grip and control meetings regarding - External Audit review of downgraded to 20, financial performance financial performance and governance and (vii) Turnaround programme board (within Annual Accounts CIP elements taken and robust governance arrangements work) out to form separate over delivery of the CIP plan risks. (viii) Performance review meetings with NHSI. (ix) All directorates signed up to control totals
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No. Risk Lead Risk Current Risk Existing Controls Gaps in Control Assurance Gaps in Assurance Actions to address gaps Milestones / timescale for Target Risk Previous / Proposed BAF CRR Director Source Rating completion Rating Changes
Potential Actual
DATIX REF. DATIX
StrategicGoals
Q3 Risk Rating Risk Q3
Likelihood Consequence Rating Likelihood Consequence Rating
4 Failure to deliver 2, DSI Exec 2 3 6 9 (i) CIP delivery supported by: - Quarterly CE objectives - Rapid Cost Reduction & - Previous CIP - Support through PMO - Achievement of CIP's 2 4 8 22/3/2017 - Ratings BAF Cost Improvement 3, CRR Team - full Quality Risk Assessment and reports turnaround report performance office to progress CIP by end of each month, and assurance Plans in this 4 operational deliverability assessment - CE Reports to BoD - At month 11 still ahead of plan - Not all cost reduction schemes as part of and quarter aginst reviewed financial year of plans. - Business Intelligence - Performance against CIP for initiatives are at delivery Turnaround phasing and CIP Tracker leading to impact (ii) Governance structure inc. bi- Reports 16/17 of £11.9m (3%) /outcomes stage. - Establishment of new New dates proposed to 9/12/2016 - Risk on Turnaround weekly Delivery and Accountability - FinOC cost reduction - Monthly turnaround reports Turnaround Programme NHSI are: rating revised in and bi-weekly Finance Accountability reports (FinOC) Board - 5 year Financial view of 2016/17 meetings led by TD . - Internal & external - KPMG enaged through FIP - Progress against CIP Sustainibility Strategy position and (iii) Grip & Control meetings provide audits programme to undertake Phase Tracker at fortnightly 17 February 16 combined with old quarterly monitoring at individual - Reported progress One and Pre-Planning for Phase Financial Accountabilty risk 5 around Failure scheme, Care Group / Directorate and against Monitor Two work to support Trust in meetings to deliver Trust levels. Undertakings Turnaround. Their report to the - Quarterly Grip and Control turnaround / cost (iv) Collaboration with other Trust in July detailing their meetings reduction providers, to identify joint baselining approach, including programme. opportunities. run rate and care group (v) CIP tracker developed to provide establishment analysis, provided 28.7.16 - Risk rating visibility of progress agianst plan increased assurance to NHSI downgraded to (vi) Phasing of 16/17 CIP (33:67 half over the Trust’s ability to meet its reflect additional year forcast) control total, subject to ongoing assurance in Q1 (vii) Engagement in working together grip & control, and pace around 2016/17 programme CIP implementation. (viii) PMO, with associated - NHSI have agreed no further 29.03.16 - Risk management processes, key work is required by KPMG as part added to register to deliverables, risk logs and reporting to of the FIP programme. reflect specific risk of FinOC. - Provided high level assurance not delivering CIP in (ix) Implementation of innovation to NHSI - last meeting in March 2016/17 from external reviews 2017 (x) Regular meetings with Monitor to track progress against Monitor Undertakings
5 12 Failure to ensure 2, DoEF Exec 5 4 20 20 (i) Annual business plan supports - Board briefing sessions - Monthly capital expenditure 2014 external report Development of Estates 2016 onwards 2 4 8 22/3/2017 - BAF that appropriate 3 CRR Team identification of issues by Care Groups - Capital Expenditure reports (Canty) highlighted condition operational risk Controls and estates / Directorates reports - Estates report to ANCR compliance issues and investment assurance reviewed infrastructure is in (ii) Risk-based capital investment plans - Internal Audit reports (18.03.16) reporting remedial requrements – short term place (revised Oct 16) Coporate Investemtn - Internal risk assessment reports action. Estates Strategy. Currently 9/12/2016 - Risk (iii) Revised business planning process Committee (CIG) from - 2015 PLACE Assessment & Nov 2015 - 360 in draft, requires validation rating changed from for all capital investments to be 2017 update report (ii) Assurance audit – quotes being sought L4 x C5 to L5 x C4. completed for consideration by end of - Newly introduced 1/4 - CE Objectives report (quarterly) highlighted remedial March 17, paper to ANCR April new Corporate Investment estates report to Board (i-ix) action and BOD June 17 28.07.16 - Action to Group (CIG) and supporting structure - Revised Trust health -Director of EFM Objectives, address gaps in place and safety committee agreed Dec 16 (quarterly) Ongoing action: updated. (iv) Business continuity and disaster TOR’s, and introduction - Completed 6/7 facet recovery plans of Estates & Facilities survey. 29.03.16 - Risk (v) Process for post project Health & Safety - Asbetos and window upgraded to 20. implementation review for all major Committee from Feb 17 surveys complete. schemes being developed - Estates strategy in draft - Asbestos management 04.02.15 - gaps and (vi) Progress and monitoring of actions 2017 – 2022, to be plan up to date. actions updated. undertaken through compliance completed by June 17 - Window risk assessments committees. complete. - Fire strategy drawings completed and programme commenced. - Fire risk assessments for MMH EWB and womens and childrens complete and progress commenced. -Water management protocols complete and progress commenced. - Electrical infrastructure surveys complete.
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No. Risk Lead Risk Current Risk Existing Controls Gaps in Control Assurance Gaps in Assurance Actions to address gaps Milestones / timescale for Target Risk Previous / Proposed BAF CRR Director Source Rating completion Rating Changes
Potential Actual
DATIX REF. DATIX
StrategicGoals
Q3 Risk Rating Risk Q3
Likelihood Consequence Rating Likelihood Consequence Rating
6 1245 Risk of failing to 1, MD / Exec 3 4 12 12 (i) Enhance recruitment of medical (i) Unfilled training Workforce plan - Finance Reports - Absence of tracker - Develop new service 16/17 2 4 8 9/12/2016 - Rating BAF address the effects 4 CRR DOPD Team staff including international posts - P&OD / Workforce reports to system model to mitigate medical revised with of the medical recruitment. (ii) Unexpected leave BoD staff shortage additional assurance agency cap, leading (ii) Improve recruitment timescales (sickness, - Workforce and Education - Develop and progress 16/18 to gaps in medical (iii) Care Group to escalate compassionate) Committee workforce from using 28.07.16 - Additional rotas recruitment difficulties to MD/COO (iii) Difficult to recruit - Agency spend and breaches alternative workforce for control added (v) (iv) Use of Trust staff in first instance specialties going to Exec Team and FinOC service delivery to address gaps wherever possible - Better system around rate-to-fill - Agree with Trust in WTP to 29.03.16 - Risk (v) Signed memo of understanding and fill rates minimise cap breaches added to corporate between all Trusts in the WTP to abide - Ensure patient safety and risk register by a standard set of principles quality - Decrease local agency spend - New Holt agency supplier
7 19 Failure to engage 4 DPOD Exec 3 4 12 12 (i) HR/Communication plans Formal engagement - Staff Survey results - Casework reports (ANCR, No KPIs agreed other - Staff survey action plans Monthly monitoring. 2 3 6 22/3/2017 - CRR and communicate BAF Team supporting change strategy still in - Grievance and quarterly) (iv) than staff survey results. (corporate & local). Care Controls and with staff and (ii) Process to engage with LNC development. employment tribunal - P&OD reports (BoD, quarterly) Group action plans being assurance reviewed representatives in (iii) Process to engage with JSCC rates (i-v) developed. relation to (iv) HR policies and procedures - Outcomes of - Briefings regarding staff 9/12/2016 - Rating immediate (v) staff engagement project strands negotiation & work with engagement during restructures - Development of March 2017 revised down in view challenges and (vi) monitoring and challenge of staff staff side. (i) engagement plans as part of of improved staff strategic survey actions via accountability - Delivery of engagement - Records of ongoing a refreshed People & OD side relationships development meetings plan KPIs. engagement via JSCC (iii) Strategy (vii) Communications strategy for 29.03.16 - Risk turnaround plan - Listening events led by the March 2017 reframed and CEO upgraded to 16
28.04.15 - risk rating downgraded to 6 following executive team review.
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No. Risk Lead Risk Current Risk Existing Controls Gaps in Control Assurance Gaps in Assurance Actions to address gaps Milestones / timescale for Target Risk Previous / Proposed BAF CRR Director Source Rating completion Rating Changes
Potential Actual
DATIX REF. DATIX
StrategicGoals
Q3 Risk Rating Risk Q3
Likelihood Consequence Rating Likelihood Consequence Rating
8 7 Failure to achieve 1, COO Exec 4 4 16 16 (i) Performance Management and - Shortfalls in capacity - Quarterly CQC - 2015/16 Monitor declarations A&E performnce Q4 - Outsourcing of work to 2 4 8 22/3/2017 - BAF compliance with 3, CRR Team Accountability Framework. identified. compliance reports (i-vii) address shortfalls in Controls and performance and 4 (ii) Business planning processes - Workforce tracker - Compliance - Full and unconditional capacity, alongside work to assurance reviewed delivery aspects of (iii) Relevant policies and procedures performance reported in registration with CQC (viii) recruit staff Monitor Risk (iv) Daily, weekly & monthly Care Group dashboards / - CQC Inspection result, April 9/12/2016 - Assessment monitoring of targets BIR 2015 (viii) Controls and Framework, CQC (v) Regular monitoring of compliance - Business Intelligence - Business Intelligence Reports assurance reviewed and other (vi) Data analysis of trends and action Reports (BoD - monthly) (i-vii) regulatory to address shortfalls - Quarterly Monitor - Annual Report & Quality 28.07.16 - Actual standards, (vii) Continued liaison with leads to declarations Account 2015/16 (i-vii) assurance and triggering identify risks to delivery - Annual reports - CQC health-wide inspections of milestones and regulatory action (viii) CQC Compliance Governance and safeguarding 2014 & 2015 (viii) timescales updated Assurance Process - CE quarterly objectives report (ix) External reviews policy (BoD - quarterly) (i-ix) 29.03.16 - - Risk (x) Monitoring at monthly Care Group - CQC internal audit (viii) added to register to accountability meetings. - Infection Control internal audit reflect specific (xi) A&E QAT process (i-vii) performance/ (xii) Demand and capacity planning - CQC Intelligent Monitoring delivery element of proccesses reports & risk ratings (viii) regulatory risk (xiii) Weekly review of A&E Action plan - Duty of Candour Update Report in accountability meeting chaired by (Feb 2015) (viii) COO. - In Group 2 on four hour waits - A&E Improvement Progarmme North - example of best practice
9 10 Failure to sustain a 1, MD Exec 3 4 12 12 (i) Participation in WTP - NHS England - External reviews - Peer review programe Issues in vasuclar still - Strategic review of In progress 3 4 12 22/3/2017 - BAF viable specialist and 3, CRR Team (ii) Local commissioner commissioning - Patient outcome and outcome (9 June 2016) unresolved - meetings specialised services in Y&H Controls and non-specialist range 4 engagement intentions service quality - Patient outcome and service taking place with STH. currently in progress. assurance reviewed of services. (iii) Involvement/influence NHSE - National Service quality as published by National (external action) commissioning intentions. Specification and size Registries - Due to report in 28.07.16 - Actual (iv) R & D support for specialist of catchment September assurance and services population actions to address (v) Ensure specialist service delivering - Vascular services not gaps updated high quality care. compliant with (vi) Quarterly Executive discussions national service 29.03.16 - Controls, with STH specification assurance and (vii) Contribution to reconfiguration - Renal dialysis actions updated. discussions footprint is small (viii) Consultant led paediatric 16.02.16 - actions assessment service in place updated.
14.04.15 - actions updated.
10.10.14 - actions updated.
10 14 Failure to deliver 1, COO Exec 3 4 12 12 (i) CaMIS support available from EMIS Review lists need input - Business Intelligence - Information flows correct from - Seeing a stablisation in Q4 2016/17 2 4 8 22/3/2017 - BAF accurate and timely 2, CRR Team (ii) Weekly PAS user group from EMIS to be Reports data warehouse, validation CaMIS, working to continue Controls and performance 3 (iii) Reports now available for all completed - Performance exercise completed. Action plans to ensure correct data assurance reviewed information elements management for data quality agreed. - Focus on education through CaMIS (iv) Information working group information reported - CaMIS post implementation 9/12/2016 - system. reviewing key datasets internally and externally review completed November Controls and (v) Revalidation exercise completed - Internal Audit reports 2016 assurance updated (vi) Weekly monitoring of activities - Coding Audits - Bariatric work moves to CCG - Records audits and arrangements in place for 28.07.16 - Action to renal. address gaps - Validation of 14 week waits updated
29.03.16 - Risk reframed to focus on CaMIS and downgraded to 12.
November 15 - risk increased to 16 due
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No. Risk Lead Risk Current Risk Existing Controls Gaps in Control Assurance Gaps in Assurance Actions to address gaps Milestones / timescale for Target Risk Previous / Proposed BAF CRR Director Source Rating completion Rating Changes
Potential Actual
DATIX REF. DATIX
StrategicGoals
Q3 Risk Rating Risk Q3
Likelihood Consequence Rating Likelihood Consequence Rating
11 18 Breakdown of 4 CEO Exec 3 4 12 12 (i) Partnership working processes Leadership transition - CE Reports - CE Reports (i-ix) 2 4 8 22/3/2017 - CRR relationship with BAF Team including team Doncaster and at the Trust and across - Outcomes of contracts - Updates on HWB activity (BoD) Controls and key partners and Bassetlaw Integrated Care Board partnership negotiations (iv) assurance reviewed stakeholders (ii) Engagement in Working Together - Peer reviews of local - Updates regarding Working programme (chairing HR Group and authority services Together and STP programme via 9/12/2016 - member of CE steering Group) - Peer reviews of Health CE report (BoD) (ii) Assurance updated. (iii) Engagement with Commissioners and Wellbeing Board - Doncaster Better Care Fund & other local trusts - Feedback from CCGs application approved 08.09.14 - Likelihood (iv) Engagement with two Health and - CQC Visit Report - Nottinghamshire Better Care increased to 2, Wellbeing Boards - NHSI reports under Fund approved resulting in a current (v) Attendance at CCG governing body enforcment - Successful Working Together and target risk rating meetings arrangements Vanguard New Care Model of 8 (high). (vi) CE meetings with NHS England application (Sep 2015) (vii) Regular monthly briefings to local - Support from commissioners in authorities members of parliament relation to cash position. (viii) Partner Governor seats on the - Bassetlaw and Doncaster Place Board of Governors Plans endorsed. (ix) Engagement in Working Together - Final sign off of consolidation of (and associated Vanguard work) back office work. Engagement with SYB Sustainability - Well Led Governance Review and Transformation Planning process reinforces the Trust's partnership at multiple levels including CE leading arrangements. Cancer Workstream - Approval in principle of committees in common work - Involvement of Trust in Place Plan activity
12 16 Inability to recruit 1, DPOD Exec 4 3 12 12 (i) HR policies and procedures - Training needs Achievement of - Nursing Workforce Reports Workforce tracker - e Roster / NHSP system Ongoing cohort 3 3 9 22/3/2017 - BAF right staff and 4 CRR Team (ii) Monitoring of use of agency staff analysis required eRostering KPIs (monthly) (i-vii) interface implementation recruitment - ongoing Controls and ensure staff have through robust processes to stay - Lack of processes to - Compliance reports - P&OD reports (quarterley) (i-vii) - Cohort recruitment for Development of assurance reviewed the right skills to within cap support values based - OLM reports - Quarterly suspensions & HCA, NQ and RN. workforce planning meet operational (iii) Medical staff recruitment action recruitment - reports on reduced exclusions report (ANCR) (i) - Establish processes to processes - 2017/18 9/12/2016 - Risk needs plans - Robust workforce agency usage - CE Objectives report (BoD, support values based International rating revised in light (iv) Care Group Business Plans – planning processes - Outcomes from quarterly) (i-xii) recruitment recruitment - March of additional workforce plans required turnaround workstreams - HEE Y&H multiprofessional QA - International recruitment 2017 assurance (v) E-Rostering processes (and make better use of visit 2016 (iii-iv) - Transactional recruitment implementation of eRoster v10) resources - Staff survey (annual and process redesign project 28.7.16 - Controls (vi) VCF processes - Achievement of health quarterley FFT) (i-xii) - Training Needs Analysis updated (vii) Consultant appointment approval and well-being CQUIN - RCP national audit of NICE underway processes - Continued Achievement public health guidance for the - Development of robust 14.04.15 - actions (viii) NHS Professionals processes & of HWB awards - bronze workplace (i) workforce planning updated. management information level achieved - Workforce data quality audit processes (ix) New recruitment processes (ANCR Dec 2015) - Review international 08.09.14 - Likelihood (x) Calderdale framework - 9 funded recruitment increased to 4 and training places for DBH staff, consequence commenced Oct 2014 reduced to 3; risk (xi) Turaround workstreams and their rating of 12 (high) impact on workforce unchanged. (xii) Processes to ensure compliance with 'Hard Truths'. (xiii) Increase in placements for professional programmes e.g. medical students, Physcians Associates, Pre- registration nursing students. (xiv) Pilot of Assistant Practitioner role and possibly Associate Nurse
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No. Risk Lead Risk Current Risk Existing Controls Gaps in Control Assurance Gaps in Assurance Actions to address gaps Milestones / timescale for Target Risk Previous / Proposed BAF CRR Director Source Rating completion Rating Changes
Potential Actual
DATIX REF. DATIX
StrategicGoals
Q3 Risk Rating Risk Q3
Likelihood Consequence Rating Likelihood Consequence Rating 13 20 Failure to ensure 1, COO Exec 2 4 8 8 (i) Business continuity plans - Peer review of plans - Joint multi-agency desk top - Further work required 2 4 8 22/3/2017 - business continuity 4 BAF Team (ii) Business Continuity Policy - Response to incidents exercise March 2014 testing the to expand training and Controls and / respond (iii) Statement of Compliance against - EPRR assurance process management of significant staff exercising schedule assurance reviewed appropriately to National Core Standards for EPRR - Mass casualty testing shortages (i-v) beyond the minimal major incidents (iv) Severe Weather Plan - Joint multi-agency desk - Response to incidents & requirements. 9/12/2016 - (v) BRSG which monitors BC planning top exercise business continuity challenges - Evacuation exercise Controls and progress - Evacuation plan for East 2014 (power outage, fire, flood, required. assurance reviewed. (vi) Business Continuity Group linked Block industrial action etc.) (i-iii) to operational structures - Annual confirmation of 28.07.16 - Actions to (vii) Major Incident Plan compliance against National Core address gaps (viii) Training of A&E staff on CBRN Standards for Emergency updated incidents Preparedness, Resilience and (ix) Emergency response plans in place Response (BoD, Nov 2016) (i-vi) 29.04.15 - Business (annually reviewed) - Test exercises: Sickness, fuel continuity and major - Evacuation of a hospital site (2016) incident risks - Mass Casualty Plan - Internal Audit follow-up review merged. - Pandemic Influenza Plan of business continuity - Prison Plan arrangements (i-vi) 02.01.15 - Actions - CBRNE plan - Risk assessment of major updated. (x) Statement of Compliance against incident and business continuity National Core Standards for EPRR plans with NHS England (2015) 08.09.14 - Likelihood (xi) Incident Control Room in line with -Y&H peer review of major increased to 2 and EPRR Command and Control incident plans 2016. consequence guidelines - External review of HAZMAT - reduced to 4, (xii) Communications exercises compliant (September 2015) resulting in a current undertaken twice yearly as required - EPRR assurance process (Q4 and target risk by statute 2015-16) rating of 8 (high). (xiv) Command & control training for - Hazardous Substances policy BoD & senior managers on-call agreed by Board 29.11.2016 (xv) Revision of plans following test - Tabletop exercises undertaken, exercises. SY risk assessment completed 14 13 Risk of Fraud 2 DF Exec 3 2 6 6 (i) Local Counter Fraud Specialist work - Quarterly Reports to - Quarterly and annual LCFS 3 2 6 22/3/2017 - BAF Team plan and investigations ANCR reports (i-iii) Controls and (ii) Fraud awareness training. - Annual Report to ANCR - Achievement of satisfactory assurance reviewed (iii) DH Counter-Fraud regime and - Annual NHS Protect NHS Protect Quality Assessment oversight Quality Assessment SRT outcome (i-iii) 9/12/2016 - - External Audit opinion Controls and assurance reviewed
28.7.16 - Risk rating downgraded in view of assurance measures in place.
November 2015 - Risk increased to 8 due to control weaknesses which inherently increase the risk of fraud.
28 July 2016 - Risk reduced from 8 to 6 to reflect the reduced impact on fraud from strengthening internal controls.
15 TBC Trust becomes All CIO ANCR 3 5 15 15 (i) Penetration test of systems to Dedicated resource (i) Penetration test N/A Proactive testing and (i) Penetration test report March 2017 2 4 8 22/3/2017 - BAF non-operational identify gaps and risks; to deal with report monitoring (ii) Board restructure report March 2017 Controls and due to cyber (ii) Firewalls, passwords, anti-virus information security (ii) Restructure which (iii) KPMG Capability March 2017 assurance reviewed equipment. assessment attack will see information (iii) Policies and reinforcement through communication to staff; security post (iv) Staff awareness through Certified (iii) KPMG audit and Security Professional course and other capability assessment training; (v) Trigger alerts; (vi) Care Cert system at NHS Digital.
16 TBC Risks from board All CR BA CEO ANCR 2 4 8 8 (i) Rigorous interview processes Executive support (i) Governance and peer (i) Chair and DoF experience of (i) Number of governance 2 3 6 22/3/2017 - leadership R F structure reviews NHS and LHE issues identified are already Controls and transition including (ii) Support from NHSI (ii) Board development (ii) Chair involvement in Trust to being worked on e.g. review assurance reviewed new Chair and Chief sessions and self- date of FinOC and capital Executive, DoF and evaluation governance structure 30.01.2017 - Change non-executive (iii) Pre commencement checks e.e. (iii) Objective setting and (iii) NHSI endorsement of senior to assurance directors references and FPP appraisals appointments (iv) Structured induction process (iv) Internal and external (iv) Internal interim CEO audits providing stability and continuity
(v) Handover arrangements (v) Business intelligence (v) NHSI PRMs and performance reports
(vi) Interim arrangements for CEO and (vi) Licence conditions (vi) First Board meetings DoF removed happened (viii) New chair involvement in CEO (vii) Well Led Governance Review and NED recruitment (ix) Stakeholder, Governor, exec and NED involvement in all senior appointments (x) Board brief sessions and NED pre meetings (xi) Appraisal processes
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Title Chair and NEDs’ Report
Report to: Board of Directors Date: 23 May 2017
Author: Suzy Brain England, Chair of the Board
For: Noting Purpose of Paper: Executive Summary containing key messages and issues
The report sets out the Chair’s activities since the last Board meeting on 25 April:
Be our eyes and ears NHS Providers Visit to Therapies Team meeting Governor matters DBH Star presentation Chairs working together NED reports
Colleagues are encouraged to make suggestions for future engagement activities for the Chair and NEDs.
Recommendation
That the Chair and NEDs’ report be noted.
Related Strategic Objectives Provide the safest, most effective care possible Control and reduce the cost of healthcare Focus on innovation for improvement Develop responsibly, delivering the right services with the right staff Analysis of risks
None, report is for information only.
1
Chair’s Report – May 2017
Be our eyes and ears
Back in March you will have read how the Trust is supporting Keep Britain Tidy’s Spring Clean campaign and I have been pleased to see us beginning to get on top of the litter situation at our three sites.
Showing ‘we care’ covers other aspects of the Trust too. Linn and I have been working closely with Kirsty on ensuring that there is a daily maintenance programme in place for our toilets which is important in terms of patients’ - and their visitors’ - first impressions of our hospitals.
Last week I had the pleasure of using our clinical services at Bassetlaw for the first time. The care and treatment I received was first class but, whilst waiting to be called in, I noticed a number of signs and posters that were either not in corporate style, not relevant or up-to-date or not legible from a waiting room seat. I have asked Kirsty and Emma to look into it.
As somebody new it is easy to see these things but I want all of us to approach things with fresh eyes and ears and, most importantly, do something about it or report it to someone who can. That is what it means to show ‘we care’.
NHS Providers
Many of you will know NHS Providers as the membership organisation and trade association for NHS acute, ambulance, community and mental health services that treat patients and service users in the NHS.
They act as a voice for NHS providers and are recognised for their effective government and policy influencing, promotion of learning and development for NHS leaders, and providing exceptional support to members through training and other ways. A copy of a recent info-graphic showing the issues and challenges for the NHS moving forwards is appended to this report.
Around 94% of providers are members of NHSP, including ourselves.
With the support of the chief executive, I have put myself forward for one of the Acute Chair roles on the NHSP Board which, if successful, will help to keep us well informed about national initiatives and issues facing the NHS. I will let you know the outcome shortly.
I will also be attending an NHSP lunch at the Confederation Centre to discuss the requirement to have 50/50 gender balance on boards by 2020 on 14 June and there is a NHS Chairs’ Dinner in the evening of this Board meeting on 23 May.
2
Visit to Therapies
Last week I met with the leaders of Therapy services where I outlined my role and priorities which were well received. I then visited some of the individual services to lean more of their work and current challenges and developments. This included visiting the Orthotics department, where I have asked Graham Moore, Orthotics Clinical Lead, to make a presentation to Board or an upcoming members’ meeting.
I also spent time with Fiona Leahy and Heather Jackson who have lead roles in MSK OP Physiotherapy services and gained insight into these services which are provided on all Trust sites and several community venues. There is significant development work underway with commissioners and wider partners with these services promoting models of self-management and supported care alongside professional interventions.
My final visit was to the Acute Stroke Unit on Ward 16 where Jaimie Shepherd, a physiotherapist and the Stroke Pathway Lead highlighted the integrated work of the MDT across the full pathway and current work with the STP. I am planning a further visit to other therapy areas including Acute Services and Children’s Therapy teams.
Governor matters
We held what I felt was a very productive Board of Governors meeting on 27 April where we agreed the NED objectives. It was very well attended by governors and the public (some possibly seeking election in June) and observers from RDaSH.
We also held the second of our Governor Briefing sessions in April on operational performance and the budget looking back at last year and forwards to this year. The next session is after this Board meeting on 23 May at 5.30pm and execs and NEDs are welcome to stay and join us.
Ballot papers for the Governor elections have hit the doormats and we are planning the new Governors’ induction in July. Due to the election on 8 June, we have moved the Governor Timeout to the afternoon of 26 June from 2.00pm. Please join us if you can.
DBTH Star presentation
I was pleased to present Andrea Colton, Healthcare Assistant in the Outpatient Department at Bassetlaw, with a DBTH star award for her fundraising efforts earlier this month. Andrea is musical director of Worksop Amateur Operatic Society and has used her operatic contacts to raise funds for a new ECG machine at Bassetlaw.
Chair’s Working Together
I attended the first meeting with other trusts, local authorities and CCGs to propose the best governance arrangements for the STP.
3
I was grateful to Alan for standing in for me at the chair and chief executives’ Working Together Partnership meeting on 8 May. The meeting included an update on committees in common and the Sustainable Hospital Review. Progress is still not at the pace we would have hoped and there is still some room for improvement on the communication front. Nevertheless, we remain committed to participating at all levels.
Upcoming
I am participating in the acute medical interviews that follow this Board meeting and I am attending the second day of the NICE Conference in Liverpool on 19 May.
NED reports
Linn Phipps attended the NHS Providers’ NEDs Networking Event on 21 April. This meeting was held under “Chatham House” (confidential) rules. It focussed on Workforce and on Strategy, policy, finance and performance more generally – and system pressures on every front. There was a strong interest in STPs (Sustainable Transformation Plans).
Recently Alan Armstrong chaired the recruitment of consultant anaesthetist and carried out a ward visit at St Ledger. The use of visual management on notice boards was impressive. Boards for improvement, falls, infection, PJ paralysis and John's story were up to date, easy to understand and demonstrated sustained improvement was applicable.
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THE NHS NHS Providers AT THE HEART OF OUR NATIONAL LIFE
THE NHS PLAYS A FUNDAMENTAL ROLE IN SOCIETY AND IS A CENTRAL PILLAR OF OUR ECONOMIC STRENGTH AND STABILITY The NHS in England... ● Provides 54 million citizens with care free at the point of need The NHS also plays a key ● Provides jobs for 1.2 million people, making role in maintaining the it the country’s largest employer global competitiveness of ● Provided education and training the UK’s life sciences opportunities for over 38,000 nurses, sector, which: scientists, and therapists and over 50,000 doctors and dentists last year ● Generates around £50 billion annually ● Provides 165,000 UK jobs
THE NHS DELIVERS WORLD CLASS SERVICES
The NHS is an international leader...... providing comprehensive care to millions...
● The Commonwealth ● Every year, NHS trusts: Fund ranks the NHS as ● manage 21 million A&E attendances the world’s best and over 113 million outpatient healthcare system, appointments ahead of comparable ● systems on measures provide 100 million contacts in including quality of community services care, cost and efficiency ● provide specialist mental health 1st and learning disabilities ● The NHS provides good value for money; services for over 1.8 the UK spends $3,406 per person on million people healthcare each year compared to $4,361 in ● In 2014, the first NHS France and $4,920 in Germany national waiting times ● 69% of the public in England report they targets for mental get good healthcare, compared with 57% in health services France and 59% in Germany were introduced
...and has a strong track record of improving care quality and our global competitiveness
● The NHS is a world leading research organisation, ● Given the right resources, NHS foundation trusts and with billions invested in NHS research every year. trusts have shown that they can make huge gains in The service has been at the forefront of key medical improving care quality breakthroughs, such as pioneering the first and outcomes, including combined heart, lung and liver transplant; heart attack and cancer survival introducing CT scans; and the 100,000 rates, reducing infections and genomes project. The NHS also saving money. In 2015/16 helps make the UK a global hub alone NHS trusts made for the medicines and health £2.9 billion of cost technologies industries improvement gains
All statistics and references available on our website
GENERAL ELECTION 2017 More information about our work is available at www.nhsproviders.org NHS CHALLENGES NHS Providers INVESTMENT AND SUPPORT NEEDED
BUT OVER THE COURSE OF THE NEXT PARLIAMENT, THE NHS FACES MAJOR, UNPRECEDENTED CHALLENGES Demand is rising...
● The over-85s population has increased by ...at a time when funding almost a third since 2005 to 1.3 million is not keeping pace... and will double in the next 20 years ● Demand for NHS services is rising by 4% each year ● The prevalence of long-term conditions just as spending per person such as diabetes, arthritis and on health services is falling hypertension is rising, with people with long-term conditions ● Demand for ambulance accounting for 70% of services is growing on inpatient bed days average by 5% a year ● One in four people will ● An extra £10 billion of experience a mental investment in NHS health issue each year buildings and equipment is needed ● GPs delivered an estimated 370 million consultations to support current plans to improve local health services in 2016, an increase of 70 million in 5 years ● Reductions to social care budgets mean that around 400,000 fewer people over 65 now receive social care ...so putting pressure on than in 2010 frontline services... ● A lack of funding, reductions in capacity and staff shortages have seen signi cant reductions in ● Performance against key the numbers of beds and other services in standards is deteriorating: the community ● in the 12 months to January 2017, an average ...and strain on the NHS workforce of 89% people were seen within 4 hours at A&E, ● All trusts report compared to the di culties in recruiting 95% standard and retaining staff ● the 92% 18-week elective surgery target has not ● There are persistent been met since February 2016 shortages across key ● the ambulance target for 75% of the most urgent sta groups including calls to be responded to within 8 minutes was not nurses, paramedics, met in any month in 2016/17 mental health support workers and A&E doctors ● There remains uncertainty about the future rights and status of the 161,000 EU nationals working in health and social care in England after the Public concern about the future of the NHS is UK leaves the EU the highest it’s been since June 2002: 57% think the NHS’s ability to deliver care and services has been getting worse and will continue to decline. To sustainably meet the changing needs of our growing and ageing population, the NHS has to transform, o ering more personalised care closer to home. This will take time and will also need investment and political support. All statistics and references available on our website
GENERAL ELECTION 2017 More information about our work is available at www.nhsproviders.org
Chief Executive’s Report 23 May 2017
NHS Cyber Attack
On Friday 12 May, a number of NHS organisations were affected by a ransomware attack, through a malware variant known as Wanna Decryptor.
The attack was not specifically targeted at the NHS and affected organisations across a range of sectors. Nevertheless, it is understood that the attack affected 48 NHS trusts, almost a quarter of the total, as well as 13 NHS organisations in Scotland.
At this stage there is no evidence that patient data was accessed. NHS Digital is working closely with the National Cyber Security Centre, the Department of Health and NHS England to support affected organisations and ensure patient safety is protected.
Doncaster and Bassetlaw Teaching Hospitals was not affected during the attack. This was because DBTH does not expose its internal service to the Internet. Our IT team isolates activity through something known as a DMZ (Demilitarised Zone) and this way we protect the Trust’s network from untrusted external sources, such as the one involved in this particular attack.
Nevertheless, as news filtered through on Friday that a number of NHS organisations were affected, I took the decision, as a precaution, to temporarily stop inbound and outbound emails from outside sources (DBH and NHS mail was still operational). Full email access was restored a few hours later, on the Friday evening.
NHS Digital and CareCert have provided the Trust with a ‘signature’ of the infection which the IT Team have blocked, preventing it from affecting our systems, and we have also upgraded our systems. While the IT team continues to investigate we believe that we are protected against this type of attack. However, failure of services due to cyber-attack remains an extreme risk on our corporate risk register.
Election Leaflets in Mexborough
Prior to the Council elections in Doncaster, we were made aware that residents in Mexborough had received some publicity material from a political group on the Council known as Mexborough First relating to the Montagu Hospital. In particular, the leaflets suggested that the shuttle bus service was under threat and that the Trust may not be committed to the future of the hospital site.
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I wrote to the councillor named on the leaflet to ensure that in future they can ensure accurate and up-to-date information is disseminated to residents and, in view of other rumours that naturally circulate in the run up to elections, we also shared a front- page “Bringing You the Facts” Q&A for staff in the 25th April edition of DBH Buzz.
The information made it clear that there are no plans to withdraw the shuttle, but that the Trust is exploring funding the shuttle rather than continuing to draw down monies from the Legacy, as has been discussed with the Fred and Ann Green advisory group.
In respect of the commitment to Montagu, one of the aims in our new Strategic Plan will be to try to develop Montagu as a centre of excellence for rehabilitation services and also to look at opportunities to enhance the day case and diagnostic services we provide on-site. While cases for Legacy funding will continue to be considered, taking into account the requirements of the Trust and the wishes of Fred and Ann Green, Montagu is and will continue to be an important part of the Trust’s activities moving forwards.
Black Start Power Testing
Between 10 and 16 May, the Estates team held successful ‘Black Start’ tests as part of generator testing. In a ‘Black Start’ test all mains power is switched off in an area so that we are essentially working in ‘power cut’ cut conditions. After a short delay the emergency generator starts and standby power will be supplied to essential circuits. Essential supplies are indicated to staff.
These tests started at 6.00am and lasted until 6.30am. Care groups and departments planned for these tests for a number of weeks and they presented an opportunity for departments to fully ascertain essential power supplies in their areas. It is hoped that by completing these tests each area will be in a position to improve contingency plans for any future occurrences of mains power loss.
Hand Hygiene
The Trust supported Hand Hygiene Day on 5 May to help raise awareness of the importance of infection prevention within our hospitals. The campaign was promoted heavily through our DBTH Staff Facebook page with a number of staff getting involved in activities on the day.
2 Parking charges
Since becoming DBTH chief executive, one of the issues that has been raised again and again by staff, in the Staff Survey and in my listening exercises across the Trust, is car parking.
Whilst it is necessary to the Trust’s financial plans for us to charge staff for parking, I felt that we need to find a better balance on this issue that has not only had a significant effect on staff morale but has also had an impact on nearby residents in Bassetlaw and Doncaster.
That is why in the 9th May edition of DBH Buzz, I announced a new tariff for staff parking that is cheaper than other trusts in the area and can be absorbed by our estates’ income stream. This has been warmly received by staff. We will continue to monitor our rates via our car parking working group that includes staffside representation.
Working Together Partnership Meeting
I attended a meeting of the Acute Care Federation on 8 May where a range of issues were covered which are included in the briefing contained within Part 2 of this meeting. Work is moving forwards on pathology and ophthalmology out of hours’ services.
Leading the way in Procurement
Earlier this month ourselves and Rotherham NHS FT were awarded level one in NHS Procurement and Commercial Standards which recognises that both organisations have the ‘awareness and building blocks in place’ to achive the highest standards of procurement and get the best deal for the local NHS.
Both organisations are part of the Working Together Partnership. By working together as large and influential health care providers, trusts can command larger discounts than would be available if working alone.
All trusts have been given a target to achieve the level one accreditation from NHS Procurement by March 2018 as part of the vision set out in the Operational Productivity and Performance in English NHS Acute Hospitals report written by Lord Carter. The four remaining Working Together Trusts from the procurement workstream remain on track to achieve Level 1.
Changes to NHS Mail
Over the next few months, all Trust email accounts will be migrating to NHSmail 2. This means that everyone will be moving from their current @dbh.nhs.uk email addresses, over to @nhs.net accounts. E-mail addresses will change and we will ensure that everyone is kept informed as to the new email addresses of key staff.
3 International Clinical Trials Day
The Trust is proud to support Clinical Trials Day on 20 May.
It was an opportunity for all staff to promote research within the Trust. DBTH conducts all types of research, whether it is through completing a questionnaire, giving a blood sample or taking part in a clinical trial within a variety of specialty areas.
There were research display boards across the sites, providing patients and staff with information about current research taking place at the Trust.
The Research & Development team is committed to the successful delivery of clinical research across a range of specialties and services and we have a strong reputation for delivering high quality research. There was an opportunity to find out more as part of the team’s presentation to the Board at this meeting.
Visit to Doncaster Chamber of Commerce
Doncaster Chamber invited the Trust to attend their patron and guests evening on Tuesday 9 May and present the impact of hospitals on the local economy. I presented information about the size and geography of the Trust, our biggest achievements, the workforce and the current challenges we face, the recruitment, education and development opportunities offered to our local communities, and how local members can get involved and support the Trust.
The presentation was well received and I would like to formally thank Doncaster Chamber for the fantastic opportunity to speak to their members. I see this as an excellent start to further developing our relationship with the Chamber and would welcome future opportunities to engage with them.
Celebrating our Nurses and Midwives
The Trust held two fantastic celebration events for our nursing and midwifery staff as part of International Day of the Midwives on 5 May and International Nurses’ Day on 12 May with plenty of corridor decoration and cake sales to make people aware of the fantastic job our staff do 24/7, 365 days a year.
Today’s nurses and midwives are not confined to traditional stereotypes, instead providing crucial experience in a number of positions from education to promotion and research, as well as leadership. The role does not stop at the hospital, but now influences legislation, changes how care is delivered and helps to prevent disease and infection. They really are wide and varied job roles with masses of opportunity and potential.
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As a registered nurse myself, who has worked in the profession for the past 32 years, I can vouch for the fact that nursing and midwifery are two of the most rewarding professions in the NHS. Yet the challenges of recruiting more nurses and midwives remain and it is up to all of us to encourage and support our next generation of nurses to come through the ranks.
Staff and appointments
Congratulations to Emma Sweeting and Maria Brownson on receiving the Inspirational Mentor Award at SHU’s 2017 Nursing and Midwifery Mentor Conference on 20 April.
Data manager Marilyn Strawn has been recognised as 'Audit clerk of the year' for her outstanding work in managing data quality that reflects activity and outcomes for patients in critical care.
Helen Green, DBTH’s new Person Centred Care Practitioner, started in post on 17 April.
Jeannette Reay (pictured), Emergency Planning Officer, started at the Trust on 1 May having previously worked at Chesterfield NHS FT.
Petra Bryan, Head of Quality Improvement, and Myra Knight, Head of Imaging, have also recently joined the Trust.
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DONCASTER & BASSETLAW TEACHING HOSPITALS NHS FOUNDATION TRUST
Minutes of the Financial Oversight Committee Meeting held at 10am on Monday 24 April 2017 in the Boardroom, DRI
PRESENT : Neil Rhodes, Non-executive Director (Chair) Philippe Serna, Non-executive Director
IN ATTENDANCE : Jon Sargeant, Director of Finance Marie Purdue, Acting Director of Strategy & Improvement Andrew Thomas, Project Consultant Matthew Kane, Trust Board Secretary Angela O’Mara, Exec Team PA
APOLOGIES : John Parker
Action Apologies for Absence 17/4/1 Apologies were noted from John Parker.
Introductions 17/4/2 Introductions were made around the table at Neil Rhodes’ first meeting as Chair.
17/4/3 Discussions regarding a consistent and timed meeting structure for Board sub- committee meetings were noted. The Chair declared his intention to bring to Board an additional item of business on preparations to become a Finance & Performance Committee. No other business was declared.
Minutes of the previous meeting 17/4/4 The minutes of the meeting held on 27 March 2017 were APPROVED as a true record.
Matters arising 17/4/5 17/3/11 - Jon Sargeant advised that discussions in respect of the catering bid were ongoing; a paper was expected to be brought to May’s Board of Directors. In response to a question from Philippe Serna, David Cuckson’s involvement in the process was confirmed in his capacity as public governor. Board members were also sighted on the tender process and progress to date as part of sub- committee and Board Brief updates from the Director of Estates & Facilities. In order to ensure Neil Rhodes was fully briefed on the matter Jon Sargeant agreed to make arrangements for him to meet with the respective finance colleague and Kirsty Edmondson-Jones. JS
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17/4/6 16/12/6 – Marie Purdue confirmed that a report would be brought to next month’s Committee meeting to address this action.
17/4/7 17/1/30 – the matter of low clinical value procedures had been escalated for discussion in the confidential element of April’s Board meeting.
17/4/8 17/2/16 - a discussion took place around the possibility of providing an earlier or interim view of the impact of the Overseas visitors’ team. It was agreed that the target date would remain as August 2017.
17/4/9 The action log was reviewed and updated. Strategy & Improvement Report 17/4/10 The report provided an update on 2016/17 CIP, a forward view of 2017/18 and commentary on NHSI’s revised grip and control measures.
17/4/11 The 2016/17 cost improvement programme had delivered 11.893m against a plan of 11m, 487k less than the reported forecast to NHSI and 1.107m less than the initial stretch target. This was a positive achievement and a credit to staff at all levels within the Trust.
17/4/12 Work to identify the remaining 8.252m of cost savings for 2017/18 continued. Plans were in place for Jon Sargeant and Marie Purdue to review a pipeline of ideas, an update of which would be provided at the next Committee meeting.
17/4/13 Outstanding items from the initial list of grip and control measures would be reviewed alongside the newly identified actions. Clarification was provided to the Chair in respect of the nature of these measures and an update of the review would be provided in next month’s report.
17/4/14 The scale of the challenge to identify schemes for the unidentified 8.252m 2017/18 CIP was acknowledged. A number of potential savings had been discussed at a recent Executive Team meeting but further exploration was required. An update would be provided to Board and a more clearly defined plan provided at the next Committee meeting. JS/MP
17/4/15 The Director of Finance and Acting Director of Strategy & Improvement briefed the Chair of the various workstreams and care group personnel involved in the delivery of CIPs and budget management, including the manner in which they are held to account. It was agreed that a yearly programme of visiting workstreams would be prepared for the next meeting. It was recognised that this may be subject to change. JS/MP
The Strategy & Improvement Report was NOTED.
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Escalation items from workstreams 17/4/16 No items were noted for escalation at this stage. It was anticipated that those workstreams that had regularly attended the Committee previously were likely to continue to do so; but a more informed picture would be available at the next meeting.
Preparation to become a Finance and Performance Committee 17/4/17 Neil Rhodes shared with the Committee discussions between himself and the Chair of the Board in relation to alignment of the Trust’s committee structure to that of other NHS bodies. The proposed change for this Committee was the creation of a Finance & Performance Committee. Initial observations were shared and views sought to determine a clear future purpose, with clarity around the differences in role between the sub-committee and the Board.
17/4/18 It was agreed that in depth scrutiny should take place at sub-committee level, including consideration of relevant associated risks within the corporate risk
register. The need to consider the full range of factors impacting upon performance was noted, including finance, workforce, operational activity and estates and facilities.
17/4/19 In line with current practice for CGOC and ANCR it was suggested that a Chair’s report/log should be presented to Board. Suggestions were offered in terms of
reporting themes and best practice and it was decided that the content and design of the report would be subject to further discussion outside of the meeting. The Chair agreed to meet with the Director of Finance,Acting Director NR of Strategy and Improvement and Trust Board Secretary to develop this.
17/4/20 A need to consider attendees and a revised meeting schedule was noted to ensure timely feedback to the Board. Matthew Kane confirmed his intention to take a report to May’s Board of Directors with a revised committee structure effective from June 2017.
Finance Report (Month 12) 17/4/21 The financial position at month 12 was reported at 8.1m deficit. This was after receipt of 8.8m STF incentive funding and in line with the month 11 forecast of 17m deficit (prior to STF funding).
17/4/22 A higher than planned cash balance of 2.4m was reported at the month end in view of funding received from NHS England and Doncaster CCG towards the
end of the period. In order to reduce the cash balance closer to the 1.9m plan advance tax and NI payments had been made.
17/4/23 In response to a question from the Chair, Jon Sargeant confirmed that sustainability and transformation funding had initially been received in 2016/17, based on achievement of finance and performance related targets. Since that time funding had been confirmed for 2017/18 and 2018/19 but it should be noted that this was non recurrent. The additional funding of 8.8m had not been anticipated and was received due to the improvement in the Trust’s financial position as compared to its control total. Page 3
17/4/24 In response to a question from the Chair, Jon Sargeant summarised the impact of IR35 at both individual and Trust level. This was noted as a risk and a contingency reserve of 1.4m has been set aside in respect of this. The situation would be closely monitored going forward due to its potential to impact upon performance as well as representing a financial risk.
The Finance Report was NOTED. Annual Accounts – Going Concern Basis 17/4/25 In accordance with International Accounting Standard 1 the Trust, as part of its annual accounts preparation, was required to consider its ability to continue as a going concern. The report presented provided a summary in support of this which would be shared with the Board.
17/4/26 The Committee were satisfied with the assessment contained within the paper and it was noted that the accounts would be presented at the Extraordinary meeting of ANCR on 26 May 2017 for sign off.
The Annual Accounts – Going Concern Basis report was NOTED.
Year End Review Issues 17/4/27 The paper presented to the Committee documented systemic issues identified as part of the year end procedures. Despite these findings the Director of Finance confirmed the team were in a position to submit the accounts to NHSI and the external auditors within the agreed deadline.
17/4/28 A discussion took place around the detail of the findings and it was acknowledged there was a need to continue to improve working practices, ensuring they were understood, embedded and completed to the required standard. In preparation for 2017/18 year end processing a trial close down would be undertaken mid-way through the year to allow time to address any identified issues.
17/4/29 In response to a question from Philippe Serna, the Director of Finance confirmed that an action log would be compiled during EY’s audit of accounts to ensure the team were in a position to take immediate action, with any amendments being made on receipt of the audit report.
The Year End Review Issues report was NOTED.
Finance Directorate Stock Take 17/4/30 Following an initial discussion at last month’s meeting the Director of Finance summarised an updated view of the challenges faced within the Finance Team. It was acknowledged that significant steps were required to improve staff morale, structure, capacity/capability and staff perceptions. The presentation highlighted priorities and actions required.
17/4/31 Initial findings had identified the department structure did not meet the needs of the organisation and following discussions at Executive Team proposed Page 4
phase 1 changes had already been implemented. Phase 2 of the structure would be considered following completion of the year end accounts.
17/4/32 Despite the difficulties highlighted the Director of Finance indicated a positive response to the changes in phase 1, an increased awareness of priorities and a desire to improve. These initial ‘green shoots’ would be nurtured and developed over time.
17/4/33 In response to a question regarding support required to deliver these changes, Jon Sargeant acknowledged the assistance received to date from the Executives and Chief Executive. In terms of increased exposure of the senior finance colleagues it was suggested that both Andy Sidney and Anna Moulding would present to future Committee meetings. The Chair indicated his intention to visit the Finance department when the year-end pressures were over.
The Finance Directorate Stock Take report was NOTED. Any other business No additional items of other business were declared. Time and date of next meeting: Date: 22 May 2017 Time: 9am Venue: Boardroom, DRI
Signed:…………………………………………….. …………………………………. Neil Rhodes Date
Page 5 Board of Directors Agenda Calendar
STANDING ITEMS OTHER / AD HOC ITEMS MONTHLY QUARTERLY BIANNUAL / ANNUAL JUNE 2017 CE Report Board Assurance Framework MB Annual Report Business Intelligence Report Report from the Chair of the ANCR SOs, SFI, Scheme of Delegation committee (Verbal) Nursing Workforce Monitor Q4 Results Notification ANCR Annual Report Bed Plan MB Minutes Financial Oversight Minutes
JULY 2017 CE Report Chief Executive’s Objectives CGOC Annual Report Reference Costs Business Intelligence Report Complaints, Compliments, Concerns and Comments Report Nursing Workforce R&D Strategy metrics (in BIR, to include R&D annual summary) MB Minutes Safeguarding & maternity metrics (in BIR) Financial Oversight Minutes ANCR Minutes NHSI Undertakings tracker P&OD Quarterly report AUGUST 2017 CE Report Monitor Quarterly Declaration Q1 Proposed AMM arrangements Annual Revalidation update(medical) Business Intelligence Report CGOC minutes Annual Security Report Nursing Workforce Board Assurance Framework & corporate Infection Control Annual Report risk register Q1 MB Minutes ANCR Minutes Financial Oversight Minutes NHSI Undertakings tracker
SEPTEMBER 2017 CE Report Report from the Chair of the ANCR Risk Policy committee (Verbal) Business Intelligence Report Monitor Q1 Results Notification Fred & Ann Green Legacy minutes
1 As at 15 December 2016 Nursing Workforce MB Minutes Financial Oversight Minutes NHSI Undertakings tracker OCTOBER 2017 CE Report ANCR minutes Charitable Funds minutes Business Intelligence Report Chief Executive’s Objectives Nursing Workforce Complaints, Compliments, Concerns and Comments Report MB Minutes R&D Strategy metrics (in BIR) Financial Oversight Minutes Safeguarding & maternity metrics (in BIR) NHSI Undertakings tracker P&OD Quarterly report NOVEMBER 2017 CE Report CGOC minutes Annual Compliance against the National Core CaMIS 12 months post- Standards for Emergency Preparedness, implementation review Resilience and Response (EPRR) Business Intelligence Report Monitor Quarterly Declaration Q2 Nursing Workforce Board Assurance Framework & corporate risk register Q2 MB Minutes Financial Oversight Minutes NHSI Undertakings tracker DECEMBER 2017 CE Report Monitor Q2 results notification Business Intelligence Report Report from the Chair of the ANCR committee (Verbal) Nursing Workforce Grip & Control Plan MB Minutes Financial Oversight Minutes NHSI Undertakings tracker JANUARY 2018 CE Report ANCR minutes (16.12.16) Budget Setting / Business Planning / Annual Plan Business Intelligence Report Chief Executive’s Objectives SOs, SFI, Scheme of Delegation
2 As at 15 December 2016 Nursing Workforce Complaints, Compliments, Concerns and Comments Report MB Minutes R&D Strategy metrics (in BIR) Financial Oversight Minutes Safeguarding & maternity metrics (in BIR) P&OD Quarterly report FEBRUARY 2018 CE Report CGOC Minutes Budget Setting / Business Planning / Annual Plan Business Intelligence Report Monitor Quarterly Declaration Q3 Nursing Workforce Board Assurance Framework & corporate risk register Q3 MB Minutes HWB Decision Summary Financial Oversight Minutes MARCH 2018 CE Report Report from the Chair of the ANCR Budget Setting / Business Planning / Draft committee (Verbal) Annual Plan Business Intelligence Report Monitor Q3 Results Notification Staff Survey Nursing Workforce Fred & Ann Green Legacy minutes MB Minutes HWB Decision Summary Financial Oversight Minutes APRIL 2018 CE Report ANCR minutes Draft Annual Report Mandatory training update Business Intelligence Report Chief Executive’s Objectives Draft Quality Account Nursing Workforce Complaints, Compliments, Concerns and Budget Setting / Business Planning / Final Comments Report Annual Plan MB Minutes R&D Strategy metrics (in BIR) HWB Decision Summary Safeguarding & maternity metrics (in BIR) Financial Oversight Minutes P&OD Quarterly report
MAY 2018 CE Report Monitor Quarterly Declaration Q4 Annual Report Business Intelligence Report CGOC Minutes Quality Account Nursing Workforce Report from the Chair of the ANCR Annual accounts
3 As at 15 December 2016 committee (Verbal) MB Minutes Board Assurance Framework & corporate ISA260 and quality account assurance risk register Q4 (inc. annual assurance summary) HWB Decision Summary Charitable Funds minutes Financial Oversight Minutes
OTHER ITEMS Review the appointment of Peter Brindley (Executor of Fred and Ann Green Will) 3 yearly (May 2018) Constitution review 3 yearly (Jan 2018)
4 As at 15 December 2016
Minutes of the meeting of the Board of Directors Held on Tuesday 25 April 2017 In the Boardroom, Doncaster Royal Infirmary
Present: Suzy Brain England OBE Chair of the Board Karen Barnard Director of People and Organisational Development Moira Hardy Acting Director of Nursing, Midwifery and Quality Martin McAreavey Non-executive Director Richard Parker Chief Executive Linn Phipps Non-executive Director David Purdue Chief Operating Officer Neil Rhodes Non-executive Director Jon Sargeant Director of Finance Philippe Serna Non-executive Director Sewa Singh Medical Director
In attendance: Marie Purdue Acting Director of Strategy and Improvement Simon Marsh Chief Information Officer Kirsty Edmondson-Jones Director of Estates and Facilities Matthew Kane Trust Board Secretary Emma Shaheen Head of Communications and Engagement
ACTION Welcome and apologies for absence 17/04/1 Apologies for absence were received from Alan Armstrong and John Parker. The Board welcomed Neil Rhodes and Marie Purdue who were attending their first meetings in their official capacities.
Declarations of Interest 17/04/2 The re were no interests declared in respect of the business of the meeting.
Minutes of the meeting held on 28 March 2017 17/04/3 The minutes of the meeting of the Board of Directors held on 28 March 2017 were APPROVED as a correct record with the following amendment:
17/03/47 - The Trust’s rolling 12-month HSMR position at the end of December was 93 (not 87).
Actions from the previous minutes 17/04/4 The actions were noted and updated. The following updates were provided:
17/03/59 – The Board was advised that the tender for insurance had been let.
17/03/11 – All NEDs had been invited to the person centred care days and would be invited to future listening events.
Chair’s report 17/04/5 The Board considered a report of the Chair which outlined her recent involvement in the following activities:
• Meetings across the Trust Members’ Meeting NED Objective Setting Working Together Update Governor elections update Reports from the NEDs
17/04/6 The Chair commended her visit to the library, encouraging all NEDs to become members, as well as the Members’ Meeting on 13 April that she felt was a good opportunity to find out what members thought about the Trust’s services.
17/04/7 The Chair referred to advice issued in the previous week from NHS Providers as to whether elections to governor positions were affected by Purdah rules. Having taken a view from the Trust’s elections specialists and other trusts it was agreed to proceed as planned. The Board backed this course of action.
17/04/8 Further to the reports from NEDs within the report, Neil Rhodes advised Board of discussions relating to the proposed redesign of Financial Oversight Committee into a new Finance and Performance Committee. Assurance would be fed back to the Board in the form of a Chair’s Log and the Committee were supportive of working at pace in order to put in place a framework for the next Board in May.
17/04/9 Martin McAreavey fed back on the recent consultant interviews he had taken part in and the conference around duty, accountability and candour. In relation to a question relating to staff awareness of Datix statistics, the Chief Executive advised Board of plans for a new quarterly summary setting out the key complaints and risk issues to staff.
17/04/10 Linn Phipps fed back on her participation in the national "Learning from deaths in the NHS – new responsibilities for Board members” event in London, and placed particular emphasis on listening - how the Trust listens and responds to the views of patients, families and staff.
17/04/11 The Chair’s report was NOTED.
Chief Executive’s report
17/04/12 The Board considered a report of the Chief Executive which outlined progress against the following:
• Next steps in the Five Year Forward View Fire Safety Compliance Update Putting an end to #PJParalysis Government changes to Midwifery Consultations into hyper acute stroke and Tier 2 children's surgery and anaesthesia services Mandatory enhanced surveillance Changes to NHS Litigation Authority New training at DRI Acute Hospital Urgent & Emergency (UE) Mental Health Liaison Services (Adults and Older Adults) Transformation Fund IR35 Strategic Hospital Review The Long Term Sustainability of the NHS and Adult Social Care Integrated Clinical Academic Programme Internships Improving interactions Changes within Executive Team
17/04/13 In drawing out some of the key headlines within the report, the Chief Executive advised that the calling of the General Election on 18 April may result in delays to moving forward some of partnership working as councils entered purdah. Board was also advised of changes to the management structure at Sheffield Teaching Hospitals.
17/04/14 In respect of IR35 rules, the Chief Executive advised that plans had been put in place over the Easter Bank Holiday period to mitigate against spikes in A&E activity but that the period had gone without major incident. IR35 rules had resulted in some shift cancellations, It was confirmed that these should be subject to a four week notice period otherwise the Trust had a duty to consider informing the General Medical Council. The Chair reiterated the Trust’s commitment to finding a long-term solution to temporary staffing issues.
17/04/15 The Board commended the Trust’s work on ending PJ paralysis as a means MK of reducing patient dependency and institutionalism. It was agreed to write to the team expressing thanks for the work being undertaken.
17/04/16 The Chief Executive’s report was NOTED.
Carol’s Story
17/04/17 The Board watched a short film and received a presentation from Dr Lee Cutler, Consultant Nurse – Critical Care, on an item relating to a patient experience at two hospitals in the Trust. The film had been produced in association with Metro Films who had previously produced Gina’s Story.
17/04/18 Having watched the film, the Board reflected on its key messages around culture, the power to choose and staff empowerment. The Chair reminded Board that its new committee structure would see an added emphasis on patient experience through the new Quality and Effectiveness Committee.
17/04/19 Carol’s Story was NOTED.
Use of Trust Seal
17/04/20 The Board APPROVED the use of the Trust Seal in respect of the sale of land at 28-50 Ryton Street, Worksop, Notts.
2016 Staff Survey Results and Action Plan
17/04/21 The Board considered a report of the Director of People and Organisational Development that set out the Trust’s staff survey results and action plan.
17/04/22 Between October and November 2016, 47% (2,938) of DBTH staff completed the NHS staff survey. This was the third year using an online survey of all staff and showed a continuing improvement on previous years’ completion rates of 44%.
17/04/23 The survey highlighted a deteriorating picture for the Trust overall. Compared to all acute Trusts, of the 32 key findings this year:-
1 issue was in the best 20 3 issues were better than average 4 issues were at the average 5 issues were worse than average 19 issues were in the worst 20%
17/04/24 Compared with the Trust’s 2015 results, one issue had improved, 17 stayed the same and 14 issues deteriorated. Upon the new Chief Executive coming into post a number of actions had taken place to address the issues raised and an action plan had been formulated around:
How the Trust communicated with and listened to staff How the Trust involved staff Supporting managers to engage effectively with their staff
Staff experience
17/04/25 Following consideration of the report further work on the action plan was KB required around highlighting measures of success and ensuring objectives were smart. Details of individual care group responses would also be forwarded to non-executives.
17/04/26 Linn Phipps raised a question discussed at the recent NHS Providers Network meeting which she had attended, around how the Trust measured how staff felt outside the staff survey, as well as how the Trust were enabling managers to support their staff.
17/04/27 The Board NOTED the outcomes from the 2016 staff survey and APPROVED the actions set out in the action plan, subject to the improvements highlighted above.
Annual Accounts - Going Concern Basis
17/04/28 The Board considered a report of the Director of Finance that sought authority for the Trust to prepare its financial statements on a going concern basis and to make the necessary declarations as part of its annual report and annual accounts.
17/04/29 In accordance with International Accounting Standard 1 the Trust, as part of its annual accounts preparation, was required to consider its ability to continue as a going concern. The report provided a summary in support of this. Board were satisfied with the assessment contained within the paper.
17/04/30 Board APPROVED that:
1. The Trust should be considered a going concern for accounts preparation purposes. 2. The Trust should prepare its annual accounts for the year 2016/17 and balance sheet as at 31st March 2017 on that basis. 3. The annual report should clearly state this assessment whilst also outlining the risks facing the trust. 4. Power be delegated to ANCR to sign off the accounts at a special meeting of the Committee on 26 May 2017.
Strategy & Improvement Update
17/04/31 The Board considered a report of the Acting Director of Strategy and Improvement that included updates on CIP progress, the 2017/18 CIP programme, the strategic planning process and the move from turnaround to transformation.
17/04/32 The report highlighted that savings at M12 were £11.893m, a decrease since M1 of £522k and a decrease since M11 of £69k. Delivery in M12 was £1.833m, ahead of plan in month by £516k and ahead of stretch by £433k in month.
17/04/33 The CIP for 2017/18 is £14.5m, of which £6.248m has been identified in developed delivery plans. Further CIP ideas were at varying stages of scoping and development with the relevant scheme SROs.
17/04/34 In response to a question from Linn Phipps on how assured the Trust was MP on delivering CIPs, the Board was advised that it would be important to consider not just internal savings but place based and partnership initiatives too. The need for a six month review of CIPS was emphasised.
17/04/35 The Board RECEIVED the Strategy and Improvement Report for assurance.
Finance Report as at 31 March 2017 17/04/36 The Board considered a report of the Director of Finance that set out the Trust’s financial position at month 12 2016/17.
17/04/37 The Board was advised that the year-end position was a £17m deficit, in line with the financial forecast. In response to the strong performance against the original financial plan, the Trust had received one-off support from the NHS Improvement in the form of a bonus payment which reduced the deficit to £6.7m.
17/04/38 Key points from the report included:
• Income was £1.6m higher than expected in month, £1.1m of which related to STF funding.
Capital expenditure year to date was £10.1m of which £2.1m was funded from Charitable Trust Funds leaving £8m. The major areas of expenditure were on fire safety improvements, property works, medical equipment replacement and IT developments. Charitable Funds expenditure was focused on the Ophthalmology scheme.
There was a cash draw down of £3 million to meet the anticipated high volume of creditors resulting from clearance from Agresso to the new Oracle system.
17/04/39 The Board briefly discussed the challenges on capital for the forthcoming year and it was agreed this would return to Board for discussion. If the Trust was successful in levering in STF funding for capital works then there may be opportunities to address a number of priorities.
17/04/40 It was AGREED that the Finance Report be NOTED.
Business Intelligence Report as at 31 March 2017
17/04/41 The Board considered a report of the Chief Operating Officer, Medical Director, Acting Director of Nursing, Midwifery and Quality and Director of People and Organisational Development that set out clinical and workforce performance in month 12.
17/04/42 Performance against key metrics included:
4 hour access - In March the Trust achieved 92.7% (93.4% including GP attendances) against the 95% standard. The Trust continued to perform within the top quartile of trusts and at the end of the financial year was the top performing adult service in South Yorkshire.
RTT - In March, performance remained below the standard, achieving 90.5%, with eight specialities failing to achieve the 92% standard for the month.
Diagnostic waits – The Trust missed the 99% standard in March achieving 97.4%.
Cancer - In February, two-week waits were 85.5% against the 93% standard. The key issues related to patient choice and capacity in Dermatology and Urology departments. The 62-day performance achieved 86.8% against the 85% standard.
HSMR – The Trust’s rolling 12-month position at the end of December was 92.8, positively remaining below 100.
C.Diff – In 2016/17 there was a 19% reduction in the number of C. Diff cases than in 2015/16.
Falls – In 2016/17 there was a 14% reduction in the number falls resulting in harm than in 2015/16.
Pressure ulcers - In 2016/17 there was a 25% reduction in the number of hospital acquired pressure ulcers than in 2015/16.
17/04/43 Further to a question from Martin McAreavey, Board were advised of recruitment issues within Ophthalmology and Audiology that had affected the month’s performance. Issues with patient transfers from Bassetlaw to Doncaster were being addressed and issues relating to miscoding in pain management were being reviewed. In response to a question from the Chair, the Board was advised of plans to change the existing trauma model to increase capacity.
17/04/44 Neil Rhodes emphasised the importance of ensuring objective setting and appraisals at senior management level were undertaken early in the year to ensure dissemination of actions further down the structure. The Director responsible was seeking to remodel the appraisal timetable over an April-September time period.
17/04/45 The Chief Operating Officer advised of changes to the way in which emergency activity could be reported from 1 April. This would be measured in shadow format until confirmation of the requirements from NHSI.
17/04/46 The Business Intelligence report was NOTED.
Quarter 4 People and Organisational Development Update
17/04/47 The Board considered a report of the Director of People and Organisational Development which set out progress made in Q3 to deliver the current P&OD Strategy in 2016/17; the annual workforce related KPIs, corporate objectives and P&OD led projects.
17/04/48 The report advised that the cumulative sickness rate for the year was 4.46%, with a reduction in the numbers of long-term sick and an increase in sickness capability discussions. Compliance with Statutory and Essential Training (SET) continued to rise each month and at the end of March the rate was 69.54%. Official appraisal rates stood at 61.27% across the Trust although the staff survey indicated that 82% of staff had been appraised. The Directorate would continue to focus on improving the quality of appraisals as reported by staff.
17/04/49 The Q4 People and OD Update was NOTED.
Nursing Workforce Report 17/04/50 The Board considered a report of the Acting Director of Nursing, Midwifery and Quality which provided detailed information relating to the nursing workforce, highlighting issues that could impact on the Trust’s ability to sustain appropriate staffing levels and skill mixes.
17/04/51 The overall planned versus actual hours worked in March 2017 was 99%, one per cent down on February. Care Hours Per Patient Day (CHPPD) stood at 7.5 across the Trust, up 0.3 on February.
17/04/52 Details of the quality and safety profile were provided in the report. Three wards triggered red in the month; the Acute Medical Unit, C2/CCU and Ward 25. These areas would be reviewed through a quality summit.
17/04/53 Further to a question from Linn Phipps, non-executives would be invited MH to attend a future quality summit.
17/04/54 The report in respect of Nursing Workforce was NOTED and the actions identified to ensure that the risks associated with inappropriate nurse staffing levels were appropriately managed was SUPPORTED.
Complaints, Concerns, Comments and Compliments Quarter 4 and Annual Report 2016/17
17/04/55 The Board considered a report of the Acting Director of Nursing, Midwifery and Quality which set out Quarter 4 performance using the information available from Datix and the learning points from the organisation, summarising the end of year activity.
17/04/56 Key points contained in the report were as follows:
There had been a steady increase in numbers of complaints and concerns since December (less than 100 a month) to March (150 per month).
Individual care groups had seen normal variation of complaints with the exception of Obstetrics and Gynaecology. Reasons for the increase in Obstetrics and Gynaecology were set out to the Board.
Included for the first time in the report were concerns, comments and complaints from Members of Parliament.
The main reason for complaints remained as communication. Training was being offered to staff around improving interactions with patients.
Numbers of complaints being investigated by the Ombudsman were reducing.
17/04/57 The complaints, concerns, comments and compliments report was NOTED.
Junior Doctors Safe Working quarterly report
17/04/58 The Board considered a report of the Guardian for Safe Working that set out background and context around the introduction of the Guardian of Safe Working as part of the 2016 Terms and Conditions for Junior Doctors and implementation of that role within the Trust together with the second quarter update.
17/04/59 The report advised that no gross safety issues had been raised with the Guardian by any trainee. There had been 37 exceptions raised by junior doctors that had been resolved without any fines being levied. The processes for the payments highlighted in the report were being addressed.
17/04/60 The report of the Guardian of Safe Working was NOTED.
Chair’s Log: Audit & Non-clinical Risk Committee and Clinical Governance Oversight Committee
17/04/61 The reports of the chairs of Audit & Non-clinical Risk Committee and Clinical Governance Oversight Committee were NOTED.
Reports for Information
17/04/62 The following items were NOTED:
Learning from Deaths in the NHS EU General Data Protection Regulations Physical Assaults 2016/17 Financial Oversight Committee minutes, 27 March 2017 STP Collaborative Partnership Board, 17 March 2017
17/04/63 It was agreed that the item on Learning from Deaths would be brought MK back to Board in June. It was agreed that future reports on physical assaults would include normalised data.
Items escalated from Sub-Committees
17/04/64 None.
Any other business
17/04/65 There were no items of other business.
Governors questions regarding business of the meeting
17/04/66 None.
Date and time of next meeting 17/04/67 9.00am on Tuesday 23 May 2017 in the Boardroom, Doncaster Royal Infirmary.
Exclusion of Press and Public
17/04/68 It was AGREED that representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.
Suzy Brain England Date Chair of the Board