Annual Report and Accounts 2016/17 Royal Devon and Exeter NHS Foundation Trust

Royal Devon & Exeter NHS Foundation Trust Annual Report and Accounts 2016/17

Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 © 2017 Royal Devon and Exeter NHS Foundation Trust Annual Report 2016/17 Contents Page CHAIRMAN’S INTRODUCTION...... 7

PERFORMANCE REPORT: OVERVIEW...... 9 Introduction by the Chief Executive...... 9

About the Royal Devon & Exeter NHS Foundation Trust...... 12

Our Strategy...... 19

PERFORMANCE ANALYSIS...... 31

ACCOUNTABILITY REPORT...... 39 Enhanced Quality Governance Reporting...... 46

Stakeholder Relations...... 52

Disclosures...... 54

Remuneration Report...... 55

Staff Report...... 64

Board Assurance Framework...... 74

Audit Committee...... 75

NHS Improvement Single Oversight Framework...... 78

Care Quality Commission...... 79

Statement of Accounting Officer’s Responsibilities...... 80

Annual Governance Statement...... 81

Our Governors and Members...... 88

Sustainability Report...... 100

Equality and Diversity...... 104

ANNUAL ACCOUNTS...... SEE SEPARATE REPORT

QUALITY REPORT...... SEE SEPARATE REPORT

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Annual Report 2016/17 CHAIRMAN’S INTRODUCTION It is my pleasure to introduce our Annual Report, Quality Report and Accounts for 2016/17. Shortly after I joined your Board of Directors five years ago, we agreed to establish a hierarchy of priorities: ‘what matters; who matters’. It was clear at that time that the gap between demand and expectations on the one hand and financial resources on the other would continue to grow and that we needed to be very focused and consistent in the way we take decisions to ensure the optimal use of the resources available to us.

Our top three priorities for ‘what matters’ were: outcomes, safety and quality and, for ‘who matters’: our communities, patients and staff. We recognised that finances and regulators were important (both fourth in our hierarchy) but believed that good finances and regulatory compliance must be the product of what we do and not the drivers of what we do.

So how did we do? Our new Chief Executive will go into more detail in her report but I wanted to set out my own “score card”.

We have continued to improve safety within the RD&E from an already strong level and outcomes and quality remain very good. Timely access to our services-judged by several metrics-remains challenging, however. We have struggled to meet our A&E four hour wait for most of the year and have also struggled with a number of our cancer waiting time targets and more recently our 18-week Referral to Treatment (elective care) target. It would be very easy to take solace from the fact that our performance is better than most others and that we are assured that patients are not coming to harm. These targets are important, however, and we will continue to strive to improve upon the current performance, particularly for A&E and cancer waiting times. In this respect, I would congratulate our colleagues on recovering by the end of the year compliance with our diagnostic targets which we were failing to meet as a consequence of significant growth in demand.

I am particularly pleased with the results of our staff and patient surveys. There is strong evidence that happy and supported staff provide safer and more compassionate care. Our staff surveys have improved in each of the last five years and our various patient surveys show strong support for the RD&E and its services. I was particularly proud of our cancer patient survey. Despite missing some of the waiting time targets, our patient survey ranked us third highest in the whole country and we were the only complex cancer centre to feature in the top 10 - a truly extraordinary performance.

And how did we do with our finances and regulators? As predicted last year, we budgeted for a lower deficit and we did much better than we had planned for, coming in at £2.3m (including STF, but excluding impairment and gains on transfer by absorption), less than half the budgeted deficit we had agreed with our regulators. Our quality rating was as planned (the best rating of Green) and our (financial) sustainability rating was a 2, better than the 3 agreed with our regulators. Importantly, our cash reserves which we had budgeted to fall have actually risen from £6.7m planned at year end to £17.5m .

There were three major developments in 2016/17. In October, 2016 we took over the community hospitals and community nursing in Mid and East Devon. While unconnected, our assumption of these services (which had been long delayed) coincided with a review of beds required in community hospitals in our area. We welcome our new staff and thank them for the way in which they have engaged with us, particularly in challenging circumstances. While the integration plan is still at an early stage, the benefits (both patient and financial) we have already seen are promising. The integration of acute and community health services is important in its own right but is also just one stage in integrating care so that we can focus on the total health and well-being of our communities and not just individual episodes of care. Your Board is firmly of the view that we need to focus on what matters to our communities, rather than imposing on them our views of what we believe is the matter with them. We are also absolutely convinced that it is in the interests of our patients that they should only be admitted to acute hospitals when requiring acute intervention and should be discharged from hospital (with appropriate care packages) as soon as they are medically fit for discharge.

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The second major development was the formation of the Sustainability and Transformation Plans/Partnerships (STPs). Forty-four STPs were established across England to bring together leaders across health, social care and local government to develop and implement new models of care which are both clinically and financially sustainable. Our STP covers the whole of Devon (including Plymouth and Torquay) and built on the work already commenced by the Success Regime. Your Board fully supports the general ambitions of the STP and has committed significant management resource to it. We are very keen that the debates with our communities are candid and transparent, that the allocation of the resource that we have is fair and that the changes we make are implemented in a way that ensures that new services are available before old ones are reduced or removed. We will endeavour to ensure that the new models of care are aligned with the hierarchy of priorities we have set out. The third was the appointment of our new Chief Executive Officer, Suzanne Tracey, who had previously been the Trust’s Deputy Chief Executive and Chief Financial Officer. Suzanne’s appointment followed an international search after the departure of Angela Pedder to become Lead Chief Executive of the Devon Success Regime. Suzanne has hit the ground running and she and her executive colleagues are having a positive impact on both the Trust and the wider health and social care system in Devon.

So what do I feel about the future? The RD&E is a great organisation. It is so because of the talent, vocational drive, passion and compassion of its people. The values that we collectively hold run through the organisation from top to bottom and across the Trust. I love to hear our colleagues in the laundry, for example, explaining their contribution to high quality, safe care. We must not kid ourselves, however, about the challenges that we face. All the evidence suggests that demand, acuity and expectations will continue to grow at a level which is much higher than the growth in the resources available to us and, based on the formulas used by the Department of Health, Devon is already perceived to be spending more than its fair share of the NHS budget. We will be able to address part of the shortfall by working more efficiently - both within current organisational boundaries and beyond – but I do not believe that there is any prospect that this will meet the growing gap. So as well as becoming more efficient we will inevitably need to reduce the services which we currently provide and we must do this in a candid and transparent manner. In my view we must focus on delivering the possible and not get distracted by trying and failing to deliver the impossible. I will conclude with a thank you to our staff, our volunteers, our Governors and our partners (in health, local government and more widely) and my fellow directors, especially our Vice-Chairman and Senior Independent Director, Andy Willis, who left at the end of the year after over 6 years’ service to chair another NHS Foundation Trust – I wish him well. James Brent Chairman

Page 8 Annual Report 2016/17 PERFORMANCE REPORT: Overview The purpose of the Overview is to provide a short summary that provides readers with sufficient information to understand the organisation, its purpose, the key risks to the achievement of its objectives and how it has performed during the year.

Introduction by the Chief Executive I am delighted to be introducing the Royal Devon & Exeter NHS Foundation Trust’s Annual Report 2016/17 and it is a real honour to be doing this in my new role as the Trust’s Chief Executive. I have been part of the team here at the RD&E for the last eight years, and I know that it’s a very special place full of talented and extraordinary people, and that makes me very proud to have been appointed to lead the organisation. We all know that we face many difficult and testing challenges ahead, but this also brings with it opportunities, and I am committed in my new role to finding the best way to deliver high quality, safe and sustainable care to the people we serve within the resources we have available. One of the things I am keen to do as Chief Executive is to learn more about what working at the Trust is really like for staff at all levels. This is important to me because I need to have a good insight into how hard staff work, the ideas they have and the opportunities there are to do things differently. Most importantly, for me it is all about listening to our team and promoting a greater sense of engagement at all levels of the Trust. Over the last few months I have been going back to the floor and spending time with teams so I can experience first-hand what it’s like for them. So far I have spent time in all areas – both patient facing and support services – and I have already learned a huge amount: how hard staff work but also how smoothly and professionally the service we provide is for the patients who need us even at times of great pressure. To see this first-hand has been a genuine privilege and reminds me once again that our teams are the greatest asset the RD&E has. This year has been one in which we have continued to work hard, together with our partners, to develop a health and social care system for Devon that is clinically and financially sustainable for the future. Tackling these two things together is no small feat and requires us all to think and work differently. The RD&E is playing a central role in this transformation and over the next five years the way we deliver services will change. That has implications for the way staff work and how they carry out their roles, and I know for some that may bring uncertainty and anxiety. The Board and I recognise this, but it is important to emphasise that the community we serve and our staff will be at the heart of any plans we set, or decisions we take. This is entirely consistent with the Board’s “hierarchy of priorities” we developed a few years ago and that has been reported in previous Annual Reports. This hierarchy sets out who and what is most important in influencing our decision making and our patients, our community and our staff are at the top of this list. The Trust has been working closely with our partners county-wide to develop the latest draft of the Sustainability and Development Transformation Plan (STP) for Devon. This sets out a bold ambition to improve health and care services to meet the increasing needs of local people, whilst ensuring sustainability and affordability by 2021. The STP emphasizes the importance of preventative measures and promoting people’s independence, along with providing more effective joined up services in or closer to peoples’ homes, thereby reducing reliance on inpatient hospital care. Delivering the scale of change required is incredibly challenging but the only way to secure an effective and sustainable health service in Devon is by making the courageous decisions now but doing so in a way that clearly explains why we need to make the changes and how people can contribute to our thinking. Although the context in which we are operating has never been more challenging, the RD&E and its amazing staff, continue to deliver incredible results.

● It was inspiring to see how staff, from all corners of the hospital, responded positively to the pressures we faced through the upsurge in demand over the winter period. This year we took a different yet robust plan to safely and effectively manage demands over winter by increasing our capacity through innovative approaches to reduce/ minimalize hospital stay and maximise efforts to prevent admissions to hospital and keep people safely at home. A new escalation plan helped to manage demand more effectively by predicting upsurges in demand and putting in place action to mitigate the situation. These additional

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measures helped improve bed capacity and, thanks to the integration with community services, our community colleagues helped to increase the number of patients discharged into community hospitals compared to previous winters. The new RD&E Community Response team which was launched at the end of the financial year offers real potential to release more capacity in the hospital over time and make the care we deliver more clinically and financially sustainable. Our close partnership work with other health and social care organisations in Devon is also key to this.

● As is clear from our experience over winter, the integration of community services from 1st October was a significant moment for the RD&E. Bringing together community and acute services was an important step in the Trust’s aspiration to be a part of a care system which promotes independence, prevention and citizen wellbeing. The acute part of our Trust has and will continue to benefit from the experience and insight that the community team bring to the table and we have embarked on a process of mutual learning which is ultimately about improving the offer we provide to the communities we serve. Now that the outcomes from the NEW Devon CCG consultation on new models of care has been announced, including a reduction in beds in community hospitals, our attention is now focused on managing the implications.

● Elsewhere, the Trust has been trailblazing neonatal care and became the first Neonatal Unit in the country to be accredited by the prestigious UNICEF UK Baby Friendly Initiative. The team worked closely with parents and our parent support group SNUG to place the needs of the mother, baby and family at the heart of the care provided.

● This year the Trust marked its fifth anniversary since the last incident of hospital acquired MRSA blood stream infection and is the only general hospital in England to have avoided such infections for the last five years. This remarkable accomplishment results from 10 years of continuous improvements led by our dedicated staff both clinical and domestic. The RD&E is now considered a national leader in infection control, having also achieved one of the lowest rates of Clostridium Difficile (C.diff) infection.

● While, like many Trusts, we have struggled to consistently meet all the cancer targets, the results from the National Cancer Patient Experience Survey demonstrated that our patients highly value the service we offer. Patients scored their overall experience of care at the RD&E as 8.9 out of 10. Areas in which we exceeded included patients’ involvement in decisions about their care, their treatment and inpatient experience and the level of advice and support offered to them and their families. Much of this has been achieved with the support of FORCE our amazing local cancer charity.

● We know we face some difficult workforce challenges. That is why I was really proud that the RD&E was designated as the Lead Training Partner for a new Nursing Associate role training pilot in Devon. Staff in this role work alongside Registered Nurses (RN) and Health Care Assistants (HCA) to deliver high quality, hands- on nursing care to patients. This new role will not only give HCAs greater job satisfaction but will also create an alternative pathway for individuals to develop within the nursing profession if they wish to do so. Their training will take two years to complete and will be combination of work-based competencies, hands-on experience and study days.

● I was really pleased with the results we achieved in the latest NHS staff survey. At a time when the NHS faces some big pressures it is incredible that 85% of staff said they would be happy with the standard of care we provide, which is the joint highest score in the country. We’re also in the top 20% of trusts nationally for many other areas in the survey, and our overall combined staff engagement score is in the top ten of acute trusts in the country. Of course the survey also helps focus attention on the things we need to do to improve and we will be looking at this closely to see how we can address these issues.

● I am also very proud that we are a key partner in the South West Genomics Medicine Centre, working closely with the University and other organisations. Research has always played a vital part in our work but genomics offers massive potential to transform healthcare and unlock the secrets of many major diseases such as diabetes and cancer. It’s very exciting to see our clinicians working in the field of genetics – for example, some of our senior cancer specialists took part in the official launch of the South West 100,000 Genomes Cancer project last November, and one of our neurogenetic consultants, Dr Julia Rankin, played a key role in the discovery of a new genetic form of childhood-onset dystonia, a rare progressive muscle disorder. I am committed to continue building on this partnership with the University of Exeter to help develop research and embed it into healthcare – it offers real potential to transform the lives of our patients and their families.

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● It is also important to underline that we have delivered against our financial plan. This has helped keep the deficit under firm control and ensure that we are putting money where it is most needed. Once again, this effort has been led and delivered by the RD&E’s first rate team. Of course not everything we have set out to do at the start of the year has been achieved. We have made strenuous efforts to meet some of the key targets we have – such as the four hour waiting target and also cancer waiting times – but we have not been able to sustain performance at the level expected. Efforts continue to bridge the gap between current and desired performance and I am confident that we can and will continue to make progress. So, while there are big challenges, there are also fantastic opportunities to sort out some of the longstanding problems we have faced. We all know that we have many problems with delayed discharges, that there is great pressure on our Emergency Department and other areas, and we also know there’s a lot of waste across the system as a whole. The opportunity is now there for us to start to tackle these problems that we have long wanted to do something about. And I know that if we work together as a team, and if we work constructively with others outside the RD&E, then we can make something really great for the people of Devon in the future. Suzanne Tracey Chief Executive

Page 11 Annual Report 2016/17 About the Royal Devon & Exeter NHS Foundation Trust

The Royal Devon and Exeter NHS Foundation This is a significant step for the Trust in becoming an Trust provides integrated health and care services organisation that is part of a place-based system of across Exeter, East and Mid Devon. With 8,000 care which promotes independence, prevention and staff, it manages a large acute teaching hospital, citizen wellbeing. This system places the needs of the 12 community hospitals and provides community individual firmly at the centre, supporting them to live services to a core population of over 450,000. the life they want to lead.

The Royal Devon and Exeter NHS Foundation Trust (RD&E) has a long and proud history dating back Our Year over 250 years. The Trust has earned an international reputation as a recognised provider of high quality healthcare services, innovation, research and Spring education. The Trust is nationally and internationally RD&E Diabetes staff are top performers! recognised for excellence in a number of specialist fields including the Princess Elizabeth Orthopaedic Last Spring, the Trust’s Diabetes Team celebrated Centre, the Centre for Women’s Health (maternity, several significant achievements. neonatology and gynaecology services), Cancer The Monogenic Diabetes Team, a partnership Services, Renal Services, Exeter Mobility Centre and between the RD&E Trust and the University of Exeter Mardon Neuro-rehabilitation Centre. Medical School, won ‘Diabetes Team of the Year’ at As a teaching hospital, the RD&E delivers the British Medical Journal (BMJ) Awards for their undergraduate education for a full range of clinical work on ‘Better Monogenic Diabetes Care’. The team professions; is established as a leading centre for high has identified 12 genes responsible for monogenic quality research and development in the South West diabetes and has been providing laboratory genetic peninsula and is the lead centre for the University testing for hospitals across the country since 2000. of Exeter Medical School. The RD&E became one of They have also developed an innovative UK-wide the first foundation trusts in 2004 and this status, education programme to teach other medical with accountability to local citizens through our professionals to identify monogenic diabetes to membership and governors, is an important way of ensure patients received the correct diagnosis and connecting with the people and communities we treatment. serve. Professor Sian Ellard added: “This award represents The Trust’s strategy is focused on ensuring that it 20 years’ work by a team of scientists, clinicians provides safe, high quality services delivered with and nurses from the RD&E and the Medical courtesy and respect. This was reflected in the Care School, working together to make exciting genetic Quality Commission (CQC) inspection in November discoveries that are rapidly translated into new 2015 which praised the Trust’s culture as “strongly diagnostic genetic tests to improve care for patients focused on quality with patients being the absolute with monogenic diabetes.” priority.” Rated as good overall, the first in the South In April, the Inpatient Diabetes team also celebrated West, the CQC rated seven out of eight services a pleasing set of results in the 2015 National at the Wonford site as either outstanding or good Diabetes Inpatient Audit (NADIA). The team scored including outstanding for Caring Services (Trust highly for patient experience and displayed excellent wide), Urgent and Emergency Care and Critical Care. daily diabetes management for patients across the On 1 October 2016 the Trust welcomed responsibility hospital. Key areas of success include an excellent for Eastern Community Services. By bringing acute reduction in the rates of hypoglycaemia (11.2%) and and community services under one organisation in severe hypoglycaemia (0%) which are well below Eastern Devon, we aim to deliver more efficient and the average for England; low rates of intravenous joined up ‘integrated’ care. Working together with insulin infusions (2.3%); and a continued increase health and care partners and local communities, we in ‘good diabetes days’ (an average of 5 out of 7 can better meet people’s needs to ensure a hospital days). Patients also praised the care and knowledge stay is only when acutely necessary and instead keep of staff, with 88.7% saying they were satisfied or more people well at home and supported within their very satisfied with their care, which places the RD&E community. amongst the top performing English Trusts in the audit.

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R&DE celebrates the hard work of Nursing Auxiliaries and healthcare volunteers during Volunteers Week 2016 apprentices show their commitment to compassionate care The contribution made by an army of volunteers at the RD&E was celebrated during national Volunteers Scores of healthcare apprentices and Nursing Week in June. The Trust currently has over 300 Auxiliaries (NAs) successfully achieved their Care volunteers who give up approximately 1750 hours of Certificates throughout 2016, demonstrating their their time a month to help support staff, patients and competency and skill in providing safe, high quality visitors. They play a vital role in helping to improve care as they begin their careers in the NHS. patient experience, enabling frontline, clinical and nursing staff to focus on providing patient care. The Care Certificate assesses the skills and knowledge required to provide safe, effective Volunteers make a difference in a range of roles and compassionate care. It is awarded to staff in across the Trust and many volunteers also come from healthcare roles who have demonstrated they meet external partners such as the RVS, FORCE Cancer each of the 15 Care Certificate standards, including Charity, the Exeter Leukaemia Fund (ELF), Hospital caring with privacy and dignity, awareness of mental Radio Exeter and the League of Friends. health, safeguarding and infection control.

Their contribution to the Trust was celebrated at a The certificate was introduced at the RD&E in special afternoon tea in Oasis hosted by Chairman October 2015, following recommendations in the James Brent and the Board. Chairman James Brent Cavendish review. said: “Our volunteers are a real asset to the Trust and they make a huge difference to our patients In April the second cohort received their certificates and staff. They help to make the RD&E a friendlier at a special celebration event in RILD from Deputy and more welcoming place and we really value their Chief Nurse/Midwife Tracey Reeves, who said: “Our contribution to the running of this hospital. I am Health Care Assistants play a vital role in supporting delighted to host this tea party to thank them for clinical teams to provide safe, compassionate their hard work and dedication over the past year.” and high quality care. So this is a celebration of your achievements. I know that you have worked Revamped play area for Bramble ward really hard, both at work and in your own time, to opens after major fundraising drive complete this course and therefore this certificate is a testament to your commitment and dedication to In June, Bramble ward celebrated the completion of your patients and your colleagues.” their newly revamped outside play area thanks to a massive fundraising drive by local people.

More than £32,000 was raised thanks to a campaign kick-started by The Exeter Lions in 2014. The campaign was also backed by The Exeter Foundation, bike riders from ‘Otter Wheels’, and a multitude of other generous individuals, including the children themselves.

The play area has been given a full range of new brightly-coloured equipment including a large wooden climbing frame, walkways, buggies and play house.

Sarah Haywood, Senior Nurse for Paediatrics, said: “We could not have done this without the support, dedication and generosity of all the fundraisers involved, and I would like to thank them for everything they have done and continue to do for the RD&E and our children, young people and families. The new play area is a wonderful outside space which will serve our children and their families well for many years to come.”

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Summer Judy Potter, Joint Director of Infection Prevention and Control, said: “We know that infection control is Kidney patients find out more about the an important priority for the communities we serve, exciting potential of transportable dialysis therefore we are understandably very proud of what machines the Trust has achieved over the last decade. We have a zero tolerance approach to hospital associated In July, renal patients were offered the opportunity infections at the RD&E, and it is very rewarding to see to find out more about the potential benefits of how everyone’s hard work has paid off.” transportable dialysis treatment at a series of public information events in Exeter and Torbay. Dr Alaric Colville, Joint Director of Infection Prevention and Control, added: “Fighting these Clinicians from the home-haemodialysis team and infections is a constant battle. We must remain current patients already using the transportable vigilant 24 hours a day to ensure our high standards machines were on hand to demonstrate how they are maintained. New infection risks emerge and can be easily installed at home or even taken on antimicrobial resistant organisms develop on an holiday – freeing-up dialysis patients from the burden almost daily basis, therefore it is critical that we of frequent hospital visits and allowing them to win maintain our focus on this area for the continued back more control over their lives. benefit of our patients and communities.” The RD&E has only a small number of patients using Integrating acute and community services in the home-haemodialysis machine and the Trust is Eastern Devon keen to increase this number. In October 2016, the management of community David Dobbs, Home-Haemodialysis Nurse, said: “Our services in Exeter, East and Mid Devon transferred home haemodialysis machines offer real potential from Northern Devon Healthcare Trust (NDHT) to the to improve the lives of our kidney patients. Kidney RD&E. The services included community hospitals, patients who are on long-term haemodialysis face a nursing, therapies and some specialist services, along huge burden, with many long hospital visits, and all with over 1400 staff. the logistical and emotional stress these can create despite our efforts to make them comfortable, but Integrating community services was an important dialysis in a home, even holiday location offer more step in developing sustainable, seamless care closer positive alternatives and the chance to regain some to home. This is aligned to the strategic direction control over their illness.” of the Success Regime, of which all NHS bodies in Devon are a part. RD&E celebrates its achievements in the fight against infection Em Wilkinson-Brice, Deputy Chief Executive/Chief Nurse said: “Bringing acute and community services Significant achievements in infection control and together under one organisation will enable us, prevention were celebrated in September, as the our partners and local communities to work more hospital marked the fifth anniversary since its last effectively to develop services which support people incident of hospital acquired MRSA blood stream to live the lives they want to lead. All of us at the infection. This remarkable accomplishment comes as RD&E are very much looking forward to welcoming the result of continuous improvements at the Trust our new colleagues and continuing the integration over the last 10 years. journey together.”

The Trust is now considered a national leader in The transfer was a result of NEW Devon Clinical infection control, being the only general hospital in Commissioning Group’s (CCG) Transforming England to have avoided having any MRSA blood Community Services (TCS) procurement process and stream infections for the last five years. It also has the CCG, NDHT and the RD&E worked together to one of the lowest rates of Clostridium Difficile (C.diff) enable a smooth transition since the beginning of the infection, having had the lowest rate in the South year. West last year.

Staff across the hospital worked together to achieve this, from the Infection Control and Prevention Team and clinical staff on the wards to the domestic services team and the Executive Board.

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RD&E performs above the national average Autumn in cancer patient experience survey Nearly £6 million for patient-centred Last summer, the results of the 2015 National Cancer research facility Patient Experience Survey placed the RD&E among the top performing Trusts nationally for the level In November, it was announced that the NIHR Exeter of care provided. The Trust performed above the Clinical Research Facility (CRF) was to receive a expected national level in 22 out of 59 questions in further £5.7 million in funding to help it continue its the survey, ranking the RD&E as the third highest patient-centred approach to clinical research. performing trust in England. The facility, which is a partnership between the 1,044 RD&E cancer patients took part in the survey, University of Exeter and the RD&E, supports high with response rate of 76%. Patients were impressed quality research by bringing together members of with their experience, scoring their overall care at 8.9 the public with researchers who are working to find out of 10, giving the Trust a rating of ‘higher’ than solutions to some of the greatest health challenges expected. facing society, including diabetes, obesity, heart disease and dementia. One of its key areas of work is The indicators in which the Trust exceeded the the Exeter 10,000 project where the NIHR Exeter CRF national level included patients’ involvement in is recruiting 10,000 local people to provide data and decisions about their care, their treatment and samples for medical research. inpatient experience and the level of advice and support offered to themselves and their families. Dr Gillian Baker, CRF Operations Manager said “This great outcome is testament to the excellent Tina Grose, Lead Nurse for Cancer, said: “More and partnership between the University of Exeter, the more people are living with and beyond cancer, so NHS and the people of the South West who support we are delighted to receive this year’s results – the and participate in our clinical research. Having nearly continued improvement in patient care is a reflection 10,000 people on our research register means we on a number of key areas including the great can undertake excellent clinical research that benefits work delivered daily by our clinical teams and the local people and helps to improve the health and introduction of the Living with and Beyond Cancer wellbeing of the nation.” programme, which underpins the clinical treatment by providing signposting for patients and their New public sector energy company families to holistic support and information. Cancer is announced for Devon changing, and so are we.” A pioneering new energy company, designed to deliver more efficient heat and power in Devon was launched in December. The innovative company, called Dextco, aims to develop ground-breaking sustainable projects to provide environmentally friendly energy to homes and businesses across Exeter.

The company – whose founder members and shareholders comprise of RD&E, the University of Exeter, Devon County Council, Exeter City Council and Teignbridge District Council – is the first specifically Exeter-based energy company in almost 70 years.

Dextco’s first project was to start work on developing a revolutionary new network to transport heat generated at the RD&E’s Wonford Hospital to consumers across the city, with future plans looking at distributing heat from other sites in Exeter. The schemes are currently looking to attract funding for central government and are leading a procurement process for a private sector partner.

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Dave Tarbet, the RD&E’s Business Development Exeter Foundation donate 200 mini Big Director said: “The heat network will enable the Chiefs for children having MRI scans at the Wonford site to generate most of the electricity it RD&E uses on site which will help cut our energy costs and carbon dioxide emissions providing more resource for Last autumn, the Exeter Foundation donated 200 patient care.” mini Big Chief soft toys to the Medical Imaging Department to give to children to help comfort them RD&E doctor scoops prestigious national when they have an MRI scan. health award The Trust recently introduced the MRI buddy scheme In November a Spanish doctor from the Emergency where young patients are offered a soft toy to Department received national recognition for cuddle when having a scan to make it less scary. The his inspirational contribution to his patients and toys were initially offered to children undergoing colleagues. Dr Jaime Puente was one of six European treatment for cancer. staff from hospitals across the country to be awarded the ‘EU Staff Award’ at the Health Service Journal Ellie Ormesher, Senior Cross Sectioning Radiographer/ (HSJ) Awards. Paediatric Lead, explained: “Having an MRI scan can be really quite daunting for children. Now, thanks The award recognises and celebrates the unique to this donation, we’ll be able to offer them an MRI contribution of staff from countries in the European buddy to choose from, which they can cuddle during Union. the scan and take home afterwards. The children we scan who have cancer often need to come in for Jaime was nominated by the ED team for his strong multiple scans, so we hope this will help take some work ethic and upbeat manner as well as his of the anxiety away for them.” expertise and skill in emergency medicine. Nine year old Mia became the first child to receive He said: “I have the honour to be chosen to collect one of the Foundation’s MRI Buddies because she an award in the name of all the EU citizens working starred in a film showing the journey of a child in and for the NHS, and especially in the RD&E’s undergoing an MRI scan to help young patients A&E Department. Overall, I am overwhelmed for the understand what to expect. great recognition and response given by everybody towards me.” Mia said: “I think the mini Big Chief would make you feel happy and less scared when you’re in the The evening also saw the inspirational work of some scanner. And it makes you feel special that you get to of the hospital’s research teams recognised, with two take it home with you afterwards.” RD&E teams, Devon Dementia Collaboration and the Emergency Department Research Team, being shortlisted for the Clinical Research Impact Award.

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Winter Geoff’s donation will enable local people to undergo the diagnostic procedure at Exmouth Community Call the midwife – RD&E launches new Hospital rather than having to travel further afield to phone number for mums-to-be Exeter and will reduce the amount of time they have to wait for the test. In January the RD&E launched a new 24-hour maternity triage service to provide additional Malcolm Crundwell, Consultant Urologist and Clinical support to expectant mums and other healthcare Lead for Urology, explained: “We are extremely professionals if they have concerns about their grateful for this donation as it has allowed us to set pregnancy. up a new service in Exmouth for prostate biopsy using state-of-the-art equipment. Men in Exeter, The service includes a new triage team of East Devon and surrounding areas now have access experienced midwives, a triage unit within the Ante/ to the most up-to-date diagnostic and treatment Postnatal Ward and a dedicated 24-hour phone facilities for prostate cancer in the UK. None of this number to call for help and guidance. would be possible without the support of charitable The triage service has been designed to ensure contributions and the tireless work of men like mums-to-be receive consistent and timely advice over Geoff.” the phone from a midwife who can decide whether New renal unit officially opened for North they need further assessment. The phone number Devon patients can also be used by GPs and community midwives to refer patients to the RD&E for further examination. Patients in North Devon can now access a brand new renal facility to undergo their life-saving kidney It is hoped that the new triage service will provide dialysis treatment. The opening of the satellite renal a simpler and more efficient service to patients and unit in Barnstaple was officially marked by staff reduce unnecessary admissions to the hospital by and patients from the RD&E and partner Fresenius ensuring women are accessing right maternity service Medical Care at an event to celebrate the project’s for their needs. completion in January. Jo Bassett, Senior Midwife, said: “We feel that The new unit replaces existing facilities in South offering consistent advice via one telephone line will Molton, which no longer meet the needs of the improve the information given and the subsequent growing service. The facility includes 20 state-of- care that women using our service will receive. It also the-art dialysis stations which can provide treatment means that women will be seen in the right location for up to 60 patients a day and it includes a central by the most appropriate person and this fits in with water plant meaning that staff can offer a wider the Trust agenda to ensure seamless working across range of treatment options. Its central location and services.” ample parking also means that travel time has been New prostate cancer diagnostic service reduced for many patients. at Exmouth thanks to Geoff’s fundraising Patient Barrie Petts was one of the first patients to try mission out the new unit. He said: “It seems really modern The Trust was able to open a new prostate cancer and they’ve got newer machines than they had in diagnostic service at Exmouth Community Hospital in South Molton which are better for my type of dialysis February thanks to the fundraising efforts of former prescription. I have to come here three days a week patient Geoff Fidler. and when I had to travel to Exeter it took a good couple of hours out of my day, so getting here is Sixty-five year old Geoff raised almost £47,000 for much quicker.” the Urology Team to part-fund the purchase of an ultrasound scanner used to diagnose prostate Jason Moore, Consultant Nephrologist, said: “This cancer. The additional cost of the £100k scanner was is truly a comfortable and state-of-the-art dialysis funded by the Chestnut appeal. unit which will serve the patients of North Devon for many years to come.” Geoff began his fundraising campaign in December 2014 after being treated for prostate cancer at the RD&E and deciding that he wanted to raise money to help support the work of the service.

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Staff give the RD&E a glowing report in annual NHS Staff Survey Staff gave the Trust a glowing report in the 2016 NHS staff survey. The survey results showed staff highly recommended the Trust as a place to work and to receive treatment, placing it in the top 20% of Acute Trusts nationally. The RD&E has been rated the joint highest acute trust nationally for the proportion of staff (85%) who would be happy with the standard of care provided by the Trust. In addition, the survey findings place the RD&E in the top 20% of hospitals nationally for half of the key findings, including staff involvement in improvements at work, effective team working and placing the care of patients as the organisation’s top priority. The RD&E’s overall ‘staff engagement’ indicator – which is assessed using the responses to nine separate questions – has continued to improve year on year, with the Trust performing well above the national average following a detailed programme of activities to transform our culture and to engage staff in change. The results build on positive NHS Staff Friends and Family Test results for Q1 and 2 this year, which show that 9 out of 10 staff would recommend the RD&E as a place to receive treatment. Tracey Cottam, Executive Director of Transformation and Organisational Development, said: “It is clear that motivated and engaged staff deliver better quality and safer care, which is why we have focused on improving the way we engage with staff. There is always more to do to build on what we have achieved but I am pleased that staff are predominantly positive about their experience of working at the Trust.”

Page 18 Annual Report 2016/17 Our Strategy

Our vision remains, as it has over recent years, to The Board and the senior leadership team have “provide safe, high quality care, delivered with developed seven integrated strategies that underpin courtesy and respect.” the Trust’s corporate strategy:

This is underpinned by three key corporate strategic ● Clinical services objectives: ● Workforce ● Maintaining sound operational delivery of existing clinical, research and teaching services. ● Information technology ● Estates ● Integrating core pathways from the community coming through to acute care within its acute ● Stakeholder communication and engagement services catchment area and out again into the community. ● Business development

● Further development of the Trust’s acute services ● Finance across a wider area by building upon the clinical networks and partnerships already in place.

The clinical services strategy sits at the centre of One of the key rationales for reviewing its corporate our corporate strategy because it is central to our strategy in detail is because the Trust is increasingly purpose. It provides the direction of travel for all the working in partnership with NHS and local authority supporting strategies which together will deliver the partners as part of the Devon Success Regime Trust’s vision. During the financial year 2016/17, the and more recently the Devon Sustainability and strategic objectives continued to provide a framework Transformation Plan (STP). The STP for Devon seeks for the Trust’s work with, as last year, the emphasis to respond to some of the key challenges facing the being placed on the first two strategic objectives on county, primarily the ability to continue to deliver maintaining sound operational delivery and making financially and clinically sustainable services in the progress towards greater integration of services and face of increasing demand from a growing and care. ageing population. The Devon-wide STP aims to address the financial challenge whilst improving During the year the Trust began a process of health outcomes for people in an equitable way reviewing and refreshing its corporate strategy. This through shifting our model of care to provide more work is on-going and is planned to be completed in effective joined up services in, or closer to, people’s the first quarter of 2017/18. The current iteration of homes and thereby reducing reliance on bed-based the Trust’s strategy has been regularly refreshed since care. it was first put in place in 2012. The Board has taken the view that the vision and strategic direction set out The RD&E is a full partner, along with other 5 years ago has served the organisation well and the health and social care organisations across Devon, general direction remains valid and relevant; however, responsible for working within our local communities in the light of a fast changing external context in order to deliver this vision. It is still relatively early nationally, regionally and locally and the renewed days and whilst the vision and outlined plan are course set out in the “Next steps on the NHS five year starting to take shape, there is still a great deal of forward view” report it was timely to take a more work to be undertaken to reflect detailed plans for fundamental reappraisal of the corporate strategy. delivery. Good progress is being made and following This revised strategy will be reported on in next year’s submission of STP during the year, further work has Annual Report & Accounts. continued to ensure the RD&E can meet the needs of today whilst transitioning towards the model of care for tomorrow.

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Sustainability & Transformation Acute Services Review Plan (STP) Devon’s Acute Services Review (ASR) was To address the patient demand and financial announced on 4 November 2016, when the final challenges Devon’s health and social care system draft of the five-year Wider-Devon Sustainability faces, local authorities and health and social and Transformation Plan was published. Acute care organisations (including the RD&E) in areas services are currently provided for the people of covered by the Northern Eastern and Western plus Devon by our four major hospitals (in Barnstaple, South Devon and Torbay Clinical Commissioning Exeter, Plymouth and Torbay). The review will have Groups have come together to form a single three parts: strategic planning ‘footprint’. 1. Examine the gaps in our current acute services The aim is to address together and in partnership a and/or whether we are fully meeting the common set of financial and service challenges national clinical standards to achieve ‘best care around health and care in Devon. The key for Devon’. aspiration is that by 2021, the benefits of health, 2. Identify those acute services that are vulnerable education, housing and employment to economic because of workforce shortages, other and social wellbeing for our communities will challenges and which are at risk of becoming be realised through joint working of statutory unsustainable in the near future. partners and the voluntary and charitable sectors. 3. Engage staff, stakeholders and the public on The Wider Devon Sustainability and what they consider to be most important. Transformation Plan (STP) Senior clinicians in Devon, through the pan-Devon To achieve this aspiration, a Wider Devon Clinical Cabinet, have identified the highest priority Sustainability and Transformation Plan (STP) has services for review, and the services they consider been produced and submitted to NHS England, a most vulnerable. These include Stroke services, process led by RD&E former chief executive Angela including hyper-acute and stroke rehabilitation, Pedder. The plan is the overarching strategic maternity and paediatrics and urgent and framework within which people residing in wider emergency care. Devon will experience safe, sustainable, integrated, local support by 2021. Essentially, the STP is a five- The CCG held a series of public pre-consultation year plan to transform health and care services in discussion events across Devon throughout March Devon. 2017.

The STP will drive delivery of a major programme of transformational change and improvement across Devon starting from 2016/17, with local delivery plans. The change will be enabled by investment in technology, changes in workforce and ensuring that where estate is required, it is fit for purpose. The RD&E is a key partner in the STP and has been integral to developing plans, which are fully in- line with several current RD&E initiatives and our Corporate Strategy.

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‘Your Future Care’ The ‘Success Regime’ ‘Your Future Care’ is one aspect of the STP and The STP builds upon work kick-started by the is the name given to the proposed new model Devon Success Regime – which was established of integrated care for Devon. This focuses on the to provide special support to the area due to provision of community beds in the county and deep-rooted, systemic pressures, such as financial where exactly these should be to help unlock deficits or issues of service quality. resources and capacity to achieve some of the wider aims in the STP. The CCG carried out a Key Strategic Challenges public consultation in late 2016 on proposals for community hospitals in Eastern Devon. Throughout The Trust faces a number of strategic challenges. the consultation period the CCG attended over Rising demand for healthcare, growing financial 70 events and public meetings. In total more than deficits, and missed targets are signs that the NHS 2000 people attended these events and discussed faces its most significant challenge for generations. the proposals. 1552 responses were received by the In Devon we are not immune from these pressures. CCG to the survey, plus more than 650 letters and Analysis done by the Devon Success Regime showed emails in total, reflecting a wide spectrum of views that without change, Devon’s health economy faces a from a range of stakeholders including; members of deficit of over £500m by 2020. This matters because the public, voluntary and community organisations, if finances fail then the quality of care will follow suit. clinicians and staff, elected representatives, The Trust’s strategy aims to address these strategic statutory organisations and regulatory bodies. challenges as in addition, the Trust faces other challenges arising from the geography of the area it Following its consultation, NEW Devon CCG serves: agreed some decisions on the location of inpatient beds in the Eastern locality. At the start of the ● Devon is a large rural area of dispersed consultation, the preferred option was for beds communities with relatively poor connectivity. at Tiverton, Seaton and Exmouth. However, following consultation an option which places ● Different and complex issues facing rural, coastal, beds at Tiverton, Sidmouth and Exmouth emerged urban centres. as the preferred option, by a fine margin. This ● An ageing population with increasingly complex is because the analysis of material following the care needs with some areas in East Devon having consultation resulted in Seaton and Sidmouth a demographic profile that is over twenty years being of equal merit as locations for community ahead of the rest of the country in regards the beds. The CCG looked in more detail at the data proportion of elderly residents. collected by Devon County Council, known as the Joint Strategic Needs Assessment. This showed that ● An increase in number of people living with long in terms of comparable deprivation, Sidmouth has term conditions and mental illness. the highest level and it is on this basis that we have ● Rising in-migration into new and existing recommended Sidmouth rather than Seaton retains communities. its inpatient beds. ● Across Devon, marked pockets of significant This means that community inpatients beds at deprivation and marked health inequalities within Sidmouth, Exmouth and Tiverton will remain, while Devon. those at Seaton, Exeter (Whipton), Okehampton and Honiton will close. ● A period of prolonged austerity and relatively weak economic growth has impacted on Devon’s Implementation on these changes is led by the economy. Trust following the earlier transfer. This work will continue into the new financial year. It is important ● Local health and social care services are under to stress that the timing for any changes in the severe financial pressure as extra demand and future will be dictated by an implementation technological advances create a 4% requirement assurance process. Inpatient beds will only close for growth each year. when the assurance process has been completed. ● Despite real terms protection, NHS funding growth is much slower than the historic long-term trend. NHS funding has fared better than other public services, and the Spending Review provides

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real-terms growth in NHS England revenue Strategic Objective 1: Maintaining funding, although age-weighted real-terms funding per person will go down in 2018/19 and Sound Operational Delivery 2019/20, and capital investment has been limited The foremost priority for continuing to provide safe, in recent years. high quality services delivered with courtesy and respect was to maintain our core business as usual ● Funding for public provision for adult social care services and support functions, make efficiency is under enormous pressure. The LGA estimates savings, improve the care we offer our patients and that adult social care faces a funding gap of £1.3 apply our research and development work into better billion by the end of the decade as part of the care. At the beginning of the year, this focus was £5.8 billion funding gap facing local government translated into two key delivery priorities: overall. ● Safe, high quality services delivered with courtesy ● There is a difference of 15 years in life expectancy and respect across North, East and West Devon and spending per person on health and social care differs ● Financial sustainability markedly between the three locality areas with spend being 10% lower in the most deprived Supported by two key supporting priorities: areas. ● Organisational Development (OD) and Workforce Analysis undertaken as part of the Devon Success ● Safety and Quality Regime showed that: Safe, high quality services delivered with ● Care is not sufficiently person-centred and co- ordinated especially for people with more than courtesy and respect: Operational priorities one long-term condition and there are too many In 2016/17 our operational priorities were to: people in hospital beds who don’t need to be there which is a symptom of a fragmented ● continue to improve discharge from the hospital system. and reduce reliance on bed-based care

● Local people are waiting too long to access some ● improve performance on the ED 4-hour wait cancer services. target

● There are difficulties with recruiting and retaining ● implement the Trust’s bed capacity plan staff at all levels making it hard to provide ● achieve the 18 week referral to treatment (RTT) comprehensive and high quality services. target achievement ● Not enough is done to prevent people from ● make further improvements in cancer waiting getting ill in the first place. times ● The health and care system is outdated and not ● develop 7-day services plans plugged into the digital world. The performance analysis section of this report highlights progress against these priorities.

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Safe, high quality services delivered with The RD&E Appoints a New Chief courtesy and respect: Financial sustainability Executive At a time when resources are tight the Trust needed The Royal Devon & Exeter NHS Foundation Trust to continue to do more for less over the years. The appointed Suzanne Tracey as its new Chief RD&E has become used to making efficiency savings Executive in November. Ms Tracey had been and finding new ways of delivering good quality the Trust’s Director of Finance and Business healthcare to the people who need it. This work Development, Deputy Chief Executive and Chief continued during the year and included examining Financial Officer and acting Chief Executive. why we deliver services/care the way we do, and working out how to do what is needed in a different Commenting on the appointment, RD&E way. Chairman James Brent said: “Suzanne has been a key member of the Trust’s well-regarded executive In 2016/17 our financial sustainability priorities were team for almost eight years and has made a to: significant contribution to the success of the RD&E during this time. ● Deliver the full year and current year CIP “She brings with her extensive NHS experience ● Deliver the Success Regime/STP savings and right- having worked at a senior level in a number of size accordingly acute trusts and a commissioning organisation. ● Undertake the Carter Review implementation She also has in-depth local knowledge of the Trust and the wider health economy and a compelling ● Deliver procurement savings vision for how she would like the Trust to develop ● Put in place strategies to maintain the Trust’s cash over time. reserves “Suzanne has done an outstanding job over the The performance analysis section of this report last few months as interim Chief Executive and I highlights progress against these priorities. believe the Trust will continue to go from strength to strength under her leadership.” In seeking to meet these core priorities, the Trust also determined the focus for two key support strategies Commenting on her appointment, Suzanne said: as follows: “I am honoured to be appointed to this role and it will be a privilege to serve our patients and Safe, high quality services delivered with staff. I know full well that the RD&E is a superb courtesy and respect: Organisational organisation that delivers the very best care to Development (OD) and Workforce the people who need it, largely because we have incredibly committed and compassionate staff ● Deliver the RD&E milestones for the Success who do their utmost for the people in their care. Regime Agency Work Stream

“This is a time of profound change in the NHS ● Deliver 2016/17 workforce plan milestones but I and my fellow Board members are fully committed to helping steer the Trust through the ● Deliver Culture Change/Development milestones challenges we face so that we continue to provide ● Deliver Staff Engagement action plan safe, high quality care delivered with courtesy and respect to the communities we serve.” Safe, high quality services delivered with courtesy and respect: Safety and Quality Suzanne’s appointment followed the departure of Angela Pedder OBE. The Trust said a fond farewell ● Deliver CQC Report actions to Angela following 20 years of committed and exceptional leadership. The RD&E’s loss however ● Deliver Commissioning for Quality and Innovation was Devon’s gain, as Angela took up the post (CQUINs) of Lead Chief Executive for the Success Regime ● Deliver Safety and Quality improvement plan in Northern, Eastern and Western (NEW) Devon and the STP – leading a collaborative approach to The performance analysis section of this report develop improved and sustainable health and care highlights progress against these priorities. services for local people throughout Devon.

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Strategic Objective 2: Integrating ● Changing the way the current health and care system works for individuals rather than for Core Pathways from the separate organisations and actively removing Community Coming Through organisational barriers to Acute Care Within its Acute Moving in this direction is essential but it does not Services Catchment Area and Out take away from the fact that people will still require Again into the Community great care delivered with courtesy and respect; with people being able to access the right care and Given the scale of the problems, we know that there treatment in the right facility when they need it. That is a need to make some far-reaching changes to the is why we must continue to provide the care that way in which health and care services are organised people need and expect when they face a health and delivered in the future – for example we know crisis. we need to change the way we run outpatient appointments because it is currently inconsistent At the RD&E we are working to bring this vision into across Devon and is not very efficient. We also know reality through: we need to find alternatives to bed-based care. ● transferring community services to the RD&E Across the Devon system we are starting to – a vital first step towards a more integrated fundamentally rethink how we currently organise approach the delivery of care and developing new ways of ● developing the future model/s of care – and doing this which are not only more efficient but are engaging communities and our staff in this work better for people and improve outcomes. The RD&E is playing a key role in leading this work and last ● developing the future workforce model – year we set up the RD&E FutureCare Programme to identifying what new shape, roles and skills will prepare the ground for the work which will need be needed and how best to develop them to be done to put in place a new more sustainable, effective, efficient and personalised care system for ● purchasing a new electronic patient record system the population of Devon over the next decade. This that will support big changes in patient pathways. new way of working is built around the grain of Given our financial position we are working with people’s lives, assets, ambitions and the communities our preferred supplier to explore leasing options they live in. It is about: so that we can use the system we have chosen ● working with our public and voluntary sector ● Helping people to stay well, take more responsibility for their own health and avoid partners on new ways of working on place health crises and giving them more control to live through the Integrated Care Exeter project the life they want ● working with voluntary groups and colleagues in the health system and local government on ● Continuing to care for and treat people who need it using the latest technologies and innovations in how we can develop a new approach to knit a more joined up and efficient way delivered close services together at a local level in ways which to or in their home support and enhance the assets, strengths and connections of existing communities ● Changing the way the current health and care system works for individuals rather than for In the broader context, the Devon health and care separate organisations and actively removing system is now working together to produce a multi- organisational barriers year plan that sets out how local services can evolve, be more sustainable and deliver better health, better ● Using information technologies to give access to care and greater efficiencies. This 5-year plan for the right information at the right time. the county is called the Devon Sustainability and Transformation Plan (STP) and we are working with ● Reducing the time patients spend in bed-based our partners on six key programmes as part of the care in hospitals STP. ● Working with people and communities to Through these plans, we believe we can deliver more use their assets and energies to support more joined-up, better care that best meets the needs of personalised care are encouraging them to take individuals and communities in a sustainable way. more responsibility for their own health

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This new approach marks a decisive and fundamental ● Produce Integrated Care Exeter (ICE) plan and shift, and begins to establish a “new deal” with implement the population about how we can now develop a new way for people to receive the care they need Integrated Care Exeter (ICE) was established in in the future. It also has implications for existing 2014, with recognition that, in order to meet the organisations and our staff. For our patients, people needs of a changing demographic, there needed and communities it will mean: to be significant changes made to the ways in which public services were being delivered. ICE ● a more joined-up system that will ‘wraparound’ membership spans representatives from across people from community into hospital and back the NHS, local authorities and the voluntary out again sector. The alliance is working toward a future in which local services will be arranged on an ● more personalised care and less time in hospital individual basis, will provide preventive care and ● a greater focus on personal responsibility, support, and will be designed and delivered in wellbeing and prevention partnership with communities where people live.

● empowered patients who take more control of Through ICE’s four distinct programmes of work, their own care a new model of population health and wellbeing is being established which has a greater focus on ● more emphasis on prevention and early warning early intervention and prevention, more care and but the assurance that high quality, safe care in support out of hospital, and services designed hospital is there for those who need it around the needs of individuals and their family:

● greater emphasis on developing systems of care ● Place-Based Care: Developing a Health and that are focused on tackling community needs Wellbeing Hub in Exeter In 2016/17 our delivery priorities were: In partnership with seven GP practices in Exeter we are co-designing and prototyping new models Integrating core pathways: Integration for reducing demand, preventing admissions and ● Complete community services transfer and improving hospital discharge. In December 2016 implement ICE was successful in a bid to join the National Association of Primary Care (NAPC) Primary Care From 1 October 2016, the management of Home Learning Community. community services in Exeter, East Devon and Mid Devon transferred to the RD&E. Community ● Reducing High Cost Demand: Street services, which include community hospitals, Homeless and Vulnerably Housed nursing, therapies and some specialist services, It is estimated that there are about 500 adults in along with over 1,400 staff joined the RD&E from Exeter facing a combination of complex problems Northern Devon Healthcare Trust (NDHT). including homelessness, substance misuse, mental Integrating community services with the RD&E ill health and offending behaviour. The aim is to is an important step in developing sustainable, prevent entrenched health problems for people seamless care closer to home. This is aligned to who are street- homeless and vulnerably-housed the strategic direction of the Success Regime, of by identifying problems sooner and providing which all NHS bodies in Devon are a part, and is rapid and responsive support rather than waiting entirely consistent with the Trust’s own corporate for people to get into crisis. Exeter City Council strategy. Continuing to work in partnership with and Northern Devon District Council were both local communities will be vitally important as we awarded Homeless Prevention grants in December move towards a system of care which focuses on 2016 which featured ICE work in their bids. prevention and citizen wellbeing. ● Diverting Demand: Risk Stratification The transfer is a result of NEW Devon Clinical Working with all the GP practices across Exeter Commissioning Group’s (CCG) Transforming we are developing a systemic way to identify Community Services (TCS) procurement process people who could benefit from early interventions and since the beginning of 2016, the CCG, NDHT to improve outcomes and reduce overall system and the RD&E have been working together to costs. enable a smooth transition.

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There is growing local and national interest in and developing individuals to better understand the tool as it builds population profiles through how to implement change in the system – linking existing data sets primary care, acute focusing their thinking around problems and healthcare, social care, deprivation indices, health solutions. outcomes and social marketing. Integrating core pathways: Transformation ● Diverting Demand: Community Resilience and Social Prescribing ● Progress Electronic Patient Record (EPR) development and Digital Roadmap An integrated network of primary care based Community Connectors covering a population The EPR business case has been developed and of around 100,000 is offering alternatives to approved by the Board, and work continued this statutory services. The pilot will provide a better year on securing investment funding required for understanding of how communities can do implementation. more to help themselves and reduce demand on ● Define the future model of care and produce statutory services. Rate of referrals is growing implementation plan / place-based systems each week with a total of 699 referrals since pilot of care start-up. Under the Trust’s Future Care Programme a Care SERIO, an applied research unit at Plymouth Design Group was established. 60 frontline staff University, was commissioned in 2017 to provide spanning the whole health and care Community a review of the ICE programme’s strategic added came together and designed a new framework value, in order to understand its impact on model of care, under which new service delivery stakeholders and wider programmes of work. models will be designed and tested forming the The review identified a high level of consensus on foundation for more integrated and personalised the value and impact of the ICE programme. Key care. The Care Design Group has been findings included: instrumental in shaping and influencing the New ● A shift in thinking amongst those at the Models of Care work being undertaken by the highest levels of each organisation with Wider Devon STP. movement towards a new person-centred This new model of care focuses equally on wellness, model of care, where the focus is on the prevention and ill-health management, seeing individual patients as people, empowering them to be in ● Increased understanding and acceptance control of their own care and aligns to the direction that a collaborative systems approach was of travel outlined in the NHS Five Year Forward View. necessary going forward, as the issues being In order to best meet the needs of our population our faced were beyond the scope of any individual initial areas of focus are: organisation ● Identifying need – using a local place-based ● Advanced levels of trust across partner population segmentation approach, which organisations, paving the way for more identifies current and predicts future need productive collaborative working ● Frailty – improving the coordination of services ● A broadening of stakeholders’ scope and wrapped around frail older people and providing a understanding of the wider system resulting rapid and integrated response to crisis supported from the space and capacity to come together by intensive re-ablement aimed at minimising the ● More actively exploring new and innovative institutional length of stay as well as maximising modes of working rehab potential

● ● A desire to take the learning from ICE and use Long-Term Condition (LTC) management of it to enhance their own organisations’ way of mostly well and pre-frail people. This includes a working. fundamental review of how, why and where we deliver ambulatory and outpatient services for Whilst it is not yet possible to evidence outcomes people with multiple LTCs that work to meet the or measure the financial savings to the system, holistic needs of the people (not just their disease the impact on individuals involved in the ICE management) and pulls on a wider spectrum of programme is clear. ICE is helping people to service providers, in particular the voluntary sector realise the necessity of a preventative approach, and local community groups

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● Increased delivery of outpatient and ambulatory 3. Comprehensive Rapid response (care at home) services closer to the people they serve, making service, to help people to remain at home with better use of community and social capital support, rather than being admitted to hospital and where hospital admission is unavoidable, it ● Work with the established social care cluster will provide the additional support at home that footprints to develop care coordination, makes it safe to leave hospital. This will include navigation and collaboration of multidisciplinary health and care workers delivering rehabilitation teams harnessing social capital alongside traditional care. ● Work with Eastern Devon GPs, identifying As a Foundation Trust, we recognise our responsibility population groups with multiple comorbidities to the community, which includes listening and and partnering with them to redesign services responding to the views of our Members and the whilst promoting self-management and control public. The Trust acknowledges that the delivery of for people, for example through Integrated care in the most convenient but also appropriate Personal Commissioning location is an important consideration for our public. The Trust’s reputation for effective leadership, The transfer of community services for the Eastern innovation, quality improvement and safe care locality to the Trust is therefore consistent with underpinned by its strong partnerships with people, the delivery obligations the RD&E has laid out in patients, providers and communities forms the its corporate strategy direction with reference to foundation of our new system of care. integration and personalised care. The Trust’s aim is to create an effective, efficient From a citizen’s perspective the emphasis for health and sustainable system of care which, from the and wellbeing might be framed by the concept of perspective of the individual (patient, relative or ‘living well’. carer), is: When an individual is out of balance from a health ● Flexible, local and personalised perspective, they might need assistance to either ● Focussed on self-help and wellbeing support them to manage an ongoing health need or require a single episodic intervention which will ● Supportive of people living healthier lives in restore their previous level of wellness. healthy communities As we live longer, the likelihood and indeed evidence And where: is that an increasing number of people will live with multiple comorbidities and frailty. The current system ● Targeted resources follow need in a seamless way across Devon, and within the RD&E catchment ● Our service offer is dynamic and sustainable population geography relies too heavily on bed- based, institutionalised care. ● Quality of care is continuously improved For elderly people, particularly those with multiple Co-design with patients, carers and communities is a conditions and/or dementia, admission to an significant feature throughout our work to date and institutionalised bed whether in an acute or will continue such that we will shift the focus from community hospital results in deconditioning; the loss “patients” to “people”, and from “What is the of physical and psychological reserve and increases matter with you?” to “What matters to you?” long term dependence. In the first year the focus is on: The solution to this lies in the development and delivery of a new model of care which has at its heart 1. Comprehensive assessment to identify people the promotion of: who are frail or could soon be, to put a care plan in place and to outline potential avenues for ● Self-management escalating care when it is required. ● Community based services 2. A single point of access – making it easier for GPs and others to get additional support when ● Re-ablement it is needed urgently. It will be connected to a ● Care coordination Comprehensive Rapid Response service. ● Prevention All the above is seated within a place-based concept.

Page 27 Annual Report 2016/17

Delivery of services within a local system of care, organisational focus and orientation on the care under the leadership and management of one pathway will ensure business options are considered provider will mean that service delivery can mirror and decisions made in that light, accompanied by the the care continuum which facilitates less time spent ability to flexibly deploy resources along that pathway in institutions and more time spent in local place such that they add the most value to the individual and community for individuals. In addition, an and population we serve.

New Ways of Working: A Patient Story Amy Maggs grins from ear to ear in excitement. “I Amy says that her life has not been straightforward love my life” she says. In three days’ time she will “I have faced lots of obstacles along the way” she be going on holiday to Cornwall in her brand new explains. Like other cystic fibrosis patients she faces retro VW campervan and she cannot wait. This will a number of long term conditions that impede her be the first time she has used the campervan since and make doing some of the things that most of us buying it a few weeks ago and is looking forward take for granted much more difficult. to sharing the experience with her husband, her young daughter and her dog Hugo. Although this But with the right support and a dedicated care will be her first trip in the new campervan, it is not team around her, alongside some fairly simple the first time she has been on holiday – whether interventions such as a portable nebuliser and the that is camping in England or going to more far- ability to self-administer her medicines, Amy is able flung places such as Florida, Cuba and Kenya. to lead a full and active life – including using her campervan to go on holiday. Amy receives amazing Living a full and productive life is important to 26 support from her family and friends and this is year old Amy from Dawlish in Devon. Like any other complemented by her medical team – who she talks young mother, she is determined to lead the life she to several times a week and who are there for her wants to lead and build a happy and loving family when she needs them. She also currently receives caring for those around her and giving her daughter much needed physio at home. the best start in life. She works in her family’s electrical business and when she’s not working she Through the support she received from the NHS, looks after her three-year old daughter. Amy was able to fulfil an ambition that she thought may well be unattainable: having a baby daughter. Yet Amy faces some difficult issues since being “It was the most amazing thing that has happened diagnosed with Cystic Fibrosis at the age of three. to me” she says. “They give me brilliant support. They are like my second family.”

Page 28 Annual Report 2016/17 Key Issues and Risks Quality The outline in the preceding sections provides an ● Continued financial constraints and the delivery overview of the Trust’s strategy and its fit with the of CIP have the potential risk of impacting on the broader Success Regime programme. quality of services. The risk mitigation centres on the robust quality assurance framework which is As the Trust continues to pursue its corporate in place, incorporating a balance of hard, empiric objectives, it is clear that there are a number of key data and soft intelligence which alerts relevant risks and issues that it currently faces and will face in levels of clinicians and managers throughout the the future. The Trust’s key strategic risks are captured Trust to any deterioration in quality. in its comprehensive Board Assurance Framework (BAF) which is regularly updated and reviewed by the ● Despite considerable attention and progress over Board as part of its deliberations. The BAF identifies the past 12 months, delayed Transfers of Care key risks to the Trust’s three strategic objectives and continue to represent a significant system quality what the organisation is doing to manage or mitigate risk. The Trust is actively engaged in the system the risks. The core risks are as follows: work plan, aligned to the Success Regime and Future Care Programme focused on redesigning Operational the model of care and associated service delivery model required to ensure that citizens are cared ● External and internal pressures on the Emergency for in the right place, at the right time, by the Department may add further pressure on the right people. delivery of the important 4-hour A&E target. This indicator is an important indicator of quality, Financial as well as having significant funding attached to its delivery from the sustainability and Following three years of increasing deficits, the transformation fund. A comprehensive, system- deficit in 2016/17 reduced to £2.3m, (before wide plan is in place to improve performance impairment and gain on absorption) from £20.1m and the achievement of this KPI is supported in 15/16. £12.6m of this improvement resulted from by an extensive process of monitoring and achievement of financial and operational targets in management. the form of the Sustainability and Transformation Funding (STF). Plans for 2017/18 continue this ● Activity flows may change rapidly causing improvement with a planned deficit of £0.5m which unpredictable changes and possible unintended is based on achieving CIP of £21.6m. The Trust has a consequences. robust approach to mitigate against cost overspends and to tackle issues where CIP plans may not be ● Providers may reduce capacity faster than demand delivering against expectations. reduces, causing further Referral to Treatment (RTT) pressures. The Trust is working closely with The Trust’s 2017/18 plan has been established in the its commissioners and as part of the Success context of the wider plan established for the whole Regime to manage activity flows and demand on Devon population, driven by the Devon Success its services. Regime and more recently the Devon Sustainability and Transformation Plan (STP). The STP for Devon ● The Trust may not be able to recruit suitably seeks to respond to some of the key challenges qualified staff for key areas and workforce facing the county, primarily the ability to continue to consultation processes may delay change deliver financially and clinically sustainable services in temporarily. The Trust will continue to work with the face of increasing demand from a growing and education providers and Health Education South ageing population. The Devon STP aims to address West to inform their plans, ensuring workforce the financial challenge whilst improving health supply needs are met for the Trust and regionally. outcomes for people in an equitable way through shifting our model of care to provide more effective joined up services in, or closer to, people’s homes and thereby reducing reliance on bed-based care. While work is well underway, the risk exists that partners may not be able to release costs as outlined which could have a deleterious impact on the Trust’s financial position.

Page 29 Annual Report 2016/17 Going Concern Statement 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.

For further details, please see Note 1 to the Accounts on page 13.

Page 30 Annual Report 2016/17 PERFORMANCE ANALYSIS Performance Management and Assurance

The Trust uses a Performance Assurance Framework representative local indicators are included in the (PAF) which measures key performance data and templates along with trajectories for 2017/18. provides assurance that performance, including safety and quality indicators, will be effectively monitored The Trust continues to use the “Connecting Care” and reported to support managers and clinicians in methodology to support the delivery of good delivering the required targets. Monthly PAF meetings performance. Connecting Care enables teams to take place with each Division in a meeting chaired work together in a more joined up approach that by the Chief Operating Officer to review a set of supports all our staff to find new and better ways Divisional and Specialty-level dashboards covering of working, from making small changes that make a more detailed set of indicators across all themes. a difference to much larger scale improvements. The reports that are prepared for the meeting Connecting Care provides a systematic way provides the opportunity for the Clinical Division to of working together using a set of continuous undertake its own triangulations and this is tested improvement tools and techniques that have been and challenged in the meetings. rolled out across the Trust over the last 2 years and is now used in all parts of the Trust. The Trust’s Performance Framework ensures that performance monitoring and performance are Single Oversight Framework aligned from service line and ward level to Board. The monthly Integrated Performance Report (IPR) to A revised performance framework has been Board includes a wide range of national and local established by NHS Improvement to support performance indicators grouped by the following delivery of their 2020 objectives; to help more trusts themes: achieve a CQC rating of ‘Good’ or ‘Outstanding’, to reduce the numbers of Trusts in special measures, ● Clinical Effectiveness to support achievement of aggregate financial balance from 2017/18 and to ensure that Trusts ● Finance meet NHS Constitutional standards. The purpose of ● Operational Effectiveness the framework is to identify where providers may benefit from, or require, improvement support across ● Patient Experience a range of areas. The Single Oversight Framework is closely aligned to Care Quality Commission (CQC) ● Safety and Safer Staffing standards, and replaces Monitor’s Risk Assessment ● Workforce Framework and the Trust Development Authority (TDA) Accountability Framework. It applies to both These are accompanied by a traffic light system NHS Trusts and NHS foundation Trusts irrespective (RAG) ratings of historic and current performance, of their legal form, and is based on the principle of assessments of future risk, narrative commentary and earned autonomy. remedial action plans as required. The integration of these indicators within a single report provides a There is a new emphasis on the importance of read-across between indicators and themes that is leadership and improvement capability within NHS made explicit within the accompanying narrative. organisations, and an expectation that providers will engage constructively with local partners to build An appendix within the IPR includes the ‘Ward to shared understanding of local challenges and patient Board’ report that displays ward-level safety and needs, and to design solutions which will drive quality indicators and thereby provides triangulation improvements in the care of the local population. at a more granular level, minimising the risk that Financial measures also play a key part in the Single Trust-wide performance could mask individual areas Oversight Framework, and focus on sustainability, of concern. This report also goes quarterly to the efficiency, and control. Board. Many of the previous core performance metrics The range of indicators covered by the IPR and relating to access to services remain within the the Divisional Performance meetings is extensive. framework, including Referral to Treatment access As part of the Operational Plan submission, ten targets, 4-hour maximum waiting times within

Page 31 Annual Report 2016/17 the Emergency Department, and waiting times for performance continues to compare favourably with diagnostic tests. The previous Cancer Standards have other Trusts in the region, some important local been consolidated and now focus on the delivery of pressures have made delivery of the key performance the 62- day wait for first treatment target. indicators difficult over the past year. Locally, significant increases in demand for Urology cancer The Integrated Performance Report has been services (16%), and orthopaedic surgery (8%), have redesigned for 2017/18 to reflect the new reporting placed additional pressure on the achievement of regime and ensure robust scrutiny of the key the cancer and RTT standards. Furthermore, added indicators within the Single Oversight Framework. pressure on the Emergency Department has arisen from some key changes externally, which include Overview of Performance in changes to local services outside of the Trust and 2016/17 an increase in the number of psychiatric patients attending the ED. The Trust is working closely with Both nationally and across the Southwest, 2016/17 partner agencies and is making steady progress in has been a challenging year with regards to achieving resolving these complex issues. Internally, workforce performance targets, as demand has remained high, challenges relating to medical staffing have also and in some key areas continued to grow greater placed pressure on the Emergency Department, than the availability of resources. Although the RD&E particularly out-of-hours.

Trust performance in figures - 2016/17

Indicator Measure Standard/target 2015/16 2016/17 Infection Control Meet the C.Diff objective 31 (2016/2017) 2 16 (14 of which were 31 (2015/2016) agreed with the CCG as being unavoidable) Infection Control Meet the MRSA objective 0 (2016/2017) 0 0 0 (2015/2016) 18-week RTT % admission – incomplete >92% 93.0% 91.6% pathways Cancer access Urgent GP referrals seen >93% 92.1% 92.4% within 2 weeks – all cases Cancer access Breast cancer symptomatic >93% 95.4% 71.2% referrals seen within 2 weeks Cancer access Cancer treatment started >96% 93.4% 97.2% within one month of diagnosis Cancer access Cancer treatments started >85% 81.1% 79.7% within 2 months of urgent GP referral Waiting times A&E max waiting times of 4 Less than 4 hours 94.8% 92.5% hours Patient Compliance on access to Compliance Compliant Compliant Experience healthcare for people with learning disabilities

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Operational Performance Considerable progress has been made over a number of years to reduce the risk of health care This section looks in more detail at some of the Trust’s associated infection. Health care associated infection key operational performance issues during the year. often results in prolonged hospital stays, increased resistance to antibiotics and unnecessary deaths. Staff Staff at the Trust worked tirelessly to provide high across the hospital have worked together to achieve quality and seamless care for patients delivered with this. From the Infection Control and Prevention courtesy, respect and kindness. Strenuous efforts are Team and clinical staff on the wards to the domestic made each and every day to make improvements, to services team and the Board, everyone has pulled reach performance and operational targets and to together to ensure that the patients at the RD&E will manage and mitigate risks to these targets. Broadly receive safe, high quality and infection-free care. speaking on a range of indicators and targets, the Trust performs strongly. However, there are some A&E Maximum Waiting Time of Four areas where performance has been challenging over Hours from Arrival to Admission, Transfer the course of the year. The RD&E is firmly committed or Discharge (excluding Walk In Centre to meeting key national waiting targets because activity), and Ambulance Handover Delays we recognise the impact delays can have on our patients and their families. Achieving some these The Trust was challenged throughout the year targets consistently is extremely challenging due to on meeting the A&E maximum waiting time of 4 high demand and the challenge of maintaining safe hours target. This was because of increased ED staffing levels but we work hard to recover any lost attendances as well as bed capacity pressures caused ground as quickly as possible. It is important to stress by increased levels of emergency medical admissions. that the safety of our patients will always be our Comprehensive plans were developed and highest priority and we work carefully to avoid any implemented, which were integrated with the System clinical harm coming to a patient whose procedure Resilience Group and the Devon Success Regime we need to postpone. plans in order to optimise performance against this target. The remedial action plan was monitored Infection Control: Clostridium Difficile internally through the fortnightly Operational The number of cases of Clostridium Difficile for the Capacity Steering Group and through the appropriate 2016-17 year until March 2017 was 15 and is well contracting meetings with the CCG. As a result of within the target of no more than thirty one. Of these measures the number of delays attributable to these fifteen cases, only one case was determined the Emergency Department (ED) continued to reduce to be avoidable. Results from the 2016 National month on month from August 2016, indicating Point Prevalence Survey of all types of healthcare benefits of process optimisation, as well as benefits acquired infection have been received by the of front door streaming to other services being fully Infection Prevention and Control Team. This shows operational. Despite this failure to meet the target, that the RD&E acute hospital infection rate is 2.8% in the RD&E’s performance compared favourably to comparison to a national rate of 7%. This a further similarly sized Trusts in England. reduction on the previous low point prevalence rate 62-day wait for first treatment (all cancers) of 3.6% in 2011. Plans implemented throughout 2015/16 substantially Infection Control: MRSA improved the Trust’s performance against the range The number of cases of MRSA for the 2016-17 year of cancer targets, with the Trust achieving eight out until March 2017 was zero which is in line with the of nine cancer standards in Q1. However significant target for the year which is also zero. This remarkable referral growth in some sub-specialties, as well as accomplishment comes as the result of continuous two senior medical staff being absent from work for improvements at the Trust over the last 10 years a prolonged period within Urology, made delivery thanks to the dedicated work of our staff. The Trust is of the 62-day standard challenging. Delivery of now considered a national leader in infection control, the cancer targets continued to be challenging. being the only general hospital in England to have During Q3 there was an issue in the Breast Care avoided having any MRSA blood stream infections for Unit (BCU), as well as further challenges of medical the last five years. It also has one of the lowest rates staffing within Urology. An issue relating to the of Clostridium Difficile (C.diff) infection, having had environment in the BCU led to a decision to close the lowest rate in the South West last year. the Unit to all activity pending further investigation.

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As per its business continuity plan, the service was factors within Orthopaedics continued to drive the relocated temporarily, which resulted in appointment deterioration in Trust aggregate performance. Firstly, delays beyond the two week target timescale for a GP referrals across all commissioners were 9% above significant number of patients. The BCU reopened the 2015/16 actuals at month 11, in the context of to full capacity in January 2017 and while the teams an expectation of no growth. So far this year this has are working hard to clear the backlog of patients, led to approximately 765 additional referrals and 480 there is likely to be an impact to later stages of the more patients on the admitted waiting list. Secondly, pathway for some patients, resulting in potential there continues to be a pause on the use of the 62-day treatment breaches. The BCU team are closely independent sector, which has been in place since monitoring patient pathways and have provided October 2016. This has resulted in approximately assurance that patients’ outcomes have not been 250 patients who would have undergone surgery adversely affected as a consequence of the additional within the independent sector but who have 1-2 weeks’ waiting time. remained on the waiting list. As these patients are now almost all waiting longer than 18 weeks, the One further issue that impacted our waiting times impact on trust aggregate RTT performance was was the unexpected cessation of the Dermatology equivalent to 1%. Further actions to address the issue Service at Taunton from 1 November 2016. This have been taken including: contributed to pressures to the RD&E service as patients will be referred from further afield. ● As part of the process of resource planning and budget setting for 2017/18, demand and capacity Average number of patients reportable as a are being carefully planned to ensure that the delayed transfer of care Trust can resiliently and sustainably manage The volume of patients awaiting onward care current levels of demand. remained high throughout the year. The Trust ● The Trust is working with partners in the local continued to work with NEW Devon CCG and healthcare community to support measures to providers on the implementation of a system- wide reduce demand wherever possible. remedial action plan. This work was also progressed by the Success Regime’s bed based care work stream. ● A comprehensive action plan has been developed for every specialty aimed at maximising Whilst there is no specific target for delayed transfers performance. This is monitored closely via the of care (DTOCs), the impact of patients medically Trust Access meeting and the monthly Divisional fit to be discharged who occupy inpatient beds Performance Assurance Process. underpins the achievement of a number of key performance indicators, most notably the A&E 4-hour Time to surgery for patients with a fractured target. Consequently, a great deal of management neck of femur attention has been placed on working with partner organisations to reduce DTOCs and increase the Throughout the year the Trust failed to meet the system capacity for community and domiciliary care. 90% target for Fractured Neck of Femur patients Within the wider health and social care system, there receiving surgery within 36 hours. The main reason were a number of challenges in both the personal for missing this target was the number of trauma care market (domiciliary care) and the care home admissions through the year which meant that market, including the closure of a residential home in scheduled operations were delayed. In circumstances Exeter, which resulted in a reduction of 16 local care in which theatres are utilised for trauma patients, the home beds. theatres are then also utilised for additional trauma patients with issues such as complex spinal surgery 18 weeks referral to treatment incomplete which further delays routine operations. A number pathways (RTT) of initiatives have been implemented to enable the Trauma surgery team to cope with surges in demand, The greatest challenges to achieving the 18 week which have worked to varying degrees. However, a RTT target were within the Orthopaedics, General task force comprising of clinicians and managers from Surgery, Cardiology and Urology specialities. A the orthopaedics and anaesthetics teams has been detailed, specialty-level review of RTT performance, established to consider alternative service models, so identifying key barriers and actions for improvement that the service can respond in a highly flexible way. took place in November 2016. These actions helped To support this work a detailed analysis of the trauma to improve performance with managers and clinicians theatre operating metrics has been compiled. The focused on maximising performance against the RTT team are expected to report back in quarter one of standard despite this the target was not met. Two key 2017/18.

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Seven day services Financial Performance The RD&E has already made substantial progress As reported in the Annual Accounts, the Trust posted towards the implementation of 7-day services. a deficit in 2016/17 of £2.3m before impairment and There has been a significant increase in the number gain on absorption accounting (£16.9m net deficit). of specialties offering a full 7 day consultant- This provides the basis for the Trust going forward delivered service and an increase in the capacity in the coming years to bring the organisation back within diagnostics to provide 7-day access for into financial balance. The Trust is planning a deficit inpatients admitted as emergencies. We have of £0.5m in 2017/18 and a surplus of £1.0m in extended and increased consultant cover / input 2018/19. on the Acute Medical Unit and implemented a The deficit position is an improvement compared to Surgical Assessment Unit, operating 7 days per the planned deficit of £6.6m and has been achieved week, to improve our time to first consultant mainly by: review. ● delivering the CIP challenge in full on a current Through our robust mortality review processes, we year basis, regularly track mortality rates in a granular level of detail. This shows that we consistently achieve ● under-spending on employment expenditure, within the expected ranges for patients admitted ● maximising the benefit of in-year expenditure at both weekends and week days. Our crude provisions mortality rate shows no difference for patients admitted as emergencies on either weekdays or ● Receiving £12.6m Sustainability and weekends. The changes that have been made Transformation Funding (STF) by delivering in implementing 7-day services are a significant financial and operational targets. contributory factor to this position. A major part of the delivery of the CIP challenge Given the progress already made, 2016/17 has during the year is as a result of the Trust working been a year of consolidation rather than extension closer with our partner health organisations to deliver of 7-day services. We have continued to monitor better patient outcomes and reduced expenditure. our performance against the 4 priority clinical The main areas contributing during the year are: standards – using a specialty-level case note review process and responding to any material changes in ● integration of East Devon community hospitals performance which required addressing. Through and community services which has improved the triangulation of our data we monitored patient flow through the acute hospital, any patient safety, clinical outcome and patient ● a bed-reduction programme to reduce inpatient experience concerns pertaining to current access beds. This has been achieved by improving patient to 7-day services, and sought to further mitigate discharge, getting patients home with appropriate these concerns where changes could be achieved care packages and reducing the length of stay in within the existing resources available, or provide the hospital through efficient working. an affordable cost-benefit. The 2017/18 Cost Improvement Plan (CIP) is In parallel we have continued to work on challenging and as a result, the Trust is putting in incremental technical / process changes to support place a comprehensive programme to deliver this the implementation of the wider clinical standards plan of £21.6m on a number of levels. Schemes e.g. creation of a standardised electronic inpatient continue to be identified and developed to ensure the referral process, the use of summary care records, plan is delivered in 2017/18, especially operational further improvements to shift handover processes. changes that will contribute a financial benefit. The 2017/18 Clinical Service Plan has been developed which will look at “In Hospital”, “Out of Hospital” and the “Bridge” between the two. Areas expected to reduce expenditure from the plan include:

● Demand management to reduce activity. This will be achieved by an improved conversation with GPs on referral management

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● An elective delivery plan which will focus on Workforce Performance pathway variation in a number of specialties The last year has seen our workforce grow in size ● Continued work on reducing non-elective and complexity with the transfer of almost 1500 admissions and length of stay across the hospital. staff following the award of the contract for Eastern This will include a focus on reducing the level of community services. The rationale for transferring Delayed Transfer of Care (DToC) services is to further integrate community health At the Trust level plans are in place to: and social care services across East Devon with the acute services at the RD&E. It provides an exciting ● Reduce costs particularly in temporary staffing, opportunity to develop joined-up care in a way support functions and procurement of non-pay that best meets patients’ needs, is personalised and items sustainable. That the transfer went so smoothly is a credit to all of our staff who continued to focus on ● Focus on productivity improvements, e.g. Lord the delivery of high quality patient care throughout Carter Review the period of instability that is associated with ● Deliver the full year benefit of the inpatient bed any such large-scale transfer of services. Work is reduction commenced in 2016/17 continuing to integrate staff and service delivery across health and social care services. A significant workforce priority during 2016-17 has been the focus on reducing spending on agency staff. In 2014-15 the trust spent around £11.5m on agency staff, the majority being on registered and unregistered nursing staff. Over the last two years considerable resources have been applied to deliver a range of initiatives targeting the attraction and recruitment of both registered and unregistered nurses. When combined with other approaches, including the tenacious renegotiation of agency rates, the trust has reduced the total spend on agency staff by £5.4m since 2014-15 to £6.1m in 2016-17. This work continues and we expect to make further savings next year. The Trust recognises that there are increasing pressures on our staff and has taken a range of actions to help maintain the health and wellbeing of our people. These have included improving access to physiotherapy services for staff, introducing a range of mental health initiatives such as stress management courses, line management training, mindfulness courses, counselling services and mental health first aid training. A range of physical activity schemes for staff such as team sports, fitness classes, running clubs and team challenges have also been introduced to aid both physical and mental wellbeing. In December the Trust appointed Consultant Colorectal Surgeon Miss Trish Boorman as its new Guardian of Safe Working Hours. Significant staff fatigue is a hazard both to patients and to the staff themselves and Miss Boorman’s appointment is part of a new national drive to ensure the working hours of doctors and dentists in training, stay within safe limits. The guardian is independent of the Trust’s management structure and is responsible

Page 36 Annual Report 2016/17 for protecting the safeguards outlined in the 2016 Within the context of the Devon Sustainability & Terms and Conditions of Service (TCS) for doctors Transformation Plan the Trust is continuing to play a and dentists in training. The guardian will ensure leading role across the Devon system to design and that issues of compliance with safe working hours establish a new model of care which supports the are addressed as they arise with the doctor and / needs of the public and patients across Devon. As or employer, as appropriate. They also will provide plans progress this work will focus on translating the assurance to the Trust Board or equivalent body that workforce implications of the future model of care doctors’ working hours are safe. and the design and delivery of a plan to migrate from old to new. Some examples of the changes in the In February the Trust appointed three Freedom to new model of care is likely to result from a workforce Speak Up Guardians who are available for all staff perspective are: employed by the Trust across all sites. They will work alongside the Trust leadership team to support ● Changes to clinical practice the organisation in becoming a more open and transparent place to work, where all staff are actively ● Introduction of new roles encouraged and enabled to speak up safely. They will ● Redesign of existing roles requiring new skills to act in a genuinely independent and impartial capacity be learned to support staff who raise concerns and will have direct access to the Chief Executive and Chairman ● Greater flexibility in terms of working location as required. The Freedom to Speak Up Guardian role We are committed to working with and supporting is designed to contribute to achieving the following our staff through all changes to how we work. outcomes:

● A culture of speaking up is instilled throughout Capital Programme the organisation The Trust’s capital programme has been limited ● Speaking up processes are effective and to investment in essential capital assets to help continuously improved support the Trust’s cash liquidity. The value of capital expenditure continues to remain lower than the value ● All staff have the capability to speak up effectively of depreciation. A robust capital planning process and managers have the capability to support has been undertaken, capital requests have been those who are speaking up risk assessed and checked for consistency, linked ● All staff are support appropriately when they to the Trust’s strategy, with procurement and lead speak up times being duly considered. Leasing arrangements will be further considered for larger schemes, to help ● The Board of Directors is sighted on, and engaged support the Trust’s cash liquidity. in, all Freedom to Speak Up matters and issues that are raised by people who are speaking up Capital funding has been focused on replacing existing equipment and IM&T and for re-investment ● A culture of speaking up is instilled throughout in the Trust’s current estate. the NHS

The introduction of the new national junior doctors contract resulted in industrial action being taken by our junior doctor colleagues. Throughout this national dispute, local relations remained good and following the action the Junior Doctor Representative Committee (JDRC) was created to represent all junior doctors at the RD&E. The committee aims to provide information, advice and support to doctors on issues specifically affecting them, and act to facilitate communication between the Trust, senior clinicians and junior doctors.

Page 37 Annual Report 2016/17

Environment, Employee Matters, ● Ensure that the Trust is a positive place to work and that staff are supported appropriately. The Social, Community & Human Rights Trust has a positive staff programme – engaging Issues working lives – that brings together our approach to equality and diversity, support for health and As a public benefit corporation, the Trust takes its wellbeing, staff benefits, staff engagement and responsibilities towards the community it serves very training and development. seriously. We recognise the responsibility we have to:

● Meet the acute health needs of the population Important Events Since the End of we serve as safely, effectively and efficiently as the Financial Year possible There are none to report. ● Ensure that in designing and delivering health services we fully take into account, and are Suzanne Tracey influenced by, the views and opinions of our Chief Executive patients and patients to be. Our Members’ Say events are a good example of where we listen and Date: 24 May 2017 engage with members – who broadly correspond to the profile of the wider community – on important healthcare matters. In addition we undertake formal and informal consultation with patients when we need to redesign or improve services

● Take into account the impact we have on the environment because this will ultimately have an effect on the communities we serve. As we set out in the sustainability report section of this Report, we are committed to reducing our environmental impact

● Take into account our status as the largest employer in Exeter and surrounding area. This means that decisions we make may well have an impact on the local economy and the health and wellbeing not only of our staff but their families and communities as well

● Take into consideration our responsibilities, as an ethical organisation, to respect human rights and to ensure that our actions or decisions do not have an adverse impact on upholding human rights

● Uphold the tenets of the NHS Constitution which brings together in one place details of what staff, patients and the public can expect from the NHS

● Uphold the legal framework that exists to promote equality and diversity

● Take very seriously our commitment to ensuring that staff feel motivated, empowered and are clear about the difference they are making to patient care and the pursuit of our strategic objectives. The section in this Report on “Our Staff” sets out some of the work we have done to improve staff engagement and motivation

Page 38 Annual Report 2016/17 ACCOUNTABILITY REPORT

The Board of Directors of the RD&E is ultimately Directors’ Report and collectively responsible for all aspects of the The RD&E is a NHS Foundation Trust that is performance of the Trust. The Board of Directors’ role constituted as a public benefit corporation. Its is to: governance structure is founded on a constitution ●● Provide effective and proactive leadership of the that is approved by the regulator, NHSI. The Trust within a framework of processes constitution sets out how the organisation will operate from a governance perspective and what ●● Develop procedures and controls which enable arrangements it has in place, including its committee risk to be assessed and managed. structures and procedures, to enable the Trust to be governed effectively and within the legislative ●● Take responsibility for making sure the Trust framework. The Trust’s constitution incorporates the complies with its Licence, its constitution, legal and statutory requirements necessary to govern mandatory guidance issued by Monitor, relevant the Trust. In addition, Monitor (NHSI) has developed statutory requirements and contractual obligations a Code of Governance which all Foundation Trusts ●● Set the Trust’s strategic aims at least annually, must comply with (or explain if they choose not taking into consideration the views of the Council to comply). This details the necessary governance of Governors structures and processes that Foundation Trusts should have in place. ●● Be responsible for ensuring the quality and safety of healthcare service, education, Essentially, there are three basic components to the RD&E’s governance structure: ●● Training and research delivered by the Trust

●● The Membership ●● Ensure that the Trust exercises its functions ●● The Council of Governors effectively, efficiently and economically

●● The Board of Directors ●● Set the Trust’s vision, values and standards of conduct and ensure the Trust meets its obligation Members of the RD&E consist of members of the to its members, patients and other stakeholders general public who choose to apply for membership and communicates them to these people clearly and Trust staff (unless they opt out). Members are located in a defined number of constituencies. ●● Take decisions objectively in the interests of the Members elect Governors and can stand for election Trust themselves. ●● Take joint responsibility for every decision of the The Council of Governors (CoG) consists of elected Board, regardless of their individual skills or status public Governors, staff Governors and appointed individuals from key stakeholder organisations (as ●● Share accountability as a unitary Board defined in the constitution). Governors help bind ●● Constructively challenge the decisions of the the Trust to its patients, service users, staff and board and help develop proposals on priorities, stakeholders. Governors are unpaid and volunteer risk, mitigation, values, standards and strategy part-time on behalf of the Trust. They are not Directors and therefore do not act in a directional The Board of Directors has both Executive and capacity as their role is very different. The Trust Non-Executive Directors (NEDs). All Non-Executive Chairman is chair of both CoG and the Board of Directors are independent. It is a unitary Board Directors. which means that both Executive and Non- Executive Directors share the same liabilities and Governors are the direct representatives of local joint responsibility for every decision of the Board. communities. They collectively challenge the Board The Chief Executive is the nominated Accounting of Directors and hold them to account for the Trust’s Officer and is responsible for the overall organisation, performance, as well as presenting the interests management and staffing of the NHS Foundation of Foundation Trust Members and the public and Trust, for its procedures in financial and other providing them with information on the Trust’s matters, and for offering appropriate advice to performance and forward plan. Governors have the Board on all matters of financial propriety and a range of statutory powers as well as significant regularity. influence over the Trust.

Page 39 Annual Report 2016/17

In carrying out their role, Directors need to be able In addition to its ten formal Board meetings, the to deliver focused strategic leadership and effective Board also holds a number of development and scrutiny of the Trust’s operations, and make decisions strategy sessions. objectively and in the interest of the Trust. The Board of Directors will act in strict accordance with the The framework within which decisions affecting accepted standards of behaviour in public life, which the work of the Trust are made are set out in the include the principles of selflessness, openness, Trust’s published Standing Orders, Standing Financial honesty and leadership (The Nolan Principles). Instructions and Scheme of Delegation, copies of which may be viewed on the Trust’s website The Board of Directors is legally accountable for (www.rdehospital.nhs.uk) or on request from the services provided by the Trust and is responsible for Foundation Trust Secretary. setting the strategic direction, having taken account of the views of the Council of Governors, and of the The composition of the Board is in accordance overall management of the RD&E. with the Trust’s constitution and the Policy for the Composition of NEDs on the Board. The Board The Board is led by the Non-Executive Chairman. considers it is appropriately composed in order to There are six Non-Executive Directors who, together fulfil its statutory and constitutional function and with the Chairman, form a majority on the Board. remain within NHSI’s Licence. In consultation with The six Executive Directors manage the day-to-day Governors, it has, through its recruitment of NEDs, operational and financial performance of the Trust. been able to maintain a good quality and effective Board that is appropriately balanced and complete. The Board of Directors works on a unitary basis, being collectively responsible for the performance There is a clear division of responsibility between the of the NHS Foundation Trust and exercising all the Chairman and the Chief Executive. The Chairman powers of the Trust. In so doing, Board members bear heads the Board, providing leadership and ensuring full legal liability for the operational and financial its effectiveness in all aspects of its role, and sets performance of the Trust. the Board agenda. The Chairman ensures the Board receives appropriate information to ensure that The Board normally meets to conduct its core Board members can exercise their responsibilities and business at least ten times a year. At these meetings it make well-grounded decisions. The Chief Executive takes strategic decisions and monitors the operational is responsible for running all operational aspects of performance of the Trust, holding the Executive the Trust’s business, assisted by the team of Executive Directors to account for the Trust’s achievements. Directors. Board Meetings The Chairman and all Non-Executive Directors meet the independence criteria laid down in Monitor’s / The papers for the monthly Public Board meeting NHSI’s Code of Governance (Provision A.3.1). The and the approved minutes of the previous meeting Board is satisfied that no direct conflicts of interest are published on the Trust’s website in advance of exist for any member of the Board. There is a full the Board meeting. In advance of the legislation disclosure of all Directors’ interests in the Register compelling NHS Foundation Trusts to hold their of Directors’ Interest which is available on the Trust’s Board meetings in public, the RD&E decided in June website or upon request from the Foundation Trust 2012 to move to public Board meetings that were Secretary. Directors and Governors may appoint accessible to the public. These are meetings that advisors to provide additional expertise on particular take place in the public arena rather than public subjects if required. meetings, although members of the public have the opportunity to ask questions at the end of the public The Board of Directors is accountable to the section of the meeting. Items of a confidential nature membership via the Council of Governors. The are discussed by the Board in private in a monthly Chairman informs the Council of Governors about confidential meeting. The issues discussed in the the work and effectiveness of the Board at each closed sessions tend to be commercial in-confidence Council Meeting. issues that may impede the conduct of the Trust’s The business of the Trust is conducted in an open business if they were to be aired publicly. The 1960 manner and annual schedules of meetings for the Act on Admission to Public Meetings is used by the Board of Directors and Council of Governors are Board to help determine which topics are discussed published 12 months in advance. privately and, over the course of the year, the Board has sought to discuss the majority of its business in the public session.

Page 40 Annual Report 2016/17

Board Focus Board Effectiveness and Evaluation Over the year the RD&E Board has led and governed The Board continued to develop its effectiveness the organisational successfully. Our focus has been during the year primarily through its programme of on ensuring a sustainable and safe clinical financial “development days”. Development days are seminar service. A clear governance and management system sessions that allow the whole Board to explore a is in place. The Board reviews in detail the Trust’s range of issues and topics and develop and discuss safety, quality, financial and operational performance ideas outside the formal setting of the Board. In at every Board Meeting. addition, the Board held seminar and development sessions on the days in which the formal Board Some of the key issues the Board focused on during sessions took place. the year included discussions and debates on: These seminars and development sessions enable the ●● Transfer of Services – Eastern Locality Board to examine issues in more details, to explore ●● Operational Performance key strategic issues as well as develop the capacities of the Board collectively. These sessions are vital to ●● Corporate Strategy continuously improve the performance of the Board and to ensure that the Directors are able to discuss ●● Success Regime and STP and debate key issues confronting the Trust in real ●● Workforce depth. The issues discussed over the last year include:

●● Junior Doctors ●● Transfer of Services – Eastern Locality

●● Infection Prevention and Control ●● Corporate Strategy

●● Research and Development The Chairman undertook appraisals for all Non- Executive Directors (NEDs). The process used a system ●● Operational Capacity that was co-designed and agreed by the Appraisals Working Group, a group made up of the Chairman, ●● Emergency Preparedness, Resilience and Response the Senior Independent Director and the Governors ●● Board Assurance Framework who sit on the Nominations Committee. The process involved a questionnaire aimed at the specific role ●● Electronic Patient Records of Board members that was used as part of a 360

●● Lord Carter Recommendations degree feedback by fellow NEDs, Executive Directors and Governors. ●● CEO Recruitment Feedback on the performance of the NEDs was ●● Board Development considered by the Chairman and fed back to the NEDs in appraisal meetings. Feedback on the Outside Interests performance appraisals was provided in written form and verbally to the Nominations Committee The Board regularly updates its Register of Directors’ and an overview of the appraisals was discussed Interests to ensure that each member discloses with the COG. All the appraisals undertaken were details of company directorships or other material favourable with all NEDs performing at or above interest in companies which may conflict with their the expected level. In the event of concerns being management responsibilities. Board members also identified through the appraisal process, this would have an opportunity at the start of each meeting to be managed in line with the appropriate Human declare any interests which might impede their ability Resource policy. to take part in discussions and Directors are aware that such a declaration would be permissible at any A similar process was undertaken for the Chairman. time during a meeting, dependent on the issue being In this case there was a longer questionnaire linked discussed and the potential for any conflict to arise. to the specific role of the Chairman and the process The Directors’ Register of Interests is available from was led by the Senior Independent Director. Feedback the Foundation Trust Secretary (01392 404551) or on on the performance of the Chairman was provided the Trust website: to the Nominations Committee and a summary was provided to the full Council of Governors. This was www.rdehospital.nhs.uk/trust/ft/documents. also a very positive appraisal. html and Directors can be contacted via e-mail at [email protected]

Page 41 Annual Report 2016/17

The Chief Executive undertook the appraisals of There are no material inconsistencies between the Executive Directors using a similar process including Annual Governance Statement, Board statements feedback from Non-Executive Directors. Feedback on required by the Risk Assessment Framework, the the appraisals was provided by the Chief Executive Quality Report and the Annual Report. to the Executive Director Remuneration Committee (EDRC). The Chairman undertook an appraisal of the The Board, through its sub-committees, regularly Chief Executive and the results of this were fed back reviews the effectiveness of the Trust’s system of to the EDRC. internal controls.

Quality Governance Reporting Suzanne Tracey Chief Executive We have put in place a rigorous approach to governing the quality of our services. More details Date: 24 May 2017 about these arrangements are included in our Quality Report as well as in the Annual Governance Statement (page 101 of this Report). Summary Board Attendance 2016/17

P = Public Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 C = Confidential P C P C P C P C C P C Mr J Brent P P P P P P P P P P P Mr P Adey P P P P P P A A P P P Mrs J Ashman P P P P P P P P P P P Ms T Cottam P P P P P P P P A P P Mr P Dillon P P P P P P P P P P P Mr A Harris P P P P A A P P P A A Prof J Kay P P P P P P P P P P P Mrs A Pedder A A P P P P Mr D Robertson P P P P P P P P P P P Ms M Romaine P P P P P P P P P P P Mr P Southard P P P P P Mrs S Tracey P P P P P P P P P P P Mrs E Wilkinson-Brice P P P P P P P P P P P Mr A Willis P P P P P P P P P P P P = Public Oct-16 Nov-16 Jan-17 Feb-17 Mar-17 C = Confidential P C P C P C P C P C Mr J Brent P P P P P P P P P P Mr P Adey A A P P P P P P P P Mrs J Ashman P P P P P P P P P P Ms T Cottam P P P P P P P P P P Mr P Dillon A A A A P P P P P P Mr A Harris P P P P P P A A P P Prof J Kay P P P P P P P P A A Mrs A Pedder Mr D Robertson P P P P P P P P P P Ms M Romaine P P P P P P P P P P Mr P Southard P P P P P P P P P P Mrs S Tracey P P P P P P P P P P Mrs E Wilkinson-Brice P P A A P P P P P P Mr A Willis A A P P P P P P P P Key: P = Present A = Apologies

Page 42 Annual Report 2016/17 Board of Directors Non-Executive Directors

James Brent Janice Kay Chairman Non-Executive Director James joined the Trust in May Janice joined the Trust in April 2014. 2012 and is both Chairman of the She is Provost of the University Board of Directors and Council of of Exeter and Deputy to the Vice Governors. He was an investment Chancellor. She line manages the banker for twenty-five years and established Akkeron University of Exeter Medical School among other Group which has key business activities in hotels, key roles. She holds a number of national positions urban regeneration, retail and leisure (including in Higher Education, including the HEFCE Strategic Plymouth Argyle Football Club). He has combined Advisory Committee on Quality, Accountability and his commercial ventures with a desire to contribute Regulation. Janice is a member of the Governance in a range of public sector settings as well, for Committee. example previously as Chairman of Plymouth City Development Company and of Plymouth University. David Robertson Non-Executive Director Jane Ashman Non-Executive Director David joined the Trust in October 2010 and is a Fellow of the Institute Jane joined the Trust in April 2014. of Chartered Accountants in England A Social Worker by profession for and Wales and a graduate in the last 34 years and a passionate Business Studies. He was Finance Director of Viridor believer in the integration of Health Limited, the waste management subsidiary of Exeter and Social Care, Jane was a Director of Social Services based Pennon Group plc, until March 2011. He was for nine years until 2009. As well as her Non- with the Pennon Group for twenty years, prior to Executive Director role at the RD&E, until recently which he was with KPMG for fourteen years. He is Jane was the independent Chair of two Safeguarding also Chairman of South West Lakes Trust. David is Adult Boards and undertook Serious Case Reviews Chairman of the Audit Committee. and Domestic Homicide Reviews for other agencies when the need arises. Jane is the Chair of the Trust’s Michele Romaine Organ Donation Group and is a member of the Non-Executive Director Patient Experience and Governance Committees. Michele joined the Trust in Peter Dillon September 2012. She has held a Non-Executive Director number of senior roles in public sector organisations, including the Peter joined the Trust in July 2013. BBC as its Director of Production. Ten years ago After more than ten years with Michele helped steer the course for the BBC in a Deloitte, he now runs his own time of significant change setting the vision for the company advising businesses that technology, people and the process change necessary require turnaround, stabilisation, cash management, to modernise the BBC’s production capabilities. budgeting, cost reduction or interim finance. In Michele has more recently served for three years as addition to the time he gives to the RD&E, until a Non-Executive Director on the Board of Salisbury November 2015 Peter was also a Non-Executive NHS Foundation Trust. She continues to travel Director in the Devon & Cornwall Housing Group, a internationally through her consultancy business. social and affordable housing provider. Peter chairs Michele took over the role as Chair of Governance the Patient Experience Committee and is a member Committee in September 2014, and is a member of of the Audit and Governance Committees. the Audit Committee.

Page 43 Annual Report 2016/17

Andrew Willis Director of Operations in 2016, formally took up Non-Executive Director his position on the Board in March 2016 and from March 2017 has assumed the role of Chief Operating Andy joined the Trust in February Officer. 2011. A corporate lawyer by profession, he has worked for Tracey Cottam City and regional law firms and Executive Director now specialises in legal training and corporate of Transformation & governance. He is also a Leadership Associate of Organisational Development the King’s Fund, focusing on NHS Board/ Director development. Andy was appointed Vice Chairman Tracey joined the RD&E in 2013 and Senior Independent Director in April 2014 having worked in industry for and was Chair of the Governance Committee over 30 years in a variety of senior leadership and from February 2012 to August 2014 inclusive. consulting roles. Since joining the Trust Tracey’s Andy chairs the Executive Director Remuneration portfolio has included the delivery of a range of Committee. Other current Board experience includes strategic programmes including the Workforce serving as a non-executive director of an NHS Strategy, a Trust-wide Culture Change Programme teaching hospital, a trustee of a third sector drug with a particular focus on staff engagement and an and rehabilitation service in Exeter and Chairman of internal and external Stakeholder Communication & a housing provider in Bristol. Prior to this, he served Engagement Strategy. Tracey passionately believes on two NHS acute provider Boards and held board in delivering the Transformation & OD services appointments in the housing and education sectors. and support to the Trust that enables continuous improvement and innovation in how care and services Executive Directors are delivered to the population of East Devon. Suzanne Tracey Adrian Harris Chief Executive Executive Medical Director Suzanne Tracey joined the Trust Adrian has spent the last 20 years as in 2008. Suzanne joined the NHS a Consultant Emergency Physician in 1993 having qualified as an at the RD&E. Adrian has directed accountant with Price Waterhouse. the RD&E’s Emergency Department She held the post of Director of Finance/Deputy Chief for 12 years and has been seconded to both North Executive at Yeovil District Hospital NHS Foundation Devon District Hospital and Yeovil District Hospital Trust since 2002 before joining the Trust to take as a Clinical Director. Prior to his appointment as up the role of Director of Finance in 2008. She was Medical Director, he served as Associate Medical appointed Chief Executive in 2016 (Acting from Director for the Surgical Division. In preparation July 2016 and substantively appointed in November for the post of Medical Director which Adrian was 2016). She is the Chair of the Healthcare Financial appointed to in April 2015, Adrian completed the Management Association (HFMA) and past President NHS Leadership Academy’s Executive Fast Track of the HFMA. Programme. Adrian is also a Sports Physician and Head of Sports Medicine at Exeter Chiefs Rugby Pete Adey Union Football Club. Operations Director Paul Southard Pete qualified as a nurse in Acting Chief Financial Officer 1988, subsequently working at Hammersmith Hospital on a number Paul started his career working of medical speciality wards prior to in industry, before moving to the progressing to Senior Nurse. He joined the RD&E in RD&E in 1991 to take up a role in 1995 and undertook roles as Divisional Manager in Finance. Paul has held a number a number of services including Child and Women’s of positions within the Finance Department, as Health, Cancer Services, Radiology and Pathology well as undertaking a secondment in Operational prior to his appointment as Deputy Chief Operating management. Paul has worked as Deputy Director Officer in 2012. Pete was appointed as Executive of Finance since 2006, and was appointed as Acting Chief Financial Officer in July 2016.

Page 44 Annual Report 2016/17

Em Wilkinson-Brice Non-Executive Director Deputy Chief Executive/Chief Remuneration Committee Nurse The Non-Executive Director Remuneration Committee Em joined the RD&E in July 2010 (NEDRC) comprises five elected Governors and is after qualifying as a nurse in chaired by the Lead Governor. The Committee is 1992 in Exeter. She subsequently supported by the Deputy Director of Transformation worked in Oxford specialising in Cardiology and and Organisational Development. high dependency care. A firm interest in facilities management alongside nursing resulted in Em taking Recommendations for any changes to remuneration the post of Director of Nursing and Facilities at Derby for the Chairman and other Non-Executive Directors Hospitals NHS Foundation Trust prior to coming are made by the NEDRC for consideration by the back to Exeter. During her time at the RD&E Em has Council of Governors at a general meeting. Similar to undertaken numerous roles alongside the Chief Nurse last year, the Committee did not meet during the year including Chief Operating Officer for a time and lead as it did not need to on the basis of decisions reached for the Trust’s five year Transformation Programme in 2012/13. The decisions set out that the NEDs focused on delivering, in partnership with local would not receive any increase in remuneration over agencies, a new model of care to facilitate population and above any changes made in uplifting salaries in health and wellbeing. In recognition of the close line with that agreed for staff generally as part of the working partnership between the Trust and Plymouth nationally agreed Agenda for Change. University, Em was appointed Associate Professor Faculty of Health and Human Sciences. Em was in the Membership of NEDRC first cohort of the national NHS Leadership Academy (as at 31 March 2017) Aspiring Chief Executive programme, completing it in February 2017. ●● Richard May (Lead Governor and Chairman of the NEDRC)

Non-Executive Director ●● Hazel Hedicker (Staff Governor) Appointments ●● Alan Murdoch (East Devon, Dorset, Somerset & The Chairman and Non-Executive Directors are the Rest of England) appointed by the Council of Governors (CoG) ●● Geoff Barr (Exeter & South Devon) acting on the recommendation of the Nominations Committee, which is a committee of the CoG. ●● Cynthia Thornton (Mid, North, West Devon & Cornwall) The Chairman chairs the Committee when appointing Non-Executive Directors. Membership of the Committee can be found in the Governors section on pages 118-124.

The Chairman and Non-Executive Directors are initially appointed for three-year terms, as approved by the CoG. Re-appointments for a further three years can be made, subject to satisfactory appraisal and the approval of the Governors. Consideration of extension beyond six years is subject to rigorous review, in line with the agreed process.

There have been no new Non-Executive Director appointments during 2016/17.

Page 45 Annual Report 2016/17 Enhanced Quality Governance Reporting Patient Care The section of this report which details the performance of the Trust (pages 30-32) details The Trust is a public benefit corporation which is the areas that have been challenging over the last inextricably linked, through the Council of Governors, year. When compared to the key messages from to our members. The demographic information we our patients, specifically in the National Patient hold about our members suggests that there is a Survey results on pages 57-58, the impact from reasonable correlation with the demographics of those challenges would appear to have been well the wider population. To this end, we have sought managed. to involve and engage members to seek their views on strategic direction, on service improvements or Monitoring Improvement in Quality changes and on improving patient experience as a reasonable proxy for the broader population served The Trust approach adopts a balanced scorecard, by the Trust. represented through the Board’s Integrated Performance Report (IPR). Governance and The Governors and Members contribute to the Performance are managed via the Governance, quality agenda as described on page 5 of the Quality Operations and Performance System, overseen by the Report. The main contributions are through three Governance Committee which takes a comprehensive Governors being members of the Patient Experience oversight of the quality and safety of care including Committee, and the participation of Governors in the all inpatient and outpatient areas. Patient-Led Assessments of Care Environment, as well as identifying Governors priorities which inevitably The Trust’s Clinical Quality Assessment Tool (CQAT) have a quality aspect. forms part of the monthly Ward to Board framework where key quality and safety indicators are reported Performance Against Key and monitored. Furthermore a quarterly drill down report is also presented to the Board of Directors Healthcare Targets where Divisions report by exception any ward/ The Trust has continued to deliver each of the key department area that flags on the framework. national health care targets relating to quality of In addition the Trust uses a performance framework care throughout 2016/17. Notably, there have been which provides assurance that performance including no Trust attributable MRSA bacteraemia for the fifth safety & quality indicators are effectively monitored consecutive financial year, and the rate of Clostridium and reported to support managers and clinicians Difficile infections per 100 000 occupied bed days is in delivering the required targets. Observations of the lowest in the South West. care are secured through Chief Executive “Back to The Trust is monitored against a wider suite of the Floor” sessions, Deputy Chief Executive/Chief metrics through its internally developed Ward to Nurse clinical shifts, “Observe and Support” by Board framework. This incorporates process and Senior Leadership Team and Non-Executive Directors outcome metrics across a range of domains relating attendance on Safety Thermometer days. to quality of care including pressure ulcerations, nutrition, infection control, falls and delivery of harm free care. In 2016/17, the Trust on average:

●● Delivered harm free care within the hospital on 94% of occasions

●● Achieved hand hygiene compliance rate of 90.81%

Undertook risk assessments for the likelihood of:

●● developing pressure sores for 97% of patients

●● falls for 93% of patients

●● venous thromboembolism for 96.0% of patients and

●● nutritional needs for 96.48% of patients

Page 46 Annual Report 2016/17

Service Improvements Orthopaedics One of the most significant developments for the An increase in demand for appointments and RD&E was the integration of acute and community complexity of cases at the Princess Elizabeth services which has been described in the report on Orthopaedic Centre (PEOC) meant that clinics often page 11. This is a major step for the Trust and will over ran, resulting in patients waiting for long periods enable it to review, develop and implement revised of time. There was also a large number of patients clinical pathways; ensuring that we provide care for awaiting routine review due to capacity issues. The the our community in the right place delivered by service introduced virtual clinics conducted by a nurse staff with the right skills. practitioner to enable some patients to be reviewed more quickly. In addition, patients are able to be Ambulatory Care Unit seen by their local hospital for x-ray appointments at which time they complete an assessment form which On Monday 7th November 2016 the Royal Devon is later reviewed by a Surgical Care Practitioner; the and Exeter Hospital opened an Ambulatory Care Unit results are then sent to the patient and their GP. on Wynard Ward. The Trust recognised that at the These changes have improved the service resulting in time it offered a number of ambulatory/hot clinic/day reduced waiting times for patients. case facilities for patients, and it was hoped that the new unit would give further opportunities to reduce Emergency Department admissions to inpatient beds and to facilitate earlier discharge, as well as improving the overall patient Two rooms across the Emergency Department (ED) experience. The unit is staffed by experienced nursing and the Acute Medical Unit have been converted into and medical teams who work alongside referring a Liaison room specifically for Mental Health patients. specialties to offer a range of ambulatory and day All clinical equipment has been removed from the case procedures, including: rooms (reducing potential for patient self-harm) and bespoke furniture has been fitted. Work is on-going ●● Day-Case Blood transfusions, drug infusions, to ensure the room meets the criteria set out by interventional radiology, lumbar punctures, pleural the Royal College of Psychiatrists. Further funding and ascitic taps has been obtained from NHS England to develop a second bespoke and dedicated space within the ED. ●● Urgent clinic review of patients to avoid admissions or facilitate early discharge e.g. Following completion of a Mental Health risk patients who are clinically improving but their CRP assessment, a need was identified for a tool to is lagging enable the ED nurses to assess the care and safety of patients whilst awaiting review by the psychiatric ●● Urgent investigation - CT, USS, repeat bloods. team. This tool and the associated leaflets formed ●● IV antibiotics – for patients who are well enough part of both organisations’ CQUIN schemes for to be at home but require a prolonged course 2015/16. The development of the tool resulted in a of IV antibiotics that cannot be delivered in the structured approach for ED nurses to assess the risk community of self-harm or the likelihood of patients absconding prior to psychiatric assessment. Within the first 4 months, feedback has been very positive and includes: Dermatology

●● Patients managed quickly and efficiently e.g. 1-3 Dermatology has developed local services run by GPs hr wait now treated within 30 minutes with special interest to deliver skin cancer clinics. These are run in the local community and provide ●● Released inpatient beds and pressure on inpatient integrated care for patients. Those who require more beds complex care are referred to the RD&E for surgery One Patient reported that we had changed his life by or on-going treatment. The initiative has been being able to have treatment on a daily basis. nominated for a General Practice award and Dr Noel Lawn and team have been shortlisted.

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Patient Surveys What went well? Over the last year, a number of surveys have been ●● The speed at which patients were seen, reported which demonstrate the effectiveness of our whether arriving by ambulance or presenting in services. These include: the department ●● The length of time spent in the department ●● National Inpatient Survey Results ●● The amount of time that patients had to ●● Emergency Department Survey Results explain their issues with a doctor or a nurse ●● How staff explained the patient’s condition and ●● National Cancer Survey Results treatment National Inpatient Survey Results What could be better? The Survey results were received in February 2017 ●● The provision of enough information on the and will be reviewed through the Patient Experience condition or treatment required Committee. There was an overall response rate of 55 ●● Availability of food and drink The results were very positive, with the overall rating being very good. At the time of writing this report The department will develop an action plan to ensure the results were being analysed. that all learning from the National Survey will be used to further improve the service. What went well? ●● Respondents confirmed that they felt treated National Cancer Survey with respect and dignity and were well looked The National Cancer Patient Experience Survey results after were published in July 2016 and presented to the ●● Doctors and nurses listened to patients and Trust’s Patient Experience Committee in December provided understandable information 2016. Overall the Trust performed extremely well, ●● Patients confirmed that they knew who to being in the top three in the country. Patients contact and felt involved about going home, responded very positively with the Trust overall with enough information notice and no delays scoring 8.9 out of 10.

What could be better? What went well? ●● Ensure that bathroom facilities are clearly ●● 81% of respondents said they were involved as identified for single sex purposes much as they wanted to be in decisions about ●● Consider how to ensure that patients are their treatment and care. provided with as much information as ●● 92% were given the name of their Clinical necessary about operations and procedures Nurse Specialist who would support them ●● Further improve the information about through their treatment, and 90% confirmed medication side-effects that they found it easy or very easy to make contact with them. ●● Promote how patients can feedback on services whilst in hospital ●● 91% of respondents confirmed that they were treated with dignity and respect when they The results will be triangulated with other were in hospital, information to provide assurance and to inform ●● 94% or respondents knew who to make further work. contact with at home if they were worried Emergency Department National Survey about their condition. Results What could be better? The Survey results were received in March 2017. ●● Gaining views on cancer sites where less than They will be reviewed by the service and through the 20 patients have responded. The lead nurse is Patient Experience Committee. The overall results are working with the national team to explore a positive. collective approach to the rarer tumours to gain views across the Peninsula. ●● Administration processes causing some concerns for patients. This will be addressed in relevant site-specific action plans.

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Learning from Patient Feedback of the process in Paediatrics and Specialist Surgery. It was identified that paediatric plastic The “Demonstrating the Difference” approach is surgery did not have a consistent pre-operative used, where learning from patient and carer feedback service. A pathway was identified and developed is captured and used to demonstrate the changes which included paediatric nurses with specialist that have been made in response to feedback. knowledge and extending existing clinics. The The information is reviewed in the Performance complainant has been advised of the outcome to Assurance Divisional Monthly meetings, the Patient demonstrate how their feedback has informed Experience Committee and Board reports. The and improved the process for future patients. following examples demonstrate how the Trust has learnt from and therefore further improved patient ●● A patient was deemed medically fit for discharge experience based on feedback received. after a prolonged stay in hospital but required one further week of IV antibiotics. The Pharmacist ●● A patient on Yeo Ward who was on an end-of- arranged for IVs to be administered at home by life pathway, requested a chicken curry at 9.30 community nurses and a peripherally inserted am and this was responded to swiftly by the central catheter (PICC) line was inserted. The Catering Department. The patient, their family patient was able to be discharged and only and the ward staff expressed their appreciation to needed to return to hospital for line removal and the Catering Department for responding to the bloods. patient request. ●● In cancer services, comfort packs are used for ●● In our Surgical Services Division, a learning relatives of patients who are in the last few days package has been devised which will enhance the of life to enable them to remain at the bedside of knowledge of the team when assessing patient those nearing death. The aim is to help families alcohol consumption following identification of a feel valued during the last few days of their loved lack of understanding in this area. The e-learning one’s life so they do not need to worry about package will be used by staff who work with having the essentials with them. The Comfort this cohort of patients; the aim being to create Packs included items such as toiletries, pen and a wider understanding and develop competency note pad, tissues and razors. for staff to deal with patients who have difficulty in providing an in-depth clinical history in relation ●● Following feedback from relatives about a lack of to alcohol use. The benefit of this is that it will facilities in Tiverton Hospital to support interaction increase staff confidence in dealing with the with patients with dementia, a number of side- effects associated with alcohol withdrawal; changes have been implemented, including culminating in safer pathways for our patients. refurnishing the day room with new furniture, books, games and puzzles etc. The local team ●● To give support for women following a pregnancy have also arranged visits to the museum and loss, one-day bespoke bereavement training was Morrison’s café, as well as arranged visits by the arranged for Midwives. The attendees provided school choir, local band, and craft sessions. The excellent feedback on how this has helped them work has been well received by patients and to provide sensitive and individualised care for this relatives. group of women. ●● Following feedback from patients who misplaced ●● The Cystic Fibrosis (CF) team has set up a parent valuable items during assessment, e.g. hearing support group providing the opportunity to aids, the medical imaging team have reviewed enable parents to meet others with children with its practices in relation to personal possessions CF. Parents of some of our older patients also to ensure notes are kept when patients have to attended which gave reassurance for parents of remove these items for their diagnostic procedure. newborn and young patients, to see how the children have grown up. For some parents it was ●● A concern was raised by the parents regarding the first time they had met another parent of a availability of vegetarian formula, for a baby child with CF and it was a time of encouragement whose mother was unable to express milk. A and support for them regarding issues such as discussion was held with the family and the NNU physiotherapy or dietetics. The team are now senior nurse, matron and the infant feeding thinking about articles for the CF newsletter. co-ordinator. The care plans and guidance have been reviewed to ensure that information ●● Following a parent’s complaint regarding their for vegetarians and other cultural and dietary child’s delayed surgery, a review was undertaken considerations are included.

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●● A theme within the complaints for Ophthalmology information is as appropriate as possible and ensuring relates to concerns about delayed follow up that any learning from issues are fed back to the appointments. To provide the patient with a more clinical teams. timely response the outpatient booking team now transfer calls where concerns are raised by One of the main areas of concern for patients patients about their delayed appointment in order is where there is confusion around making to achieve an early resolution which should result appointments. To help address this issue a number in a reduction in complaints and concerns for this of changes have been put in place over the last year. area. These include: ●● Where appointments are cancelled and patients ●● In some cases a patient’s relatives in trauma and orthopaedics seem to have been unaware placed on a pending list, a checklist has been of the complete patient pathway and level of introduced for staff to ensure patients get a treatment and care that occurs. There are now further appointment. more meetings offered to complainants, which ●● A review of the appointment booking processes has resulted in more awareness of the level of has been undertaken. Theatre lists will now only support, care and attention their relatives have be filled where cover for annual leave has already received. It has been found that these meetings been found, rather than trying to find cover for have usually had a very positive outcome. In a list already filled. This should avoid lists being holding these meetings documentation indicates cancelled with short notice to patients. that communication is not always received or recalled after the event, possibly due to the very Complaints Handling difficult circumstances and stressful situations patients and carer found themselves in rather The last annual review (2015/16) confirmed that the than communication from staff being poor. Trust received a reduction in complaints and a slight increase in concerns. This is felt to reflect the revised ●● Following feedback from bereaved relatives approach to complaint handling that has been in cancer services predominantly through adopted, whereby early contact is made with the complaints; a group was invited to a feedback complainant to ensure that the organisation is clear session, where they were able to share their about the issues, specifically how the complainant recent experiences. Feedback from the group wants the issue to be addressed. This has led to confirmed that it was both a useful and positive earlier resolution and an overall decrease in the experience. As a result, the group will be number of written complaints. continued and a work plan will be developed to support the clinical teams. Two members of the All feedback from patients and their families is group will become part of the End of Life Steering used to help us to further improve our services. Group. On a quarterly basis a detailed analysis on patient experience including complaints is reviewed by our Improvements in Patient/Carer Patient Experience Committee which has Governors Information as part of its membership. In this Committee we ensure that learning from complaints and The Trust has around 770 leaflets which are generally Demonstrating Difference examples are shared. reviewed on a three-yearly cycle. The clinical services own this information and ensure that it is kept up- The top complaint or concern themes were: to-date for patients and their carers. Information Lack of communication leaflets are often developed to help enhance the explanations provided by clinicians and to reinforce Communication is often highlighted as a component information on treatment choices. Information for of complaints. Generally when investigated, it is patients can help to ensure that they know what to an individual failing around an issue and it is hard expect when attending for a procedure or a clinic to pull repeated themes for learning from these. and are often developed and / or revised following Each one is reviewed and shared with the teams feedback from patients. Where a complaint has to highlight where issues have occurred to try and occurred patients and carers are often involved in prevent similar situations arising again. Issues include: reviewing and revising the information to ensure being kept waiting in clinics with no information that it as useful as possible. An area of focus over about delays; appointments being cancelled at short the last year has been to ensure that the provision of notice and letters not being received till the day of

Page 50 Annual Report 2016/17 the appointment; communication between clinicians whether the complainant was satisfied with the when a patient is under more than one clinical team handling of the case and actions taken. During the and therefore the patient may not feel they have period 1 July 2015 to 31 October 2016 surveys were received full information. Where individuals are sent out with the written response from the Chief identified in complaints relating to communication, or Executive to complainants. During that period 708 attitude, the issue is discussed with them so that they cases were closed with a written response and 145 are supported in learning from the patient experience (20%) completed surveys were returned. The results and can use this to improve the care of patients in were broadly in line with the previous year and the the future. actions implemented last year have been continued. The attitude of nursing staff This included an emphasis on the importance of regular contact with the complainant, supported by a These complaints are reviewed and fed back to monitoring report on ‘last contact’ which is reviewed the team member(s) concerned for their individual at the monthly Complaint Leads meetings, alongside reflection and learning. Any issues relating to performance on completion of complaint responses attitude are monitored for themes relating to in a timely manner, through the Performance process. particular individuals and these issues are addressed. When complaints relate to individuals, the person The main emphasis has been early contact with concerned is made aware of the complaint and meets complainants by telephone to ensure clarity regarding with an appropriate senior colleague. They are given the issues raised and to achieve a more personal an opportunity to reflect upon the concern raised and and focused response. This has served to improve learn from the experience. Training is also given when understanding of the nature of complaints and required e.g. End of Life Care training. If necessary, ensured that patients and/or their relatives are a formal disciplinary process may be implemented. satisfied with the responses and outcomes. The Trust Complaints are monitored for trends relating to is increasingly receiving thanks from complainants particular individuals and when noted these issues are relating to how their concerns were addressed. addressed. Feedback from staff who telephone complainants is positive as they feel this approach facilitates a positive The Trusts band 6/7 leadership programme, the outcome and they have enjoyed receiving positive preceptorship programme and the nursing auxiliary feedback from complainants. training programme have revised training within them that focuses specifically on complaint handling The Trust also monitors compliments as part of our and the impact of staff attitude. patient experience. Communication and attitude of nursing staff are the top two positive themes. Medication issues Many of the complaints and concerns logged under this theme highlight issues with prescribing and/or administration, for example, medications prescribed at discharge and communication surrounding the medication i.e. what medication has been prescribed and why it is needed. These complaints relate to both medical and nursing staff, and are closely linked with communication and discharge. In addition to the work being done around communication, a lot of work is also being undertaken to improve discharge pathways as this will address many of the complaints within this theme. Annual results of complainant satisfaction survey To ensure the Trust is making every effort to meet the needs of complainants, a satisfaction survey is included with all the Chief Executive’s written responses to complainants for all complaints and concerns. The survey sought information about the timeliness and clarity of the response, together with

Page 51 Annual Report 2016/17 Stakeholder Relations The Trust has developed its understanding of the of communications channels, including a dedicated central importance of stakeholder relations and the website. This engagement activity will continue need to engage, involve and communicate with through the review process. By summer 2017, the stakeholders in order to build a new compact that aim is to generate feedback from clinicians, the will result in better, more effective, personalised public, and finance and workforce professionals care based on the needs of the individual. Working to draw up proposals about how to make Devon’s with and alongside key partners and stakeholders Stroke, Maternity and urgent care services fit for the is essential and this has been amplified during the future and provide the best possible care for patients. year through the Trust’s participation in the Success It is anticipated that these proposals may require Regime and the Sustainability and Transformation consultation with the public and staff. Plan (STP). Finally, the Trust has developed a positive on-going To deliver the plan, the NHS partners within Devon relationship with the Health and Wellbeing Scrutiny are conducting reviews of key areas of service. The Committee of Devon County Council over recent ‘Your Future Care’ consultation looked at community years. During the year the Trust has met with the services and this was followed by a review of the Committee on several occasions and has also acute services. The acute services review, announced informally discussed a number of issues with the on 4 November 2016, began a review of how Stroke, Committee Chairman. The Trust continues to enjoy Maternity, Neonatology and Paediatrics, and urgent positive relations with local charities (FORCE and ELF) care services will be provided in the future across and it works together with Devon Healthwatch to Devon, Plymouth and Torbay. These are services improve services. where sustainability and, potentially, patient safety are a concern. Doctors, midwives, nurses and An example of how we have worked in partnership is other professionals met at a series of workshops to set out in the box. understand the service challenges and consider how best to work together to meet those challenges in future. Patients, stakeholders and unions have also participated in these workshops.

Four workshops were held from January to March for each of the service areas listed above, and each workshop included patient representatives with ‘lived’ experience of the services under review. Ten members of the public were involved. Feedback from the workshops fed into the acute services review, and helped to develop the draft criteria on which any future decisions relating to acute services are based. To ensure that these were the right criteria to use, and to identify any missing criteria that the public felt needed to be included, the CCG ran 12 events across the CCG area. Between 15 and 45 members of the public attended each event.

Feedback was collated into themes and will form the final decision-making criteria. For example, people said they feel strongly about travel times and distances, so this is likely to influence decisions on future plans.

As with other engagement work, these activities are structured and supported by a system-wide engagement plan. Members of the public are, and will be, kept informed of progress and opportunities to be involved through a wide range

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Integrated Care Exeter existing data sets primary care, acute healthcare, social care, deprivation indices, health outcomes and Integrated Care Exeter (ICE) was established in social marketing. 2014, with recognition that, in order to meet the needs of a changing demographic, there needed Diverting Demand: Community Resilience to be significant changes made to the ways in and Social Prescribing which public services were being delivered. ICE membership spans representatives from across the An integrated network of primary care based NHS, local authorities and the voluntary sector. The Community Connectors covering a population alliance is working toward a future in which local of around 100,000 is offering alternatives to services will be arranged on an individual basis, statutory services. The pilot will provide a better will provide preventive care and support, and will understanding of how communities can do more to be designed and delivered in partnership with help themselves and reduce demand on statutory communities where people live. services. Rate of referrals is growing each week with a total of 699 referrals since pilot start-up. Through ICE’s four distinct programmes of work, it is establishing a new model of population health SERIO, an applied research unit at Plymouth and wellbeing which has a greater focus on early University, was commissioned in 2017 to provide intervention and prevention, more care and support a review of the ICE programme’s strategic added out of hospital, and services designed around the value, in order to understand its impact on needs of individuals and their family. stakeholders and wider programmes of work. The review identified a high level of consensus on Place Based Care: Developing a Health and the value and impact of the ICE programme. Key Wellbeing Hub in Exeter findings included:

In partnership with seven GP practices in Exeter ●● A shift in thinking amongst those at the highest we are co-designing and prototyping new models levels of each organisation with movement for reducing demand, preventing admissions and towards a new person-centred model of care, improving hospital discharge. In December 2016 where the focus is on the individual ICE was successful in a bid to join the National ●● Increased understanding and acceptance that a Association of Primary Care (NAPC) Primary Care collaborative systems approach was necessary Home Learning Community. going forward, as the issues being faced were Reducing High Cost Demand: Street beyond the scope of any individual organisation Homeless and Vulnerably Housed ●● Advanced levels of trust across partner It is estimated that there are about 500 adults in organisations, paving the way for more Exeter facing a combination of complex problems productive collaborative working including homelessness, substance misuse, mental ●● A broadening of stakeholders’ scope and ill health and offending behaviour. The aim is to understanding of the wider system resulting prevent entrenched health problems for people from the space and capacity to come together who are street homeless and vulnerably-housed by identifying problems sooner and providing rapid and ●● More actively exploring new and innovative responsive support rather than waiting for people to modes of working get into crisis. Exeter City and Council and Northern Devon District Council were both awarded Homeless ●● A desire to take the learning from ICE and use Prevention grants in December 2016 which featured it to enhance their own organisations way of ICE work in their bids. working. Diverting Demand: Risk Stratification Whilst it is not yet possible to evidence outcomes or measure the financial savings to the system, the Working with all the GP practices across Exeter impact on individuals involved in the ICE programme to develop a systemic way to identify people who is clear. ICE is helping people to realise the necessity could benefit from early interventions to improve of a preventive approach, and developing individuals outcomes and reduce overall system costs. to better understand how to implement change in the system – focusing their thinking around There is growing local and national interest in the problems and solutions. tool as it builds population profiles through linking

Page 53 Annual Report 2016/17 Disclosures Statement as to Disclosure to Income Disclosures Required by Auditors Section 43 (2a) of the NHS Act 2006 The Annual Report, Quality Report and Annual The Trust has complied with Section 43 (2a) of the Accounts have been approved by each individual who NHS Act 2006 (as amended by the Health and Social is a Director at the time. Care Act 2012). The Trust’s income from the provision of goods and services for the purposes of the health Disclosure to Auditors and Further service in England is greater than its income from Disclosures the provision of goods and services for any other purposes. So far as each Director is aware, there is no relevant Income generated from the provision of goods and audit information of which the RD&E’s External services for any other purposes is used by the Trust to Auditor is unaware. Each Director has taken all the provide healthcare services. steps that they ought to have taken as a Director in order to make themselves aware of any relevant audit information and to establish that the RD&E’s external auditor is aware of that information.

After making enquiries, the Directors have a reasonable expectation that the RD&E 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.

If management wishes to use the services of the Trust’s external auditor for any non-audit purposes, we demonstrate why this is appropriate. The Acting Chief Financial Officer will provide professional advice on the appropriateness of such an arrangement and the Audit Committee keep under review the level of non-audit services provided by the External Auditor taking into account relevant guidance. The safeguard is in place to ensure independence.

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At the EDRC meeting in June 2016 the committee Remuneration Report approved a temporary increase in salary for Suzanne The membership of the Executive Director Tracey in recognition of her taking on the role Remuneration Committee (EDRC) consists of the of Acting CEO and Accountable Officer for the Chairman and all the Non-Executive Directors. Trust. The salary was set through a benchmarking During the year, the Committee was chaired by exercise conducted internally and an external review Andrew Willis as the Senior Independent Director. completed by the executive search firm Harvey Nash The Chief Executive and as necessary, other Executive and was payable with effect from 1 July 2016. This Directors were invited to attend the meetings in was subsequently made substantive on confirmation an advisory role but are excluded on issues directly of her appointment as CEO with effect from 21 relevant to them by the Chair of the Committee. The November 2016. In accordance with HM Treasury Committee is supported by the Deputy Director of guidance the contract for the new Chief Executive Transformation and Organisational Development. Officer includes a clause permitting 10% of salary to be clawed back if performance is not considered to The Committee’s main purpose is to set rates of be satisfactory. remuneration, terms and conditions of service for the Chief Executive, Executive Directors and their direct In February 2017 Suzanne Tracey completed a review reports, i.e. those persons in senior positions having of the Executive Team to address the number of authority or responsibility for directing or controlling temporary arrangements that were in place, provide the major activities of the Trust. Since completion additional stability within the team and to better of the Senior Management Review in 2014 the role meet the leadership requirements following the of the Committee has extended to include direct merger with community services that took place in reports to the Executive Directors who moved to October 2016. This review confirmed Em Wilkinson- ‘spot’ salaries outside national terms and conditions Brice as the single Deputy Chief Executive and Chief within the review of the Trust’s senior management Nurse with effect from 1 March 2017 with no change arrangements. to her remuneration. At the same time, Pete Adey was appointed as Chief Operating Officer replacing During 2016-17 there have been several changes his temporary role as Director of Operations with within the Trust’s executive team. Angela Pedder a corresponding small uplift to salary to reflect this stood down from her role as Chief Executive Officer change in role with effect from 1 March 2017. to take on leadership of the Devon Success Regime The EDRC approved a minor increase in salary for and lead for delivery of the Sustainability and Tracey Cottam, Director of Transformation and Transformation Plan with effect from 1 July 2016. Organisational Development, to ensure that senior Suzanne Tracey, previously Deputy Chief Executive salaries are no less than an average level when and Chief Financial Officer, became the Acting Chief compared to other similar sized Trusts (also effective Executive and Accountable Officer on 1 July 2016. on 1 March 2017). Following a meeting of the Non-Executive Directors, Suzanne Tracey’s appointment as Chief Executive was Attendance at EDRC Meetings in 2016/17 confirmed with effect from 21 November 2016. In February 2017 Suzanne Tracey completed a review Name Apr Jun Oct Feb of the Executive Team and formally confirmed Em 2016 2016 2016 2017 Wilkinson-Brice as the single Deputy Chief Executive J Brent P P P P and Chief Nurse and appointed Pete Adey as Chief J Ashman P P P P Operating Officer both with effect from 1 March P Dillon P P P P 2017. J Kay A A P A D Robertson P P P P Non-Executive Director and Chairman M Romaine P P P P Remuneration is dealt with by the Non-Executive A Willis (Chair) P P P P Director Remuneration Committee (NEDRC). The arrangements are set out on page 45. In addition to the scheduled EDRC meetings, the Committee members met for a number of minuted In-year Remuneration Decisions meetings in the context of the appointment of the new Chief Executive Officer. These extraordinary A 1% cost of living increase was authorised by the meetings included discussion of remuneration for the EDRC for all Executive Directors and their direct new Chief Executive Officer. Details of the agreed reports paid ‘spot’ salaries outside of the national remuneration for the CEO role are set out in the Agenda for Change terms and conditions. This was Director’s Remuneration tables on page 61 and 62. payable from 1 April 2016.

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Senior Managers Remuneration less frequently than every two years. This work will be undertaken on behalf of the EDRC by a Policy senior Human Resources adviser or competent The Trust adopts the principles of Agenda for Change and suitably qualified external organisation. The terms and conditions when considering Senior EDRC will identify a suitable comparator subset of Managers pay, remuneration is set on a spot salary Foundation Trusts and Trusts from which it wishes basis. The spot salaries are based on market testing to derive data based on turnover, geography and to identify the market rate and the experience of the other factors. NHS Providers benchmarking data, candidate is also taken into account. The principles trust annual reports published data is summarised guiding the approach of the Committee’s decision- and made available to the EDRC. The Committee making approach, agreed and are annually reviewed will make judgements on where it wants to by the Executive Director Remuneration Committee, position its relative remuneration package for are set out below: Executive Directors and their direct reports in any one year in relation to comparison data from 1. The Committee’s approach to remuneration will other Foundation Trusts. The EDRC will treat seek to position the Trust in a way that it is able comparator data with caution not least so as to to attract, retain and motivate Executive Directors avoid undue pay inflation. and their direct reports of sufficient calibre to maintain high quality, patient-centred healthcare 6. The Committee will seek to apply the principles and effective management of the Trust’s fairly and transparently and on the basis of data resources. and advice from competent external bodies/ consultants or senior Human Resource adviser 2. The Committee understands that senior level as necessary. The Committee understands that positions in the Trust operate in a regional/ it will use the data it gathers and the framework national context and that remuneration for these set out in the principles to exercise the necessary positions is primarily determined by the market. judgment on pay and reward issues. The In order to remain competitive and attract and Committee will ensure that remuneration reflects retain high calibre staff, the salaries of senior staff the extent of the role and responsibilities of must be regularly reviewed to ensure that they individual posts and their contribution to the remain broadly competitive and that the salaries organisation and will be based on judgements offered to incumbents do not denude over time relating to: so that they are out of line with comparable Trusts. Nevertheless, the Committee will avoid ●● Market rates for comparable roles in paying more than is necessary to recruit, retain comparable organisations and motivate Executive Directors and their direct ●● Interpretation of the data from an agreed reports and will take positions that are publicly comparator group defensible. Moreover, the Committee understands that its approach must strike an appropriate ●● The size and scope of the role in question balance with the Committee’s duty to ensure the effective stewardship of public resources. ●● Advice from the Chairman of the Trust in relation to the Chief Executive 3. The Committee will be rigorous in ensuring that potential conflicts of interest are recognised and ●● Recommendations from the Chief Executive avoided. Executive Directors and their direct in relation to the Executive Directors and their reports will not be involved in deciding their own direct reports remuneration package. ●● Affordability 4. On an annual basis, the Committee will consider ●● Other NHS pay settlements the remuneration packages of all Executive Directors and their direct reports bearing in mind ●● Wider implications that may arise from setting the performance of the Executive Directors and the remuneration packages of Executive their direct reports in fulfilling their duties and in Directors and their direct reports in relation regard to the overall performance of the Trust. to pay levels determined through national agreements within the NHS; 5. The Committee will use external comparison data on the pay and conditions of Executive ●● Any other factors deemed appropriate Directors in comparator Foundation Trusts no

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7. The Committee will seek to achieve broadly over and above the core salary, in recognition of standardised terms and conditions, for example extraordinary factors such as matching market on notice periods for all posts which fall within forces in recruitment; exceptional endeavour etc. the scope of the principles. The EDRC has resolved to move towards a situation in which there is a ●● Additional non-pay benefits over and above the higher degree of conformity (a notice period of six core salary including pensions, vehicle/lease car months). issues, mobile phones and other such benefits

8. The Committee will be transparent in the ●● The terms and conditions in regards to issues application of its remuneration principles. It is (such as notice periods, conditions attached at a requirement that details of the remuneration recruitment stage for professional development package for Board Directors are recorded in the for example) etc Trust’s Annual Report. ●● Arrangements for termination of employment and 9. The Trust recognises that the EDRC has the other contractual terms authorised responsibility to apply its independent On an annual basis the Committee will consider judgement on matters within its remit within whether any issues have emerged which require the wording and the spirit of the agreed consideration of any adjustments to existing principles. However, there may be times when remuneration packages such as: a different approach is required which steps outside the scope of the principles and in these ●● At the beginning of a process to recruit a cases, particular care must be taken and clear replacement Executive Director or direct report justification must be given and recorded. Some ●● When issues concerning inflationary uplifts within circumstances which may require flexibility include the NHS need to be considered – on an annual temporary promotions; atypical employment basis; conditions; specific issues related to individuals etc. The Committee will reserve the right to ●● When changes are made to the size and scope of recruit an Executive Director or a direct report on Executive Director or direct report portfolios a salary below the market value in cases where a development plan would enable the employee The Chief Executive completes a formal annual to reach the minimum standards to undertake performance review for all Executive Directors and the role at a satisfactory level. The Committee the Chairman reviews the performance of the Chief also reserves the right to pay additional payments Executive. These reviews are reported to EDRC to Executive Directors and their direct reports and, whilst the Trust does not currently operate a when deemed necessary because of exceptional performance-related pay scheme, these reviews are circumstances. The occasions when additional considered as a part of the review of remuneration. payments are required will be limited. When Any salary that is in excess of £142,500 is subject to considering using additional payments, the EDRC particular scrutiny against the policy to ensure that will need to be able to fully justify and explain the remuneration is reasonable. why it has opted to take this course of action. It The Executive Directors are appointed on permanent would only normally consider such action on the contracts and have a six month notice period. basis of a clear business case. Special care must be taken to ensure that the use of additional The Executive Directors are appointed on permanent payments is completely transparent and that contracts and have a six month notice period. consideration has been given to the impact on pay inflation among Executive Directors and The Trust follows Agenda for Change principles in their direct reports as well as to guard against calculating severance packages for redundancy. The accusations of bias or arbitrary practice. redundancy payment will take the form of a lump sum, dependent on the employee’s reckonable The principles will apply to the pay, awards and service at the date of termination of employment. terms of employment of the Trust’s Chief Executive The lump sum will be calculated on the basis of one and Executive Directors and their direct reports and month’s pay for each complete year of reckonable include the following components: service, subject to a minimum of two years’ continuous service and a maximum of 24 years’ ●● The core salary reckonable service being counted. Fractions of a year ●● Any supplementary payments to the Director of reckonable service will not be taken into account.

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In accordance with the Agenda for Change Terms ●● they are offered a renewal of contract (with the and Conditions of Employment, Executive Directors substitution of the new employer for the previous shall not be entitled to redundancy payments or early NHS one); or retirement on grounds of redundancy if: ●● where their employment is transferred to another ●● they are dismissed for reasons of misconduct, public service employer who is not an NHS with or without notice; or employer.

●● at the date of the termination of the contract There were no payments for loss of office made to have obtained without a break, or with a break any person who was senior manager in the current not exceeding four weeks, suitable alternative or previous financial year made during the 2016/17 employment with the same or another NHS financial year. There were no payments of money or employer; or other assets made to any individual who was not a senior manager during the financial year but who has ●● unreasonably refuse to accept or apply for previously been a senior manager at any time. suitable alternative employment with the same or another NHS employer; or There were no new components of the remuneration package introduced during the year. ●● leave their employment before expiry of notice, except if they are being released early; or

Future Policy Table

Element How component Operation of the component Performance metric of pay supports short and long- used and time (Component) term strategic objective/ period goal of the Trust Basic salary Provides a stable basis for Following market testing (undertaken Pay is reviewed recruitment and retention, every two years) which seeks to annually in relation to taking into account the identify salary paid for similar role, individual performance Trust’s position in the labour individuals are remunerated by spot based on agreed market and a need for a salary on a case by case basis. There is objectives set out consistent approach to no predefined upper limit. prior to the start of leadership. that financial year In accordance with the NHSI Guidance which runs between Stability, experience, on pay for very senior managers in 1 April and 31 March. reputation and widespread NHS trusts and Foundation Trusts Increases are ordinarily knowledge of local needs the Chief Executive Officer contract in line with the wider and requirements supports includes a clause permitting 10% NHS workforce as the Trust’s short-term of salary to be clawed back if recommended by the strategic objectives outlined performance is not considered to be NHS Pay Review Body. in its annual priorities and satisfactory. its long- term strategic goals. Benefits N/A N/A N/A Pension Provides a solid basis for Contributions within the relevant Contribution rates recruitment and retention of NHS pension scheme. Details of the are set by the NHS top leaders in sector. schemes currently in place can be Pension Scheme. found at: www.nhsbsa.nhs.uk/Pensions.aspx Bonus N/A N/A N/A Fees N/A N/A N/A

Page 58 Annual Report 2016/17 of £000 Total Total 45-50 15-20 15-20 10-15 10-15 15-20 15-20 45-50 £5000) (bands 225-230 135-140 205-210 265-270 195-200 185-190 ------£000 of £5000) for loss of office (bands compensation Golden hello / ------£000 Other £5000) (bands of Remuneration ------£000 £2500) related related Pension Benefits 27.5 - 30 30 - 32.5 25 - 27.5 42.5 - 45 (bands of 110 - 112.5 177.5 - 180 ------£ 100 100 4,700 1,300 2,400 2,600 £100) Taxable Taxable Benefits the nearest the nearest (Rounded to £000 45-50 10-15 10-15 10-15 10-15 10-15 10-15 45-50 85-90 115-120 110-115 170-175 170-175 140-145 of £5000) Salary and Fees (bands Chairman Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director 30 June 2016) Chief Executive (resigned known Chief Operating Officer (previously of Operations) (appointed 1 April as Director 2016) and Transformation Executive Director Organisational Development Executive Medical Director Acting Chief Financial Officer (appointed 1 July 2016) Deputy Chief Executive / Financial Officer to 30 June 2016, Acting Chief Executive 1 July 2016 to 20 November 2016, 21 November 2016 Chief Executive from Deputy Chief Executive / Nurse Name and Title 2016/17 J Brent J Ashman P Dillon J Kay D Robertson M Romaine A Willis A Pedder P Adey T Cottam A Harris P Southard S Tracey E Wilkinson-Brice Directors’ Remuneration 2016/17 Directors’ no annual were five) and there were (2015/16, there of six Executive Directors 2017, the table includes remuneration In the year ended 31st March No element of the senior manager’s bonuses paid to any individual in the financial year. bonuses or long-term performance-related performance-related not part of their management role. to additional duties that are relates remuneration

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Pension related benefits for defined benefit schemes: The amount included is the annual increase (expressed in £2,500 bands) in pension entitlement determined in accordance with the ‘HMRC’ method. The HMRC method derives from s229 of the Finance Act 2004, but is modified for the purpose of this calculation. In summary the increase in value is calculated as follows: (((20 x PE) + LSE) – ((20 x PB) + LSB)) - employee contributions.

●● 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.

For two of the Directors, the pension related benefit represents the change in the lifetime pension pot which has arisen from pay increases received in the year. Ratio between highest paid director and median remuneration received by employees of the Trust Reporting bodies are required to disclose the relationship between the remuneration of the highest paid director in their organisation and the median remuneration of the organisation’s workforce.

The banded remuneration of the highest paid director in the organisation in the financial year 2016-17 was £170k-175k (2015-16, £180k - £185k). This was 6.7 times (2015-16, 6.8 times) the median remuneration of the workforce, which was £27.3k (2015-16, £26.7k).

In 2016-17, 11 (2015-16, 7) employees received remuneration in excess of the highest-paid director. Remuneration ranged from £175k to £224k (2015-16, £183k-£251k).

Total remuneration includes salary, non-consolidated performance-related pay and benefits-in-kind. It does not include severance payments, employer pension contributions and the cash equivalent transfer value of pensions.

2016/17 2015/16 Band of highest paid Director – as above 170-175 180 - 185 Median remuneration received by employees within the Trust 27.3 26.7 Ratio 6.3 6.8

Page 60 Annual Report 2016/17 £000 Total £5000) 45 - 50 15 - 20 10 - 15 10 - 15 10 - 15 15 - 20 15 - 20 180 - 185 135 - 140 170 - 175 175 - 180 165 - 170 (bands of ------£000 compensation Golden hello / for loss of office (bands of £5000) ------£000 Other 6.6 27.6 Remuneration 2014/15 180 - 185 (bands of £5000) ------£000 0 – 2.5 £2500) Benefits (bands of 25.0 - 27.5 30.0 - 32.5 20.0 - 22.5 6.8 26.7 Pension related Pension related 2015/16 180 - 185 - - - - - £ 100 100 100 2,400 1,000 2,300 2,800 nearest £100) nearest (Rounded to the Taxable Benefits Taxable £000 £5000) 45 - 50 10 - 15 10 - 15 10 - 15 10 - 15 10 - 15 10 - 15 180 - 185 110 - 115 170 - 175 140 - 145 140 - 145 (bands of Salary and Fees Chairman Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Chief Executive Executive Director of Transformation & Organisational Development Executive Medical (appointed 1 Director April 2015) Deputy Chief Executive/ Chief Financial Officer Deputy Chief Executive/ Chief Nurse Name and Title 2015/16 J Brent J Ashman P Dillon J Kay D Robertson M Romaine A Willis A Pedder T Cottam A Harris S Tracey E Wilkinson-Brice Band of highest paid Director – as above Band of highest paid Director by employees within the Trust received Median remuneration Ratio Directors’ remuneration 2015/16 remuneration Directors’ bonuses paid to any individual in the financial year. bonuses or long-term performance-related no annual performance-related were There For Non-Executive Directors relate to the mileage allowance paid over and above HM Revenue & Customs for Executive Directors. The benefits in kind up figures. Tax and NI based on Grossed Trust makes payments for (PSA) with HMRC, and the official mileage is paid under a Payment Settlement Agreement by employees of the Trust received and median remuneration Ratio between highest paid director

Page 61 Annual Report 2016/17 - 28 80 40 66 20 145 Real £000 in Cash Transfer Transfer Increase Increase Equivalent Value at 31 Value March 2017 March - 72 675 669 465 781 Cash 2016 £000 1007 Transfer Transfer Value at Value 31 March 31 March Equivalent - 820 100 709 531 801 Cash £000 1087 Transfer Transfer Equivalent Value at 31 Value March 2017 March 0-5 £000 80-85 £5,000) 265-270 120-125 160-165 110-115 145-150 60 at 31 (bands of sum at age March March 2017 related lump related Total accrued Total 5-10 £000 Total Total 85-90 45-50 50-55 40-45 30-35 50-55 £5,000) accrued (bands of pension at March March 2017 age 60 at 31 Real £000 2.5-5.0 0.0-2.5 5.0-7.5 5.0-7.5 0.0-2.5 (bands £2,500) increase increase 15.0-17.5 20.0-22.5 at age 60 in pension related sum related Real £000 0.0-2.5 5.0-7.5 0.0-2.5 0.0-2.5 5.0-7.5 0.0-2.5 2.5-5.0 (bands £2,500) increase increase at age 60 in pension Chief Executive (resigned 30 June Chief Executive (resigned 2016) Chief Operating Officer (previously of Operations) known as Director (appointed 1 April 2016) Transformation Executive Director and Organisational Development Executive Medical Director Acting Chief Financial Officer (appointed 15 July 2016) Deputy Chief Executive / Financial Officer to 30 June 2016, Acting Chief Executive 1 July 2016 to 20 November 2016, Chief 21 November Executive from 2016 Deputy Chief Executive / Nurse Name and Title A Pedder P Adey T Cottam A Harris P Southard S Tracey E Wilkinson-Brice Pension Benefits 2016/17

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As Non-Executive members do not receive Real increase in CETV – This reflects the increase in pensionable remuneration, there will be no entries in CETV effectively funded by the employer. It takes respect of pensions for Non-Executive members. account of the increase in accrued pension due to inflation, contributions paid by the employee A Cash Equivalent Transfer Value (CETV) is the (including the value of any benefits transferred from actuarially assessed capital value of the pension another pension scheme or arrangement) and uses scheme benefits accrued by a member at a particular common market valuation factors for the start and point in time. The benefits valued are the member’s end of the period. accrued benefits and any contingent spouse’s pension payable from the scheme. A CETV is a payment Cash Equivalent Transfer Values (CETV) are not made by a pension scheme, or arrangement to available for members that have reached the secure pension benefits in another pension scheme normal retirement age or who have commenced or arrangement when the member leaves a scheme drawing their pension or are a deferred member. and chooses to transfer the benefits accrued in their No CETV is therefore available, as at 31 March former scheme. The pension figures shown relate 2016 for A Pedder. 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 Suzanne Tracey capacity to which the disclosure applies. The CETV Chief Executive figures, and the other pension details, include the value of any pension benefits in another scheme or Date: 24 May 2017 arrangement which the individual has transferred to the NHS pension scheme. They also include any additional pension benefit accrued to the member as a result of their purchasing additional years of pension service in the scheme at their own cost. CETVs are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries.

Page 63 Annual Report 2016/17 Staff Report The Trust recognises the exceptional work of all our us maintain our position as an employer of excellence staff and the Trust has created a variety of initiatives and choice. We have engaged with several initiatives and schemes to help support the commitment and this year that we are using to further enhance this hard work of our dedicated workforce through these position including the Royal College of Midwives challenging times. ‘Caring for You’ and the Royal College of Nursing ‘Healthy Workplace, Healthy You’ campaigns as well Last year the Trust embraced the Department of as a range of internal actions to promote the physical Health ‘Improving Working Lives’ initiative that helps and mental wellbeing of our staff. Staff Numbers Staff numbers (Whole team equivalents (WTE) have increased significantly this year as a result of the transfer of community services staff on 1 October 2016.

Of note across our range of Corporate Support Services our spend is below expected levels enabling the RD&E to be within the national lower quartile for corporate service costs. Staff Costs Gender Equality Staff costs for 2016/17 and 2015/16 are summarised The Trust is committed to achieving equality and in the table below. diversity in all that we do, for our staff and in the services they provide. 2016/17 2015/16 £000 £000 Female Male Total Salaries and wages 221,678 202,987 Directors 6 6 12 Social security costs 19,516 14,298 Other Senior 0 0 0 Employer contributions to NHSPA 26,042 23,913 Managers Termination benefits 43 284 Employees* 6276 1704 7980 Agency and contract staff 6,952 7,995 *The figure for employees is the total number of 274,231 249,477 employees as opposed to the whole time equivalent reported in the staff number section above. Analysed into operating expenses

Employee expenses staff 268,353 243,925 Employee expenses executive 1,073 924 directors Research and development 4,805 4,628 274,231 249,477

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Sickness Absence headcount resulting from the integration of staff from community services. There is no change to the The increase in the total number of days lost in average working days lost per WTE when compared 2016/17 is a direct reflection of the increased to last year.

Disability Recruitment In March 2016 the Board formally reviewed the The Recruitment and Selection Policy is designed to recommended Trust Equality Objectives for 2016- ensure that recruitment is carried out in accordance 20 within their formal meeting. Four objectives with the Equality Act 2010. Its aim is to ensure were agreed by the Board one of which specifically that applicants feel that they have been dealt with addresses the experience of staff with disabilities. professionally, fairly and that they feel that the Trust values its staff. The Executive Director of Transformation and Organisational Development is personally responsible The Trust is accredited by Jobcentre Plus to use the for ensuring that the Trust complies with equality law ‘Positive about Disabled People’ symbol. This means and any relevant NHS standards for the promotion that the Trust will: and assessment of equality. This reflects the importance placed by the Trust on the proper and ●● Interview all applicants with a disability who meet equitable treatment of all applicants, workers and the minimum criteria for a position and consider service users regardless of disability. All staff undergo them on their abilities equality and diversity training, raising awareness of ●● Consult with employees with a disability about personal and Trust responsibilities to those with any how the Trust can help develop their abilities protected characteristic including disability. ●● Make every effort when employees acquire a The core Trust Policy that applied during the financial disability to make sure they stay in employment year is the Equality and Diversity Policy. This policy gives full and fair consideration to applications for ●● Take action to ensure that all employees develop employment made by disabled persons relating to sufficient awareness of disability to make these their particular aptitudes and abilities;, for continuing commitments work the employment and arranging appropriate training ●● Review these commitments and plan on ways to for employees who have become disabled persons improve them. during the period and for the training and for career development and promotion of disabled employees All applicants for employment with the Trust is the Equality and Diversity Policy. This policy was complete a Health Questionnaire that is reviewed by subject to periodic review and was ratified by the the Occupational Health Service (OHS) as a part of Workforce and Governance Committee in May 2015. the recruitment process. If issues are identified, the individual will be invited to attend the OHS where The ultimate aim of the policy is to harness the an assessment is completed and recommendations individuality of every employee, so everyone is fully made so that whenever possible the person may be engaged in the work of the Trust and to protect employed safely. Experts from both the Occupational all workers and service users from all forms of Health Service and Human Resources are available to discrimination, harassment and victimisation on the provide reasonable adjustment advice and guidance basis of any protected characteristic. to managers during and after the recruitment We have been recognised as Positive about Disabled process. People, for our work supporting employees with disabilities and hold a number of accreditations demonstrating our supportive approach towards staff and applicants with both physical and mental health issues.

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Staff Who Become Disabled Provide non-judgemental and proactive support to individual staff who experience mental health issues. Whenever possible we support staff to either prevent or minimise the impact of any disability on the ability Ensure all line managers have information and to work. Early referrals to the Occupational Health training about managing mental health in the Service are encouraged so that action can be taken to workplace. aid rehabilitation and return to work following illness or injury, making any reasonable adjustments that Career Development and can assist. Actions taken to assist staff who develop Promotion disability include provision of additional software, specially adapted hardware or larger screen to The Trust holds a commitment to the support and facilitate use of technology, adjustments to desks or development of all our staff, irrespective of any chairs through to job redesign to enable a person to disability, and this is supported by managers creating continue working. Personal Development Plans (PDPs) with their staff in order to identify any areas for them to learn and Training has been designed and delivered for develop within the hospital. These are then used in managers to raise awareness of mental health issues conjunction with our comprehensive Learning and helping them to identify and support staff more Development Department who can offer a range of effectively, including the introduction of a two day training from clinical skills and management skills Mental Health First Aid training programme for training to customer care. Many of our training and managers. The Stress Management: Prevention, development programmes are accessible through a Recognition and Support Policy is supported with an range of training approaches including both face to extensive Manager’s Toolkit to help managers have face and e-learning giving staff the opportunity to a positive impact on the health and wellbeing of learn in through the methodology best suited to their employees and by doing so, indirectly have a positive learning preferences and needs. impact on patient care. The key policy that guides all staff is the Recruitment Mindful Employer and Selection Policy. It is designed to ensure that selection and promotion is carried out in accordance Renewed in April 2014, this award accredits the with the Equality Act 2010. A range of policies way we promote good mental health among our including Staff Development, Essential Learning, employees. The Mindful Employer scheme delivers e-Learning and Study and Professional Leave are all against the following aims: designed to support staff equitably in their career development. Show a positive and enabling attitude to employees and job applicants with mental health issues. This will include positive statements in local recruitment Countering Fraud and Corruption literature. The Trust is committed to countering fraud and Ensure that all staff involved in recruitment and corruption and achieves this by a close working selection are briefed on mental health issues and the relationship with the Counter Fraud Team (who Disability Discrimination Act, and given appropriate monitor and report fraud through the Audit interview skills. Committee) and by raising awareness of fraud through face to face presentations delivered to staff Make it clear in any recruitment or occupational at both Divisional and Speciality Level. The Trust has health check that people who have experienced a number of policies to guide and support staff such mental health issues will not be discriminated against as the Standards of Business Conduct and the Trust’s and that disclosure of a mental health issue will Whistleblowing Policy. Staff access Trust policies via enable both employee and employer to assess and the internal intranet (HUB) and are encouraged to provide the right level of support or adjustment. seek clarification direct from the policy author or through the Head of Governance. Not make assumptions that a person with a mental health issue will be more vulnerable to workplace stress or take more time off than any other employee or job applicant.

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norms and ways of working in order to facilitate the Staff Survey new ways in which care will need to be delivered differently, now and into the future. Statement of Approach Building on our achievements to date the RD&E staff Over the last 4 years the RD&E has consciously engagement and communications approach is central sought to improve staff engagement as part of a to a comprehensive transformational organisational broader organisational development and culture development approach tackling a range of factors change agenda. Our approach focuses on mobilising that impact on staff engagement as well as focus on the organisation around improving staff engagement key workforce issues through the Workforce Support and to promote conversations around consistent Strategy. messages and clear expectation of behaviour changes incorporated into the Trust’s culture. Our approach It is essential to continue to maintain and improve is one that encompasses the whole organisation and patient experience, outcomes, and performance is based on the understanding that all staff have a but also to equip staff with the optimal behaviours level of responsibility to consider and act on staff required to manage the level and scale of change engagement and that engagement is a two way required to deliver health and care differently into process. the future. Our new organisational structure – as an acute and community provider – aims to deliver more The Trust defines staff engagement as: joined- up care for people out of hospital and this will only be realised if the culture and outlook of staff “a workplace approach designed to ensure that right across the organisation rapidly adapts. employees are committed to their organisation’s goals and values, motivated to contribute to In addition, the organisation is increasingly organisational success and are able, at the same working in ever closer partnership with other NHS time, to enhance their own sense of wellbeing”. organisations, local government, private providers and the voluntary sector. This shift also requires a Engagement is therefore a tool for organisational change in attitude and outlook away from narrow success and improved outcomes – a way of organisational interests to the broader interests of developing a culture that enables and sustains people and communities living in Devon. continuously improving, safe, high quality and compassionate care. Since the MacLeod Report in The Trust believes that improving staff engagement is 2009, the focus on employee/staff engagement has critical: increased significantly and there is now a strong ●● There is strong evidence that a high level of staff body of evidence which underlines the importance engagement is linked to better quality of care for of committed and motivated staff and how this can patients. Indeed, the level of staff engagement enhance and improve patient safety, outcomes and as reported in the NHS staff survey has long experience. been recognised as one of the most reliable The challenges facing the NHS in terms of rising indicators of quality, including by the Care Quality demand and cost, the difficulties in maintaining Commission. This is supported by extensive performance whilst resource levels have remained academic research which has consistently found a broadly the same and the need to fundamentally correlation between staff who are highly engaged transform how citizens engage with care services and a number of quality indicators. Research on in the future means that we are in a period of employee engagement and NHS performance unprecedented change. In response to these carried out by Professor Michael West and Jeremy challenges, the NHS Five Year Forward View sets out Dawson in 2012 found a clear link between staff a clear direction for the NHS – showing why change engagement and outcomes within NHS trusts: is needed and what it will look like. The challenges “The more positive the experiences of staff and the response will place new demands on staff within an NHS trust, the better the outcomes that, if not well-managed or engaging staff properly, for that trust. Engagement has many significant will make realising change hard to sustain. associations with patient satisfaction, patient mortality, infection rates, Annual Health Check Our staff need to be at the heart of these changes as scores, as well as staff absenteeism and turnover. we lead the way in helping to innovate and transform The more engaged staff members are, the better services, to ensure that our current health system is fit the outcomes for patients and the organisation for the future. In the context of the changes required, generally.” there is a need to address the entrenched cultural

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●● A report by The King’s Fund in 2015 confirmed ●● The NHS Constitution addresses the issue of staff this finding: “Trusts with more engaged staff engagement and commits NHS organisations as tend to have lower levels of patient mortality, follows: make better use of resources, and have stronger financial performance and higher patient ●● to provide all staff with clear roles and satisfaction, with more patients reporting that responsibilities and rewarding jobs for teams they were treated with dignity and respect.” and individuals that make a difference to patients, their families and carers and ●● Organisations in both the public and private communities sectors report significant benefits from improving their levels of employee engagement, including: ●● to provide all staff with personal development, increased productivity, higher quality, greater access to appropriate training for their jobs innovation AND better customer service. People and line management support to succeed who feel committed to the organisation they ●● to provide support and opportunities for staff work for, to their colleagues, patients and to maintain their health, wellbeing and safety communities, will go the extra mile to do their jobs well. If you show that you value people, you ●● to engage staff in decisions that affect them will get the best out of them. and the services they provide, individually, through representative organisations ●● Making new care models a reality across the and through local partnership working health, care and voluntary sectors depends arrangements. All staff will be empowered to on people. The NHS Five Year Forward View put forward ways to deliver better and safer recognised this: “Healthcare depends on people services for patients and their families. — nurses, porters, consultants and receptionists, scientists and therapists and many others. We Key Activities and Approach can design innovative new care models, but they simply won’t become a reality unless we have a As noted above, the Trust takes an integrated and workforce with the right numbers, skills, values holistic approach to improving staff engagement. and behaviours to deliver it.” What is more, This section highlights some of our core activities people who work in the health and care system designed to boost staff engagement levels. want to do the best for the people they care for, but a workforce that does not feel involved in Values and behaviours planned changes or does not believe the changes The Trust’s Values and Behaviours charter continues are the best thing to do can mean that it doesn’t to be central to the Trust’s revamped Orientation and happen. The Forward View acknowledges that Induction day for new staff. Values and behaviours realising its vision for new care models: “will are also incorporated into the recruitment process require a greater investment in training for followed by the process which means that the Trust existing staff, and the active engagement of actively seeks out those that share its corporate clinicians and managers who are best placed to values. In addition, values and behaviours are a key know what support they need to deliver new part of the Trust’s staff performance reviews ensuring models of care.” This is why staff must be at that staff are accountable for their behaviours. the heart of new care models though, as stated above, this shift will require a major change in Staff engagement activities attitudes, behaviours and culture. The Trust has continued to engage each division ●● Over the last decade considerable research in developing and implementing a bespoke has taken place on employee engagement engagement plan based on the evidence collated and some of the factors that both drive and from the staff survey and other local/ anecdotal impede an engaged workforce. A combination evidence. This approach, which we have sought to of observational, empirical, sociological, improve and make more rigorous over the last year, psychological, behavioural and anthropological has helped drive improvements in staff engagement insights have helped shape and improve and other relevant indicators. The sharing of the understanding of people’s behaviour and levels of plans and support from the Communications and engagement whilst at work. Engagement team to the Divisions has enabled best practice and cross fertilisation to take place. It has also enabled bespoke support to be targeted

Page 68 Annual Report 2016/17 at those parts of the workforce that have specific Engaging with Community issues to tackle or where there is underperformance. Communication Cells continue to play a key role in Colleagues cascading messages and engaging staff to identify In October 2016, over 1400 community staff joined and solve their own problems at different levels. the Trust from Northern Devon Healthcare NHS Trust. Leading up to and over the transfer period During the year we have continued to use Executive the RD&E undertook a comprehensive engagement Conversations to give an opportunity for staff to task to ensure staff felt involved in the process and hear and discuss issues of strategic and operational had opportunities for two-way communication. The importance in sessions led by the Chief Executive and approach included the development of an online other executives. Our new Chief Executive has, since microsite as a hub for information and feedback, staff the beginning of 2017 undertaken regular video workshops to understand what community staff were blogs to update staff and provide a view from the proud of and what mattered to them, tailored staff top on key issues. The blog sits alongside one of our survey and regular and consistent leadership visibility. existing communication products – Snapshot – which Since the transfer, this programme of work has provides an at-a-glance overview of the Trust’s key continued to develop to ensure community staff can metrics and a new product, introduced during the contribute to and shape the development of services, year, called Team Briefing which is a one side of A4 feel of equal value to their acute counterparts and summary of key issues that all staff need to be aware are supported to become one team. of. Both products sit alongside each other in the Connecting Care communications cells. Summary of Performance – Results The Trust launched its new intranet service in October from the NHS Staff Survey 2016 replacing the system that had been in place for the last decade. The new system – called HUB – is the In 2016, the RD&E, as part of its staff engagement main way in which staff find out key information strategy, undertook a full census survey of its staff. about the Trust, keep up to date with news, access The response rate was 42% which was equal to vital policies and comment on key issues. Our the national average. The Trust was in the top 20% internal surveys show that the intranet is the main of Trusts nationally for sixteen of the key findings, way in which staff find out information and is the an increase of two from 2015. The Trust was in the preferential way of receiving information for the bottom 20% for no key findings compared with two majority of staff. in 2015.

Our award scheme – Extraordinary People – has The results show a positive improvement year on continued to be a success during the year with year. The RD&E has been rated the joint highest acute new award categories added to the numbers of trust nationally for the proportion of staff (85%) who awards. The scheme – which is run three times a year would be happy with the standard of care provided culminating in an end-of-year Winner of Winners by the Trust. event – still regularly attract 40-50 entries each time it is run. Out of 32 key findings, the RD&E was rated in the top 20% nationally for half of the findings, with the We also undertake regular “Staff Say” meetings. large majority being above the national average for These meetings provide a safe environment for staff acute trusts. to openly discuss issues of concern or anxiety and, through this process, anonymously raise issues with The overall ‘staff engagement’ indicator, assessed by senior management. combining the answers to nine key questions rose to 3.91 (out of 5) continuing the 5-year trend of We have stepped up work on communicating increased staff engagement at the RD&E. and engaging with the Trust’s Senior Leadership team over the previous year but we recognise that Other areas in which the RD&E does well and where more needs to be done to further engage with this we scored in the top 20% nationally include: important group. A new comprehensive programme ●● Percentage of staff experiencing harassment, has been developed in order to engage with this bullying or abuse from patients, relatives or the group over the coming year and this is having a public in last 12 months positive impact on wider staff engagement and culture change. ●● Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months

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●● Effective team working ●● Quality of appraisals

●● Percentage of staff witnessing potentially harmful ●● Percentage of staff / colleagues reporting most errors, near misses or incidents in last month recent experience of violence

●● Percentage of staff able to contribute towards ●● Staff satisfaction with the quality of work and improvements at work care they are able to deliver

●● Care of patients/service users is the organisation’s ●● Percentage of staff reporting good top priority communication between senior management and staff While the survey highlights some key achievements it also identifies a number of areas where we can ●● Staff feeling unwell due to work related stress in improve: last 12 months

●● Experienced discrimination from manager/team leader or other colleagues NHS Staff Survey – RD&E Summary table

2015 2016 Trust improvement/ deterioration Response rate RDE Trust Acute Ave RDE Trust Acute Ave 41% 41% 42% 42% No change

RD&E RD&E Acute Trust improvement/ Trust Trust Trust Ave deterioration Trust 5 Top Ranking Scores 2016 2015 2016 20165 Percentage of staff experiencing harassment, 19% 20% 27% No change bullying or abuse from patients, relatives or the public in last 12 months Effective team working 3.91 3.86 3.75 No change Percentage of staff witnessing potentially 30% 25% 31% No change harmful errors, near misses or incidents in last month Percentage of staff able to contribute towards 72% 76% 70% No change improvements at work Percentage of staff experiencing harassment, 20% 20% 25% No change bullying or abuse from staff in last 12 months

RD&E RD&E Acute Trust improvement/ Trust Trust Trust Ave deterioration Trust 5 Bottom Ranking Scores 2016 2015 2016 20165 Quality of appraisals 2.98 3.00 3.11 No change Percentage of staff / colleagues reporting most 60% 64% 67% No change recent experience of violence Staff satisfaction with the quality of work and 3.98 3.95 3.96 No change care they are able to deliver Percentage of staff reporting good 32% 33% 33% No change communication between senior management and staff Staff motivation at work 3.92 3.95 3.94 No change

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●● The Trust has begun to better embed senior level Future Priorities and “Observe and Support” sessions as part of the Targets Connecting Care methodology. This involves senior managers supporting team Communication Over the last year we have focused on two areas: Cells throughout the Trust and helping these teams address issues that they have not been able ●● Increasing the overall staff engagement score to to solve themselves. A programme of Executive 4.0 Observe and Support visits has now been put in ●● Providing bespoke support and advice to those place and this is likely to help increase the visibility areas of the Trust that were underperforming of the Executive team.

We recognised that shifting staff sentiment on ●● The Trust is genuinely proud of the sustained engagement was difficult, not only because of improvements made over the last five years. In the external context in which we operate but also 2012 the Trust was the 128th acute Trust in the because what influences staff sentiment is to a country scoring below average on the overall staff significant extent as a result of factors that were engagement score. In 2016, we were eight in determined locally or were outside the RD&E’s the country in comparison to other Acute Trusts. control. In other areas, such as training or appraisals, Although we failed to meet the self-imposed management action at a local level could make a target of 4.0, no other Acute Trust in the country quantifiable difference. did so either. We are aware that to sustain this level of performance and improvement will ●● Divisional plans have made significant require herculean efforts over the coming year as improvements over the last year but more remains some of the changes and difficulties arising from to be done to support those Divisions whose plans the STP impact on staff sentiment. are less robust then the highest performing areas. More bespoke support will be provided to these ●● The Trust has performed well in engaging with areas in the next year to drive out variation and and involving new community staff. Even though ensure that learning from elsewhere is embedded. the timing of the transfer meant that this group of staff were not included in the staff survey, ●● Staff engagement is everyone’s responsibility we are very aware that we have an ongoing and this year we want to put staff in the driving challenge to ensure that community staff are fully seat to develop engagement plans and activities engaged and involved over the coming year and that respond to their needs. An approach that in the future. facilitates and involves staff directly in the development of their own staff engagement ●● At a corporate level the Trust will be tackling plans, will help embed and promote ownership. some of the issues that scored poorly in the staff survey. In particular we will revamp performance ●● In addition to the staff survey we have also appraisals which are currently not fit for purpose. undertaken a specific bespoke survey of staff on corporate communications. The results from this ●● This year we are also seeking to triangulate data survey will be used to inform any changes we between the staff survey, national inpatient make to staff engagement and communication survey and workforce metrics to discern any clear over the coming year. One of the issues we patterns or leads that will help us undertake have considered is whether there is a need to better informed and targeted remedial actions. change the Executive Briefings/Conversations and the early results from the survey suggest that reform to the current practice would be timely. In addition, we have, as a Trust, reluctantly made a decision for financial reasons to cease our internal printed magazine – again a decision supported through the survey.

Page 71 Annual Report 2016/17

Off Payroll Payments Table 3: For any off-payroll engagements of board members, and/or senior officials with There were no off-payroll engagements of board significant financial responsibility, between members, and/or, senior officials with significant 1 Apr 2016 and 31 Mar 2017 financial responsibility during the financial year. Table 1: For all off-payroll engagements as Number of off-payroll engagements of 0 board members, and/or, senior officials with of 31 Mar 2017, for more than £220 per day significant financial responsibility, during the and that last for longer than six months financial year. No. of existing engagements as of 31 Mar 2017 5 Number of individuals that have been deemed 14 “board members and/or senior officials with Of which: significant financial responsibility”. This figure Number that have existed for less than one year 0 should include both off-payroll and on-payroll at the time of reporting engagements. Number that have existed for between one and 3 two years at the time of reporting Number that have existed for between two and 0 three years at the time of reporting Number that have existed for between three 1 and four years at the time of reporting Number that have existed for four or more 1 years at the time of reporting

Confirmation: All existing off-payroll engagements, outlined above, have at some point been subject to a risk based assessment as to whether assurance is required that the individual is paying the right amount of tax and, where necessary, that assurance has been sought. Table 2: For all new off-payroll engagements, or those that reached six months in duration, between 01 Apr 2016 and 31 Mar 2017, for more than £220 per day and that last for longer than six months

Number of new engagements, or those that 1 reached six months in duration between 01 Apr 2016 and 31 Mar 2017 Number of the above which include contractual 1 clauses giving the trust the right to request assurance in relation to income tax and national insurance obligations Number for whom assurance has been 1 requested Of which: Number for whom assurance has been received 1 Number for whom assurance has not been received * Number that have been terminated as a result of assurance not being received

Page 72 Annual Report 2016/17

Exit Packages During the course of the year a total of £43,000 was paid to staff leaving the Trust as payment in lieu of notice. There were no redundancy payments made in the last financial year. All payments for exit packages were made in accordance with the standard contractual terms and conditions of the person’s employment.

Note 4.4 Reporting of other compensation Number schemes - exit of Cost of packages departur special 2016/17 Number es where payment Note that of Cost of Total Total special element columns E, G compuls compuls number cost of payment included and K are ory ory Number of other of exit exit s have in exit entered in redunda redunda departures Cost of other package package been package £000 ncies ncies agreed departures agreed s s made s Expected Exit package cost band (including any Subcode Sign special payment element) Number £000s Number £000s Number £000s Number £000s <£10,000 11 33 11 33 400 + £10,001 - £25,000 1 10 1 10 410 + £25,001 - 50,000 0 0 420 + £50,001 - £100,000 0 0 430 + £100,001 - £150,000 0 0 440 + £150,001 - £200,000 0 0 450 + >£200,000 0 0 460 + Total 0 0 12 43 12 43 0 0 470 + There were no payments for loss of office made to any person who was senior manager in the current or previous financial year made during the 2016/17 financial year. There were no payments of money or other assets made to any individual who was not a senior manager during the financial year but who has previously been a senior manager at any time.

Suzanne Tracey Chief Executive Date: 24 May 2017

Page 73 Annual Report 2016/17 Board Assurance Framework (BAF)

The BAF is a Board-owned document whose primary wider governance arrangements within the Trust. role is to inform the Board about the totality of risks A review of the BAF by Internal Audit, undertaken or obstacles that may impede it from achieving its in 2017, declared “It is our view that the overall strategic objectives as outlined in the Trust’s long- assurance opinion on the design and operation of term Strategy document. The BAF also provides controls is Green”. The Trust’s external Auditors, assurances that adequate controls are operating KPMG, also undertook a benchmarking exercise of to reduce these risks to acceptable levels. Over the BAFs during 2016 which found the Trust to have a past two years the BAF has been on an evolutionary comparable number of risks and target risk rating on journey, in parallel with the redevelopment of the its BAF compared to the average.

Page 74 Annual Report 2016/17 Audit Committee The Audit Committee is a formal, statutory During 2016/17 the Audit Committee reviewed committee of the Board of Directors, chaired by Mr principles that the District Valuer will, as part of the David Robertson (a Non-Executive Director with a revaluation, review the Modern Equivalent Assets financial background). (MEA) assumption to optimise these values where necessary. The primary role of the Audit Committee is to conclude upon the adequacy and effective operation The Audit Committee acknowledged the revaluation of the organisation’s overall internal control system. of land and buildings principles. KPMG has confirmed In particular it is responsible for providing assurance that they were content with the principles and they to the Board in relation to the financial systems and had been reflected in the audit planning for 2016/17. controls of the Trust. Recognition of Income Four Non-Executive Directors constitute the membership of the Committee. Over 95% of the Trust’s income is received from other NHS organisations, with the majority being The Audit Committee is also attended by receivable from NEW Devon CCG. The Trust representatives of KPMG LLP the Trust’s External participates in the Department of Health’s agreement Auditors; Internal Audit and the Counter Fraud of balances exercise. This exercise seeks to identify Service. all income and expenditure transactions as well as As part of the external audit plan for 2016/17, KPMG payable and receivable balances that arise from highlighted three significant audit opinion risks which whole government accounting (WGA) bodies. The have been considered by the Audit Committee. Audit Committee is satisfied that by participating in this exercise it helps to provide further assurance that Revaluation of Property and Land the vast majority of income and expenditure with WGA bodies has been properly recognised and WGA The Trust’s accounting policies require a land and receivable and payable balances are appropriately buildings revaluation to be undertaken at least every recorded. The Trust’s external auditors have reviewed five years, dependent upon the changes in the fair the outcome of the exercise and reported their value of the property. Where assets are subject to findings to the Audit Committee. significant volatility, then annual revaluations may be required. Conversely, where changes in asset values Management Override of Controls are insignificant then a revaluation may be necessary only every 3 or 5 years. Professional standards require KPMG to communicate the fraud risk from management override of controls In 2015/16 it was agreed by the Trust’s management as significant. Management is typically in a unique that changes in fair values that exceed 10% since position to perpetrate fraud because of its ability the last valuation may provide an indication that to manipulate accounting records and prepare the change in value may be moving towards being fraudulent financial statements by overriding controls significant, and therefore the need for a revaluation that otherwise appear to be operating effectively. should be considered. KPMG have carried out appropriate controls testing An early assessment was undertaken to ascertain and substantive procedures, including testing of the estimated change in value to the Trust’s land journal entries, accounting estimates and significant and buildings as at 31 March 2017. A review of the transactions that are outside the normal course building indices (BCIS) has recently been undertaken of business, or are otherwise unusual. No specific and based upon these indices the buildings value has instances of management override were identified risen by around 12.9% since the last valuation was relating to this audit. carried out. Therefore a full revaluation of the Trust’s land and buildings was undertaken by professionally qualified valuer, in accordance with the Royal Institution of Chartered Surveyors valuation manual and it has been included within the Trust’s audited accounts.

Page 75 Annual Report 2016/17

Other Issues Considered by the Duties and Responsibilities of the Audit Committee Audit Committee Effectiveness of the external auditors Governance, risk management and internal control KPMG LLP were appointed as external auditors to the Trust from 2014/15 for a five-year period under a The Audit Committee shall review the establishment competitive tender process. and maintenance of an effective system of integrated governance across the whole of the Trust’s activities The Audit Committee assessed the effectiveness of (both financial and non-financial), that supports the the external auditors, in particular the timeliness of achievement of the Trust’s objectives. reporting, the quality of work and whether audit fees provided value for money. The Audit Committee In particular, the Audit Committee will review: provided the Council of Governors (CoG) with positive feedback and provided assurance to the CoG ●● all risk and control related disclosure statements that the external auditors provided a quality, timely together with any accompanying Head of Internal and cost effective external audit service. Audit statement, external audit opinion or other appropriate independent assurances, prior to The external auditors provided non-audit services endorsement by the board to the Trust in relation to Document Management assurance review during 2016/17. The charge for ●● the assurance processes that underpin the this service was £17,025 for the element of the achievement of the Trust’s objectives, the work completed during 2016/17. Due to the nature effectiveness of the management of principal risks of this work and the relatively low cost, the Audit and the appropriateness of the above disclosure Committee consider that there is no risk to auditor statements objectivity or independence. ●● the policies and procedures for all work related The Audit Committee met five times during 2016/17. to fraud and corruption as set out in Secretary of The names of members and their attendance at State Directions and as required by NHS Protect. 2016/17 meetings are as follows: In carrying out this work the Audit Committee will primarily utilise the work of internal audit, local Name Apr May July Nov Feb counter fraud specialists, external audit and other 2016 2016 2016 2016 2017 assurance functions, but will not be limited to these P Dillon P P P P P functions. It will also seek reports and assurances J Kay* A A P P from the Governance Committee, Directors and D Robertson P P P P P Managers as appropriate, concentrating on the overarching systems of integrated governance, risk M Romaine P P P P A management and internal control, together with *Professor Kay resigned from the Audit Committee in indicators of their effectiveness. January 2017, so there is a temporary vacancy which Internal Audit will be filled in due course. The internal audit function is provided by Audit South Key: P – Present; A – Apologies West (ASW). The Audit Committee shall ensure that there is an effective internal audit function, including the Counter Fraud function, established by management that meets mandatory NHS internal audit standards and provides appropriate independent assurance to the Audit Committee, Chief Executive and Board. This will be achieved by:

●● consideration of the provision of the internal audit service, the cost of the audit and any questions of resignation and dismissal

●● review and approval of the annual internal audit plan, ensuring that this is consistent with the audit needs of the Trust as identified in the assurance framework

Page 76 Annual Report 2016/17

●● consideration of the major findings of internal Other Functions audit work (and management’s response), and ensuring co-ordination between the internal and The Audit Committee will consider the work of other external auditors to optimise audit resources committees within the Trust, the work of which can provide relevant assurance to the Audit Committee’s ●● consideration of the annual Head of Internal own scope of work. This will particularly include the Audit’s Opinion Governance Committee because of its management of the Trust’s Corporate Risk Register and the Clinical ●● follow-up by the Governance Committee, or one Audit function. of its sub-committees, where internal audit’s work is an area covered by that committee, as set out in The Audit Committee will also: internal audit’s plan ●● review material changes to standing orders and ●● ensuring that the internal audit function is standing financial instructions and schemes of adequately resourced and has appropriate delegation and standing within the Trust, and ●● receive a report from management on the review ●● an annual review of the effectiveness of internal of data quality included in the Quality Report audit. Financial Reporting External Audit The Audit Committee shall review and, if thought The Audit Committee shall: appropriate, recommend to the Board adoption of the annual report and financial statements, focusing ●● review and monitor the external auditor’s particularly on: independence and objectivity and the effectiveness of the audit process, taking into ●● specific enquiry into the question of whether the consideration relevant UK professional and Trust keeps proper books of account regulatory requirements ●● the integrity of the financial statements ●● keep under review the level of non-audit services provided by the external auditor, taking into ●● the wording in the Annual Governance Statement account relevant guidance and other disclosures relevant to the terms of reference of the Committee ●● make recommendations to the Council of Governors in relation to the appointment, re- ●● changes in, and compliance with, accounting appointment and removal of the external auditor policies and practices

and ●● unadjusted mis-statements in the financial

●● approve the remuneration and terms of statements

engagement of the external auditor ●● major judgemental areas, and

Further, the Audit Committee shall review the work ●● significant adjustments resulting from the audit and findings of the external auditor and consider the implications of and management’s responses to their The Audit Committee shall review and provide work. This will be achieved by: assurance on behalf of the Board to the Department of Health around the costing process and ●● discussion and agreement with the external methodology as required by the Reference cost auditor, before the audit commences, of the guidance. nature and scope of the audit as set out in their annual plan Board of Directors Reporting Arrangements

●● discussion with the external auditors of their The Chair of Audit Committee will provide a report evaluation of audit risks and associated impact on highlighting the key issues arising from the Audit the audit fee, and Committee to the meeting of the Board that directly follows the Audit Committee. The minutes of the ●● review of all external audit reports, including Audit Committee will also be available to the Board. their report on the Quality Report and agreement of the annual audit letter, before submission to The Annual Governance Statement, which is included the board, together with the appropriateness of in the Annual Report, reviews in considerable detail management responses the effectiveness of the system of internal control. By

Page 77 Annual Report 2016/17 concurring with this statement and recommending its adoption to the Board, the Audit Committee also NHS Improvement Single gives the Board its assurance on the effectiveness of Oversight Framework the overarching systems of integrated governance, risk management and internal control. A revised performance framework has been established by NHS Improvement to support delivery It is the responsibility of the Trust’s Directors to of their 2020 objectives: to help more trusts achieve produce the Annual Accounts included in this report. a CQC rating of ‘Good’ or ‘Outstanding’, to reduce The external auditors provide an independent opinion the numbers of trusts in special measures, to on the Trust’s accounts and also audit the overall support achievement of aggregate financial balance position of the Trust’s management and performance from 2017/18 and to ensure that Trusts meet NHS including an opinion on the quality of the system Constitutional standards. The purpose of the of internal control. The outcome of this work is framework is to identify where providers may benefit reported in the Audit Opinion which is included from, or require improvement support across a with the accounts in this report and in the Annual range of areas. The Single Oversight Framework is Management letter to the Board. closely aligned to Care Quality Commission (CQC) Counter Fraud Monitor’s Risk Assessment Framework and the Trust Development Authority (TDA) Accountability The Counter Fraud Service for the RD&E is provided Framework. It applies to both NHS Trusts and NHS by Audit South West (ASW) via the services of a Local Foundation Trusts irrespective of their legal form, and Counter Fraud Specialist (LCFS). is based on the principle of earned autonomy.

The LCFS’s time during 2016/17 was predominantly There is a new emphasis on the importance of spent on: leadership and improvement capability within NHS organisations, and an expectation that providers will ●● Promoting an Anti-Fraud Culture engage constructively with local partners to build

●● Intelligence gathering shared understanding of local challenges and patient needs, and to design solutions which will drive ●● Raising awareness of current fraud scams improvements in the care of the local population. Financial measures also play a key part in the Single ●● Giving advice in respect of fraud risks, attempted Oversight Framework, and focus on sustainability, scams, procedures and policies efficiency and control. ●● Handling and investigating case referrals Many of the previous core performance metrics relating to access to services remain within the framework, including Referral to Treatment targets, 4 hour maximum waiting times within the Emergency Department and waiting times for diagnostic tests. The previous Cancer Standards have been consolidated and now focus on the delivery of the 62-day wait for first treatment for patients referred urgently via their GP or through a national cancer screening programme.

Page 78 Detailed Defindingstailed findings department. This is slightlydepartmentbetter. Thisthanisotherslightlyhospitbettalser thanin other• Didhospita memberals in of st• affDidtellayoumemberaboutofmedicstaff tationell yousideabout medication side England. The departmentEngland.perfTheormeddepbeartmenttter thanperfmanyormed bettereffthanectsmanyto watch for?effects to watch for? others in the nationalotherCQCsA&Ein thesurnationalvey. AnswerCQCsA&Eweresurvey. Answer• Didshospitwere al staff t•akDide yourhospitfamilyal storaffhometake yoursituationfamilyintoro home situation into particularly positive pforarticularlythe followingpositivequestions.for the following questions.account when you weracceountleavingwhentheyouA&EwerDepeartmentleaving the? A&E Department? • Did hospital staff t•ellDidyouhospitwho talo cstontaffacttellifyouyouwhowerteo contact if you were • If your family or someone• If yourelsefamilycloseor tsomeoneo you wantelseedcloseto to you wanted to worried about your cworriedonditionaboutor treyouratmentconditionafter youorlefttreatment after you left talk to a doctor, did thetalkythaveo a doctenoughor, didopportthey haveunityenoughto do opportunity to do the A&E Departmentthe? A&E Department? so? so?

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Maternity and MaternityRequirandes Requires • Did hospital staff tell you who to contact if you were The• If yourTrustf amilyunderwentor someone Gooda Careelse Qualityclose GoodtCommissiono youGoodwanted tGoodo GoodThe tablesGood Goodbelow show a GoodbreakdownGood of the ratings.Good gynaecology gynaecimprologovementy improvement worried about your condition or treatment after you left InspectionDetalk totaailed docton 3rd-6thor, did the findingsNovembery have enough 2015.opport Overallunity theto do An action plan is in place to address the areas that Services for children Services for children the A&E Department? Trustso? wasGood judged as “Good”,GoodGood with “Outstanding”GoodGood GoodGoodrequireGood improvement,Good withGoodGood many of the actionsGood and young people beingand young awardedpeople for the Caring domain and for Urgent already completed. anddep Emergencyartment. This Servicesis slightly andbe Criticaltter than Care.other hospitals in • Did a member of staff tell you about medication side End of life care EndOurEngland.of lifGoodreatingscTheare depforartmentthisGoodGoodperfhospitormedalGoodbetterGoodthan manyGoodGood effectsGoodto Goodwatch for? GoodGood Good others in the national CQC A&E survey. Answers were • Did hospital staff take your family or home situation into Outpatients and OutpatientsRequiresand Requires Requires Requires Requires Requires Ourparticularly ratingspositive forfor N/RoyaltheA following Devonquestions.Good andN/A Exeter GoodNHSac FoundationcountGoodwhen you Trustwere leGoodaving the A&E Department? diagnostic imaging diagnosticOurimprratingsovementimagingfor this hospitimpralovementare: improvement improvement improvement improvement • Did hospital staff tell you who to contact if you were • If your family or someone else close to you wanted to Safe Effective Caring worriedResponsiveabout your conditionWell-ledor treatment aftOverer youall left Detalk totaaileddoctor, did thefindingsy have enough opportunity to do Requires the A&E Department? Urgso?entRequirandtrustemeres gency Overall Overall GoodGood Good Good Good Good Good servicimpresovement improvement How we carried out this inspection Requires MedicOuralrcatingsare for this hospital Good Good Good Good Good Notes Notes improvement To fully understand the experience of people who use Prior to the inspection we obtained feedback and Ourratings ratingsfor this forhospit WonfordRalequirare:es Hospital Sursergervicyes, we always ask the following five questionsGood of Goodoverviews ofGoodthe trust performancGood e from the NewGoodDevon every service and provider:improvement Clinical Commissioning Group and Monitor (the Safe Effective Caring Responsive Well-led Overall Foundation trust regulator). Critic• Is italsafcare?e Good Good Good Urgent and emergency • Is it effective? Good We spoke withGoodHealthWatch Devon who shared with us Matservicernityes and Requires • Is it caring? Good Goodviews they hadGoodgathered fromGoodthe public in the yeGoodar prior g•ynaecIs it rologesponsivey to peopleimprRequir’ovements needs?es to the inspection. In order to gain feedback from people Medical care Good Good Good Good Good Ser• Isviciteswell-led?for children improvement and patients we held some listening events. One of these Good Good Good Good Good Good and young people events was held at a venue in Exeter city centre and two We carried out the announcRequiredespart of our inspection Surgery Good Goodothers wereGoodheld at HonitonGoodand Tiverton Libraries.GoodA total between 3 – 6 Novemberimpr2015.ovementDuring the inspection we 23 Royal Devon & Exe23Endter HospitRofoylifale Dealcar (Wonfvone & orExd)et Qualityer HospitGood Reportal (Wonf 09/02/2016ord) QualityGood Report 09/02/2016Goodof 50 peopleGoodcame to shareGoodtheir experience withGoodus and visited a range of wards and departments across the Critical care Good Good we used whatGoodthey told us to help inform the inspection. Outptrustatientsand spokande with overRequir300 clinices al and non clinical Requires Requires N/A GoodWe also received feedback Goodthat people provided via the staff and held focus groupsimprovementto meet with groups of staff improvement improvement diagnosticMaternity andimaging Requires Good GoodCQC websitGoode. Good Good gynaecand managology ers. We obserimprvedovementhow people were being cared for, talked with carers and family members and Services for children reviewed patients’ recordsRequirGoodof theires care andGoodtreatment. Good Good Good Good Overall Good Good Good and young people improvement

End of life care Good Good Good Good Good Good FNotactses and dataabout Mardon Neuro-rehabilitation Centre Outpatients and Requires Requires Requires N/A Good Good diagnosticThe MardonimagingNeuro centrimpre wovementas last inspected in August improvement improvement 2012. We reviewed five essential standards during the inspection and Mardon unit was compliant with the standards we inspected.Requires Overall Good Good Good improvement Our ratings for this hospital Notes Our ratings ratingsfor this forhospit Mardonal are: Neurological Rehabilitation Unit

23 Royal Devon & Exeter HospitSafale (Wonford)Eff Qualityective Report 09/02/2016Caring Responsive Well-led Overall

Requires Requires Requires Medical care Good Good Good improvement improvement improvement

Requires Requires Requires Overall Good Good Good improvement improvement improvement

23 Royal Devon & Exeter Hospital (Wonford) Quality Report 09/02/2016 Notes

Page 79

8 Mardon Neuro-rehabilitation Centre Quality Report 09/02/2016 Annual Report 2016/17 Statement of Accounting Officer’s Responsibilities

Statement of the Chief Executive’s ● Make judgements and estimates on a reasonable responsibilities as the accounting officer of basis the Royal Devon & Exeter NHS Foundation ● State whether applicable accounting standards Trust as set out in the NHS Foundation Trust Annual The NHS Act 2006 states that the Chief Executive Reporting Manual have been followed, and is the accounting officer of the NHS Foundation disclose and explain any material departures in the Trust. The relevant responsibilities of the accounting financial statements officer, including their responsibility for the propriety ● Ensure that the use of public funds complies with and regularity of public finances for which they are the relevant legislation, delegated authorities and answerable and for the keeping of proper accounts, guidance and are set out in the NHS Foundation Trust Accounting Officers Memorandum issued by Monitor. ● Prepare the financial statements on a going concern basis Under the NHS Act 2006, Monitor has directed the Royal Devon & Exeter NHS Foundation Trust The accounting officer is responsible for keeping to prepare for each financial year a statement of proper accounting records which disclose with accounts in the form and on the basis set out in the reasonable accuracy at any time the financial position Accounts Direction. The accounts are prepared on an of the NHS Foundation Trust and to enable him/her to accruals basis and must give a true and fair view of ensure that the accounts comply with requirements the state of affairs of the Royal Devon & Exeter NHS outlined in the above mentioned Act. The Accounting Foundation Trust and of its income and expenditure, Officer is also responsible for safeguarding the assets total recognised gains and losses and cash flows for of the NHS Foundation Trust and hence for taking the financial year. reasonable steps for the prevention and detection of fraud and other irregularities. In preparing the accounts, the Accounting Officer is required to comply with the requirements of the NHS To the best of my knowledge and belief, I have Foundation Trust Annual Reporting Manual and in properly discharged the responsibilities set out in particular to: Monitor’s NHS Foundation Trust Accounting Officer Memorandum. ● Observe the Accounts Direction issued by Monitor, including the relevant accounting and disclosure requirements, and apply suitable accounting Suzanne Tracey policies on a consistent basis Chief Executive Date: 24 May 2017

Page 80 Annual Report 2016/17 Annual Governance Statement Scope of Responsibility of the Internal and External Auditors and reports regularly to the Board. As Accounting Officer, I have responsibility for maintaining a sound system of internal control that Risk issues are reported through the Governance supports the achievement of the NHS foundation Committee via the Safety and Risk Committee and trust’s policies, aims and objectives, whilst the Trust’s management structure. Management and safeguarding the public funds and departmental ownership of risk is delegated to the appropriate assets for which I am personally responsible, in level from director through to local management accordance with the responsibilities assigned to through the Divisional management teams. There me. I am also responsible for ensuring that the are established Governance Managers in post to NHS foundation trust is administered prudently support the Divisions in implementing robust risk and and economically and that resources are applied governance processes. Each Division has a Divisional efficiently and effectively. I also acknowledge my Governance Group which meets regularly to manage responsibilities as set out in the NHS Foundation Trust risk and report and escalate concerns via the five Accounting Officer Memorandum. sub committees of the Governance Committee. Performance management of any governance/risk The Purpose of the System of action plan is managed via the Trust’s Performance Assessment Framework (PAF) led by the Operations Internal Control Director. Strategic risks are managed via the Board- The system of internal control is designed to manage owned Board Assurance Framework. This document risk to a reasonable level rather than to eliminate all focuses on risks that could prevent the Trust from risk of failure to achieve policies, aims and objectives; achieving its strategic objectives. it can therefore only provide reasonable and not The Board has appointed a Senior Independent absolute assurance of effectiveness. The system of Director to be available to Governors and Members internal control is based on an on-going process if they have concerns where contact through the designed to identify and prioritise the risks to the normal channels of Chairman, Chief Executive achievement of the policies, aims and objectives of or Deputy Chief Executive/Chief Nurse, have the Royal Devon & Exeter NHS Foundation Trust, to failed to resolve them or for which such contact evaluate the likelihood of those risks being realised is inappropriate. In addition, the Trust has a and the impact should they be realised, and to Whistleblowing Policy to guide and protect staff manage them efficiently, effectively and economically. who raise issues of concern. The Trust also has three The system of internal control has been in place in Freedom to Speak Up Guardians. the Royal Devon & Exeter NHS Foundation Trust for the year ended 31 March 2017 and up to the date of All staff joining the Trust are required to attend approval of the annual report and accounts. Corporate Induction which covers key elements of risk management. This is further enhanced at Capacity to Handle Risk departmental induction. Training courses are run on a regular basis and provide staff with the skills The Trust has a comprehensive governance system needed to undertake risk management duties. in place which has been developed and enhanced Staff are trained and equipped to manage risk in a over a number of years and continues to be subject way appropriate to their authority and duties. Risk to regular review to ensure its continued fitness management is included in the Trust’s mandatory for purpose. The current governance architecture training programme and follow-up refresher training; was established in October 2011. An Internal Audit the Trust’s risk management policies and procedures interim and full review was undertaken in July 2012 are available on the Trust’s intranet. and September 2013 and provided assurance that “the governance structure has been strengthened An electronic governance system, which has the greatly.” ability to record and monitor incidents, complaints and risks, has been operational since June The Audit Committee monitors and oversees both 2011. The system facilitates the reporting and internal control issues and the process for risk management of incidents. It has been extended management. Audit Southwest (internal audit) and to include the complaints and risk register module KPMG (external auditors) attend all Audit Committee and most recently the legal claims module to meetings. The Audit Committee receives all reports provide comprehensive reporting to support greater

Page 81 Annual Report 2016/17 triangulation of incidents. During 2014/15 additional Additionally, the Head of Governance attends functionality to identify hotspots, which automatically both the Governance Committee and the Audit pick up new trends in incident data, was established. Committee. This supports continuity and oversight of agenda preparation and completion of actions. An established cohort of senior clinical staff and The Chair of the Governance Committee is also a Governance Managers trained to conduct Serious member of the Audit Committee, ensuring the two Incidents Requiring Investigation (SIRI) is in place committees are aligned and there are no gaps in and additional staff are trained each year to add assurance. to the pool available. The Risk Management Team co-ordinates SIRIs and adverse incidents, which The Governance Committee is chaired by a Non- are reported and managed through the Incident Executive Director and provides oversight of the Review Group (a sub group of the Safety and Risk risk management process. The Committee takes a Committee). In addition to direct feedback to relevant comprehensive oversight of the quality and safety of clinical teams, Lessons Learned briefings, highlighting care provided by the Trust and provides assurance to learning points, are made available to all staff via the the Board of Directors. The work of the Governance local intranet. All SIRI investigation reports and action Committee is supported by five key sub committees: plans are shared with the Trust’s lead commissioner NEW Devon CCG. ●● Clinical Effectiveness Committee ●● Integrated Safeguarding Committee The Risk and Control Framework ●● Patient Experience Committee The Board of Directors is responsible for the strategic direction of the Trust. The Board of Directors ●● Safety and Risk Committee has reviewed and approved a revised Risk Policy ●● Workforce Governance Committee and updated, amended and approved the Board Assurance Framework accordingly. The Board These five committees are responsible for monitoring Assurance Framework identifies the key risks and and managing specific types of risk. mitigations related to the Trust’s strategic objectives and key priorities. The Board Assurance Framework ●● The Safety and Risk Committee chaired by the is reviewed by the Board of Directors on a quarterly Chief Executive has a number of key sub-groups basis. The Corporate Risk Register is reviewed by leading the Trust’s management of safety and risk. the Governance Committee each time it meets. ●● The Patient Safety Group is accountable for The Governance Committee reports to the Board of delivery of the Trust’s patient safety programme, Directors quarterly. The Audit Committee considers review of adverse incidents and Mortality and the Board Assurance Framework and the Corporate Morbidity Reviews Risk Register when setting Internal Audit’s annual work plan. ●● The Incident Review Group is chaired by the Deputy Chief Nurse and reviews all Serious The Board of Directors, as part of the Annual Plan Incidents Requiring Investigation (SIRI) and action reporting cycle, is responsible for the completion of plans the Corporate Governance Statement. The Board has adopted a process by which evidence is identified for ●● Medical Gases Group each element of the statement to provide assurance ●● Radiation Safety Group and support a decision of compliance or gap in compliance (i.e. risk). Where risk is identified this ●● Infection Control and Decontamination Group would be risk assessed, mitigating actions put in place and added to the appropriate risk register. ●● Health and Safety Group chaired by the Executive Director of Transformation and Organisational Any material gaps in controls of assurance are Development highlighted and reported to the Board of Directors. When identified, risks to the Trust’s strategic Other specialist groups whose work relates closely objectives that cannot be immediately eliminated to safety and risk report via the Clinical Effectiveness are placed on the Corporate Risk Register and action Committee. plans put in place to address any gaps. The Board of ●● Clinical Audit and Guidelines Group Directors’ risk and control framework is supported by the Audit Committee and Governance Committee ●● Medicines Management Group which provide assurance to the Board of Directors on risk and control management issues.

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The Trust has a robust, responsive and reflective There are 17 current risks on the Corporate Risk reporting and monitoring framework in place in Register (with scores of 15 and above). 2 relate relation to Mortality and Learning from Deaths. The to mental health pathways (external factors), 1 Summary Hospital Mortality Indicator (SHMI) is the relates to transfusion of blood, 1 relates to capacity main mortality measure used within the organisation management, 1 relates to the Trust’s ability to achieve and detailed Trust and Divisional level mortality cancer waiting times, 1 relates to future capacity dashboards are scrutinised by the Patient Safety, within the Emergency Department, 1 relates to a Mortality and Review Group on a monthly basis. shortage of junior doctors, 1 relates to IT legacy Mortality is reported to the Trust Board of Directors systems and 1 relates to anti-microbial stewardship. through the Governance Committee structure. The Robust actions plans are in place and these risks Trust sets a low threshold in relation to responding are assigned to an appropriate executive lead and to deviations in mortality rates, with deep dive case manager who are responsible for ensuring that the note reviews undertaken to ensure that the causes risk is either eliminated or managed appropriately. of any deviation(s) can be identified and acted upon, A robust system is in place to monitor progress of where required. Additionally, the Trust operates a action plans, which is undertaken by both the Head standardised clinical review process whereby both of Governance and the Divisional Governance Groups expected and unexpected deaths are reviewed by to ensure that risks are proactively managed down to the medical team. This ensures that learning can be their end target score. A detailed report is produced identified and disseminated and actions taken where by the Head of Governance to the Safety and Risk appropriate. The Trust is actively working to ensure and Governance Committees each time they meet. the recommendations made as part of the CQC Learning from Deaths Review are being implemented The Trust has Divisional level risk registers which and embedded in practice. This is overseen by the feed into the Corporate Risk Register. At Divisional Trust’s Governance Committee. level, the risk registers contain lower level localised risks which can be managed by the relevant Division. The Deputy Chief Executive / Chief Nurse and The Corporate Risk Register contains the high level Medical Director have joint director leadership and risks and Trust-wide risks. This ensures that risks are accountability for Clinical Governance. To ensure identified, managed and escalated appropriately Executive Directors are aware of all safety issues at all levels of the organisation. Risk assessments, in a timely manner and to utilise their expertise, including Health and Safety and Infection Control, Safety Huddles were introduced. The Safety Huddle are undertaken throughout the Trust. All areas of comprises the Deputy Chief Executive / Chief the hospital have trained Risk Management Officers Nurse, Medical Director, the Deputy Chief Nurse/ and the Risk Management Department and Head Midwife and the Head of Safety Risk and Patient of Governance facilitate Risk Surgeries to provide Experience. The huddle takes place once a week and support and training and to ensure consistency in complements the formal Governance Performance approach. System by looking at soft intelligence but also provides an opportunity to discuss incidents/concerns The Trust has a robust process for assessing real time at a very high level. risk to cost improvement plans (CIP). A Quality Impact Assessment is undertaken which includes identification of risk, risk score and mitigating actions. Risk Identification and Evaluation The assessment is reviewed and if appropriate The Trust has a Risk Management Policy which has authorised by the Divisional triumvirate (Divisional been approved by the Board of Directors and clearly Director, Associate Medical Director and Assistant sets out the process for identifying and managing Director of Nursing). Quality Impact Assessments with risk and the Trusts’ risk appetite. It incorporates a a risk score of 8 or above are reviewed by the Deputy standard methodology in which risk is evaluated Chief Executive/ Chief Nurse and Medical Director, using a likelihood/consequence matrix. The roles and with the Hospital Operations Board overseeing the responsibilities of staff in managing risk are defined total process. and key posts highlighted. The Policy also includes Other sources used to identify risks include: the governance reporting structure and the terms of reference of the Governance Committee and all the ●● Complaints, Care Quality Commission and committees reporting to the Governance Committee. Health Service Ombudsman reports and recommendations The Trust maintains a comprehensive Corporate Risk Register covering both clinical and organisational risk. ●● Inquest findings and reports from HM Coroner

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●● Health and Safety Executive and regulatory body During 2016/17 the Trust had 2 Level 2 confirmed compliance inspections Information Governance Serious Incidents which were reported to the Information Commissioners ●● Medico-legal claims and litigation reports Office in line with the Department of Health ●● Health Scrutiny Committee reports document “Checklist Guidance for Reporting, Managing and Investigating Information Governance ●● Incident reports and trend analysis (via Datix Serious Incidents Requiring Investigation”. software, identification of hot spots) The incidents were as follows: ●● Internal and external audit reports 1) A letter was incorrectly addressed and sent to the ●● Performance Assurance Framework patient’s neighbour

●● Feedback from Governors and Members 2) A ward handover sheet was found off site by a member of the public (a General Practitioner). ●● Ward to Board Framework, Care Quality Assessment Tool Both of the incidents have been fully investigated by the Trust with mitigating actions put in place. The ●● Safety Thermometer Information Commissioner has responded stating no ●● Safety Huddles further action is required.

Risk to the achievement of the Trust’s corporate NHS England guidance and embedded legislation strategy is considered, assessed and managed via on the recording and monitoring of Elective Waiting the Board Assurance Framework which is discussed Time data is complex and allows for local agreement by the Board on a quarterly basis. The Board has and flexibility in how some rules are interpreted. identified a number of financial risks to achievement To ensure that inherent risks and unintended of the corporate strategy including the Trust’s ability consequences from local interpretation are monitored to deliver the required cost savings, and the impact of the Trust has a robust framework and meeting financial pressure on performance targets. structure that supports and drives the Information Governance agenda. This provides the Trust Board via Information Governance the Safety and Risk Committee with the assurance that effective Information Governance best practice Information governance and data security is managed mechanisms are in place within the organisation. by the Information Governance Steering Group lead by the Medical Director, the Trust’s nominated Senior The Trust actively promotes the importance of good Information Risk Owner and Freedom of Information Data Quality throughout the Trust to ensure accuracy, Lead. Information Asset Owners for critical systems completeness and timeliness and the risks associated have been identified; system risk assessments and with any inaccuracies. Information Risk Management training is undertaken Assessment of Data Quality incorporating Referral annually. To Treatment/Elective Waiting List Management is An Information Security Forum, chaired by the included in the Trust’s annual Internal Audit work Caldicott Guardian (Deputy Medical Director), deals plan. The audit process provides independent with all aspects of information security and data assurance of the design and operation of controls in confidentiality. Risks to information security are place. reported directly to the Information Security Forum The Trust’s Access policy establishes a number (a sub group of the Information Governance Steering of principles and definitions and defines roles Group) and recorded on the Corporate Risk Register. and responsibilities to assist with the effective The Trust has completed the Information Governance management of waiting lists relating to outpatient Toolkit assessment and the Safety and Risk appointments, elective treatment imaging and other Committee and the Board of Directors has received a diagnostic tests. Furthermore standard operating report regarding its system for control of Information procedures are in place to support staff in applying Governance. a consistent and effective approach to Waiting List The Trust is green rated on the Information Management. Governance Toolkit, achieving an overall score of 74%.

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Detailed operational monitoring occurs across all Directors. Performance of individual clinical Divisions specialties and in conjunction with internal metrics is monitored formally on a monthly basis through against data quality. These are applied to identify the newly implemented Performance Assurance areas for improvement and are monitored on a Framework which is led by the Operations Director. regular basis. The Trust’s External Audit Management Letter The foundation trust is fully compliant with the includes commentary on the economical, effective registration requirements of the Care Quality and efficient use of resources. The Internal Audit Commission. Plan includes reviews which consider the economy, efficiency and effectiveness of the use of resources. As an employer with staff entitled to membership The findings of internal and external audit are of the NHS Pension Scheme, control measures are in reported to the Board via the Audit Committee. place to ensure all employer obligations contained within the Scheme regulations are complied with. I can confirm that the Trust complies with the cost This includes ensuring that deductions from salary, allocation of and charging requirements set out in employer’s contributions and payments into the HM Treasury and Office of Public Sector Information Scheme are in accordance with the Scheme rules, and guidance. that member Pension Scheme records are accurately updated in accordance with the timescales detailed in Internal Audit has conducted reviews against the the Regulations. Care Quality Commission regulations, records management, data quality and information Control measures are in place to ensure that all the governance. Reviews are conducted using a risk- organisation’s obligations under equality, diversity based approach. In addition they have annual reviews and human rights legislation are complied with. The of the Trust’s risk management and governance Board of Directors receive assurance that we are arrangements. meeting our legal obligations through an annual report received, on behalf of the Board of Directors, Annual Quality Report by the Governance Committee. Full evidence of legal compliance is also published on the Trust’s external The directors are required under the Health Act 2009 website. The Trust uses an NHS-designed tool, the and the National Health Service (Quality Accounts) Equality Delivery System (EDS), to ensure compliance Regulations 2010 (as amended) to prepare Quality with legal obligations and enable continuous Accounts for each financial year. NHS Improvement improvement. (an exercise of the powers conferred on Monitor) has issued guidance to NHS foundation trust boards The foundation trust has undertaken risk assessments on the form and content of annual Quality Reports and Carbon Reduction Delivery Plans are in place in which incorporate the above legal requirements in accordance with emergency preparedness and civil the NHS Foundation Trust Annual Reporting Manual. contingency requirements, as based on UKCIP 2009 weather projects, to ensure that this organisation’s The content of the Trust’s Quality Report for 2016/17 obligations under the Climate Change Act and the builds on the 2015/16 report. It has been agreed by Adaptation Reporting requirements are complied the Board of Directors and incorporates the views with. and priorities of Governors and the views of Trust members in setting priorities for improvement in Review of Economy, Efficiency 2017/18. The development of the report is led by the Deputy Chief Executive/ Chief Nurse. The views of and Effectiveness of the Use of NEW Devon CCG, as lead commissioner, Healthwatch Resources Devon and Devon County Council Health Scrutiny committee have been sought. The Trust’s Operational Plan, including financial, performance, quality and governance targets, was The Trust uses the same systems and processes to approved by the Board of Directors in December collate, validate, analyse and report on data for the 2016 with the financial and performance information annual Quality Report as it does for other clinical being revised in March 2017. Overall performance quality and performance information. The data is is monitored via an integrated performance report subject to regular review and challenge at speciality, at the monthly meetings of the Board of Directors. Divisional and Trust levels. In line with the Trust’s Operational management and the coordination commitment to openness and transparency, the data of Trust services are delivered by the Executive included is not just limited to good performance

Page 85 Annual Report 2016/17 and is publicly reported at least on a quarterly basis. Review of Effectiveness The Audit Committee undertake a review of the data assurance underpinning the Quality Report and As Accounting Officer, I have responsibility for through this process and other review of data, the reviewing the effectiveness of the system of Board of Directors are assured that the Quality Report internal control. My review of the effectiveness of represents a balanced view. the system of internal control is informed by the work of the internal auditors, clinical audit and the During 2011/12, as part of the three year audit cycle, executive managers and clinical leads within the a programme to assess quality systems and data NHS foundation trust who have responsibility for (similar to that in place for our financial systems), the development and maintenance of the internal was agreed with our internal auditors and built into control framework. I have drawn on the content of the Internal Audit plans for future years. This will be the Quality Report attached to this Annual Report an on-going process and the Board of Directors will and other performance information available to me. use the recommendations from this work to further My review is also informed by comments made by improve the robustness of the process underpinning the external auditors in their management letter and the Quality Report. A review was undertaken during other reports. I have been advised on the implications 2016/17 which gave a significant assurance level. of the result of my review of the effectiveness of the The next review is planned during quarter four of system of internal control by the Board, the Audit 2017/18. Committee, Internal audit, External audit and the Head of Governance. The system of internal control is Audit of Mandated Indicators regularly reviewed and plans to address any identified weaknesses and ensure continuous improvement of The indicators audited were: the system are in place. ●● Percentage of incomplete pathways within 18 The processes applied in maintaining and reviewing weeks for patients on incomplete pathways at the the effectiveness of the system of controls includes: end of the reporting period ●● The maintenance of a view of the overall position ●● Percentage of patients with a total time in A&E with regard to internal control by the Board of of four hours or less from arrival to admission, Directors through its routine reporting processes transfer or discharge and its work on corporate risk KPMG has provided assurance on the process for the ●● Review of the Board Assurance Framework and recording the percentage of patients with a total time receipt of Internal and External Audit reports to in A&E of four hours or less from arrival to admission, the Audit Committee transfer or discharge. ●● Personal input into the controls and risk KPMG were unable to provide assurance on the management processes from all Executive Percentage of incomplete pathways within 18 weeks Directors, Senior Managers and clinicians for patients on incomplete pathways at the end of their reporting period. The Trust has two routes ●● The review of the Trust’s risk and internal control for receiving referral letters. Eighty-five percent framework is supported by the Annual Head of referrals are received by the Trust through an of Internal Audit opinion which states that electronic referral system, Choose and Book. This significant assurance can be given, that there is a system automatically records the date the referrals sound system of internal control and that controls letter is received by the Trust. The remaining Fifteen are generally being applied percent of referrals are received in traditional paper form. Part of the Trust’s data recording process for ●● Evidence gathering for core Care Quality paper communications is that they are date stamped Commission regulations and registration. to indicate the date received. In the sample of 20 ●● Self-assessment against the Care Quality patient records checked by KPMG, three letters had Commission’s Essential Standards for Quality and not been date stamped confirming date of receipt. Safety (reviewed by internal audit) The requirement to date stamp referral letters will be reinforced to all staff and will be monitored to ●● Self-assessment against NHSI’s Code of ensure on-going compliance. Furthermore the Trust Compliance and NHSI’s Governance Framework is currently working towards one hundred percent ●● Performance monitoring by the Board of Directors electronic referrals via the E-referral service to meet of the Trust’s strategy and operational milestones the CQUIN for October 2018. to achieve internal and external targets

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● Results of the national patient and staff survey results and development of targeted action plans

● Delivery of the health and safety action plan

● The Trust’s compliance with the Hygiene code

● The Trust’s unconditional registration with the CQC, rated overall as ‘Good’ February 2016

● Safe Staffing reviews

● Safety thermometer

● Safety Huddles My review of the effectiveness of the system of internal control has been presented to and approved by the Board of Directors. The Board of Directors and the Audit and Governance Committees have been kept informed of progress against action plans throughout the year.

Conclusion There are no significant internal control issues I wish to report in respect of 2016/17.

Suzanne Tracey Chief Executive Date: 24 May 2017

Page 87 Annual Report 2016/17 Our Governors and Members Council of Governors ●● proposals to reform Outpatient appointments The Trust’s Council of Governors (CoG) remains an ●● Mental health and Maternity important part of the RD&E’s governance structure ●● Mental health and Children and Young People providing a vital connection between the Trust, its members and the wider community. ●● Holding a hustings for the Deputy Lead Governor (Rachel McInnes was duly elected) During the year, the Council has continued to develop its joint roles of holding the Board of ●● The role of Patient Experience Committee via a Directors accountable and representing the views briefing from the NED Chair of members and the wider public to the Trust. In carrying out these duties, the Trust seeks to support ●● The work of the Nominations Committee and an the Council and individual members to ensure that update and approval of NED and Chair appraisals there is the means and capacity to carry out its ●● Updates on Success Regime and the Devon various duties effectively and with impact. At the Sustainability & Transformation Plan (STP) same time, the Trust is mindful that the Council is an elected representative voluntary body that ●● Promoting informal discussions on developing has a distinct role separate to that of the Board of relationships Directors. ●● A briefing from Chair of Audit Committee on the The Council met four times during the year. During performance of the External Auditors these meetings, the CoG collectively considers ●● Re-appointing two NEDs, Janice Kay and Janice the performance of the Trust over a quarter Ashman (though new terms begin in the FY highlighting any issues or concerns it may have in 2017/18) relation to the way in which the Board of Directors is managing performance. The performance report ●● A briefing from the Chair of Governance contains information about the Trust’s operational Committee performance and its adherence to various national targets, its financial performance and how it is ●● Recommendations on equality and diversity performing in relation to the quality priorities set developed from a task and finish group by the Governors themselves in the annual Quality ●● Reviewing a new process for the alleged breach of Report. The report also provides details of what the Governors Code of Conduct the Board has considered during the quarter in question and the response from Monitor on its own ●● Taking forward the outcomes from the joint assessment of the Trust’s performance during the development session with the Board same quarter in order to provide assurance to the Council. The quarterly CoG meetings also focus on In addition to these meetings, two extraordinary updating the Governors themselves on a number of CoG meetings took place in June and November regular topics including updates from the three key 2016 to approve the appointment of the CEO. It working groups (see below), the Patient Experience is also noteworthy that the CoG took part in the Committee, and on elections. As well as transacting recruitment process for a new CEO for the Trust its core business of holding the Board accountable, including participating in a stakeholder workshop the meetings focused on: that was conceived as part of the process. In addition, the Deputy Lead Governor was on the ●● Updating the Council on the approach taken to interview panel for the CEO position. the community services transaction During the year the Governors held development ●● Reviewing the performance report and the sessions on: rescheduling CoG meetings to ensure that the Council has access to the latest performance ●● The CoG’s statutory functions in a joint session information available with the Board of Directors. This was followed later in the year by a further joint session on ●● Selecting quality priorities for the year (as set out strengthening the relationship between the two in the Annual Quality Report) including: bodies and a further discussion on the Trust’s Corporate Strategy refresh and Operational Plan 2017/18 and 2018/19.

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●● NED and Chair appraisals The CoG has continued to organise itself through three key working groups: ●● A Healthwatch Devon presentation on engagement ●● CoG effectiveness

●● the Trust’s Operational and Capacity Plan 2016/17 ●● Member and public engagement

●● understanding performance metrics ●● Patient safety and quality

●● Values and Behaviours These groups are responsible for identified elements of the agreed consolidated CoG business plan and ●● An update from the Chairman on the Devon to provide a Governor perspective on key issues healthcare system and the STP within the groups’ remit (i.e. they do not undertake ●● The CoG effectiveness review executive functions that are the remit of the Trust).

●● The selection of quality priorities for 2017/18 The groups have a Chair and a Committee membership but are open to any member of ●● Community Connect and out of hospital care CoG that wishes to participate. The groups are accountable directly to the CoG and the Chairs report ●● The Acute Services Review on progress and outcomes to every CoG meeting. The Council has continued to establish a positive The CoG Coordinating Committee, which is relationship with the Board as befits its role. The comprised of the Trust Chairman, the Lead Governor relationship is one in which both the Board and (and Deputy), the Chairs of the three working groups, Council share the same broad objectives of acting a staff Governor representative and secretariat staff, in the interests of the organisation whilst retaining meets every quarter and focuses on coordinating the sufficient distance to enable the Council to act as work of the CoG and ensuring that progress is being a critical friend and ensure that the Board is acting made against the business plan as well as facilitating in the best interests of members and the public, cooperation between the CoG and the Board of is operating effectively and has the right mix of Directors. experience and skills within the Non-Executive Directors to manage the key challenges facing the The work programme of each of the working groups Trust. Non-Executive Directors regularly attend CoG is amalgamated into a single CoG business plan meetings for informal face-to- face meetings as well which is overseen by the Coordinating Committee to as more formally representing some of the work they ensure that Governor priorities and plans are kept on are responsible for at CoG meetings. A regular rota track. of Governors attending the public Board meetings has also helped to enable the Governors to see the In addition, three Governors sit on the Trust’s Patient Board ‘in practice’ as well as help provide intelligence Experience Committee representing the views of that individual Governors have used in contributing Governors, members and the wider public. to the performance assessment of individual Non- During the last year, these groups have been busy Executive Directors. During the year, the Governors implementing programmes of work linked to have developed a “score-card” to enable them to Governor’s key roles and stated priorities and the assess the contributions of individual NEDs at a details of the work of these Groups can be found number of meetings where their paths cross including in the Council’s papers and minutes on the Trust Board of Director meetings. website and the new members’ website.

The Trust has an “Engagement Policy” agreed The following sets out some of the key highlights for between the CoG and the Board of Directors to help each of these groups over the year: manage situations in which the Council’s concerns about the performance of the Board of Directors or Nominations Committee the welfare of the NHS Foundation Trust, have not been resolved through the normal channels. This ●● Annual Chair and NED appraisals – approved at policy was not required at any time during the year. October 2016 CoG In addition, the Senior Independent Director acts as ●● Re-appointment of Janice Kay and Jane Ashman an independent facilitator through which concerns (take effect in 2017/18) about the Board or the Chairman can be managed if appropriate. This facility was not required during the ●● Sub-group development of a process for the year. removal of a Chairman or a NED

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CoG Effectiveness Working Group ●● Continued to develop and implement the membership strategy and take stock in relation to ●● Review of prospective governor meetings and the new models / place based care Annual Members Meeting ●● Continued to the launch and on-going ●● Working Group Terms of Reference development of the members website

●● Code of Conduct – review and procedure for ●● Contributed to the success of the members’ Say breach event

●● Review of CoG meeting timings and the In addition to this work it is also worth noting that Performance Report Governors have been involved during the year in:

●● Annual effectiveness review – outcomes from ●● Prospective governors meetings 2016 and planning for 2017 ●● New governor induction ●● Review of the schedule of document reviews ●● Patient-led Assessments of the Care Environment ●● Review of website information (PLACE)

●● Review of method of election to CoG committees ●● CoG representation by three governors on the and working groups Patient Experience Committee

●● Review of allocation of places to Governor at ●● Peta Foxall being a member of the NHS Providers external events Governor Policy Board

Patient Safety & Quality Working Group ●● Governor attendance at regional and national Governor conferences ●● The Group’s then Lead drafted the Governor comment on the Quality Report 2015/16 Governor Expenses ●● Agreed stronger ties between the group and the Seven Governors claimed expenses during the year. Patient Experience Committee The aggregate sum of expenses paid to Governors

●● Focused on the 2016/17 Quality Priorities – during this period was £1,677.55. In 2015/16 the Mental Health (for Maternity and children and figure was £2,193. young people; the outpatient appointments system) Our Members

●● Chose the priorities for 2017/18 - TBC The Trust is a public benefit corporation that exists for the sole purpose of providing healthcare services ●● Received an update on the Trust’s Patient Safety to the population it serves. All Foundation Trusts are Programme from the Lead Nurse for Patient obliged, under statute, to have members. The Board Safety, Risk and Patient Engagement of Directors are obliged to keep in touch with the opinions of members and the wider public as key Membership & Public Engagement stakeholders. Membership is a distinguishing feature ●● Continued to monitor membership volume and of FTs which brings with it substantial benefits. As membership profiles through the “Member a membership organisation, the RD&E endeavours Communication Response Report” to reach out to inform members about what is happening at the Trust as well as listening to their ●● Shared a stand at the Exmouth Careers Fair event concerns and opinions on service delivery, on how held at the Community College, to encourage to improve patient experience and on influencing its new members longer term strategy. ●● Held meetings with St James’s School, Exeter to About our members discuss setting up a medical or health society group On the whole, the Trust’s membership broadly reflects the average profile for the wider community ●● Helped to run Medicine for Members events served by the Trust. Key findings from an analysis through the year undertaken of our members in comparison to the wider community showed that members are:

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●● Similar to the social-demographic groups found in the year, a number of initiatives were undertaken to our constituencies. The majority of members are, increase membership. However, over the last year, we on the whole, comfortably well off have not made sufficient progress in encouraging a more diverse membership. ●● Representative of the ethnic diversity within the wider public Membership Analysis ●● Are older than the general public served by the At the end of the financial year 2016/17, the Trust Trust had 10,787 public members and just over 8,000 staff ●● Marginally more likely to be female than males members. For research purposes, engaging with members Members’ Say about their priorities, concerns and ideas for healthcare provides a “good enough” correlation The Members Say event - in which Trust members are with the broader community. This means that in our invited into the Trust for a day to hear from clinicians engagement with members, we can be confident about key health-related topics as well as take part that the views we hear can be said to be sufficiently in interactive dialogue – remains the most significant overlapping to what members of the public generally way in which the Trust engages with its membership would say. This provides a useful rationale for base. Members’ Say events provide members with membership for Foundation Trusts. However, it is the opportunity to give voice to their views and becoming increasingly apparent that there is a need influence the Trust in a number of different ways in for the Trust to extend its conversations with a wider line with the ethos of a public benefit corporation. group of the public in the future. The model works well as a way of engaging a Having a membership base allows a meaningful particular group of members and the outcomes relationship to be developed between members of the activities and focus groups provides useful and the Trust. Developing this engagement helps research data on the perceptions and views of us to deepen our understanding of their views and members (and thus the public) on specific topics opinions which we can correlate to the views of the which can help inform and influence: wider community. Developing an on-going dialogue with members provides an opportunity for the Trust ●● Overall strategic direction of the Trust to develop its thinking, test ideas, and give members ●● Strategic issues or “wicked” problems an overview of potential future strategic options which it can then engage with members on in a way ●● Service changes or improvements that genuinely allows for influence and boundary setting (i.e. options which members would find ●● Experiential feedback and customer insight unpalatable for example). ●● Lower level service changes or improvements

The on-going conversation with our members – In considering the outcomes of the Members’ Say expressed primarily through our Members’ Say events, it can be assumed that they represent the events, through surveys of members and in the best possible interpretation of the broader views feedback from Governors – is a very important aspect of the membership and thus the wider public and of the Trust’s work that provides genuine added therefore provide a “good enough” basis for analysis. value in informing its work, whether that is in a relatively minor operational detail, potential service The Members Say approach enables the Trust to change, ways to improve services in the best interests identify, explore and understand the views, opinions, of patients/public or on bigger and more strategic preconceptions and concerns of members on aspects issues. The feedback from the interactive activities of healthcare. As the profiling of our members and focus groups at Members Say helps provide an on a range of indicators mirrors that of the wider agenda for the Governors as well as providing insight population (being somewhat older and somewhat into the views of members – and thus the public – for wealthier than the broader population), the views the Board of Directors. of members can be, with sufficient caveats, be seen as representing the broader views of the population This makes it even more important, therefore, that served by the Trust. we have a membership base that corresponds ever more closely with the demographics of the broader In addition, Members’ Say events provide part of the population served by the Trust. Over the course of rationale for membership of the Trust: having the

Page 91 Annual Report 2016/17 opportunity to attend an event is part of the benefits Key Issues: that being a member entails and holding such Funding events demonstrates to existing and potential future members that membership means something and ●● “Social care budget is being squeezed and the offers those that want it a way of becoming more NHS is being asked to step in and pick up the actively engaged. pieces.” Members’ Say September 2016 ●● Opportunities to reduce costs – rolling prescriptions for example and people who were During the Members’ Say event last September, given prescriptions but then don’t use what they we held five focus groups for groups of between have. Also, the waste that occurs from having 8-15 Trust members. The focus group conversations consultant letters to GPs etc. – “must be a better examined a broad range of issues in relation to way of doing things.” “new models of care” using the Futurecare film as a ●● Many supported the idea that the fundamental provocation. Each focus group held a conversation on problem is a lack of money being given to the the same topic. NHS. “A lot of what is being done is cuts dressed At the beginning of each group session there was a up as reform.” Also, needed more transparency brief introduction and ground rules and then the film on how funds were being used. was played. Following the film, the facilitators used a New models of care number of prompts to aid and promote the ensuing dialogue. The event sought to capture the views of ●● Hospital at home is a “good idea because the attendees (which were all recorded) and were you make a faster recovery and you are more genuine “listening” events; thus, questions about the comfortable” but there is a lack of evidence to Trust or NHS policy were not answered. say that it works – where is the evidence? Also, concerns that whatever the promise, the reality The following analysis is based on an analysis of will be different in practice with too little help around 4 hours of transcript from these meetings. given by unqualified people with carers changing They highlight a range of issues and concerns that too often meaning little continuity. Concerns were aired by those present in the groups. During too about “taking too much out first – needs a the facilitation process, a technique was used to more gradual approach.” “Closing community gauge the amount of support for particular views beds will mean that people have to travel longer being expressed. On many occasions, there was a into Exeter” – very stressful. Continuity of carers convergence of ideas and views and elsewhere there at home is vital – “otherwise this causes untold was either not a clear view expressed or there were stress and anxiety.” “Need the new way of differing views and even, in one case, profound working in place before shutting down the beds” disagreement. The analysis picks out a range of statements made verbatim (or in summarised form) ●● “Going back to the ways things used to be used by group members through the process on organised” but concern that “what seems like as which there was some unanimity of view. Where good idea on paper won’t materialise in practice.” there were differences this has been highlighted. In ●● “Should be a properly joined up service addition, the comments are grouped together under between health and social care.” certain themes. ●● Concerns that the workloads of the coordinator It is worth noting that this is a qualitative analysis role may be too big and that there may not be of textual data and represents a “good enough” the right workforce: “Are there the people with overview of the views expressed. The findings provide the right skills in the system to implement this some degree of insight into member sentiment and new way of working?” some of the issues that drive some of the views that are being expressed. Clearly, even in areas where ●● “Getting people out of hospital quick is fine there is a good deal of consensus, this should not but in practice people are leaving too early when lead to the conclusion that this is necessarily the they are still ill and the support is not there when majority view of our membership base. Nevertheless, they need it.” the findings present a useful insight into the views ●● “We need people who can help people at of the members that choose to take part in these home and organise things like walking clubs etc.” events. ●● “Care needs to be more individualised and personalised to the patients and carers.”

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●● “Patients should set their own goals rather ●● Need to utilise new technologies but without than have them set for them by someone else.” alienating older people who are the biggest users “Too many people go through the system doing of the NHS. IT not the answer because of slow what the doctors want not what people want. broadband and insufficient use by elderly people. Physios much better at setting patient goals.” ●● Strong support for a more honest debate – ●● Voluntary sector can be useful but concerns people’s expectations have exceeded what is about whether this will lead to a “patchwork quilt possible. However, there was an acknowledgment approach.” that people who often most need help or who live unhealthy lives are precisely those that are ●● Questions raised by many attendees about the more resistant to change and taking on personal role of GPs in a new reconfigured system. responsibility. ●● “Wellness is about more than medication.” ●● Some support for rationing for people who Need to focus on keeping people well and not need surgery but are too obese or smoke. just on ill health. Many had examples of self-help Knowledge that this was tried but the outcry and community group activities such as walking meant it didn’t happen but “this doesn’t mean football etc. Although it was acknowledged that it wasn’t a good thing to do.” Real worry about knowledge of these services and communicating “going back to the days of long delays” waiting to the right people was difficult. for an appointment linked to concerns about the ●● Social isolation seen as just as important a need to ration healthcare in the future. Some health determinant as smoking or obesity. felt that we may be moving towards a system where people will need to pay for some forms of Personal/community/social/corporate treatment like dentistry. The majority felt that the responsibility NHS needs to remain free at the point of use but ●● Differing views about the role of neighbours others felt this was a good idea and that those and communities in helping each other – some who can pay should pay. One respondent cited thought this was good and participants pointed her experience of the Italian system where you to the fact that many of them volunteered within must pay a set amount for visiting a hospital/GP their communities but there was some cynicism etc. Others felt that those who abuse the system about the “big society” approach. – missed appointments etc. – should be fined.

●● Widespread concerns that people were “far too ●● Care homes should not be portrayed as the reliant on the NHS always being there” to help worst option for care. Although some felt that them so that they could do what they wanted some people were making big profits at the to do without consequences. Need more robust expense of patients. Real concern about the costs approaches to smoking, obesity, and alcohol of residential homes and confusion about how misuse. “Smoking shows what can be done”. these are paid for. People need to take more responsibility – not ●● Transportation is a problem for people in rural overuse services or regularly go to GPs when they communities. IT is not necessarily the answer. don’t really need to. Other views ●● Support for concept of social prescribing and more community focus on helping each other. ●● “Not enough attention on mental health.”

●● Supermarkets should be doing more to tackle ●● NHS Direct not seen as useful way of managing obesity and diabetes – they have a social demand. responsibility. It was also felt that schools should ●● “Must be better ways of managing the do more to educate the young – too much fast numbers coming in to the A&E department – food, sugary drinks, snacking. many don’t need to be there at all.” ●● Insufficient focus onsports facilities especially ●● Already having to wait too long to see a GP – those at low cost these “waits make the illness and other problems Concerns about the future of care provision worse.”

●● Some expressed trust that the NHS will try to do ●● “People shouldn’t be discharged in the evening what’s best for people especially the RD&E. or at night.”

Page 93 Annual Report 2016/17 Governor Profiles

Mid, North, West Devon and Michael James Cornwall Michael was elected for a term of three years in 2015. James Bradley Michael lives in Copplestone near James was elected in September Crediton. An engineer and scientist 2014 for a term of three by trade Michael has worked in years. James was a Chartered many industries including aviation medicine. Having Environmental Health Officer owned and run his own business with his wife in the and Chartered Safety and Health heart of Devon for over 20 years he is now retired Practitioner who having completed a and is looking forward to offering some of his time to military career has worked in Local Government, the support and represent his local community. National Health Service and finally as an international consultant. He is a member of Mid Devon Patient Cynthia Thornton Forum, a Community Representative for the Mid Devon sub locality and the Public Representative for Cynthia lives in Willand. She has had the Patient and Public Engagement Committee of the wide nursing experience, including Eastern locality of NEW Devon CCG. He is a member ten years as a district nursing sister. of the CoG Effectiveness working group and the She has also held University teaching Chairman for the Member and Public Engagement and research posts in London working group; as that Lead he sits on the CoG Co- and Reading. She has a MSc. in Care, Policy and ordinating committee and also on the NHS England Management. Public and Patient Voice Assurance Group for Cynthia was elected in September 2016 for a term Specialised Services member. James lives with his wife of 3 years, but has previously held a Governor role and cat near Okehampton. being elected in 2008, re-elected in 2011 and was a Anne Stobart member many different committees. Anne was elected as a Governor in East Devon, Dorset, Somerset and September 2012 and re-elected for a term of three years in 2015. She the Rest of England has lived in Mid-Devon since 1990. Kay Foster Anne has taught in adult education, colleges and universities for over thirty years. Kay was elected in September 2014 for a term of three years. Kay lives in Anne has clinical, research and management Exmouth. experience in complementary health sciences, most recently in the School of Health and Social Sciences She is a retired State Registered at Middlesex University and she retired from there in Nurse and Midwife with over thirty August 2010. years of nursing experience. She held Sisters post at the RD&E in ITU and CCU. Kay also served as a Christopher Wilde Nursing Officer for 18 years with Queen Alexandra Christopher was elected in Royal Army Nursing Corps retiring in the rank of September 2014, re-elected in Major. She has a BSc (Hons) in Health Services 2015 for a further one year term Management. and has been re-elected again in Kay is a member of the Patient Experience 2016 for three years. Christopher Committee, and of the Member and Public has been an owner of a general dental practice, as Engagement and Patient Safety and Quality working well as a Managing Director of a limited company groups. She is committed to her role as Governor and specialising in dental material research. Christopher is fiercely proud of working as a volunteer at such an was Chairman of a government-sponsored group excellent Foundation Trust as the RD&E. (SW-Smart) of research companies. Christopher lives in Tiverton.

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Jill Gladstone Peta has over thirty years of professional commitment to the NHS, working as a biomedical scientist, Jill lives in Otterton. Her varied clinical researcher and educator at Great Ormond nursing career included acute and Street Hospital for Children, the SW Thames Renal & emergency medicine, clinical audit Transplantation Unit and the Universities of London and nursing adviser to the Health and Exeter. She became Chair of Devon Wildlife Service Ombudsman. Trust in December 2016 having been a Trustee for six Jill was first elected in 2008 and re-elected for further years. three year terms in 2011 and 2014. Jill is a member Peta sits on the Nominations Committee and the of the Patient Safety and Quality working group as Member and Public Engagement Group. well as the Nominations Committee. Douglas Hull Alan Murdoch Douglas lives in Axminster and was Alan was elected in September 2014 elected in September 2016 for a for a term of three years. term of 3 years. Alan spent 17 years in the RAF followed by employment in the electronics and scientific instruments Trish Llewellyn industries before retiring as a Director with a Multinational company. Alan lives in Exmouth. Trish lives in Exmouth and was elected in September 2016 for a Alan is a member of the Non-Executive Director term of three years. Trish has a Remuneration Committee (NEDRC) and Nominations wide variety of business experience Committee. He is also a member of the CoG in national business, over many Effectiveness Working Group, and the Member and years, achieving accolades such as ‘manager of the Public Engagement Group. year,’ amongst many others. She was appointed as Richard Bowes Travel Lodge Company Trainer for the South West of England, teaching various health and safety courses, Richard was elected for a three year in line with Government guidelines. term in September 2015 . Trish has been a volunteer member of staff at the Richard has lived in West Hill, Ottery RD&E for many years, taking a role within the St Mary since 1988. He served on hospital trolley shop service, of which all profits go to East Devon District Council between the hospital wards for patients. Trish also sits on the 1986 and 1991. From 1980-2014 he worked in the committee and runs the rota for the service and was South West in the Pharmaceutical Industry across 16 recently elected to the Volunteer leads Forum. different therapy areas, including: Cardiovascular, Trish has lived and worked in Singapore and is very Diabetes, Osteoporosis, Dementia, Renal, Infectious sport minded she has played league netball in both Diseases, Parkinson’s and Musculoskeletal the Far East and the UK. She has 2 sons and five (Osteoarthritis and Rheumatoid Arthritis). grandchildren, with one son being the head of an Previously, Richard graduated with a BSc (Hons) International School in Switzerland and another son Environmental Sciences in 1977. having his own business in Exeter for the past 25 years. Peta Foxall Trish is looking forward to her new challenge as a Peta lives in East Budleigh and Governor and will be committing 100%. was elected in September 2016 for a term of three years. She has contributed to the Council of Governors since 2013 through representation of the University of Exeter Medical School as an appointed governor. Peta is also a co- opted member of NHS Providers Governor Advisory Committee.

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Exeter and South Devon Molly Holmes Keith Broderick Molly was elected in September 2014 for a term of three years. Molly Keith is an accountant who took lives in Exeter. Molly is currently early retirement from the public Chief Officer at Age UK Mid Devon. sector in 2005. He lives in Exeter and Molly also works as a freelance was re-elected in 2011 and again in consultant specialising in housing, health and 2014. Keith is Chairman of the CoG supported living. Molly previously held posts at Effectiveness working group and is also a member of Director level with a national Housing Association; the Audit working group and the CoG Coordinating with NHS (E) as Better Care Manager and as a Non- Committee. Executive Director with Devon PCT and Torbay Care Trust. Geoff Barr Molly is a member of the Patient Experience Geoff was elected in 2013. Committee and Vice Chair of the Patient Safety and Geoff taught politics and other social Quality Working Group. studies at Exeter College for many Richard May years; however, he has now moved on to teach at the Open University Richard, who lives in Exeter, is and University of Exeter Medical School. a chartered civil engineer, and latterly ran a waste management Geoff is an active member of the St Leonard’s Practice company providing a range of waste Patient Participation Group and the practice research management services within Exeter team. Alongside this he is an active member of Keep and the surrounding areas. Richard was re-elected Our NHS Public and 38 degrees. Geoff is a member in September 2012 and again in 2015. Richard of The Labour Party and a life member of the Neuro was elected Lead Governor in 2010 and re-elected Foundation. in 2013 and 2016. He is a member of the CoG Tony Ducker Coordinating Committee as well as the Nominations Committee and Non-Executive Director Remuneration Tony was elected in September Committee. 2014 for a term of three years. Tony spent his career in the NHS, Rachel McInnes including five years as a Lecturer in Rachel is a scientist who works in the Department of Child Life and climate research at the Met Office. Health at St George’s Medical School and twenty- Originally from Scotland, she has two years as a Consultant Neonatal Paediatrician lived in Exeter since 2009. Rachel in Kent. He served on various hospital and regional was elected for a term of three years committees including a National Institute for Health in September 2013, and re-elected in September and Care Excellence (NICE) guideline group. Tony 2016. Rachel was elected by the Council as Deputy spent 28 years as a doctor in the Territorial Army Lead Governor in July 2016. Rachel sits on the CoG serving in four medical units including five years as Coordinating Committee as well as the Nominations Commanding Officer in 220 (1st Home Counties) Field Committee. Ambulance. Faye Doris Since retirement Tony has worked with Clinical Commissioning Groups (CCGs) as Lead Clinician for Faye was elected in September the appraisal of neonatal units in East of England and 2016 for a term of three years. Faye South West England. lives in Exeter and is a retired nurse, midwife, Supervisor of Midwives and Tony retired to South Devon 10 years ago. He is Associate Professor of Midwifery Chairman of the CoG Patient Safety & Quality for the University of Plymouth. She was responsible working group and Vice Chairman of the to the university for the education and practice Effectiveness working group. He is a member of of midwives across the southwest peninsula. Faye the Nominations Committee and represents the has been a senior manager at the RD&E for two Governors on the Extraordinary People Awards panel. years and at Plymouth University for over 20 years. She was initially the Head of School for the Health

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Professions which included Dietetics, Midwifery, Catherine Geddes Podiatry, Physiotherapy and Occupational Therapy. She also chaired the Race Equality Committee and Catherine’s career with the Royal was very involved in the promotion of diversity and Devon & Exeter NHS Foundation inclusion. She was a member of the University’s Trust began as a student nurse in Academic Board for three years. Nationally, Faye was 1995. As a staff nurse she worked a member of the Nursing and Midwifery Council’s in both the community and within Lead Midwife for Education Group. Faye’s key skills the acute setting at the RD&E. In 2000 she qualified include; leadership and management, selection and as a midwife and spent the next 11 years working in recruitment, listening, evaluating and responding to both community and hospital settings. After gaining staff and stakeholder feedback. Faye is a member of her PGCE Catherine took a career break in 2009 and the Patient safety and Quality working group. spent a year teaching student nurses and midwives in Western Australia. Catherine successfully completed Staff Governors her PGCert in obstetrics and gynaecology ultrasound in 2011 and has been the Clinical Lead Midwife Paul Bedford Sonographer in the Centre for Womens’ Health since 2014. Paul was elected in September 2014 for a term of three years. Catherine was elected in September 2016 for a term of 2 years. Paul has nearly thirty years NHS experience with fifteen years Michele Baxendale-Nichols in finance and the remainder Michele has been a nurse for 23 in Information Services, with eleven years at the years and over the course of her RD&E. His work involves providing information for career has gained wide-ranging the RD&E’s Safety Thermometer and supporting experience, from frontline nursing in Child and Women’s Health services. Paul’s previous acute settings, including Oncology voluntary experience includes being a Treasurer for and Gastroenterology; as a Clinical Nurse Salisbury League of Friends. Specialist in Sexual Health; and as a Site Practitioner Hazel Hedicker at the RD&E. Michele is currently a Band 7 Hazel commenced employment Community Nurse Team Manager and she feels that with the NHS in 1994 and joined as the RD&E has recently integrated with Community the RD&E in 2000, having previously Services, worked for another large acute Trust it is vital that there is a voice for Community Services in the southwest. on the Council of Governors. Michele was elected for Having worked within NHS facilities management for a one year term in December 2016. 16 years, Hazel joined the Programme Management Loveday Varian and Service Change department in May 2012. She currently provides project management support for Loveday has worked for the NHS as projects that sit within the Trust wide Integration a hospital-based medical secretary Programme including the Transfer of Community for the past thirty years. She has Services (TCS) in 2016 and more recently Trust worked at the RD&E for the last 13 wide Outpatient Services. She also provides project years as a medical secretary within management support and advice to colleagues within the renal team. Loveday was elected for a term of Corporate and Support Services division. Hazel has one year in December 2016, having previously been a Master’s degree in Business Administration and is a member of the Council of Governors as Staff a fully qualified Prince 2 Practitioner. She also has Governor between 2009-2015. a keen interest in Communications & Engagement particularly around the involvement of patients, carers and staff within service redesign and the implementation of change. She was first elected as a staff governor in September 2013 and was re-elected for a further 3-year term in 2016. Hazel is a member of the Nominations Committee.

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Appointed Governors Staff Governors The RD&E has two appointed Governors on its Hazel Hedicker re-elected unopposed for a term Council of Governors. of three years with Catherine Geddes elected unopposed for a term of two years. Cllr Andrew Leadbetter As there were only two candidates for four vacancies, Appointed by Devon County Council. Andrew is an the terms of office were decided by the drawing of elected County Councillor representing Topsham lots. Two vacancies for terms of one year remained and St Loyes and has been a member of the RD&E and a by-election was held in December 2016. Council of Governors since 2012. The following Staff Governors were elected at the December 2016 by-election. Professor Angela Shore Michele Baxendale-Nichols and Loveday Varian Appointed on behalf of the University of Exeter, from elected for terms of one year. The turnout was October 2016 11.1%. Election Results The Board confirmed that all elections to the Council of Governors are held in accordance with the election The following Governors were elected at the annual rules as stated in the Constitution. Governors can be elections 2016. contacted via email at: rde-tr.foundationtrust@nhs. Public Governors net The Governor’s Register of Interests is available for inspection on the Trust website or from the Trust East Devon, Dorset, Somerset and the Rest of Secretary (01392 404551). England (35.8% turnout) Peta Foxall, Trish Llewellyn and Douglas Hull elected terms of three years.

Exeter & South Devon (31.5% turnout) Rachel McInnes and Geoff Barr re-elected for terms of three years. Faye Doris elected for a term of three years.

Mid, North, West Devon and Cornwall Chris Wilde re-elected unopposed for a term of three years and Cynthia Thornton elected unopposed for a term of three years.

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Summary of attendance of Governors at CoG meetings for 2016/17 Attendance at Council of Governor meetings from April 2016 onwards. Governors in post at year end.

Name of Governor Apr-16 Jun-16 Jul-16 Annual Oct-16 Nov-16 Feb-17 Members P C Extra- P C P C Extra- P C Meeting ordinary ordinary P = Private – Sept C C C = Confidential 2016 Barr, Geoff P P P P P A P P P P P Bedford, Paul P P P P P A P P A P P Bowes, Richard P P P P P P P P P P P Bradley, James P P A P P P P P P P P Broderick, Keith P P P P P P P P A P P Doris, Faye P P P P P P Ducker, Tony P P P P P P P P P P P Foster, Kay P P P P P P A A P P P Foxall, Peta A A P P P A P P A P P Geddes, Catherine P P P P A A Gladstone, Jill P P P P P A P P A P P Hedicker, Hazel P P P A A P P P P P P Holmes, Molly A A A A A P P P A P P Hull, Douglas P P P P A A James, Michael P P P P P A P P P P P Leadbetter, Andrew P P A A A A P P P P P Llewellyn, Trish P P P P P P May, Richard P P P P P P P P A P P McInnes, Rachel P P P P P P A A P P P Murdoch, Alan P P P P P A P P P P P Shore, Angela P A A Stobart, Anne P P P P P P P P A P P Thornton, Cynthia P P P P P P Wilde, Christopher P P P P P P P P P P P James Brent (Chairman) P P P P P P P P P P P

Key: P = Present A = Apologies

Other Governors in post during the year

● Kate Caldwell

● Stacey Flay

● Dianah Pritchett-Farrell

● Mervyn Symes

● David Wilkinson

● Lynne Wright

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Voluntary Disclosures ●● Reduce carbon dioxide emissions ●● Make financial savings through energy and water Sustainability Report conservation

As an NHS organisation, the RD&E has an obligation ●● Make procurement processes more sustainable to work in a way that has a positive effect on the ●● Reduce resource intensity communities for which it provides healthcare services. We acknowledge this responsibility to our patients, ●● Adapt buildings and services to a changing local communities and the environment by working climate hard to minimise our footprint. The RD&E takes this obligation seriously and during the last year has Carbon reduction and resource use dedicated resources to deliver several projects that The RD&E has plans to reduce its carbon emissions will demonstrate its commitment and provide lasting overall. The key focus areas are those recommended social, economic and environmental benefits. in the NHS Sustainable Development Unit’s (SDU) In October this year, as part of the Transforming technical guidance note 9. Carbon emissions are Community Services agenda, the RD&E took on reported as tonnes of carbon dioxide equivalent the provision of services from extra sites across (tCO2e), in line with SDU guidance. Devon. Integration is not complete, so the scope of The highlighted blue areas are the emissions which this sustainability report is the RD&E’s performance the RD&E has set specific reduction targets, known as excluding those sites. “output” targets. The RD&E has prepared a Sustainable Development The areas which are not highlighted have “process” Management Plan (SDMP). The plan details how the targets assigned to them. These are targets which are RD&E will: not currently quantifiable, but would realise a benefit were they applied.

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The RD&E does not have any financial obligations Scope 3: waste carbon emissions under the Carbon Reduction Commitment. Waste 2013/14 2014/15 2015/16 2016/17 As a part of the NHS, public health and social care (tonnes) 296.00 492.00 462.00 449.22 Recycling system, it is our duty to contribute towards the tCO2e 6.22 10.33 9.24 9.43 National target of reducing the carbon footprint of Other (tonnes) 27.00 27.00 32.00 331.80 recovery the NHS, public health and social care system. It is tCO2e 0.57 0.57 0.64 6.97 High Temp (tonnes) 792.00 831.00 816.00 840.00 our aim to contribute to this by reducing our carbon disposal tCO2e 263.74 253.46 241.54 248.64 emissions by 28% by 2021 using 2013/14 as the (tonnes) 791.00 824.00 882.00 420.00 Landfill baseline year. This year carbon emissions increased tCO2e 193.33 201.40 215.58 130.20 due to an increase in gas and electricity consumption. Total Waste (tonnes) 1906.00 2174.00 2192.00 2041.02 This was due to overall site activity increasing and % Recycled or Re-used 16% 23% 21% 22% there was a cooler winter than last year. Further Total Waste tCO2e 464 466 467 395 investigations are underway to identify how to Waste emissions have fallen due to domestic waste mitigate against this in future. The graphs below no longer being sent to landfill. This waste stream show the RD&E’s emissions over the last four years: now goes to energy from waste. Scope 1 and 2 carbon emissions Water consumption and emissions

Water 2013/14 2014/15 2015/16 2016/17 3 m 245,412 242,643 225,480 215,577 Mains tCO2e 231 228 212 203 Water & Sewage Spend £ 1,019,565 £ 1,010,662 £ 901,172 £ 892,489

Water consumption has been declining; this is for a number of reasons including: better leak detection and utilisation of more efficient equipment. Modelled carbon footprint The majority of the environmental and social impacts Resource 2013/14 2014/15 2015/16 2016/17 Use (kWh) 46,173,133 52,980,456 52,984,297 56,724,151 arise from the goods and services that the RDE Gas tCO2e 9,795 11,115 11,089 11,855 commissions. Therefore, the following information Use (kWh) 2,195,477 495,645 494,308 453,814 Oil uses a scaled model based on work performed by tCO2e 701 159 158 144 the Sustainable Development Unit (SDU). More Use (kWh) 264 17 0 13,400,371 Non-green information available here: http://www.sduhealth. tariff Electricity org.uk/policy-strategy/reporting/nhs-carbon- tCO2e 0 0 0 6,925 footprint.aspx Green Use (kWh) 19,554,600 14,224,744 13,916,659 895,915 Electricity* tCO2e 10,949 8,789 7,967 435 This is generated using actual data where it is On site Use (kWh) 0 7,113,000 7,856,817 7,571,765 generated available (which includes energy, waste, water, electricity tCO2e 0 0 0 0 business travel mileage and anaesthetic gas usage). Total Use (kWh) 19,554,864 21,337,761 21,773,476 21,868,051 If data is not available, the SDU model generates Electricity tCO2e 10,949 8,789 7,967 7,360

Total Energy CO2e 21,445 20,063 19,213 19,358 estimates based on the RDE’s financial information. Total Energy Spend £ 3,987,215 £ 3,354,268 £3,230,576 £3,371,701 *Electricity bought on a green tariff and on site renewable generation

The RD&E previously sought to buy all of its electricity from renewable sources “Green Tariffs” or generate it on site. Due to carbon accounting rules, the Trust has to account for green electricity carbon based on a grid average value, ie not carbon neutral. Unfortunately, as a result of Government policy changes, the RD&E is no longer able to receive green electricity under its current, main, electricity contract which is why the green supply drops off in 2016/17.

Page 101 Annual Report 2016/17

Page 102 Annual Report 2016/17

2016/17 Achievements For a number of years now the RD&E has been working with local partners to develop a low- carbon An assessment of the organisation’s sustainability district heating network across the city. In 2017 performance was undertaken using the SDU’s Good this reached a significant milestone: The RD&E has Corporate Citizen tool. This divides the organisations formed a company with Exeter City Council, Devon activities into nine “sections”, or areas of focus County Council, Teignbridge District Council and the with each section assigned a percentage rating. The University of Exeter. The company is called Dextco RD&E scored 25% overall, which is on target with and its function is to procure a partner that will take SDU recommendations. The SDMP details how this the multimillion pound project forward. This has score can be increased and seeks to meet the 2018 been the culmination of extensive work between target of at least 25% in all sections with 4 sections the partners and will enable the project to achieve meeting 50% of criteria assessed. Meeting this target its goal of saving around 3,600 t/CO2e per year and is achievable, as the RDE already scores close to or refurbishing the RD&E’s energy centre. above 50% in four areas and requires improvements in only a further four to meet 25% in all areas. The RD&E has recently purchased two electric vans to use around the Exeter sites. These will reduce harmful In October, the RD&E’s domestic waste ceased being on-site emissions such as nitrogen dioxide and sent to landfill and instead goes to an energy from particulates which contribute to lung problems. waste plant (EfW) in Plymouth. This is one of the most efficient EfW plants in Europe and it generates Next Steps usable heat and electricity from the waste. This means that the RD&E sites included in this year’s The RD&E is developing plans for estate wide energy report are effectively zero to landfill. It is anticipated and water investments. It is estimated that this that going forwards, this will be the standard for all could cost circa £6m and save around £500,000 per sites including TCS sites. year. This could be implemented under an Energy Performance Contract to minimise the Trust capital A significant proportion of the RD&Es recycling is requirement. paper that has been securely shredded. This year the RD&E sent out 120 tonnes of paper for recycling. This The first stage of this is to make a £200,000 has resulted in: investment in 2017-18 in energy infrastructure, including lighting improvements and steam ●● around 2000 trees being saved from being pulped efficiencies in the laundry. It is anticipated that these for virgin fibres will save around £40,000 per year and 120t/CO2e. ●● over 3 tonnes of air pollutants being prevented from entering the atmosphere

●● 161m3 of water saved

●● 2660 tonnes of carbon dioxide equivalent not emitted

Page 103 Annual Report 2016/17 Equality and Diversity Key Achievements ●● Incidence of discrimination at work, as reported in Equality Objectives the staff survey, is low.

At the March 2016 Board Meeting the Board formally ●● Overall satisfaction of ethnic minorities, as reviewed the recommended Trust Equality Objectives evidenced in the staff survey, continues to be for 2016-20. Four objectives were agreed which good. included two focused on patient equality issues and two focussed on staff equality issues. Briefly, these ●● Satisfaction for staff with disabilities is slightly objectives are: improved from 2015-16.

●● To improve the experience of staff with disabilities. ●● The staff survey shows good levels of satisfaction, overall, for staff identifying themselves as LGB. ●● To understand and improve on the underrepresentation of black and minority ethnic ●● We are successfully participating in the national staff in administration, managerial and board Supported Internship Programme, pioneering roles. workplace equality for young people with learning disabilities. ●● To improve the mental health experience of all patients. ●● Successes in engagement work include:

●● To improve the experience of trans-gendered/non- a. Active steering groups for both race and binary patients. disability equality, to support our work against both of the staff equality objectives. A comprehensive dashboard of staff equality performance indicators, to measure overall b. Equality focus groups for disability and sexual performance and progress against our equality orientation, which gave useful information, objectives, has been developed. These will be with groups on race being planned. reported to the Governance Committee, on behalf c. Outreach to “hard to reach” ancillary ethnic of the Board, in summer 2017 and published on our minority workers which has provided an website shortly afterwards. Work has already begun opportunity to pilot support measures, to deliver against these objectives with a series of specifically for them. focus group meetings being held with representatives of the groups impacted. d. Use of posters and plans for further written information to all staff to disseminate key During the course of the last year we have also taken equality messages. time to ensure that we were following a social model of disability. The social model of disability says that e. Launch of a successful, multi-lingual poster disability is caused by the way society is organised, campaign to support staff who experience rather than by a person’s impairment or difference. ‘Race Hate’ behaviour, encouraging all It looks at ways of removing barriers that restrict incidents to be reported by staff. life choices for disabled people. When barriers are removed, disabled people can be independent and ●● We have piloted career development support equal in society, with choice and control over their measures for ethnic minorities with pleasing, own lives. Experts from Occupational Health and although small-scale success.

HR work with managers to ensure that all means of ●● We have drafted a policy to formalise best reasonable adjustment are considered when required practice in supporting staff with disabilities and to help staff into or to remain in work. continue to mainstream good practice through our routine case management.

●● We have secured Disability Confident accreditation at level 2. This Government-led accreditation programme replaces the “Two Ticks award” and is much more demanding than its predecessor. Work continues to engage with the Disability Employment Advisors at the Exeter Job Centre to support them in enabling disabled job seekers to be successful in obtaining employment.

Page 104 Annual Report 2016/17

Gender Pay Gap Pay Gaps Within Specific Pay Bands With effect from April 2017 Gender pay reporting In guidance issued during 2011 NHS Employers legislation requires employers with 250 or more recommended that the gender pay gap be measured employees to publish statutory calculations every year between those staff in the most populous grade showing how large the pay gap is between their male bands. The analysis below is based on the Band 2 and and female employees. As a Trust we believe that Band 5 pay bands, the staff groups with the highest measuring the gender pay gap is an important way staff numbers. of showing whether men and women have equal pay and have included a overview of pay within the Average of Hourly Trust below. Gender pay gap analysis looks at broad Rate Female Male Variance patterns of pay and can suggest structural issues, for Band 2 £8.52 £8.56 -0.5% example, whether women’s careers are progressing Band 5 £13.38 £12.94 3.3% as well as men’s. This type of headline analysis cannot in itself prove whether individual men are being paid more than individual women to do the same job.

The table below uses the standard national reporting method to show our gender pay gap. The negative percentages show where women are paid less than men. It shows the average hourly rate for basic salary by staff group:

Average of Hourly Rate Female Male Variance Prof Scientific and Technic £15.81 £14.93 5.6% Additional Clinical Services £9.16 £9.06 1.1% Administrative and Clerical (B1-4) £9.60 £9.31 3.0% Administrative and Clerical (B5+) £18.25 £19.81 -8.6% Allied Health Professionals £16.46 £16.16 1.8% Estates and Ancillary £8.17 £8.79 -7.6% Healthcare Scientists £17.38 £18.08 -4.0% Medical and Dental £20.00 £21.28 -6.4% Medical and Dental - Consultant £168.26 £173.94 -3.4% Nursing and Midwifery Registered £15.37 £14.51 5.5% All Staff* £12.93 £13.62 -5.3%

*All staff averages excludes consultants

Page 105

ROYAL DEVON AND EXETER NHS FOUNDATION TRUST

ANNUAL ACCOUNTS

YEAR ENDED 31 MARCH 2017

Royal Devon and Exeter NHS Foundation Trust - Annual Accounts 2016/17

ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2016/17

INDEX

Page

STATEMENT OF CHIEF EXECUTIVE'S RESPONSIBILITIES AS THE ACCOUNTING OFFICER 2

INDEPENDENT AUDITOR'S REPORT TO THE COUNCIL OF GOVERNORS 3

FOREWORD TO THE ACCOUNTS 8

STATEMENT OF COMPREHENSIVE INCOME 9

STATEMENT OF FINANCIAL POSITION 10

STATEMENT OF CHANGES IN TAXPAYERS' EQUITY 11

CASH FLOW STATEMENT 12

NOTES TO THE ACCOUNTS 13

Page 1

Page 1 Royal Devon and Exeter NHS Foundation Trust - Annual Accounts 2016/17 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2016/17

Statement of the Chief Executive's responsibilities as the Accounting Officer of the Royal Devon and Exeter NHS Foundation Trust

The National Health Service 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.

NHS Improvement, in exercise of the powers conferred on Monitor by the NHS Act 2006, has given Accounts Direction which require the Royal Devon and Exeter NHS Foundation Trust to prepare for each financial year a statement of accounts in the form and on the basis required by those Directions. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of the Trust and of its income and expenditure, total recognised gains and losses and cash flows for the financial year. Independent In preparing the accounts, the Accounting Officer is required to comply with the requirements of the Department of Health Group Accounting Manual and in particular to:

- 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; auditor’sreport - state whether applicable accounting standards as set out in the NHS Foundation Trust Annual Reporting Manual and the Department of Health Group Accounting Manual have been followed, and disclose and explain any material departures in the to the Council of Governors of Royal Devon financial statements; and Exeter NHS FoundationTrust only - 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. Opinions and conclusions The Accounting Officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the Trust and to enable her to ensure that the accounts comply with requirements outlined in the above arising from our audit mentioned Act. The Accounting Officer is also responsible for safeguarding the assets of the Trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities.

1. Our opinionon the financial statements is Overview To the best of my knowledge and belief, I have properly discharged the responsibilities set out in the NHS Foundation Trust unmodified Accounting Officer Memorandum. We have audited the financial statements of Royal Materiality: Trust £9.0m(2015/16:£8.0m) Devon and Exeter NHS Foundation Trust for the year financial 2%of total revenue (2015/16:2%) Suzanne Tracey - Chief Executive ended 31 March 2017 set out on pages 9 to 37. In statements our opinion: Date: 24 May 2017 — the financial statements give a true and fair view of Risks of material misstatement vs 2015/16 the state of the Trust’s affairs as at 31 March 2017 Recurring risks Valuation of land and ◄► and of the Trust’s income and expenditure for the buildings year then ended; and — the Trust’s financial statements have been Recognition of NHS and non- ◄► properly prepared in accordance with the NHS income Department of Health’s Group Accounting Manual 2016/17. Key ◄► Risk level unchanged from prior year

Page 2

Page 3 Page 2 Royal Devon and Exeter NHS Foundation Trust - Annual Accounts 2016/17 Independent auditor’sreport to the Council of Governors of Royal Devon and Exeter NHS FoundationTrust only

Opinions and conclusions arising from our audit

1. Our opinionon the financial statements is Overview unmodified We have audited the financial statements of Royal Materiality: Trust £9.0m(2015/16:£8.0m) Devon and Exeter NHS Foundation Trust for the year financial 2%of total revenue (2015/16:2%) ended 31 March 2017 set out on pages 9 to 37. In statements our opinion: — the financial statements give a true and fair view of Risks of material misstatement vs 2015/16 the state of the Trust’s affairs as at 31 March 2017 Recurring risks Valuation of land and ◄► and of the Trust’s income and expenditure for the buildings year then ended; and — the Trust’s financial statements have been Recognition of NHS and non- ◄► properly prepared in accordance with the NHS income Department of Health’s Group Accounting Manual 2016/17. Key ◄► Risk level unchanged from prior year

Page 3

Page 3 2. Our assessment of risRoyalks of Devonmaterial andmi Exetersstate mNHSen tFoundation Trust - Annual Accounts 2016/17

2. Our assessment of risks of materialmisstatement In arriving at our audit opinion above on the financial statements, the risks of material misstatement that had the greatest effect on our audit, in decreasing order of audit significance, were as follows: In arriving at our auditThopeinriiskon above on the financial statements, the risks of mateOriualr mreissspotantseement that had the greatest effect on our audit, in decreasing order of audit significance, were as follows: Land and ThVaelruiskation of land and buildings: Ouurr reprospocendseures included: Buildings Land and buildings are initially recognised at cost, but — Assessment of the external valuer: We L(£184and a.1ndmi llion; Vsaublusaetqiouennoftlylarnde reandcognbuisieldid ngat csu: rrent value in existing Our apsrosecssedeudrestheincluomded:petence, capability, 2015/16: £181.1 use (EUV). For non-specialised property assets in objectivity and independence of the valuer Buildings Land and buildings are initially recognised at cost, but — Assessment of the external valuer: We operational use EUV is market value in existing use. and the overall methodology of the (£184million).1 million; subsequently are recognised at current value in existing assessed the competence, capability, Specialised assets where no market value is readily valuation to identify whether the approach 2015/16: £181.1 use (EUV). For non-specialised property assets in objectivity and independence of the valuer ascertainable, are recognised at the depreciated was in line with industry practice and the million) operational use EUV is market value in existing use. and the overall methodology of the Refer to page 13 replacement cost (DRC) of a modern equivalent asset valuer was appropriately experienced and Specialised assets where no market value is readily valuation to identify whether the approach (accounting that has the same service potential as the existing qualified. We used our own specialist to ascertainable, are recognised at the depreciated was in line with industry practice and the policy) and page property. A review is carried out each year to test verify the methodology and assess the Refer to page 13 replacement cost (DRC) of a modern equivalent asset valuer was appropriately experienced and 29 (financial assets for potential impairment and a full valuation is conclusions in the final report. (accounting that has the same service potential as the existing qualified. We used our own specialist to disclosures). carried out every five years. policy) and page property. A review is carried out each year to test — vAegrifyreethememetnt ofhodundologyerlyaindg asssseetss retheco rds: 29 (financial assThereets isforsigpontifeicantinatl ijmpudgamirmenent itn vaondlveda finulldveteraluamtioinningis cWeonclcuosmpionsareindtthheefbinasaleredport.ata provided to the disclosures). the appropriate basis (market value in existing use or valuer against the Trust s property register carried out every five years. — Agreement of underlyi’ng asset records: DRC) for each asset according to its degree of to ensure it agreed to the Trust estate; There is significant judgment involved in determining We compared the base data provided to the specialisation, as well as over the assumptions made in the appropriate basis (market value in existing use or — vaClounersiadgeariantsitontheofTvruaslut’astpionropaessrtyumregpitsiotern s: arriving at the valuation of the asset. In particular the DRC) for each asset according to its degree of toWeencsruitriecaitlly agassreedessteodthetheTassrustumpestatiote;ns DRC basis of valuation requires an assumption as to specialisation, as well as over the assumptions made in used in preparing the valuation by whether the replacement asset would be situated on — Consideration of valuation assumptions: arriving at the valuation of the asset. In particular the considering them against indices produced the existing site or, if more appropriate, on an We critically assessed the assumptions DRC basis of valuation requires an assumption as to by Gerald Eve (International Property alternative site. used in preparing the valuation by whether the replacement asset would be situated on Consultants) and industry norms; considering them against indices produced theValueaxtiiostningisscaiterrieord, ifoutmoreby a napepxrtoeprnriatle,exonperant en gaged — byImGperairamldentEver(Interneview:aWetionacloPropertynsidered how abylterthenatiTvreustite.using construction indices and so accurate records of the current estate are required. Full CtheonsGultroaupntsh)aadnassd inedussesdtrythenorneedms; for an Valuation is carried out by an external expert engaged impairment across its asset base either due valuations are completed every five years, with interim — Impairment review: We considered how by the Trust using construction indices and so accurate to a loss of value or reductions in future desktop valuations completed in interim periods. the Group had assessed the need for an records of the current estate are required. Full service potential; impairment across its asset base either due vaValuluaatiotionsnsaarerecionhemplrentlyeted ejuvdegrmy fenivetayl,etahrerefos, withre iournterwimork — toAdadloitsiosnsof vtoaluaessoretsred: Fuorctaiosansminplfutue ofr e defoscuktsoepdvoanluwathioensthercomtheplevateluderin'sintemertimhodopelroiogdys, . assumptions and underlying data, are appropriate and sasseretsviceadd pedotendurtiingal;the year we agreed Valuations are inherently judgmental, therefore our work that an appropriate valuation basis had been correctly applied. — Additions to assets: For a sample of focused on whether the valuer's methodology, adopted when they became operational and The Trust had a full valuation undertaken at 31 March assets added during the year we agreed assumptions and underlying data, are appropriate and that the Trust would benefit from future 2017 resulting in a £9.8m increase in the value of the that an appropriate valuation basis had been correctly applied. service potential. land and buildings. adopted when they became operational and The Trust had a full valuation undertaken at 31 March that the Trust would benefit from future 2017 resulting in a £9.8m increase in the value of the service potential. land and buildings.

PagePage 4 4

Page 4 2. Our assessment of riRoyalsks of Devonmaterial andmi Exetersstate NHSmen tFoundation Trust - Annual Accounts 2016/17

In arriving at our audThit eopriinskion above on the financial statements, the risks of maOtuerireal smpoissnsetatement that had the greatest effect on our audit, in decreasing order of audit significance, were as follows: NHS and non- ReThceorgisknition of NHS and non-NHS income: OurOupr rorescpoednuseres included: NHS income Of the Trust’s reported total income, £364.3 million — Contract agreement: We agreed IncoLmane:d(£a452nd .1m; (2015Valua/16,tion£3of28la.8mnd)andcambeufrilodimngcso:mmissioners Ourcopmmroceissduionreserininclucomded:e to the signed 2015B/u16:ild£ings403.5m) (CLalinndicaalnd CobmmuildiinssgsionareinginGritiaoluply res c(CoCgnGised) anadt cNoHst,S but —coAnsstreacsstsmeandnt sofelethcteeedxatesranmalplvealofuether: We (£184.1 million; Esngublsaendque). nIntlycoamere rfercomognCisCeGdsatandcurNreHntSvEanlugelaindn emxisatkeing laarsgseessst beadlathencesco(mcompetperniscine,gc95ap.a4bil%ityof, 2015/16: £181.1 upus80e (E.5U%V).ofForthenonTr-usspte’sciianlicsoedme.propertyThe maassjoretsity ofin this inocbjomeectivfromity andpaitndeientpcenaredeacncteivoitfiethes) tova luer Refemilr tolion)page 13 inocpeomraetioisn aclounsteracEUtedV isonmanrketannuvalaulebiasn iesx,isbutting acustueal. agandreeththeaot vtheyerallhmadethobeendoloingyvooficedthein line (accounting policy) i nSpceocmialiese disassbasetsedwonhecreomnoplemtainrkgetthevalpuelannisedrealdievlyel wvaithlutheationcotontridenact taifygrewemhetehentsr tahendapparyomacenh t and page 24 ofascacerttivaityinaablne,d acarehi erevincoggnkieysedpeatrftheormdaenpcreeindciatiedcat ors hwadasbeenin linerecweiitvhed.industry practice and the (financial (KPIs). If the Trust does not meet its contracted KPIs Refer to page 13 replacement cost (DRC) of a modern equivalent asset — Invacomeluer warescogniapprotionpria:teWely ecaxprriederienced and disclosures). (accounting thenthat choamms theisssaionmeerssearrveicaebl peotoenimtiapl oasethefinexs,is ting outquatelifsietingd. Weof inuvsoiedcesourforow mnasteripecailainlisctometo reducing the level of income generated. policy) and page property. A review is carried out each year to test invetherifymonththe metpriorhodtoologyandanfollod aswseingss 31the 29 (financial Inass20ets16/1for7,ptheotenTtruiasl timprecaeirimenved tSu asndtaianafbullilityvaluandatio n is Mcaonrcchlu2017sionstoin determinethe final report.whether income disclosures). TcararrnsiefodrmoutateiovneryFunfivdeinygea(Srs.TF) from NHS —waAgsrreeecmognientsedof uinndtheerlcyorreing acts saccet ountingrecords : ImThereproveismseignnti.fiThiscant isjudgrecmeientvedinovnolavedquainrtdeeterrly bmasinisi ng period,We coinmpaccareordd thaencbeasweithdatathepraomountsvided to the stheubjeacptp troo pacriahteiebvinasgisdef(mianedrketf vinaaluneciianl aenxidstopingeruasteioorna l billedvaluertoacgorreainsst pondingthe Trustp’sartiepros.perty register taDrRgeCt)sfor. TheeacThruassst ewat saccalloorcdiangtedto£1its2.6mdegrofee of — Atogrenesmuerenitt ofagrceoedntrtaocthet vaTrriuasttioenssta:tWee; trsapenscfioarlimsaatitonion, afuns wdeingll ains o2v01er6the/17.ass Thumis ipntcioludnsesm ade in —agCroenesdidtheartattheionleofvelsvalofuaotivoner aassnduumnderptio ns: aadrdirivtioinngaaltfunthedinvagluwathioicnhofwathes a vaassilaet.ble Inatp yaertaicruelanrd theas peWerforcmritaicancllye rasseporestsededwtheereasscounmpsisttentions thDeRCTrubsatsisexofceedevaludatitons plreannequiredsou anttuassrn.umption as to wuitshedcointpracrept avrainrigattheionsvaalnudaticonhalbylen ged the whether the replacement asset would be situated on An agreement of balances exercise is undertaken considering them against indices produced the existing site or, if more appropriate, on an Trust’s assessment of the level of income between all NHS bodies to agree the value of by Gerald Eve (International Property alternative site. where these were not in place by transactions during the year and the amounts owed at conConsidsulterianntg so)uranodw innduexsptryectnoatironmsof; the Valuation is carried out by an external expert engaged the year end. ‘Mismatch’ reports are available setting income based on our knowledge of the by the Trust using construction indices and so accurate — Impairment review: We considered how out discrepancies between the submitted balances client and experience of the industry. records of the current estate are required. Full the Group had assessed the need for an from each party in transactions and variances over impairment across its asset base either due valuations are completed every five years, with interim — Agreement of balances: We assessed the £250,000 are required to be reported to the National to a loss of value or reductions in future desktop valuations completed in interim periods. outcome of the agreement of balances Audit Office to inform the audit of the Department of service potential; Valuations are inherently judgmental, therefore our work exercise with CCGs and other NHS Health consolidated accounts. focused on whether the valuer's methodology, —pArodvdidierstionsandtocaosmpsetasr:eFdorthaesavamluplese theyof TheassuTmrupsttiorensportandeduntotdearll yinincgomdaetaof, a£re85a.p1pmro priate and areassdietsscloaddsinedg wdurithingin ttheheiryfeinaarnwceiala greed (2015corre/c16tly:£71appl.i2ed.m) from other activities, principally stthataemet anntsapptoroptheriatevavaluleuaotifon incboasmeis had been Education and Research. Much of this income is caapdtouprteeddinwhtheen ftinheyancbiealcsametatemopeneratsti.on Weal a nd The Trust had a full valuation undertaken at 31 March generated by contracts with other NHS and non-NHS that the Trust would benefit from future 2017 resulting in a £9.8m increase in the value of the sought explanations for any variances over bodies which are based on varied payment terms, service potential. land and buildings. £0.25m, and all balances in dispute, and including payment on delivery, milestone payments and challenged the Trust’s assessment of the periodic payments. level of income they were entitled to and . the receipts that could be collected. — Transformation funding: We agreed the STF due at the year end to the confirmation received from NHSI and agreed that this was appropriately recorded in the financial statements. — Other income: We tested material other income balances by agreeing a sample of income transactions through to supporting documentation and bank statements.

PagePage 5 4

Page 5 2. Our assessment of risRoyalks of Devonmaterial andmi Exetersstate mNHSen tFoundation Trust - Annual Accounts 2016/17

3. Our application of materiality and an overview of the Total revenue Materiality In arriving at our audit opinion above on the financial statements, the risks of material misstatement that had the greatest scope of our audit £452.1m(2015/16: effect on our audit, in decreasing order of audit significance, were as follows: The materiality for the financial statements was set at £9.0m £403.5m) £9.0m The risk Our response (2015/16: £8.0m), determinedwith reference to a benchmark of Whole financial income from operations (of which it represents approximately statements 2%).LanWed acndon sider incomVeafrluoamtiopneofratilonsandtoandbe mboreuildistngables: Our procedures included: materiality (2015/16: £8.0m) thaBnuaildsuingsrplus-related benLacnhdmaandrk. bWeuildireportngs areto tinheitiAuditally re cognised at cost, but — Assessment of the external valuer: We Commit(£184t.ee1 mianlyliocn;or rectesdubansdequnueconrrtlyecatedre rideecnogntifiedise d at current value in existing assessed the competence, capability, mi2015sstate/16:ments£181exc.1eedinugse£0(E.4U5mV).(20For15/n1on6:-£s0p.4m),ecialisinedadpropertydition assets in objectivity and independence of the valuer to other identifiedmisstatements that warrant reporting on million) operational use EUV is market value in existing use. and the overall methodology of the qualitative grounds. Specialised assets where no market value is readily valuation to identify whether the approach ascertainable, are recognised at the depreciated was in line with industry£p0rac.45ticme and the Refer to page 13 replacement cost (DRC) of a modern equivalent asset valuer was appropriatelyMexispsetartieenmencetds and (accounting that has the same service potential as the existing qualified. We used our orepownrtesped tcoi athlies tAutodit policy) and page property. A review is carried out each year to test Total revenveuerify the methodology aCnodmmasistteeses(2the015/ 16: Materiality 29 (financial assets for potential impairment and a full valuation is conclusions in the final re£port.0.4m) disclosures). carried out every five years. — Agreement of underlying asset records: There is significant judgment involved in determining We compared the base data provided to the the appropriate basis (market value in existing use or valuer against the Trust’s property register 4. Our opinion on otherDmRaCtt)eforrs peraceschrassibeedt byaccthorediCodeng toofits degree of — the Trust has ntootemnasduerepritop aergrearredangeto mtheentTrfuosrtsecsutaritnge; Audit Practice is unmodifispecieadlisation, as well as over the assumptions maedceonoin my, efficiency and effectiveness in its use of resources.— Consideration of valuation assumptions: arriving at the valuation of the asset. In particular the In our opinion: We critically assessed the assumptions DRC basis of valuation requires an assumptionInasaddtoi tion we are required to report to you if: — the part of the Directors’ Remuneration Report to be used in preparing the valuation by whether the replacement asset would be situated on audited has been properly prepared in accordance with the — any reports to ctheonsregideulraintogrthehavme beageaninmstaindide uncesderprodu ced the existing site or, if more appropriate, on an NHS Foundation Trust Annual Reporting Manual 2016/17; Schedule 10(6)byofGthere aNldatioEvneal(InternHealthaStionerviacel PropertyAct 2006. alternative site. and — any matters haCveonbesultenarepornts) atenddin intduhesputryblicnoinrmtesre; st Valuation is carried out by an external expert engaged — the information given in the Annual Report for the financial under Schedule 10(3) of the National Health Service Act by the Trust using construction indices and so accurate — Impairment review: We considered how year for which the financial statements are prepared is 2006 in the course of, or at the end of the audit. records of the current estate are required. Full the Group had assessed the need for an consistent with the financial statements. We have nothing tiompreportairmeinntreacspreocsts ofitstheassabeotvbeas e either due valuations are completed every five years, with interim responsibilities. to a loss of value or reductions in future desktop valuations completed in interim periods. 5. We have nothing to report in respect of the matters on service potential; which we are requireVdatlouartepionsortabrey einhexceprentlytion judgmental, therefore our work focused on whether the valuer's methodol6o.gy,We have comp—letAeddouritioansudtito assets: For a sample of We are required to report to you if, based on the knowledge we assumptions and underlying data, are appropriate and assets added during the year we agreed acquired during our audit, we have identifiedinformation in the We certify that wethhaavt aencomappplroepteridatthee vaauludiatiofonthbeasaisccounhadtsbe en correctly applied. of Royal Devon and Exeter NHS Foundation Trust in Annual Report that contains a material inconsistency with either adopted when they became operational and that knowledge or the ThefinancTiarul stahtemenad a tfus,llavamlauteatrioianl undertaken at 31aMccaordchance with the requirements of Schedule 10 of the that the Trust would benefit from future misstatement of fact, or2017that risesoutheltinrwg iisneam£is9le.8amdinig.ncrease in the valueNofationtheal Health Service Act 2006 and the Code of Audit Practice issued bystheervicNeatpoiontaenl Audittial. Office. In particular, we are requiredland antodreportbuildingto sy.ou if:

— we have identified material inconsistencies between the knowledge we acquired during our audit and the directors’ statement that they consider that the Annual Report and financial statements taken as a whole is fair, balanced and understandable; or — the Audit Committee’s commentary on page 94 of the Annual Report does not appropriately address matters communicated by us to the Audit Committee. Under the Code of Audit Practice we are required to report to you if, in our opinion:

— the Annual Governance Statement does not reflect the disclosure requirements set out in the NHS Foundation Trust Annual Reporting Manual 2016/17, is misleading or is not consistent with our knowledge of the Trust and other information of which we are aware from our audit of the financial statements.

Page 6

PagePage 6 4 2. Our assessment of riRoyalsks of Devonmaterial andmi Exetersstate NHSmen tFoundation Trust - Annual Accounts 2016/17

In arriving at our audit opinion above on the financial statements, the risks of material misstatement that had the greatest effect on our audit, in decreasing order of audit significance, were as follows: The risk Our response

Land and Valuation of land and buildings: Our procedures included: Buildings Land and buildings are initially recognised at cost, but — Assessment of the external valuer: We (£184.1 million; subsequently are recognised at current value in existing assessed the competence, capability, 2015/16: £181.1 use (EUV). For non-specialised property assets in objectivity and independence of the valuer million) operational use EUV is market value in existing use. and the overall methodology of the Specialised assets where no market value is readily valuation to identify whether the approach ascertainable, are recognised at the depreciated was in line with industry practice and the Refer to page 13 replacement cost (DRC) of a modern equivalent asset valuer was appropriately experienced and (accounting that has the same service potential as the existing qualified. We used our own specialist to policy) and page property. A review is carried out each year to test verify the methodology and assess the 29 (financial assets for potential impairment and a full valuation is conclusions in the final report. disclosures). carried out every five years. — Agreement of underlying asset records: There is significant judgment involved in determining We compared the base data provided to the the appropriate basis (market value in existing use or valuer against the Trust’s property register DRC) for each asset according to its degree of to ensure it agreed to the Trust estate; specialisation, as well as over the assumptions made in — Consideration of valuation assumptions: arriving at the valuation of the asset. In particular the We critically assessed the assumptions DRC basis of valuation requires an assumption as to used in preparing the valuation by whether the replacement asset would be situated on considering them against indices produced the existing site or, if more appropriate, on an by Gerald Eve (International Property alternative site. Consultants) and industry norms; Valuation is carried out by an external expert engaged by the Trust using construction indices and so accurate — Impairment review: We considered how records of the current estate are required. Full the Group had assessed the need for an impairment across its asset base either due valuations are completed every five years, with interim to a loss of value or reductions in future desktop valuations completed in interim periods. service potential; Valuations are inherently judgmental, therefore our work focused on whether the valuer's methodology, — Additions to assets: For a sample of assumptions and underlying data, are appropriate and assets added during the year we agreed correctly applied. that an appropriate valuation basis had been adopted when they became operational and The Trust had a full valuation undertaken at 31 March that the Trust would benefit from future 2017 resulting in a £9.8m increase in the value of the service potential. land and buildings.

PagePage 7 4 Royal Devon and Exeter NHS Foundation Trust - Annual Accounts 2016/17 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2016/17 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2016/17 FOREWORD TO THE ACCOUNTS STATEMENT OF COMPREHENSIVE INCOME FOR THE YEAR ENDED These accounts for the year ended 31 March 2017 have been prepared by the Royal Devon and Exeter NHS Foundation Trust in 31 MARCH 2017 accordance with paragraphs 24 and 25 of Schedule 7 to the National Health Service Act 2006 and are presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of National Health Service Act 2006.

2016/17 2015/16 Suzanne Tracey - Chief Executive Note £000 £000

Date: 24 May 2017 Income from activities 3 367,015 332,272 Other operating income 4 85,110 71,210 Operating income 452,125 403,482

Operating expenses - excluding land and buildings impairment charge 5 (448,064) (417,000) Land and buildings impairment charge 5 & 15.3 (15,404) - Operating deficit (11,343) (13,518)

Finance costs Finance income 10 56 84 Finance expense 11 (711) (773) PDC dividends payable (5,677) (5,848) Net finance costs (6,332) (6,537)

Share of profit of associates / joint arrangements 16 - - Gains arising from transfers by absorption 28 786 -

Deficit for the year (16,889) (20,055)

Other comprehensive income

Revaluation gains on property, plant and equipment 15.3 25,176 - Other reserves movements 28 (520) - Total comprehensive surplus / (deficit) for the year 7,767 (20,055)

The above land and buildings impairment charge of £15.404m has arisen due to the revaluation of the Trust's land and buildings. The expense is a technical accounting adjustment and has no detrimental impact on the Trust's cash reserves. Excluding this impairment charge and the gain arising from transfers by absorption, the Trust would have incurred a deficit of £2.271m for the year ended 31 March 2017.

Page 8

Page 8 Page 9 Royal Devon and Exeter NHS Foundation Trust - Annual Accounts 2016/17

ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2016/17

STATEMENT OF COMPREHENSIVE INCOME FOR THE YEAR ENDED 31 MARCH 2017

2016/17 2015/16 Note £000 £000

Income from activities 3 367,015 332,272 Other operating income 4 85,110 71,210 Operating income 452,125 403,482

Operating expenses - excluding land and buildings impairment charge 5 (448,064) (417,000) Land and buildings impairment charge 5 & 15.3 (15,404) - Operating deficit (11,343) (13,518)

Finance costs Finance income 10 56 84 Finance expense 11 (711) (773) PDC dividends payable (5,677) (5,848) Net finance costs (6,332) (6,537)

Share of profit of associates / joint arrangements 16 - - Gains arising from transfers by absorption 28 786 -

Deficit for the year (16,889) (20,055)

Other comprehensive income

Revaluation gains on property, plant and equipment 15.3 25,176 - Other reserves movements 28 (520) - Total comprehensive surplus / (deficit) for the year 7,767 (20,055)

The above land and buildings impairment charge of £15.404m has arisen due to the revaluation of the Trust's land and buildings. The expense is a technical accounting adjustment and has no detrimental impact on the Trust's cash reserves. Excluding this impairment charge and the gain arising from transfers by absorption, the Trust would have incurred a deficit of £2.271m for the year ended 31 March 2017.

PagePage 9 9 ROYALRoyal DEVON Devon AND and EXETER Exeter NHS FOUNDATIONFoundation Trust TRUST - Annual - ANNUAL Accounts ACCOUNTS 2016/17 2016/17

STATEMENT OF FINANCIAL POSITION AS AT 31 MARCH 2017

31 March 2017 31 March 2016 Note £000 £000 Non-current assets Intangible assets 14 330 431 Property, plant and equipment 15 202,940 199,560 Investment in joint venture 16 5 - Trade and other receivables 18 963 972 Total non-current assets 204,238 200,963

Current assets Inventories 17 9,061 6,664 Trade and other receivables 18 25,245 17,756 Cash and cash equivalents 22 17,533 16,507 51,839 40,927

Current liabilities Trade and other payables 19 (37,739) (31,178) Borrowings 20 (1,270) (1,270) Provisions 21 (211) (333) Other liabilities 19 (2,472) (1,867) Total current liabilities (41,692) (34,648)

Total assets less current liabilities 214,385 207,242

Non-current liabilities Borrowings 20 (12,591) (13,861) Provisions 21 (387) (362) Total non-current liabilities (12,978) (14,223)

Total assets employed 201,407 193,019

Financed by taxpayers' equity Public dividend capital 153,065 152,444 Revaluation reserve 34,857 24,677 Income and expenditure reserve 13,485 15,898 Total taxpayers' equity 201,407 193,019

The notes on pages 13 to 37 form part of these accounts.

The Annual Accounts on pages 9 to 37 were approved by the Board of Directors on 24 May 2017 and signed on its behalf by :

Suzanne Tracey - Chief Executive

Date: 24 May 2017

Page 10

Page 10 ROYALRoyal DEVON Devon AND and EXETER Exeter NHS FOUNDATIONFoundation Trust TRUST - Annual - ANNUAL Accounts ACCOUNTS 2016/17 2016/17

STATEMENT OF CHANGES IN TAXPAYERS' EQUITY FOR THE YEAR ENDED 31 MARCH 2017

Income and Public dividend Revaluation expenditure capital reserve reserve Total £000 £000 £000 £000

Taxpayers' equity at 1 April 2015 151,792 25,753 34,877 212,422

Deficit for the year - - (20,055) (20,055) Transfer of the excess of current cost depreciation over historical cost depreciation to the income and expenditure reserve - (1,076) 1,076 - Public dividend capital received 652 - - 652 Taxpayers' equity at 31 March and 1 April 2016 152,444 24,677 15,898 193,019

Deficit for the year excluding land and buildings impairment charge - - (1,485) (1,485) Land and buildings impairment charge - - (15,404) (15,404) Revaluations - land and buildings - 25,176 - 25,176 Transfer revaluation reserve element included in impairment charge - (13,364) 13,364 - Transfer of the excess of current cost depreciation over historical cost depreciation to the income and expenditure reserve - (1,632) 1,632 - Transfers by absorption: harmonisation of accounting policies - - (520) (520) Public dividend capital received 621 - - 621 Taxpayers' equity at 31 March 2017 153,065 34,857 13,485 201,407

Public dividend capital ("PDC") PDC represents the excess of assets over liabilities at the time of establishment of the Trust. It also includes new PDC received to fund capital expenditure on schemes supported by the Department of Health central capital budgets. PDC has no fixed capital repayment period.

Revaluation reserve The reserve reflects movements in the value of purchased property, plant and equipment and intangible assets as set out in the accounting policies.

Income and expenditure reserve The reserve is the cumulative surplus / (deficit) made by the Trust since its inception. It is held in perpetuity and cannot be released to the Statement of Comprehensive Income.

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Page 11 ROYALRoyal DEVON Devon AND and EXETER Exeter NHSNHS FoundationFOUNDATION Trust TRUST - Annual - ANNUAL Accounts ACCOUNTS 2016/17 2016/17

CASH FLOW STATEMENT FOR THE YEAR ENDED 31 MARCH 2017

Note 2016/17 2015/16 £000 £000

Cash flows from operating activities Operating deficit (11,343) (13,518)

Non-cash income and expense Depreciation and amortisation 12,240 11,882 Impairments 15,404 3,524 (Increase) / decrease in trade and other receivables (7,163) 845 (Increase) / decrease in inventories (2,293) 1,361 Increase in trade and other payables 5,219 1,493 Increase / (decrease) in other liabilities 605 (510) (Decrease) / increase in provisions (102) 30 Increase in tax liability payable 1,147 30 Income recognised in respect of capital donations (350) (105) (Profit) / loss on disposal of property plant and equipment (5) 9 Net cash generated from operations 13,359 5,041

Cash flows from investing activities Interest received 56 84 Purchase of investment in joint venture (5) - Purchase of intangible assets (9) (146) Purchase of property, plant and equipment (5,389) (8,990) Sale of property, plant and equipment 10 - Receipt of cash donations to purchase capital assets 350 105 Net cash used in investing activities (4,987) (8,947)

Cash flows from financing activities PDC received 621 652 Loans repaid (1,270) (1,271) Interest paid (706) (768) PDC dividend paid (5,994) (5,567) Net cash used in financing activities (7,349) (6,954)

Increase / (decrease) in cash and cash equivalents 1,023 (10,860)

Cash and cash equivalents at 1 April 16,507 27,367 Received from transfer by absorption 28 3 - Cash and cash equivalents at 31 March 22 17,533 16,507

Page 12 Page 12 Royal Devon and Exeter NHS Foundation Trust - Annual Accounts 2016/17 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2016/17

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES

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 Financial Reporting Manual (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

The accounts have been prepared under the historical cost convention modified to account for the revaluation of property, plant and equipment, intangibles assets, inventories and certain financial assets and liabilities at their value to the business by reference to their fair value.

Going concern

The Trust incurred a deficit of £1.485m excluding the impairment charge for the year ending 31 March 2017. The Trust has prepared its annual plan for the year ending 31 March 2018, which includes a detailed cash flow forecast which provides assurance that the Trust will remain within their current facilities. The Directors have therefore a reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they consider it appropriate to continue to adopt the going concern basis in preparing the accounts.

1.1 Income recognition

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 Trust is contracts with commissioners in respect of healthcare services.

Revenue relating to patient care treatments (also known as spells) that are part-completed at the year end are apportioned across the financial years on the basis of length of stay at the end of the reporting period. 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, less the fair value of the asset.

1.2 Expenditure on employee benefits

Short-term employee benefits

Salaries, wages and employment-related payments are recognised in the period 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 period is recognised in the accounts to the extent that employees are permitted to carry forward leave into the following period.

Pension costs

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 Trust to identify its share of the underlying scheme assets and 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 Trust commits itself to the retirement, regardless of the method of payment.

Page 13 Page 13 ROYAL DEVONRoyal Devon AND EXETER and Exeter NHS NHS FOUNDATION Foundation TrustTRUST - Annual - ANNUAL Accounts ACCOUNTS 2016/17 2016/17

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

1.3 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.

1.4 Intangible assets

Recognition

Intangible assets are non-monetary assets without physical substance which are capable of being sold separately from the rest of the 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 to, or service potential be provided to, the Trust and where the cost of the asset can be measured reliably.

Intangible assets are capitalised when they are capable of being used in the Trust's activities for more than one year and have a cost of at least £15,000.

Internally generated intangible assets

Internally generated goodwill, brands, publishing titles, customer lists and similar items are not capitalised as intangible assets.

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 fair value. Revaluation gains and losses and impairments are treated in the same manner as for property, plant and equipment (see note 1.5).

Amortisation and impairment

Intangible assets are amortised over their expected useful lives in a manner consistent with the consumption of economic or service delivery benefits.

The carrying value of intangible assets is reviewed for impairment if events or changes in circumstances indicate the carrying value may not be recoverable.

Software

Software that 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. Software that is not integral to the operation of hardware, e.g. application software, is capitalised as an intangible asset.

Purchased computer software licences are capitalised as intangible assets where expenditure of at least £15,000 is incurred and amortised over the shorter of the term of the licence and their useful lives.

Asset category Useful life (years) Software licences 3 - 10

Page 14 Page 14 Royal Devon and Exeter NHS Foundation Trust - Annual Accounts 2016/17 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2016/17

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

1.4 Intangible assets (continued)

Research and development

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, e.g. 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.

Expenditure which does not meet the criteria for capitalisation is treated as an operating cost in the year in which it is incurred.

Where possible the Trust will disclose the total amount of research and development expenditure charged in the Statement of Comprehensive Income separately. However, where research and development activity cannot be separated from patient care activity it cannot be identified and is therefore not separately disclosed.

Other property, plant and equipment assets acquired for use in research and development are amortised over the life of the associated project.

1.5 Property, plant and equipment

Recognition

Property, plant and equipment are 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 Trust;

- it is expected to be used for more than one financial year;

- the cost of the item can be measured reliably and;

- has an individual cost of at least £15,000; or

- the items form a group of assets which individually have a cost of more than £250, collectively have a cost of at least £15,000, 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 costs of a new building or on refurbishment, may also be "grouped" for capitalisation purposes.

PagePage 15 15 ROYAL DEVONRoyal Devon AND EXETER and Exeter NHS NHS FOUNDATION Foundation TrustTRUST - Annual - ANNUAL Accounts ACCOUNTS 2016/17 2016/17

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

1.5 Property, plant and equipment (continued)

Measurement and revaluation

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.

Property assets

The fair value of land and buildings is determined by valuations carried out by professionally qualified valuers in accordance with the Royal Institution of Chartered Surveyors (RICS) Appraisal and Valuation Manual. The valuations are carried out primarily on the basis of depreciated replacement cost for specialised operational property based upon providing a modern equivalent asset. Existing use value is used for non-specialised operational property. For non- operational properties, including surplus land, the valuations are carried out at open market value. The frequency of revaluation is dependent upon changes in the fair value of property assets however, in line with NHS Improvement's view, the frequency of property asset revaluations will be at least every five years.

Buildings with a number of components that have significantly different asset lives, e.g. fixed plant are depreciated over the useful economic life of the component.

Assets under construction are valued at cost and may subsequently be revalued by professional valuers when brought into use or when factors indicate that the value of the asset differs materially from its carrying value.

Non-property assets

For non-property assets the depreciated historical cost basis has been adopted as a proxy fair value. Non-property assets acquired up to 31 March 2008 were revalued through an annual uplift by the change in the value of the GDP deflator. These revalued assets are included in the non-property assets valuation, but further indexation of these assets has ceased.

Additional alternative open market value figures have only been supplied for operational assets scheduled for imminent closure and subsequent disposal.

Subsequent expenditure

Expenditure incurred after items of property, plant and equipment have been brought into operation, such as repairs and maintenance, is normally charged to the Statement of Comprehensive Income in the period in which it is incurred. In situations where it can be clearly demonstrated that the expenditure has resulted in an increase in the future economic benefits expected to be obtained from the use of an item of property, plant and equipment, and where the cost of an item can be measured reliably, the expenditure is capitalised as an additional cost of that asset or as a replacement.

Depreciation

Items of property, plant and equipment are depreciated on a straight-line basis over their remaining useful lives in a manner consistent with the consumption of economic or service delivery benefits.

Useful lives are determined on a case by case basis. The typical lives for the following assets are:

Asset category Useful life (years) Freehold property - buildings 16 - 53 Freehold property - dwellings 32 - 37 Plant and machinery 4 - 20 Equipment - transport 5 - 7 Equipment - information technology 3 - 10 Equipment - furniture and fittings 5 - 10

Freehold land is considered to have an infinite life and is not depreciated.

Page 16 Page 16 ROYAL DEVONRoyal Devon AND EXETER and Exeter NHS NHS FOUNDATION Foundation TrustTRUST - Annual - ANNUAL Accounts ACCOUNTS 2016/17 2016/17

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

1.5 Property, plant and equipment (continued)

The excess depreciation on revalued assets over the historical cost is released to the income and expenditure reserve. On disposal of an asset any remaining revaluation reserve balance is released to the income and expenditure reserve.

Impairment

The carrying values of property, plant and equipment assets are reviewed for impairment when events or changes in circumstances indicate their carrying value may not be recoverable.

Decreases in asset values that are due to a loss 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 to the lower of (i) the impairment charged to operating expenses; and (ii) the balance in the revaluation reserve attributable to that asset before the impairment.

Increases in asset values arising from revaluation are recognised in the revaluation reserve, except where, and to the extent that, they reverse an impairment previously recognised in operating expenses, such reversals are recognised in operating expenditure to the extent that the asset is restored to the carrying amount it would have been if the original impairment had never been recognised.

Other impairments are treated as revaluation losses. Reversals of 'other impairments' are treated as revaluation gains.

Gains and losses recognised in the revaluation reserve are reported in the Statement of Comprehensive Income.

1.6 Donated, government grant and other grant funded assets

Donated and grant funded property, plant and equipment assets are capitalised at their fair value on receipt. The donation/grant is recognised as income 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/grant is deferred within liabilities and is carried forward to future financial years to the extent that the condition has not yet been met.

1.7 Inventories and work in progress

Inventories and work in progress are valued at the lower of cost and net realisable value. Cost is determined using a first in, first out method.

Work in progress comprises goods in intermediate stages of production.

Provision is made where necessary for obsolete, slowing moving and defective inventories and work in progress.

1.8 Provisions

The Trust provides for legal or constructive obligations that are of uncertain timing or amount at the Statement of Financial Position date on the basis of where 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 required to settle the obligation. The Trust uses HM Treasury's pension rate of 0.24% (2015/16 - 1.37%), in real terms, as the discount rate for early retirement and injury benefit provisions.

Clinical negligence costs

The NHS Litigation Authority (NHSLA) operates a risk pooling scheme under which the Trust pays an annual contribution, which, in return, settles all clinical negligence claims. Although the NHSLA is administratively responsible for all clinical negligence cases, the legal liability remains with the Trust. The total value of clinical negligence provisions carried by the NHSLA on behalf of the Trust is disclosed at note 21, but this value is not recognised in the Trust’s accounts The provision relates only to the excess payable on each of the Trust's cases administered by the NHSLA.

PagePage 17 17 ROYAL DEVONRoyal Devon AND andEXETER Exeter NHS NHS FOUNDATION Foundation Trust TRUST - Annual - ANNUAL Accounts ACCOUNTS 2016/17 2016/17

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

1.8 Provisions (continued)

Non-clinical risk pooling

The Trust participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the Trust pays an annual contribution to the NHSLA 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.

1.9 Value Added Tax

Most of the activities of the 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.

1.10 Contingent liabilities

The Trust has contingent liabilities in respect of NHSLA legal claims arising in the normal course of activities. Where the transfer of economic liabilities in respect of legal claims is possible the Trust discloses the estimated value as a contingent liability in note 24.

1.11 Third party assets

Assets belonging to third parties (such as money held on behalf of patients) are not recognised in the accounts since the Trust has no beneficial interest in them. However, they are disclosed in a separate note, note 27, to the accounts in accordance with the requirements of HM Treasury’s Financial Reporting Manual.

1.12 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 regulation. By their nature they are items that ideally should not arise. They are therefore subject to specific control procedures compared with the generality of payments. They are divided into different categories, which govern the way the 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 the Trust not been bearing its own risks (with insurance premiums then being included as normal revenue expenditure).

The losses and special payments note is compiled directly from the losses and compensations register which reports on an accruals basis with the exception of provisions for future losses.

1.13 Critical accounting estimates and judgements

In the application of the Trust’s accounting policies, management is required to make judgements, estimates and assumptions about the carrying amounts of assets and liabilities that are not readily apparent from other sources. The estimates and associated assumptions are based on historical experience and other factors that are considered to be relevant. Actual results may differ from those estimates and the estimates and underlying assumptions are continually reviewed.

Accounting judgement - Modern Equivalent Asset valuation

The majority of the Trust's estate is considered to be specialised assets as there is no open market for an acute hospital. The modern equivalent asset valuation is based on the assumption that any modern equivalent replacement hospital would be built on an alternative site within the Exeter locality.

Revisions to accounting estimates are recognised in the period in which the estimate is revised.

Page 18 Page 18 ROYAL DEVONRoyal Devon AND EXETERand Exeter NHS NHS FOUNDATION Foundation Trust TRUST - Annual - ANNUAL Accounts ACCOUNTS 2016/17 2016/17

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

1.14 Leases

Operating leases

Where 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.

1.15 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, the Royal Devon and Exeter Healthcare NHS Trust. HM Treasury has determined that PDC is not a financial instrument within the meaning of IAS 32.

A charge, reflecting the forecast cost of capital utilised by the Trust, is paid over 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 Trust.

Relevant net assets are calculated as the value of all assets less the value of all liabilities, except for donated assets and the average daily cash held with the Government Banking Service. Average relevant net assets are calculated as a simple means of opening and closing relevant net assets in the pre-audit version of the accounts after adjusting for the average daily cash held within the Government Banking Service. The dividend charge would not be revised should any adjustments to net assets occur as a result of any changes between the draft and audited accounts.

1.16 Financial instruments and financial liabilities

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 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 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 Trust has transferred substantially all of the risks and rewards of ownership.

Financial liabilities are derecognised when the obligation is discharged, cancelled or expires.

Classification and measurement

Financial assets are categorised as ‘loans and receivables’. Financial liabilities are classified as ‘other financial liabilities’.

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NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

1.16 Financial instruments and financial liabilities (continued)

Loans and receivables

Loans and receivables are non-derivative financial assets with fixed or determinable payments that are not quoted in an active market. They are included in current assets.

The 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.

Other financial liabilities

Other financial liabilities 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 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 through the use of a bad debt provision that is determined specifically on individual assets.

1.17 Corporation tax

The Trust is a Health Service Body within the meaning of s519A of the Income and Corporation Tax Act 1988 and accordingly is exempt from taxation in respect of income and capital gains within categories covered by this. There is a power for HM Treasury to dis-apply the exemption in relation to specified activities of an NHS foundation trust (s519A (3) to (8) of the Income and Corporation Taxes Act 1988). Accordingly, the FT is potentially within the scope of corporation tax in respect of activities which are not related to, or ancillary to, the provision of healthcare, and where the profits there from exceed £50,000 per annum. Until the exemption is dis-applied then the FT has no corporation tax liability.

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NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

1.18 Consolidation of NHS charitable funds

The Trust is the Corporate Trustee of the Royal Devon and Exeter NHS Foundation Trust General Charity. The Charity has not been consolidated within these annual accounts as the value of the Charity is low and consolidation into the Trust’s accounts would have no material effect. Further information relating to transactions between the Trust and the Charity is disclosed in note 25.

1.19 Interests in other entities

Joint ventures

Joint ventures are arrangements in which the Trust has joint control with one or more other parties, and where it has the rights to the net assets of the arrangement. Joint ventures are accounted for using the equity method.

1.20 Transfers of functions to / from other NHS bodies

For functions that have been transferred to the Trust from another NHS body, the assets and liabilities transferred are recognised in the accounts as at the date of transfer. The assets and liabilities are not adjusted to fair value prior to recognition. The net gain / loss corresponding to the net assets/ liabilities transferred is recognised as a transfer by absorption within the Statement of Comprehensive Income, but not within operating activities.

For property plant and equipment assets and intangible assets, the cost and accumulated depreciation / amortisation balances from the transferring entity’s accounts are preserved on recognition in the Trust’s accounts. Where the transferring body recognised revaluation reserve balances attributable to the assets, the Trust makes a transfer from its income and expenditure reserve to its revaluation reserve to maintain transparency within public sector accounts.

Adjustments to align the acquired assets / liabilities to the foundation trust’s accounting policies are applied after initial recognition and are adjusted directly in taxpayers’ equity.

2. Segmental analysis

The Chief Operating Decision Maker, who is responsible for the allocation of resources and the assessment of the performance of operating segments has been identified as the Trust's Board of Directors.

Throughout the financial year the Trust's Board of Directors received a monthly integrated performance report, that provided information against key standards and targets. The reports included financial performance information which has assisted the Board of Directors with their financial decisions. The monthly information provided to the Board of Directors has been similar to the primary statements within these accounts.

The Board of Directors received financial information at service line level on a quarterly basis. Note 2.1 provides details of the financial information reported by the operating segments.

Page 21

Page 21 Royal Devon and Exeter NHS Foundation Trust - Annual Accounts 2016/17 [c] [a] [d] [b] [f] Note [a] [b] [c] & [d] - - - £000 87,974 (1,019) (59,316) (27,639) (Increase) / / (Increase) decrease to to decrease SOCI deficit - - £000 and figures reported SOCI in 5,546 452,967 (11,343) (16,889) 464,310 Reconciliation between segmental analysis analysis segmental between Reconciliation SOCI balance SOCI 850 £000 3.6% 2,650 5,546 3,844 9,339 16.7% (3.7%) 18,954 13,824 75,612 59,316 17,153 52,373 16,296 97,290 27,639 75,192 19,841 41,659 44,234 18,134 34,271 451,948 376,336 378,676 (11,343) (16,889) Trust total Trust ------2 3 2 13 40 14 N/A N/A N/A 253 123 234 (88) 165 £000 (101) other 15,404 (15,505) (15,505) Corporate and 2 1 1 97 87 35 51 16 158 988 808 180 129 502 849 228 830 £000 0.7% 3.7% 0.1% 1,459 5,596 3,403 3,933 26,696 25,708 25,049 10,209 Services Community Community 209 629 570 £000 7.4% 5,864 3,248 2,353 9,627 3,771 1,725 6,284 5,179 1,757 11.6% 22.9% 21,595 29,794 14,671 11,352 15,123 16,933 18,812 12,135 12,370 11,198 130,343 100,549 111,756 Services Specialist Specialist 337 £000 (542) 7,104 5,395 1,019 8,975 3,695 1,681 6,699 5,943 1,721 3,858 12.9% (3.9%) (0.4%) 21,621 19,802 20,344 24,379 39,004 15,290 11,908 10,006 (4,237) (5,918) 153,532 133,730 124,003 Medical Medical Services NOTES TO THE ACCOUNTS THE TO NOTES 302 915 £000 1.2% 5,887 5,180 5,824 8,999 1,636 4,640 2,124 5,276 3,595 1,325 9,134 2,892 17.8% (3.6%) 23,480 25,116 33,378 29,262 15,960 11,551 (3,004) (5,128) 141,212 116,096 117,828 Surgical Services ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2016/17 ACCOUNTS ANNUAL - TRUST FOUNDATION NHS EXETER AND DEVON ROYAL * [e] The segmental analysis discloses income and expenditure that is directly attributable at a service line level to a service line. Expenditure that is not directly attributable at a service at level line is disclosed separately. attributable directly is not a service that at level a service line to Expenditure attributable line. is directly that discloses and expenditure analysis income segmental The RTA income Services provided income Education R&D income Segmental analysis (continued) analysis Segmental Non-pay costs Non-pay Drugs NHS clinical income - staff income Non-patient * income Total costs Pay staff Medical & expense non-pay pay Total * Contribution % Contribution Overheads and impairments] PDC depreciation, interest, [excludes EBITDA EBITDA % * and impairments amortisation Depreciation, operating (deficit)Total surplus / * and transfers absorption by payable dividendPDC interest and net (deficit) / Net surplus % margin Net * Note analysis. segmental the in and net is shown £1,019k SOCI gross the in totalling absorption) transfer (including by income and other income Finance [a] service the at level. line attributable directly are not have £59,316k disclosed Overhead as they been separately [b] costs totalling service the at level. line attributable directly are not have £27,639k disclosed as they been separately costs totalling and impairment amortisation Depreciation, [c] service the at level. line attributable directly are not have £5,546k disclosed as they been separately costs totalling payable interest and net PDC [d] and amortisation. depreciation taxation, before Earnings interest, [e] was costs. as previouslynon-pay 2015/16 classified that within Overheads some expenditure include [f] 2016/17 within Non-patient income - other income Non-patient Clinical supplies Nursing staff staff Admin. Non clinical supplies Non clinical non-pay Other AHP staff staff Other 2.1 Page 22

Page 22 Royal Devon and Exeter NHS Foundation Trust - Annual Accounts 2016/17 [c] [a] [b] [d] Note [a] [b] [c] & [d] - - - £000 (142) deficit 59,067 (43,519) (15,406) (Increase) / / (Increase) decrease to SOCI SOCI to decrease - - figures reported SOCI in £000 6,537 403,566 417,084 (13,518) (20,055) SOCI balance SOCI Reconciliation between segmental analysis and and analysis segmental between Reconciliation £000 0.5% 1,888 2,672 1,064 8,619 4,033 6,537 11.3% (5.0%) 15,406 72,277 45,552 48,771 45,407 43,519 26,290 27,808 88,106 36,561 19,622 13,576 18,991 16,351 331,148 403,424 358,017 (13,518) (20,055) Trust total Trust ------1 1 8 7 16 72 N/A N/A N/A 478 397 104 £000 other 3,726 (1,106) (1,098) (1,576) (5,318) (5,422) (1,592) Corporate and 371 240 581 £000 7.9% 3.5% 3,414 6,061 1,869 6,157 4,288 9,571 7,730 1,779 3,165 2,249 4,980 16.5% 16,650 18,735 12,870 20,717 20,059 10,488 11,444 11,236 104,735 121,801 101,742 Services Specialist Specialist 424 £000 3,745 1,472 7,552 1,927 2,101 8,967 8,989 3,845 5,448 9,902 6,380 10.1% (1.9%) (5.9%) 23,937 37,951 13,726 18,837 14,735 17,492 12,445 (6,502) (8,603) (2,757) 114,181 145,359 130,624 NOTES TO THE ACCOUNTS THE TO NOTES Medical Services Medical 829 400 £000 8.9% 4,521 6,008 1,525 2,463 9,217 9,521 7,375 2,987 4,963 6,840 4,984 (2.4%) (7.5%) 31,690 31,419 18,956 12,189 15,523 12,483 (7,855) (3,334) 113,338 137,362 125,173 (10,318) Surgical Services Surgical ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2016/17 ACCOUNTS ANNUAL - TRUST FOUNDATION NHS EXETER AND DEVON ROYAL * [e] The segmental analysis discloses income and expenditure that is directly attributable at a service line level to a service line. Expenditure that is not directly attributable at a service at level line is disclosed separately. attributable directly is not a service that at level a service line to Expenditure attributable line. is directly that discloses and expenditure analysis income segmental The Non-patient income - staff income Non-patient * and impairments amortisation Depreciation, Segmental analysis (continued) 2015/16 comparatives 2015/16 (continued) analysis Segmental Nursing staff NHS clinical income RTA income Services provided * income Total costs Pay staff Medical costs Non-pay Drugs Clinical supplies supplies Non clinical & expense non-pay pay Total * Contribution % Contribution Overheads and impairments] PDC depreciation, interest, [excludes EBITDA EBITDA % operating (deficit)Total surplus / * payable dividendPDC interest and net (deficit) / Net surplus % margin Net * Note analysis. segmental the in and net £142k is shown SOCI gross the in totalling income and other income Finance [a] service the at level. line attributable directly are not have £43,519k disclosed Overhead as they been separately [b] costs totalling service the at level. line attributable directly are not have £15,406k disclosed as they been separately costs totalling and impairment amortisation Depreciation, [c] service the at level. line attributable directly are not have £6,537k disclosed as they been separately costs totalling payable interest and net PDC [d] and amortisation depreciation taxation, before Earnings interest, [e] Admin. staff Admin. AHP staff staff Other Education income Education non-pay Other R&D income Non-patient income - other income Non-patient 2.1 Page 23

Page 23 ROYAL DEVONRoyal DevonAND EXETER and Exeter NHS NHS FOUNDATION Foundation TrustTRUST - Annual - ANNUAL Accounts ACCOUNTS 2016/17 2016/17

NOTES TO THE ACCOUNTS

3. Income from activities 2016/17 2015/16 £000 £000

Elective income 78,219 80,642 Non-elective income 72,810 69,540 Outpatient income 56,520 54,146 Other NHS clinical income 121,151 116,103 A & E income 10,653 10,460 Private patient income 1,651 1,331 Other non-protected clinical income 74 50 Community services income from CCGs and NHS England 25,937 - 367,015 332,272

Income from commissioner requested services 365,290 330,891 Income from non-commissioner requested services 1,725 1,381 367,015 332,272

3.1 Income from activities - by source 2016/17 2015/16 £000 £000

NHS foundation trusts - 2 NHS trusts 26 49 CCGS and NHS England 364,164 328,809 Non-NHS - private patients 1,317 1,199 Non-NHS - overseas patients (non-reciprocal) 334 132 NHS injury scheme 851 1,063 Non-NHS - other 323 1,018 367,015 332,272

NHS Injury Scheme income is subject to a provision for doubtful debts of 22.94% (2015/16 - 21.99%) to reflect expected rates of collection based upon historical experience.

4. Other operating income 2016/17 2015/16 £000 £000

Research and development 18,796 19,362 Education and training 13,824 13,576 Charitable and other contributions to expenditure 350 105 Non-patient care services to other bodies 22,295 22,357 Staff recharges 4,330 4,655 Sustainability and transformation fund income 12,604 - Rental revenue from operating leases 120 134 Other 12,791 11,021 85,110 71,210

Included within "Non-patient care services to other bodies" are laundry services, transport services, payroll services, IT services, procurement services, estates services, pathology services, pharmacy services and drug sales totalling £12 million (2015/16 - £12 million).

Included within "Other income" above is catering income of £2.1 million, (2015/16 - £2.1 million), car parking income of £2.1 million (2015/16 - £2.0 million), nursery/crèche income of £1.2 million (2015/16 - £1.1 million), staff accommodation £0.6 million (2015/16 - £0.7 million).

Page 24

Page 24 Royal Devon and Exeter NHS Foundation Trust - Annual Accounts 2016/17 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2016/17

NOTES TO THE ACCOUNTS

5. Operating expenses 2016/17 2015/16 £000 £000 Services from other NHS foundation trusts 2,641 3,148 Services from NHS trusts 2,008 2,720 Services from other NHS bodies 615 929 Employee expenses - executive directors (see note 5.1) 1,073 924 Employee expenses - non-executive directors (see note 5.1) 149 145 Employee expenses - staff 268,353 243,925 Drug costs 52,768 49,075 Supplies and services - clinical (excluding drug costs) 43,695 44,072 Supplies and services - general 5,491 5,225 Establishment 2,703 2,300 Research and development - not included in employee expenses 12,950 13,629 Research and development - included in employee expenses (see note 6.1) 4,805 4,628 Transport 1,729 1,271 Premises 15,386 13,312 Increase / (decrease) in bad debt provision 58 (34) Depreciation 12,130 11,757 Amortisation of intangible assets 110 125 Impairments - Land and buildings 15,404 - Impairments - Other - 3,524 Audit fees - statutory audit 73 69 Non-audit fee - audit related assurance services 9 9 Non-audit fee - taxation advisory services 3 8 Non-audit fee - other non-audit services 14 - Internal audit fees 242 210 Clinical negligence - amounts payable to NHSLA (premiums) 12,164 11,101 Losses, ex gratia and special payments 168 132 (Gain) / Loss on disposal of plant and equipment and intangibles (5) 9 Consultancy 426 164 Other 8,306 4,623 463,468 417,000

Operating expenses - excluding land and buildings impairment charge 448,064 417,000 Land and buildings impairment charge (see note 15.3) 15,404 - 463,468 417,000

"Other expenditure" above includes operating lease expenditure, training courses and conferences, and patient travel.

The total employer's pension contributions are disclosed in note 6.1.

5.1 Directors' remuneration and other benefits 2016/17 2015/16 £000 £000 Aggregate directors' remuneration 1,115 993 Employer's contribution to pension scheme 107 76 Total 1,222 1,069

In the year ended 31 March 2017 six directors accrued benefits under defined benefit pension schemes (2016 - four).

5.2 Auditor's remuneration

The audit fee, which includes statutory audit and quality accounts, in 2016/17 was £82,000 (2015/16 - £78,000) including VAT not recoverable. This was the fee for an audit in accordance with the Code of Audit Practice issued by National Audit Office in 2015. Fees of £3,000 (2015/16 - £8,000) were incurred in respect of non-audit relating to VAT assurance services and fees of £14,000 (2015/16 £nil) were incurred for professional advice relating to non-audit services.

5.3 Auditor's liability

The Board of Governors has appointed KPMG LLP as external auditors. The engagement letter signed on 8th December 2014, states that the liability of KPMG, its members, partners and staff (whether in contract, negligence or otherwise) shall in no circumstances exceed £1 million in the aggregate in respect of all services (2015/16 - £1 million).

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NOTES TO THE ACCOUNTS

5.4 Operating leases 2016/17 2015/16 £000 £000 Operating lease payments recognised in expenses 4,307 1,974

Lease expenditure relates to minimum lease payments and is charged to the Statement of Comprehensive Income in a straight line basis over the term of the lease.

Future aggregate minimum lease payments due under non-cancellable operating leases are as follows:

2016/17 2015/16 Land and Land and buildings Other Total buildings Other Total £000 £000 £000 £000 £000 £000 No later than 1 year 3,388 396 3,784 320 264 584 Later than 1 year and no later than 5 years 6,045 560 6,605 1,274 523 1,797 Later than 5 years 2,908 - 2,908 3,200 - 3,200 12,341 956 13,297 4,794 787 5,581

On 1st October 2016, the Trust recognised a transfer by absorption of NHS community services in Exeter, East Devon and Mid Devon from Northern Devon Healthcare NHS Trust, further details are provided in Note 28. In taking on the community services in East Devon the Trust entered into a number of operating leases for the existing community buildings with NHS Property Services.

6. Staff costs and numbers

6.1 Staff costs 2016/17 2015/16 £000 £000 Salaries and wages 221,678 202,987 Social security costs 19,516 14,298 Employer contributions to NHSPA 26,042 23,913 Termination benefits 43 284 Agency and contract staff 6,952 7,995 274,231 249,477

Analysed into operating expenses (see note 5): Employee expenses staff 268,353 243,925 Employee expenses executive directors 1,073 924 Research and development 4,805 4,628 274,231 249,477

6.2 Average number of persons employed including directors Permanent Other 2016/17 2015/16 employees employees Total Total Number Number Number Number Medical and dental 660 50 710 684 Administration and estates 1,333 5 1,338 1,291 Healthcare assistants and other support staff 616 - 616 579 Nursing, midwifery and health visiting staff 2,672 4 2,676 2,361 Scientific, therapeutic, technical and healthcare science staff 975 2 977 890 Bank and agency staff - 251 251 287 Total 6,256 312 6,568 6,092

6.3 Staff exit packages 2016/17 2016/17 2015/16 2015/16 Exit package cost Number £000 Number £000 Less than £10,000 11 33 18 56 £10,000 to £25,000 1 10 4 56 £25,001 to £50,000 - - 1 32 £50,001 to £100,000 - - 2 140 £100,001 to £150,000 - - - - £150,001 to £250,000 - - - - Total number 12 43 25 284

Exit packages relate to staff redundancies and payments in lieu of notice and include employer's NIC.

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NOTES TO THE ACCOUNTS

7. Pensions

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:

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.

8. Retirements due to ill-health

During 2016/17 there were four (2015/16 - six) early retirements from the Trust agreed on the grounds of ill-health. The estimated additional pension liabilities of these ill-health retirements will be £193,000 (2015/16 - £299,000). The cost of these ill-health retirements will be borne by the NHS Pensions Agency.

9. The late payment of commercial debts (Interest) Act 1998

In 2016/17 the Trust did not incur expenditure (2015/16 - £nil) arising from claims made under this legislation.

10. Finance income 2016/17 2015/16 £000 £000 Interest on cash and cash equivalents 56 84

11. Finance expense 2016/17 2015/16 £000 £000 Loans from the Independent Trust Financing Facility 706 768 Unwinding of discount on provisions 5 5 Total 711 773

Page 27 Page 27 ROYAL DEVONRoyal ANDDevon EXETER and Exeter NHS NHS FOUNDATION Foundation TRUSTTrust - Annual - ANNUAL Accounts ACCOUNTS 2016/17 2016/17

NOTES TO THE ACCOUNTS

12. Better Payment Practice Code

2016/17 2016/17 2015/16 2015/16 Number Value Number Value £000 £000 Total non-NHS trade invoices paid in the year 112,482 211,654 109,708 147,378 Total non-NHS trade invoices paid within target 102,786 196,589 103,988 136,914 Percentage of non-NHS trade invoices paid within target 91.4% 92.9% 94.8% 92.9%

Total NHS trade invoices paid in the year 2,685 30,390 2,554 26,741 Total NHS trade invoices paid within target 2,224 25,283 2,317 25,472 Percentage of NHS trade invoices paid within target 82.8% 83.2% 90.7% 95.3%

The Better Payment Practice Code requires the Trust to aim to pay all valid non-NHS invoices by the due date or within 30 days of receipt of goods or a valid invoice, whichever is later.

13. Losses and special payments 2016/17 2016/17 2015/16 2015/16 Number Value Number Value £000 £000 Losses: Cash losses 7 2 4 - Bad debts and claims abandoned 13 3 30 1 Stores losses, including damage to buildings 1 91 2 63 Total losses 21 96 36 64

Special payments - Ex-gratia 80 72 85 68

Total losses and special payments 101 168 121 132

14. Intangible assets Software 14.1 Intangible assets at 31 March 2016 licences £000 Fair value at 1 April 2015 2,659 Additions - purchased 146 Impairments (816) Disposals (28) Fair value at 31 March 2016 1,961

Accumulated amortisation at 1 April 2015 1,433 Provided during the year 125 Eliminated on disposals (28) Accumulated amortisation at 31 March 2016 1,530

Net book value Purchased at 31 March 2016 431 Total at 31 March 2016 431

14.2 Intangible assets at 31 March 2017 Fair value at 1 April 2016 1,961 Additions - purchased 9 Fair value at 31 March 2017 1,970

Accumulated amortisation at 1 April 2016 1,530 Provided during the year 110 Accumulated amortisation at 31 March 2017 1,640

Net book value Purchased at 31 March 2017 330 Total at 31 March 2017 330

Page 28 Page 28 Royal Devon and Exeter NHS Foundation Trust - Annual Accounts 2016/17 - 350 note £000 (712) (707) (755) Total 1,709 1,030 5,234 4,160 3,724 49,174 39,856 12,130 (1,275) 202,940 242,796 199,216 248,734 (21,016) (15,404) complies owns, also Trust and ------45 45 45 43 10 45 the (43) (10) £000 that fittings fittings Standards estate Furniture and and Furniture - - - - - actual 206 126 482 Reporting (35) (35) £000 (179) (106) 5,167 3,486 6,525 3,486 1,768 1,373 7,769 the 10,011 by technology technology Information Information Financial provided ------72 is 855 286 935 286 100 (20) (20) £000 1,221 1,169 as International Transport Transport equipment equipment with potential - - - 350 169 894 746 £000 service (657) (652) (639) 1,460 1,562 3,519 29,229 13,661 46,012 32,351 12,915 44,181 (1,053) accordance Plant and and Plant in machinery machinery same the Valuer, ------give £000 1,428 1,428 1,428 2,743 1,401 (2,716) District would on account on the that construction construction Assets under Assets and payments payments and by ------96 buildings 190 107 £000 (286) (197) 2,128 2,128 2,128 2,218 undertaken Freehold dwellings was equivalent ------NOTES TONOTES ACCOUNTS THE 779 modern valuation £000 1,717 4,053 7,042 2,978 13,688 172,696 172,696 169,718 179,784 (20,730) (13,637) Freehold The buildings buildings dwellings excluding excluding utilising of 2017. ------basis £000 9,255 9,255 9,255 March 10,825 (1,570) the 31 on at as ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2016/17 ACCOUNTS TRUST - ANNUAL FOUNDATION NHS EXETER AND DEVON ROYAL Freehold land buildings revalued and land were value to dwellings and requirements buildings land, Treasury's Trust's HM Property, plant and equipment and plant Property, Cost or 2016 valuation at 1 April -Additions purchased -Additions donated Transfers absorption by Reclassifications Impairment Revaluation Disposals Disposals - harmonisation of accounting policies Total at 31 March 2017 Accumulated depreciation 2016 at 1 April Transfers absorption by Provided during the year Revaluation on disposalsEliminated Disposals - harmonisation of accounting policies Accumulated depreciation at 31 March 2017 Purchased at 31 March 2017 Donated at 31 March 2017 Total at 31 March 2017 There were no assets under held finance leases, hire purchase contracts or private (PFI) finance initiative at the statement position date. of financial The with Property, plant and equipment at the statement of financial position date comprise the following elements: following the comprise date position financial of statement the at equipment and plant Property, 15.3 provides further details. 15. 15.1 Page 29 Page 29 Royal Devon and Exeter NHS Foundation Trust - Annual Accounts 2016/17 - 105 £000 Total 7,694 3,280 49,174 39,754 11,757 (2,346) (2,337) (2,708) 196,280 199,560 245,989 248,734 ------45 45 45 45 £000 fittings fittings Furniture and and Furniture - - - 656 121 £000 (622) (622) 5,167 4,751 1,038 2,602 2,602 7,614 7,769 technology technology Information Information ------21 855 716 139 314 314 £000 1,148 1,169 Transport Transport equipment equipment - 105 767 440 £000 1,502 3,534 29,229 27,410 43,531 44,181 14,512 14,952 (1,724) (1,715) Plant and and Plant machinery machinery ------£000 4,768 2,463 2,743 2,743 2,743 (2,708) (1,780) on account on construction construction Assets under Assets and payments payments and ------95 95 190 £000 2,218 2,218 2,028 2,028 Freehold dwellings - - - - NOTES TONOTES ACCOUNTS THE 357 £000 3,587 6,737 6,951 2,840 13,688 175,840 179,784 163,256 166,096 Freehold buildings buildings dwellings excluding excluding ------£000 10,825 10,825 10,825 10,825 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2016/17 ACCOUNTS TRUST - ANNUAL FOUNDATION NHS EXETER AND DEVON ROYAL Freehold land Property, plant and equipment (continued) equipment and plant Property, Cost or 2015 valuation at 1 April -Additions purchased -Additions donated Reclassifications Impairment Disposals Total at 31 March 2016 Accumulated depreciation 2015 at 1 April Provided during the year on disposalsEliminated Accumulated depreciation at 31 March 2016 Purchased at 31 March 2016 Donated at 31 March 2016 Total at 31 March 2016 There were no assets under held finance leases, hire purchase contracts or private (PFI) finance initiative at the statement position date. of financial Property, plant and equipment at the statement of financial position date comprise the following elements: following the comprise date position financial of statement the at equipment and plant Property, 15. 15.2 Page 30 Page 30 Royal Devon and Exeter NHS Foundation Trust - Annual Accounts 2016/17 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2016/17

NOTES TO THE ACCOUNTS

15. Property, plant and equipment (continued)

15.3 Impairment and revaluation of land, buildings and dwellings

The Trust's land, buildings and dwellings were revalued by the District Valuation Office as at 31 March 2017. The Trust's specialised buildings and associated land have been valued using the depreciated replacement cost method, based upon providing a modern equivalent asset (MEA). A fundamental principle of MEA valuations is that a hypothetical buyer would purchase the least expensive site that would be suitable and appropriate for the existing operations. The valuation of the Trust's specialised land and buildings has therefore been based upon the Trust hypothetically being located on a suitable alternative site away from the city centre, where the cost of the land would be significantly lower, but where the Trust would still be able to re-provide its services. In 2016/17 there has been a net overall increase of £9.8m in the value of the Trust's Estate. A £15.4m impairment has been incurred and is recorded in the property plant and equipment note 15.1, this has been recognised as an impairment charged to the Statement of Comprehensive Income. An increase in value of £25.2m has been recognised within the revaluation reserve and is mainly due to a general rise in construction costs.

16. Investments in associates and joint ventures 31 March 2017 31 March 2016 £000 £000 Carrying value at 1 April - - Acquisitions in year 5 - Share of profit / (loss) - - Carrying value at 31 March 5 -

On the 1st December 2016 the Trust acquired a 20% shareholding in a new company Dextco Limited. Dextco Limited is a joint venture between the Trust and a number of local public sector bodies with the aim of developing energy projects in Exeter.

17. Inventories

17.1 Inventories held at year end 31 March 2017 31 March 2016 £000 £000 Drugs 1,594 1,698 Work in progress 233 86 Consumables 6,764 4,480 Energy 189 172 Inventories carried at fair value less costs to sell 281 228 Total inventories 9,061 6,664

17.2 Inventories recognised in expenses 2016/17 2015/16 £000 £000 Inventories recognised in expenses 57,372 56,291 Write-down of inventories recognised in expenses 91 49 Total inventories recognised in expenses 57,463 56,340

18. Trade and other receivables 31 March 2017 31 March 2016 £000 £000 Current NHS receivables 9,840 10,435 Non-NHS receivables 3,102 2,927 Provision for impaired receivables (110) (51) Prepayments 2,790 1,999 Accrued income 8,628 1,992 Other receivables 202 153 PDC dividend receivable 318 1 VAT receivable 475 300 Total current trade and other receivables 25,245 17,756

Non-current Accrued income 963 972 Total trade and other receivables 26,208 18,728

Provision for impairment of receivables At 1 April 51 85 Increase / (decrease) in provision 58 (34) Unused amounts reversed 1 - At 31 March 110 51

The provision for impairment of receivables relates to specific receivables over 3 months old.

PagePage 31 31 ROYALRoyal DEVON Devon AND and EXETER Exeter NHS NHS Foundation FOUNDATION Trust TRUST - Annual - ANNUAL Accounts ACCOUNTS 2016/17 2016/17

NOTES TO THE ACCOUNTS

18. Trade and other receivables (continued)

18.1 Ageing of impaired financial assets 31 March 2017 31 March 2016 Trade and other Trade and other receivables receivables £000 £000 0 - 30 days 718 797 30 - 60 Days - - 60 - 90 days - - 90 - 180 days 234 156 Over 180 days 1,352 1,106 2,304 2,059

18.2 Ageing of non-impaired financial assets 0 - 30 days 3,420 2,199 30 - 60 days 1,129 2,830 60 - 90 days 813 1,011 90 - 180 days 984 476 Over 180 days 514 269 6,860 6,785

19. Current trade and other payables 31 March 2017 31 March 2016 £000 £000 NHS payables 3,675 5,057 Trade payables - capital 1,462 1,267 Other trade payables 4,709 4,443 Other taxes payable 5,733 4,586 Other payables 3,940 3,533 Accruals 18,220 12,292 37,739 31,178

Other liabilities Other deferred income 2,472 1,867

20. Borrowings

Current 31 March 2017 31 March 2016 £000 £000 Loans from Foundation Trust Financing Facility 1,270 1,270

Non-current Loans from Foundation Trust Financing Facility 12,591 13,861

Total borrowings 13,861 15,131

Amounts falling due within: In one year or less by instalments 1,270 1,270 Between one and five years by instalments 5,082 5,082 Over five years by instalments 7,509 8,779 13,861 15,131

Two loans are repayable to the Secretary of State for Health.

The first loan of £17 million, was entered into in the year ended 31 March 2006. It is a repayable over a 20 year period, ending 30 March 2026, by equal quarterly instalments. The interest rate of the loan is fixed at 4.55% per annum.

The second loan of £10 million, was entered into in the year ended 31 March 2007, and is repayable over a 25 year period, ending 30 March 2032, by equal quarterly instalments. The interest rate of the loan is fixed at 5.05% per annum.

Page 32 Page 32 ROYAL DEVONRoyal Devon AND EXETER and Exeter NHS NHS FOUNDATION Foundation Trust TRUST - Annual - ANNUAL Accounts ACCOUNTS 2016/17 2016/17

NOTES TO THE ACCOUNTS

21. Provisions Early Legal Other Total retirements claims £000 £000 £000 £000 At 1 April 2016 107 307 281 695 Change in the discount rate 8 - 35 43 Arising during the year 5 97 - 102 Utilised during the year (10) (52) (16) (78) Reversed unused - (167) (2) (169) Unwinding of discount 1 - 4 5 At 31 March 2017 111 185 302 598

Expected timing of cash flows: 31 March 2017 31 March 2016 £000 £000 In one year or less 211 333 Between one and five years 103 99 Over five years 284 263 598 695 Legal claims relate to employee and public liability claims.

The "Other" category relates to injury benefit claims against the Trust.

Contingent liabilities relating to legal claims are shown in note 24.

The NHS Litigation Authority (NHSLA) is carrying provisions as at 31 March 2017 in relation to Existing Liabilities Scheme and in relation to Clinical Negligence Scheme on behalf of the Trust of £89.9m (2016 - £97.6m).

22. Cash and cash equivalents 31 March 2017 31 March 2016 £000 £000 At 1 April 16,507 27,367 Transfer by normal absorption 3 - Net change in the year 1,023 (10,860) At 31 March 17,533 16,507

Broken down into: Cash at commercial banks and in hand 24 21 Cash with Government Banking Service 17,509 16,486 Cash and cash equivalents as in SoFP and Cash Flow Statement 17,533 16,507

Cash and cash equivalents represents cash in hand and deposits with any financial institution with a short term maturity period of three months or less from the date of the acquisition of the investment.

23. Capital commitments

Commitments under capital expenditure contracts, which relate to property, plant and equipment, at the statement of financial position date were £1,098,000 (2016 - £1,390,000).

24. Contingent liabilities 31 March 2017 31 March 2016 £000 £000 Contingent NHSLA legal claims. - -

Page 33

Page 33 ROYAL DEVONRoyal Devon AND EXETER and Exeter NHS NHS FOUNDATION Foundation TrustTRUST - Annual - ANNUAL Accounts ACCOUNTS 2016/17 2016/17

NOTES TO THE ACCOUNTS

25. Related party transactions

The Trust is a public benefit corporation established under the NHS Act 2006. The Department of Health has the power to control the Trust and therefore can be considered to be the Trust's parent. The Trust's Accounts are included within the NHS Foundation Trust Consolidated Accounts, which are included within the Whole of Government Accounts. The Department of Health is accountable to the Secretary of State for Health. The Trust's ultimate parent is therefore HM Government.

The Trust is under the common control of the Board of Directors.

Directors' remuneration and other benefits are disclosed within the operating expenditure, note 5.1.

The Royal Devon and Exeter NHS Foundation Trust is the Corporate Trustee of the Royal Devon and Exeter NHS Foundation Trust General Charity ("Charity"), registered charity number 1061384, registered office Bowmoor House, Barrack Road, Exeter, EX2 5DW. The Charity's objective is for any charitable purpose and purposes relating to the National Health Service wholly or mainly for the Royal Devon and Exeter NHS Foundation Trust. The Trust has received during the year £58,000 (2015/16 - £58,000) revenue income and £350,000 (2015/16 - £105,000) capital contributions from the Charity. At 31 March 2017 the Trust was due £69,000 (2015/16 - £76,000) from the Charity. The Charity's most recent audited accounts were for the year ended 31 March 2016 and the Charity held aggregated reserves of £1,626,000.

During the year the Royal Devon and Exeter NHS Foundation Trust has had a significant number of material transactions with the Department of Health ("DoH"), and with other entities for which the DoH is regarded as the parent of those entities. Income from activity - by source (note 3.1) and the operating expense (note 5) provides details of revenue transactions with those entities. Below are considered to be the significant material transactions.

Income Expenditure Receivables Payables £000 £000 £000 £000 2016/17 Department of Health (excludes PDC dividend) 17,223 (1) 318 18 Health Education England 14,252 29 63 73 NHS England (Includes Bristol North Somerset and South Gloucester LAT) 99,365 4 8,474 4 NHS North East West Devon CCG 251,407 381 1,450 815 NHS Somerset CCG 4,934 - 51 3 NHS South Devon and Torbay CCG 16,248 - 32 51 Northern Devon Healthcare NHS Trust 6,421 3,045 2,645 1,499

2015/16 Department of Health (excludes PDC dividend) 17,593 9 8 - Health Education England 13,862 - 24 174 NHS England (Includes Bristol North Somerset and South Gloucester LAT) 83,757 - 4,237 - NHS North East West Devon CCG 219,506 704 2,385 3,518 NHS Somerset CCG 4,875 - - 377 NHS South Devon and Torbay CCG 16,582 - 36 51 Northern Devon Healthcare NHS Trust 7,200 2,030 918 373

PagePage 34 34 ROYAL DEVONRoyal Devon AND EXETER and Exeter NHS NHS FOUNDATION Foundation TrustTRUST - Annual - ANNUAL Accounts ACCOUNTS 2016/17 2016/17

NOTES TO THE ACCOUNTS

26. Financial instruments

A financial instrument is a contract that gives rise to both a financial asset in one entity and a financial liability or equity instrument in another entity. IFRS 7, Financial Instruments: Disclosures, requires disclosure of the role that financial instruments have had during the period in creating or changing the risks an entity faces in undertaking its activities. The financial assets and liabilities of the Trust are generated by day to day operational activities rather than being held to change the risks facing the Trust in undertaking its activities.

Credit risk

Credit risk arises when the Trust is exposed to the risk that a party is unable to meet its obligation to the Trust in respect of financial assets due.

Financial assets mainly comprise monies due from clinical commissioning groups (CCG) and local area teams (LAT) for services rendered by the Trust in fulfilment of service agreements, and cash balances held on deposit. It is considered that financial assets due from these organisations pose a low credit risk as these entities are funded by HM Government.

A significant proportion of the Trust's cash balances are held on deposit with the Government Banking Service, and as such the credit risk on these balances is considered to be negligible.

Liquidity risk

Liquidity risk arises if the Trust is unable to meet its obligations arising from financial liabilities. The Trust's financial liabilities mainly arise from net operating costs, which are mainly incurred under legally binding annual service agreements with CCG and LAT, and liabilities incurred through expenditure on capital projects. Other liquidity risks are loans repayable to the Foundation Trust Financing Facility.

Income from contracted activities with CCG and LAT are based upon a nationally set tariff, which under Payment by Results is paid to the Trust in twelve monthly instalments throughout the year; any performance in excess of agreed targets is paid in accordance with the terms of the relevant contract. Payment by instalments allows the Trust to accurately forecast cash inflows and through the preparation and review of cash flow forecasts, as well as the controls in place governing the authorisation of expenditure, ensures that the Trust maintains sufficient funds to meet obligations as they fall due.

Market risk

Market risk arises when the Trust is exposed to the risk that the fair value or future cash flows of a financial instrument will fluctuate because of changes in market prices. Market risk comprises three types of risk: currency risk, interest rate risk and other price risk.

Currency risk

The Trust receives income denominated in sterling. The Trust, on occasion, does enter in agreements to make payments in non-sterling denominated currencies. Non-sterling payments are principally short term liabilities and for non-significant amounts. Given this, the Trust does not consider that it is exposed to any material currency risk and therefore has elected not to hedge its exposure.

Interest rate risk

The Trust does not enter into contracts where cash flows are determined by the use of a variable interest rate.

Other price risk

The Trust enters into legally binding contracts with both its customers and suppliers that stipulate the price to be paid. As such it does not consider itself exposed to material other price risk.

Page 35 Page 35 Royal Devon and Exeter NHS Foundation Trust - Annual Accounts 2016/17 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2016/17

NOTES TO THE ACCOUNTS

26. Financial instruments (continued)

26.1 Financial assets by category Loans and receivables £000 NHS receivables 10,435 Accrued income 2,964 Other receivables 3,029 Cash at bank and in hand 16,507 Total at 31 March 2016 32,935

NHS receivables 9,840 Accrued income 9,591 Other receivables 3,194 Cash at bank and in hand 17,533 Total at 31 March 2017 40,158

An analysis of any impairment of financial assets is provided in note 18.1.

26.2 Financial liabilities by category Other financial liabilities £000 Borrowings 15,131 NHS payables 5,057 Other payables 7,976 Accruals 12,292 Capital payables 1,267 Provisions under contracts 695 Total at 31 March 2016 42,418

Borrowings 13,861 NHS payables 3,675 Other payables 8,649 Accruals 18,220 Capital payables 1,462 Provisions under contracts 598 Total at 31 March 2017 46,465

26.3 Fair value

For all of the financial assets and liabilities at 31 March 2017 and 31 March 2016 the fair value is equal to book value.

27. Third party assets

The Trust held £nil cash at bank and in hand at 31 March 2017 (2016 - £nil) relating to monies held on behalf of patients.

Page 36 Page 36 ROYAL DEVONRoyal Devon AND EXETERand Exeter NHS NHS FOUNDATION Foundation TrustTRUST - Annual - ANNUAL Accounts ACCOUNTS 2016/17 2016/17

NOTES TO THE ACCOUNTS

28. Transfers by absorption

On 1st October 2016, the Trust recognised a transfer by absorption of NHS community services in Exeter, East Devon and Mid Devon from Northern Devon Healthcare NHS Trust. The total gain relating to this transfer by absorption is £0.786m.

On the transfer a harmonisation of accounting policies was undertaken to realign the accounting policies of the assets that had been capitalised and transferred as detailed in Note 1. The adjustments for this are shown below.

Impact of transfers by absorption upon the Trust's financial statements

Harmonisation Transfer by of accounting absorption policies Total 2016/17 2016/17 2016/17 £000 £000 £000 Statement of Comprehensive Income Gains arising from transfers by absorption 786 - 786

Statement of Financial Position Non-current assets Property, plant and equipment 679 (520) 159

Current assets Inventories 104 - 104 Cash and cash equivalents 3 - 3 107 - 107

Total assets 786 (520) 266

Statement of Changes in Taxpayers Equity Income and Expenditure Reserve 786 (520) 266

The presentation of historical financial performance, prior to the Trust receiving the transfer of community services, is not practical due to the limited financial information available to the Trust.

Since the acquisition of the community services the revenue performance has been reported to the Trust's Board of Directors within the monthly integrated performance report. This financial information is included within the Segmental Analysis note disclosed within note 2.1.

29. Accounting standards issued and not adopted

The accounts have been prepared in accordance with the 2016/17 Department of Health Group Accounting Manual (GAM) issued by Department of Health. The accounting policies contained in that manual follow International Reporting Standards (IFRS) and HM Treasury's Financial Reporting Manual to the extent that they are meaningful and appropriate to NHS foundation trusts. Below is a list of recent standards issued but not yet adopted in the NHS. It is not known or it is reasonably estimated that when these accounting standards are adopted they will not materially affect the Trust's annual accounts.

IFRS 9 Financial instruments

IFRS 14 Regulatory deferral accounts

IFRS 15 Revenue contracts with customers

IFRS 16 Leases

Page 37 Page 37 Royal Devon and Exeter NHS Foundation Trust - Annual Accounts 2016/17

Page 38 Quality Report 2016/17 Royal Devon and Exeter NHS Foundation Trust

Quality Report 2016/17 Contents Page CHIEF EXECUTIVE’S INTRODUCTION...... 5 PROGRESS ON OUR 2016/17 PRIORITIES: GOVERNOR PRIORITIES...... 7 PROGRESS ON OUR 2016/17 PRIORITIES: TRUST PRIORITIES...... 11 Patient Safety Programme 2016/17...... 15 IMPROVEMENTS TO QUALITY AND SAFETY 2016/17...... 18 OUR PRIORITIES FOR 2017/18: GOVERNOR PRIORITIES...... 24 OUR PRIORITIES FOR 2017/18: TRUST PRIORITIES...... 25 Duty of Candour...... 31 NHS Staff Survey Results for indicators KF19 and KF27...... 31 Review of Services...... 31 Participation in Clinical Audit...... 31 Participation in Clinical Research...... 32 Goals Agreed with Commissioners...... 33 COMMISSIONING FOR QUALITY AND INNOVATION SCHEMES (CQUIN) 2016/17...... 34 CARE QUALITY COMMISSION...... 39 NHS Number and General Medical Practice Code Validity...... 40 Information Governance...... 40 Clinical Coding...... 40 CORE INDICATORS ...... 41 Single Oversight Framework...... 50 STATEMENT FROM THE COUNCIL OF GOVERNORS: ANNEX A...... 51 STATEMENT FROM THE NEW DEVON CCG: ANNEX B...... 52 STATEMENT FROM HEALTHWATCH DEVON: ANNEX C...... 53 STATEMENT FROM THE HEALTH AND WELLBEING SCRUTINY COMMITTEE: ANNEX D...... 54 STATEMENT OF DIRECTORS’ RESPONSIBILITIES FOR THE QUALITY REPORT: ANNEX E...... 55 CLINICAL AUDIT: ANNEX F...... 56 INDEPENDENT AUDITOR’S REPORT TO THE COUNCIL OF GOVERNORS OF ROYAL DEVON AND EXETER NHS FOUNDATION TRUST ON THE QUALITY REPORT...... 73

Page 3

Quality Report 2016/17 CHIEF EXECUTIVE’S INTRODUCTION Welcome to our annual Quality Report 2016/17 Our 2016/17 Quality Report sets out the progress, achievements and challenges we have faced during the year to deliver safe, high quality integrated care delivered with courtesy and respect to the people and communities we serve in Devon and beyond. Our annual Quality Report provides an overview of:

● The safety and quality of our services over the last year and how we have performed

● Some of our key achievements and challenges

● The progress we have made against the priorities set out in last year’s Quality Report

● Our quality priorities for the coming year In addition, the report provides a commentary on our quality performance during the year from our Governors, our principal commissioners (New Devon Clinical Commissioning Group), Devon Health and Wellbeing Scrutiny Committee and Devon Healthwatch. This year the Trust has worked hard to maintain its focus on delivering high quality and safe services for our people, patients and communities and making strides to transform the care we deliver. This year we have, once again, seen demand increase for our services particularly for our Emergency Department. This trend is in line with all NHS providers in England and the reasons for this are now well rehearsed. This year, as this report sets out in more detail, we have sought to rethink how best to manage these pressures which have paid dividends in helping the Trust reduce the number of days in which we were at a red escalation level and mitigating actions were necessary. The approach we have taken, which includes changes in how we manage patients to avoid bed occupancy, strengthening our partnerships with others, and – most importantly – shifting attitudes and behaviours of both staff and patients – shows that we are now in the business of making the transformational changes in care that are required to ensure that we can continue to provide high quality services sustainably. Similarly, the progress made on enabling people to leave hospital when they are fit and ready to do so is also outlined in the report. The range of changes we have implemented again amply demonstrate that the Trust is making the type of fundamental shifts in care that are required. At the heart of this shift are not the technical or service changes that are implemented – important though these are. Rather it is the change in mind-sets, attitudes, expectations and culture of our workforce, patients and carers and the wider populous that are key. I believe it is fair to say that we have all become used to an NHS that is always there for us no matter and that is something to be celebrated. An NHS that remains free at the point of access and is available to all of our citizens is something that must not change. But all of us need to consider how we can better manage our side of the deal – keeping ourselves fit, active and healthy, using public services such as A&E as wisely as possible, understanding that hospital is the place of last resort, and that we all have a stake in strengthening our local communities so that we build resilience. Helping people and communities to adapt to the realities of the way in which the NHS is transforming is a significant task and requires on-going and honest conversations. This is a task that we have started but I recognise that much more needs to be done on this agenda going forward. Equally important is the way our own staff also need to adapt to the new model of care that we are now putting in place across Devon in line with the NHS Five year Forward View. This Trust has a long and proud history of making continuous improvements but the scale of the change that we are now embarked on is formidable and, from some staff, this will present some genuine challenges. I am heartened, though, that in the results from the 2016 NHS staff survey, our staff score really well on the overall indicator on engagement and also score exceptionally well on teamwork as well as on other indicators. This represents a sustained improvement in performance that is astonishing given the context in which we are operating. This suggests to me that our staff are well placed and equipped to help lead and guide the changes necessary. This is underlined by the sheer number of brilliant examples within the report of positive changes to quality and safety. In my role as a new Chief Executive, I have consciously “gone back to the floor” to better understand our core business but most importantly the staff who deliver each and every day either in a direct patient-facing role or in our vital support services. As a senior member of the team at the RD&E for the last 8 years I knew full

Page 5 Quality Report 2016/17 well that we had a dedicated workforce. However, seeing this up close across a range of different areas has been a real inspiration for me and a source of immense pride. Patients, family and carers rightly expect that, when they come into the Trust, they will receive the best possible care, that they will be safe and cared for, that the environment will be clean and infection free and they will be treated with compassion, dignity and consideration. Thanks to the dedication, commitment and hard work of our staff and volunteers, we strive each and every day to meet these expectations despite the pressures we face. I would like to take this opportunity to thank each and every member of staff for the part they play in contributing to first rate patient care. The quality and safety of our patients remains at the very top of our agenda alongside our broader commitment to helping people live healthy lives in the community. This is reflected in the priorities we and our Governors have set out for the coming financial year. These priorities reflect on-going improvements in quality and safety for our patients and the wider community. We have sought to include priorities that are genuinely stretching so that we are continuing to do all we can for the people who need our services. The Quality Report is prepared in line with the requirements set out in the Quality Accounts legislation (part of the Health Act 2009) and Monitor’s annual reporting guidance. To the best of my knowledge and belief, the information contained in this document is accurate and, on behalf of the Board, I am confident to stand by its contents.

Suzanne Tracey Chief Executive

Date: 24 May 2017

Page 6 Quality Report 2016/17 PROGRESS ON OUR 2016/17 PRIORITIES Governor Priorities

● Patient experience of the referral and booking process and how the Trust manages the cancellation/postponement and amendment of appointments

● Mental Health Services focusing on maternity and young people

Outpatient Services condition. To prevent unnecessary appointments for this group of patients and free up vital clinic capacity, In 2015/16 the Governors asked the Trust to the Macular Team has worked closely with the focus on outpatient services as a priority area for Macular Society to enable their safe discharge. When development. Over the past 12 months a great deal discharged, these patients are now provided with of management attention has gone into reviewing ‘discharge packs’ that contain detailed information and improving outpatient services, yielding some on what triggers to look out for in their own eye encouraging improvements. For example, our health, as well as contact details for the Macular Surgical Outpatient Department and both Outpatient Team should they have any concerns or queries. clinics in the centre for Women’s Health have received Silver OQUAT (the Trust’s Outpatient Quality Audit Another important outpatient service which has Tool) in 2016; a reflection of the excellent care been significantly improved as a result of the received by patients and a testament to the strong focus on outpatient services is the Preparation for nursing leadership in these areas. Our challenge Surgery (PFS) Service, which ensures that patients however is to build upon this work to systemically undergoing operations are well supported and ready review and improve outpatient booking processes for their day of surgery. The service was previously across the Trust in 2017/18. spread across a number of locations, which made it hard to work closely as a team and often meant With 75,000 outpatient appointments each year, that patients had to walk to multiple places during Ophthalmology is the speciality which sees the most outpatient appointments, which could be confusing outpatients in the hospital. Our Ophthalmology and stressful. A project was undertaken to review the services have seen significant improvement over the situation and implement solutions which resulted in past year with the following impressive developments the service being rationalised into a single area. This for patients: has provided the following benefits:

● The glaucoma practitioner service relocated ● Less confusion and stress for patients to new facilities in Heavitree, which enabled significantly more patients to be seen.This has ● Enabled one stop services, where patients see reduced the backlog of patients requiring their surgeon and the PFS team at the same time treatment from 900 to zero! ● Provided greater economies of scale through ● Macular and diabetic virtual clinics have been closer team working and cross cover introduced as a part of a 4-tiered approach to arrangements ensuring patients are triaged to ensure they ● Modernised the environment for patients and receive the right professional treatment and care. staff This has tripled the volume of patients which can be seen in a clinic from 10 to 30. ● Increased capacity by over 2500 patients per year at no additional cost! ● Overall, these service changes have been successful in reducing the backlog of Looking forward to 2017/18, our challenge is to build ophthalmology patients from . upon these individual successes and systematically review our outpatient services, including our booking Safe Discharge of Stable Macular Patients processes. This will allow us to streamline the service A further innovation implemented by the for the patients who use our 300,000 outpatient Ophthalmology team has been the review of the care appointments each year. To support this important pathway for patients with macular degeneration. work, the Trust has allocated additional project Historically, this group of patients has been followed management support for the forthcoming year. The up for life despite experiencing no change in their project team will work within the Trust, including our

Page 7 Quality Report 2016/17 community services, as well as with other providers The Trust was also delighted to win the Community within the Sustainable Transformation Plan footprint Perinatal Mental Health Team of The Year – ‘Positive to share and adopt best practice from neighbouring Practice in Mental Health’ award – in November organisations to fundamentally review our outpatient 2016. This was a national award and is one the Trust model (please see page 32 “Clinical Conversations” is extremely proud of. The close collaborative working which is one example of the proposed changes). together (Maternity and Mental Health) is the reason this has been achieved for women and families. Mental Health Services Focus on The Positive Practice Mental Health collaborative Maternity and Young People identifies and disseminates positive practice by working with organisations to facilitate shared The RD&E Perinatal Team has been in place since learning and raise the profile of Mental Health. 2009 and during the last 7 years we have seen They share practice in a variety of ways including considerable expansion. We continue to work closely events, such as the national MH Awards to recognise as a team of Specialist Midwives, Perinatal Mental excellence in Mental Health services. This award Health Practitioners and a Perinatal Consultant placed a spotlight on our service and showcased Psychiatrist – running clinics in the Centre for the effective collaboration between Maternity and Women’s Health, seeing women on the Labour, Mental Health services which ensures a seamless Antenatal/Postnatal Ward and in the community. service for our women. The team provides a comprehensive prediction and detection pathway with Community Midwives Mental Health Services and Young People identifying women with mental health concerns early in pregnancy and offering a targeted response Recent statistics highlight Devon as having the to their level of mental health need to promote second highest number of referrals for young people mental wellbeing. The team offers preconceptual (aged 10-24) who have self-harmed in the country. assessments and accept new postnatal referrals Somerset has the highest. This suggests that mental for women who are experiencing mental health health issues for young people continue to be a relapse. Annual training is provided to all our Trust challenge throughout the country. However, in obstetricians, midwives and support workers to NEW Devon, and particularly this Trust, services for ensure best practice is embedded in the service. these young people are continually reviewed and various local initiatives have been introduced, which The pathway will be extending in the new financial not only help them with their daily mental health year (2017/18) which is exciting. The team has challenges, but have also reduced the number of submitted a bid to NHS England. The intention is young people who have to be transferred out of the to extend the service currently run with the aim to area to receive specialised mental health care. This is reach out to more women in different ways to treat particularly important as it is difficult to evaluate the mental health concerns in a timely way. Following a effectiveness of these out-of-area specialised Mental combined bid for additional funds with New Devon Health units, and often the young person is moved and South Devon and Torbay Clinical Commissioning to a placement hundreds of miles away from their Groups the Trust will soon have across the whole of home, family, and friends. In addition, the costs of Devon and in addition to current staffing: out-of-area placements are high, and reducing these costs means the funding can be reinvested in services ● Dedicated Nursery Nurses locally. ● Perinatal Clinical Psychologists Mental Health services for children and young people ● Junior Doctors (mental health) are provided by Child and Adolescent Mental Health Services (CAMHS). When there is a requirement for ● Ability to accept under 18s – in the RD&E/Exeter admission this will be to our children’s unit – Bramble, Team this will mean our pathway is open to all where we can provide medical and nursing care. women in the perinatal period. The staff on Bramble have excellent skills when caring ● Peer supporters with lived experience for children and young people with acute illness. However, they do not have specialised mental health These team members will be working with women training, and therefore the appropriate training and booked to deliver or who have delivered at the RD&E knowledge required to care for young people with as well as North Devon District Hospital, Torbay and more complex mental health needs. Derriford.

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We have developed a close working relationship with An Assertive Outreach Service has been created the CAMHS service to ensure these children and whereby specialist CAMHS workers support young adolescents receive the right care. people to stay safely at home and avoid hospital admission. They also help them to engage with more For some of the young people, once their acute activities, access education, and employment within illness has been treated there can be significant their local community. It has resulted in a reduction delays in them leaving Bramble, particularly if they in young people having to be transferred out of the require a Tier 4 Mental Health bed, which is in a area to specialist inpatient psychiatric units. As the specialised psychiatric unit where their mental health costs used to send young people out-of-area reduce, issues can be treated more therapeutically. they can be re-invested in projects such as this where To continue to support young people with mental services are provided locally, and their success can be health conditions within Exeter and East Devon the evaluated closely. Trust is an active partner and works in collaboration Specialist Training and Facilities for Bramble with CAMHs to provide a variety of services. These Staff are described below: There will always be a need for some of the above Eating Disorders young people to be admitted to Bramble ward for This is a collaborative multidisciplinary team (MDT) medical treatment and nursing care. It should be service between paediatrics, dietetics, nursing, and highlighted that in a small number of cases there is a CAMHS. There are approximately 70-80 young level of risk with regard to their antisocial behaviour. people on the caseload, with 50-60 new cases per Unfortunately this can also sometimes be unpleasant year. Most are managed as Outpatients, but we have for other children and their parents on the ward, and short-term structured ward admissions when needed. the staff. This has resulted in the service being rated as 1 of 5 To try and prevent and/or restrict the opportunity for ‘Good Practise’ Models by NHS England Guidance these incidents all Bramble nursing staff from sister on services for Eating Disorders in Young People. and above have or will receive Conflict Resolution The success has resulted in a reduction in out of area and Breakaway training, which focuses on effective transfers. communication, recognition of triggers, and body Medically Unexplained Conditions language to de-escalate challenging situations to keep themselves and others safe. This is a pilot study whereby a multidisciplinary team made-up from paediatrics, CAMHs, and education To support this, the unit has applied and been provides services for young people with medically successful in obtaining national funding to develop unexplained symptoms. These young people have the current teenager sitting room on Bramble into physical symptoms, resulting in a huge debilitating a sensory room for young people with mental effect on school attendance and life in general. There health conditions. This room will be specifically have been good outcomes to date. designed with equipment and lighting to create an environment where the young person can be Long Term Physical Conditions (Paediatric removed from the main ward area to a calm, safe, Cystic Fibrosis, Diabetes, Epilepsy Oncology) therapeutic area to help staff de-escalate challenging situations (see image overpage). The room will also The specialised services above have dedicated be designed so that the structure and anything psychology time for their patients due to the within it is safe thus reducing opportunities for any individual funding arrangements for each service. accidents. It will have changeable mood lighting However, there is a limited amount of psychology within the ceiling. time for other conditions, which results in increased waiting times, and CAMHS referrals. CAMHS Referrals into the Hospital The number of referrals of young people to Bramble ward has remained similar since last year, but this initiative contributed to the development of a new service within CAMHS.

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Example of Sensory Room Design

Page 10 Quality Report 2016/17 PROGRESS ON OUR 2016/17 PRIORITIES Trust Priorities

● Emergency Pathways

● Improving discharge processes across local care economy

● Supporting mental health needs for people

● Patient Safety Programme

Emergency Pathways Previous approaches to winter pressures tended to calculate any shortfall between demand and bed Over 2016/17 the Trust has worked closely with our capacity and bridge the gap through the conversion partners in the local health community, including the of surgical bed stock into beds for medical patients. STP and NEW Devon CCG to design and deliver a In response to the challenges and opportunities different approach to managing emergency pathways provided by the changing context above however, and winter pressures. This approach was set out the 2016/17 winter bed capacity plan was developed in the Trust’s Operational Capacity and Resilience with three key elements, all designed to reduce Plan (OCRP), which was approved by the Board in dependency upon acute hospital beds. These were: December 2016. ● Streamlining hospital care to avoid unnecessary The 2016/17 OCRP considers the changing local and hospital occupancy national context, which includes the following key features: ● Working in partnership with (and in some cases providing) community services to keep people ● Continually rising demand for emergency care healthy at home.

● An increasingly older, more frail population ● Changing attitudes and behaviours of clinical staff, patients and their relatives regarding ● An extremely constrained financial environment hospital care. ● An evidence base that unnecessary hospitalisation The approach is summarised in the illustration below, causes lasting harm to patients in the form of loss which has been a useful map of the plan to support of independence, muscle atrophy and the risk of staff and public engagement. hospital acquired infections.

Page 11 Quality Report 2016/17

So far the results of the change in approach has been has reduced the amount of time that people wait in extremely positive, with a marked improvement in the hospital for community or social care support. number of days where the hospital measures OPEL (Operational Pressure Escalation Level) one (green) Review and redesign of the discharge compared to previous years. pathway for patients that require short periods of rehabilitation For 2017/18 this approach is being further developed to maximise the opportunities of keeping patients We undertook a review of the pathways for patients healthy at home through the implementation of the that require short stay rehabilitation, which we have “Single Point of Access.” This resource will provide very successfully delivered through Yealm ward over a single, central number for professionals to call recent years. Through a comprehensive audit and to access any health or social care provision and work with the team, we have been able to ensure enable greater co-ordination of precious healthcare that patients who would have required short-stay resources. It is anticipated that this will help further rehabilitation can now receive this service in their avoid unnecessary hospital admissions and, for those own homes, thereby improving the effectiveness requiring admission, support their return home as of the rehabilitation. The new Community Connect soon as possible through the early co-ordination of service will provide this service for patients from the community services. end of March 2017.

Improving Discharge Processes Re-design of the discharge processes of patients who have more complex care needs The Trust has embarked on a large programme of We have reviewed the discharge processes for redesign to improve the discharge process. This those patients who have complex needs and have programme has covered the following: redesigned the service in place within the hospital Review of ward processes to reduce the to ensure there is greater support to focus on those time spent in a bed waiting for the next people with the most complex needs. Social workers stage in their care are now based within ward teams to ensure that there is a real partnership approach to arranging care This work was rolled out across the Trust, involving for vulnerable patients with complex needs. ward based clinicians being supported to improve the discharge pathways within their ward. The work Implementation of an ambulatory care unit focussed on ensuring that patients waited no longer The ambulatory care unit has reduced the length of than necessary for key elements of their care, such time that some people need to stay in a hospital bed as test results, discharge summaries and medication. by providing a day-case type facility for patients to In addition to this teams were supported to think access their treatment without an elongated hospital about ways they could improve the discharge process stay. The unit was opened in November 2016 and has at the weekends, ensuring patients are ‘pulled’ to had great reports from patients and staff. the right speciality base ward to meet their needs at the earliest possible time in their hospital stay. This Integrated Care Exeter – joining up primary work will continue throughout 2017/18 as part of acute and community services a continuous improvement approach to discharge processes. During 2016/17 the focus has been on developing relationships with primary care and this programme Development of the Community Connect has been developed with seven Exeter General service Practitioners (GPs) from different practices alongside the Trust’s Director of Integration. The GP practices Over the last year we have tested a model, based are all involved with the wider Integrated Care on national best practice called Discharge 2 Assess. Exeter Programme sharing their data for the Risk This model requires a multi-disciplinary team within Stratification tool (see p13) and they are all actively the community to work together with the acute participating in the extended Social Prescribing pilot: trust to safely transfer a person from the acute Wellbeing Exeter (see p14). Trust back to their home and community by swiftly putting together a plan of immediate re-ablement Through a series of facilitated workshops the group support for discharge which supports the person has identified the challenge, hypothesis, approach back home more quickly. Once home the community and outcomes that they wanted to focus on and team continue to assess what on-going support the agreed a delivery plan for small scale tests of change person needs to stay well in their own home. This to be undertaken in 2017. These will be formally evaluated and the outcomes shared with all practices

Page 12 Quality Report 2016/17 with a view to rolling out the positive benefits. In and communities who could benefit from early December 2016 ICE was successful in a bid to join interventions that could be used in future to improve the National Association of Primary Care (NAPC) outcomes and reduce overall system costs. Primary Care Home Learning Community. This has already enabled members to participate in national We are now in the final stages of completing the and regional new models of care learning events. ICE Risk Stratification Tool which has 4 component Further support will be available from this programme datasets: to expand and communicate the learning from local ● Frailty-based risk stratification (EFI data from and national tests of change. General Practices)

New Models of Care: Street Homeless and ● Pathway costing (Hospital, community health and Vulnerably Housed social care services activity data)

It is estimated that there are about 500 adults in ● Health Needs Mapping (Public Health Population Exeter facing a combination of complex problems data) including homelessness, substance misuse, and mental ill health and offending behaviour. Unless ● Geo-Segmentation Data (demographic, lifestyle, services work better together, this group will not get behaviours data at household and postcode level) the support they need. The aim of this programme Phase one has been the design and testing of the is to prevent entrenched health problems for people tool; information governance and security, design who are street homeless and vulnerably housed by and testing of extraction process, data extraction, identifying problems sooner and providing rapid and analysis and validation. All 16 Exeter GP practices responsive support (including housing) rather than have agreed to take part and we now have data waiting for people to get into crisis. for over 100,000 residents rising to 160,000 by the ICE has an agreed vision to end rough sleeping in end of March 2017. Practices participating in the Exeter by 2021 by ensuring the right support is Exeter new models of care work are able to use the available, at the right time so that no one has to electronic frailty index on their electronic systems live on our streets (Exeter City Council Homeless to identify patients who would benefit from social Prevention Strategy 2016 to 2021). In 2017 the prescribing and other community-based approaches focus is on bringing together existing resources being developed. into a new primary care based Integrated Housing, There is growing local and national interest in the Health and Wellbeing Service to provide an enhanced tool as it builds population profiles through linking health care and housing service that meets the needs existing data sets. Whilst we have learnt from work of people with transient and erratic lifestyles and undertaken elsewhere, there are some unique multiple morbidities. The shared vision is that: aspects to the product we hope to complete and the ● No one arrives on the streets – the right support approach we have taken to design and test it. We are is available early on to prevent rough sleeping now confident to move into phase two which is the before it begins. completion of the Exeter profile and the joining up of the 4 elements of the tool into a single profile by ● No second night out – anyone who ends up on March 2017. the streets should get help so they don’t spend a second night out. Phase three will be the expansion of the tool across Devon and options to include activity data from other ● No one returns to the streets – people get the sources such as mental health and community service support they need to stay in their accommodation providers. and move on with their lives for good. Diverting Demand: Community Resilience ● No one lives on the streets – we see an end to and Social Prescribing entrenched homelessness and nobody calls the street their home. This programme, under the leadership of Devon County Council, has focussed on developing a better Risk Stratification for Early Intervention and and shared understanding of what we mean by Prevention “prevention” in the context of what people can do for themselves to reduce dependency on statutory A critical component of the ICE work has been to services. work out how to get a better understanding of need by creating a systemic way to identify people By working with community and voluntary sector groups we have developed Wellbeing Exeter which is

Page 13 Quality Report 2016/17 a combination of Social Prescribing and Community Over 95% of all staff are trained in dementia Development. We are running an extended social awareness and all new starters to the Trust have a prescribing pilot with nine GP practices referring dementia and delirium awareness session as part of patients to Community Connectors to see if induction which highlights the importance the Trust social prescribing can reduce or delay demand on places on this. There is increased training for staff to traditional services and improve individual health manage challenging behaviour. This, together with and wellbeing. Early signs are very positive and the pre-existing delirium guidelines and the recently the scheme is being very well received by GPs and published rapid tranquillisation guidelines will result patients and we are hearing great transformative in better care for patients, reduce incidents where stories coming from the scheme. A formal evaluation patients can be aggressive/excessively anxious or will be published in June 2017. Social Prescribing frightened and make hospital visits or stays better for is happening alongside Asset Based Community everyone. Development (ABCD) in partnership with Exeter City Council and Exeter Community Forum, through Additionally, a bespoke ‘Applied Suicide Intervention Community Builders in targeted parts of the Skills Training’ (ASIST) two day course has been City. Wellbeing Exeter is now being led by Devon delivered to staff within the ED and the AMU to Community Foundation who are working to secure support recognising patients presenting a suicide risk. long term sustainable funding to expand Wellbeing Weekly mental health awareness training sessions Exeter. are also held with staff working in the ED, provided and delivered by the Psychiatric Liaison Team. These sessions cover a wide range of topics such as ‘Mental Supporting Mental Health Needs Health Act Assessments’, ‘Suicide and Self-Harm’ and for People ‘Common Psychiatric Emergencies’. There has been significant progress made in regard The expanded Psychiatric Liaison Team now provides to supporting patients with mental health needs for a 24/7 co-located service, vastly improving the both Adults and Children. These changes relate to a response times for patients who are referred for wide range of aspects which impact on people with mental health assessments. Whilst the volume of mental health needs, such as: referrals to the Psychiatric Liaison Team has increased significantly in the last two years, 85% of patients ● Improvements to the physical environment referred by the ED are consistently being assessed ● Improved training for staff to enable them to within one hour. In addition to the nationally better identify and support patients with mental mandated one hour response target for patients health needs referred by the ED, a voluntary target of a four hour response to patients referred by the AMU has been ● Improved provision of patient information to introduced. The Psychiatric Liaison Team has worked support better self-management and awareness extremely hard to prioritise patients on the AMU and is meeting this target the majority of the time, ● Joint working and shared governance between despite the significant increase in referrals. the Devon Partnership Trust (DPT) and the RD&E The Psychiatric Liaison Team, the ED and the AMU ● Improved assessment processes and improved teams clearly recognise the importance of working access and responsiveness regarding specialist together and regularly undertake joint ED/AMU/ mental health assessments Psychiatric Liaison Team governance meetings. Dedicated psychiatric assessment rooms have been This ensures opportunities for shared learning and developed within both the Emergency Department improvement are identified and acted upon to deliver (ED) and the Acute Medical Unit (AMU). The teams improved joint services to patients with mental health have worked with the Alzheimer’s Disease Society needs. Due to the integrated way the teams are now and Psychiatric Liaison Team to develop purpose- working they have been awarded Excellent Care built assessment rooms for patients with mental awards from both the Trust and Devon Partnership health needs so that they can be seen in a safe Trust. and private environment, significantly improving The promotion of ‘John’s Campaign’ means there is patient experience. To ensure patients are effectively open visiting for carers of people with dementia. This identified and can be cared for in the appropriate includes staying all night if necessary and we have manner, a new Mental Health Triage Tool has been now more resources to accommodate carers to do introduced within the ED and the AMU. so. There is active engagement with Age UK who

Page 14 Quality Report 2016/17 visit people in hospital and facilitate home visits after discharge if acceptable to the patients. We have used Patient Safety Programme this to help combat loneliness in elderly frail people. 2016/17 There has also been an increase in the research activity in dementia, allowing more patients with The Trust has an annual Patient Safety Programme dementia to take part in clinical trials. which is led by the Deputy Chief Executive/Chief Nurse and delivered by the Patient Safety Group (a sub group of the Governance Committee) chaired by the Head of Safety, Risk and Patient Experience. The Patient Safety Programme describes how we intend to achieve reductions in harm and mortality and improve ward / department safety, improve patient experience and reliability of care as well as supporting and empowering our staff. Below are some highlights of our achievements: Skin Matters: Pressure Ulcer Reduction

● Over 3 years since a patient suffered a grade 4 pressure ulcer

● 33% reduction in grade 3 pressure ulcers

● 56 % reduction in grade 1-4 pressure ulcers against a target of 20% reduction

● 73% of patients across the Trust receive all the interventions required of the SKIN bundle to reduce their risk of developing pressure ulcers against a target of 85% for the year. Sepsis The Trust has signed up to the National Sepsis CQUIN again during 2016/17. Each year in the United Kingdom around 65,000 people survive a life-threatening brush with sepsis (serious infection). A local variation to the national CQUIN was agreed building on the work from the previous year. For further details please refer to page 35. Acute Kidney Injury (AKI) Acute Kidney Injury (AKI) is estimated to occur in around 13-18% of hospital admissions in the UK. The cost of AKI in the UK is estimated to be £430- 620 million per annum. Having established electronic alerts for AKI and built this into our discharge summary information the year before, we have used this information to test and apply an AKI care bundle at ward level. The bundle looks at the following elements which are to be performed within 6 hours of the initial AKI warning flag: Initial Assessment

● ABCDE assessment (follow NICE CG50)

● Observations – check Early Warning score

Page 15 Quality Report 2016/17

● Look for signs of sepsis The Trust results over the year are:

● Abdominal palpation looking for full bladder ● From the five audits taken over the year only four low harm events have occurred. These were all Initial Treatment insulin related and were from three of the five ● Start Sepsis 6 bundle if signs of sepsis audit rounds. Three of the four were related to patients whose blood glucose was fluctuating ● Fluid challenge if required and difficult to control, with one having regular specialist diabetes nurse/doctor input to manage ● Medication review for potentially harmful drugs them. One of these was receiving extra dextrose and dose adjustments for AKI in an isoprenaline infusion which meant their ● Relieve abdominal obstruction if required blood glucose fluctuated during this period. Only one required the administration of a reversal The five ward areas have achieved 60% compliance agent, e.g. oral dextrose. with all the elements of the bundle. The work and learning from the approach taken work will now ● Level 2 Medicines reconciliation achieved 60-80% be rolled out Trust wide during the 2017/18 Patient over the audit period Safety Programme. ● Allergy status record achieved 94-97% over the Medication Safety Thermometer audit period Medication Safety Thermometer is an improvement Safety Culture tool that focuses on Medication Reconciliation, Safety Culture Questionnaires. The SCORE survey was Allergy Status, Medication Omission, and Identifying administered in collaboration with the South West harm from high risk medicines in line with Domain 5 Academic Health Science Network. It assessed the of the NHS Outcomes Framework. As an alternate culture, safety and communication on Labour Ward month point of care survey. The Medication Safety and Maternity Theatres at the Trust. Participation in Thermometer follows a three step process outlined this survey has helped the maternity leadership team below: to identify strengths and areas where work needs Step One: data is collected on all ward patients for to be done. How leaders act, how teams function, the previous 24h on the following: and how an organisation learns and improves were evaluated. Such attributes of a unit’s culture ● reconciliation of medicines influence what it feels like to come to work every day, and the quality of care that is delivered. ● allergy status Key findings and changes are as follows and the ● number of regular medicines safety culture questionnaire will be repeated at the ● medication omissions end of 2017:

● critical medication omissions Positives:

● high risk medicines ● Staff feel it would be safe to be treated here as a patient ● If any patient is receiving any of the listed high risk medicines then the teams move to Step two. ● Staff thought that people work well together as a co-ordinated team Step Two is a series of questions that link to each of the high risk medicines. If the answer to any of these Issues Identified: questions is yes, this could mean potential harm and ● A need to improve local leadership in relation to triggers Step Three. providing performance feedback, which has been Step Three: The patient is discussed through a addressed with a bespoke leadership development Medication Safety Huddle where the team consisting programme for the Maternity Matrons, in addition of a nurse, a doctor and a pharmacist assesses to the area being one of the pilot areas for whether or not the patient has been harmed and the Learning From Excellence level of harm. ● Staff resilience so the team have participated in the Royal College of Midwives ‘Caring For You Campaign’ which focuses on health and well- being

Page 16 Quality Report 2016/17

Learning From Excellence ● Women have access to services 24/7. A maternity triage service has been developed to facilitate an Learning from the work of Adrian Plunkett efficient and effective rapid assessment of women (Birmingham Children’s Hospital) the Trust has been 24/7, launched in January 2017 piloting in Theatres, Maternity and our Surgical Assessment Unit (SAU), an approach which focuses ● Pregnant women are advised to have the flu on recognising excellence in practice which in turn vaccination provided by primary services. The creates opportunities for learning and improving maternity service is exploring with NHSE and team resilience. It is also shown to improve patient CCG a midwifery led service to launch September care whilst enhancing staff morale 2017.

Staff are nominated for excellence by their clinical ● Currently provision of critical care support is colleagues and receive this feedback from the central managed through recovery and intensive care. Learning From Excellence Team email inbox. Many of the women transferred to critical care are there for a short period of time and generally The approach has been positive with the test areas. cannot have their newborn baby with them. The This will be rolled out Trust wide next year as part of feasibility of a maternity high dependency room the 2017/2018 Patient Safety Programme. on labour on labour ward is being considered.

The UK Confidential Enquiry into Maternal Deaths ● Women with sepsis are generally well managed highlights and recognises the importance of learning in Maternity with early warning charts and from every woman’s death, during and after guidelines in place. However to help staff pregnancy. The key areas for action from the most recognise sepsis at a crucial early stage a recent MBRRACE-UK (2015) identified areas of best maternity specific sepsis proforma has been practice to ensure safer services for women and their developed and was launched as part of our Sepsis babies. Having benchmarked their recent report areas Six campaign in January 2017. for improvement were identified by the Trust.

Page 17 Quality Report 2016/17 IMPROVEMENTS TO QUALITY AND SAFETY 2016/17

● Ophthalmic Glaucoma team

● Orthodontic Service

● Urology Prostate Cancer Nurse Specialist

● Exeter Mobility Centre – Orthotic Service

● Swimming Service for Neck Breathing Patients

● Gynaecology Ambulatory Care Unit

● Yarty Family Room

● 7 Day Ultrasound Services

● Devon Nursing Associate Collaborative

● Improvements undertaken by the Quality Improvement Academy 2016/17

Ophthalmic Glaucoma team patients, led to long waits for Orthodontic patients. New patients were waiting around 18 weeks to be Over the past 8 years the Trust has seen seen and the treatment interval had increased to 13 unprecedented rises in referrals to this service and the weeks. Glaucoma team, comprising of medical, nursing and therapy colleagues, have had to be pro-active and Moving the Orthodontic Department to the vacated open to change as a result. space at Heavitree Hospital in November 2016 has provided space for additional clinics and will facilitate The decision to develop a service at Heavitree was a new ways of working to make the service more big step to geographically move away from the West efficient. For example; we now have service clinics of England Eye Unit (WEEU) at Wonford and required where one operator runs two chairs, with two dental the clinical teams’ full engagement in working up nurses. This way of running clinics has worked well an income and expense business case. Having a when trialled so far. clear plan on how many glaucoma patients could be accommodated with increased space was important Being able to run more clinics in a new department for developing a sustainable plan to reduce waits. means that new patients waiting for an Orthodontic The plan was very successful and within two months assessment will have significantly shorter waits. The the Glaucoma team’s backlog of outpatients went interval between treatment appointments will meet from 860 down to zero. This reflected a monumental the recommended standards, and is a better service effort from our clinical team in setting up this for patients. outpatient capacity and our administrative superstars who booked and liaised with all patients. Urology Prostate Cancer Nurse Specialist Orthodontic Service The Urology Prostate Cancer Nurse Specialist team Orthodontics is an entirely outpatient-based introduced a new way of delivering care to patients speciality with no emergency element and a high who are undergoing surgical treatment for their proportion of paediatric patients. Patients referred prostate cancer. to the service and meeting the criteria for treatment undergo a two-year treatment programme, with The National Cancer Survivorship Initiative (NCSI) treatment appointments occurring every 6 to 8 recommends that all newly diagnosed patients are weeks over the two year period. This means that offered attendance at a Health and Wellbeing clinic the service grows cumulatively as the new patient as part of their pathway. Evidence suggests group referrals increase. Orthodontic new patient referrals work is an effective means of information delivery have increased significantly over recent years and as well as a good use of resource. In addition, peer with no corresponding increase in capacity to treat support can positively impact on patient experience

Page 18 Quality Report 2016/17 and outcomes (Carter et al 2011). Locally, cancer Over the past 12 months, a significant amount of patient feedback suggested a preference to have work has been done to look at different ways of information delivered at the beginning of their staffing the service as well as the installation of a treatment pathway. We observed a high Did Not new IT system to increase the efficiency of processes. Attend rate from the generic health and wellbeing Improvements have also been made to the way in clinic being offered to our patients (31%). Feedback which waiting times are monitored and this work has specifically collected from prostate cancer patients resulted in a significant reduction in waiting times indicated a need for more tailored information to down to a current position of four weeks before meet their needs. booking. The new system allows the centre to view and manage its waiting list in real time in order to Key Aims of the Initiative fully understand the impact on patients at any given ● To deliver a pre-surgery Health and Wellbeing time, allowing this position to remain sustainable in clinic for Robotically Assisted Laparoscopic the future. Prostatectomy( RALP) patients for a 3-month pilot phase Swimming Service for Neck

● To respond to feedback from patients on the need Breathing Patients: A 12 Month for more tailored information Pilot Summary ● To prepare patients for supported self- A 12 month National pilot service run by the Head management during the post-surgical and in the” and Neck Specialist Nurse Team was launched in living with and beyond” phase of their pathway March 2016 with the key objective of enabling ● To offer an informal environment with breakout adult patients who breathe through their neck sessions, patient representative question- (Laryngectomy or long term Tracheostomy) to and-answer session, information stands and re-enter the water using a specialist snorkelling presentation by the clinical nurse specialists. device. This unique pilot service has been kindly funded by FORCE – a prominent local cancer charity. ● To promote beneficial lifestyle changes including Advertisement through relevant and leading national diet and physical activity to enable patients to organisations such as The National Association of self- manage and stay well during treatment and Laryngectomy Clubs (NALC) generated interest from into their future. all parts of the UK. Financial support to cover the cost of the aquatic snorkelling device and travel to The outcomes have been overwhelmingly positive. the centre has been kindly provided by Macmillan 51 patients and their supportive person attended the Cancer Support for those patients who are financially clinic (96.2%). Feedback following attendance has eligible. To date 11 grants totalling £4,400 have been been uniformly positive with patients stating they felt awarded to patients meaning that the experience less isolated and more informed. Many mentioned has been cost neutral for 55% of patients trained to feeling in control and feeling more confident in date. their abilities to manage areas of their care such as post-operative catheter care. They also indicated Statistics knowledge on how to access emotional and financial ● Between March 2016 and March 2017, 48 help in the community, as well as a likelihood to patients registered an interest in the service. make lifestyle changes. The clinic is now firmly embedded into the patient pathway and in the words ● A total of 20 patients have been successfully of our Urologists ‘one of the best things we have trained (18 laryngectomy and 2 long term done in years to improve care for men diagnosed tracheostomy). with prostate cancer.’ ● 9 patients are currently awaiting training dates

Exeter Mobility Centre – Orthotic ● 8 patients have deferred as they are not ready at Service this present time In recent years, the Orthotics service – which both ● 3 patients were ineligible for health or practical assesses and supplies patients with a range of special reasons. devices and footwear – has been challenged due ● 1 patient sadly died before he attended for to a number of factors and, in particular, difficulties training recruiting to Orthotist posts due to a national shortage of qualified staff. This led to a growing ● 7 patients declined training after further waiting list. consideration deciding it wasn’t for them after all

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● 2 of the trained patients also received Yarty Family Room hydrotherapy with a qualified physiotherapist Within Haematology, patients are often diagnosed ● No clinical incidents have occurred during or after with life-threatening or life-limiting conditions, which training in many instances means aggressive treatment over a long period of time and several extended inpatient Views and experiences of service users episodes. The impact on the individual can be Quality of Life Questionnaires will be sent to patients significant, causing isolation and loss of control. at 6 and 12 months following training and will be Feedback from a family who lost their son to analysed for the Trust Head and Neck Annual Report. leukaemia and further work with our local charity, To date however we have received a wealth of letters, allowed the team to identify a gap in service cards and emails from those who have successfully provision. It was clear that many patients and loved undergone training and all of which were immensely ones required space to promote normality at this positive. difficult time. A lady who swam with her grandchildren for the first The nature of their condition means many of our time stated: “This is the best holiday we have had in patients are younger, often have young children, years and it’s all down to you and your team. There’s travel from North Devon and require somewhere for no doubt the experience has been life changing for their family to stay. We worked in close partnership all of us.” with the Exeter Leukaemia Fund (ELF) to develop A young lady who loves to exercise said: “A huge a space which would provide a non-clinical thank you for giving me the opportunity to achieve environment while ensuring patients have access to so much, particularly in terms of confidence and all the expert medical and nursing care they require. opening new doors for me and living life to the full.” The family room, now known as the Chevithorne suite was entirely funded by ELF. An 80 year old man who previously swam 3 times a week for most of his life (see photo below) wrote: The space has so far been a great success, with “I cannot thank you enough for all the help and patients being able to have their family with them; support you have given me. Swimming is a great maintaining normality and allowing their young pleasure of mine and with your hard work and children to stay. Our teenager and young adult dedication to this programme you have given me patients are able to invite their peers in a space back that enjoyment along with my confidence and away from the ward where they can participate in self-esteem. For that I am forever grateful.” activities such as play station etc. This is important in order for them to try and maintain normality, ready Videos of training can be viewed on the Trust website for inclusion back into society at the end of their http://www.rdehospital.nhs.uk/patients/ treatment. services/cancer_services/laryngectomy-and- tracheostomy-swimming-aquather-service.html The room can also be useful for critically ill patients with life limiting-diseases. For these patients it Ambulatory Care Unit provides a homely environment whilst allowing them to stay with the haematology team they have got to The Wynard Ambulatory Care Unit opened in know well over the years and not go to the hospice. November 2016. The unit provides a comfortable Very often, they have symptoms such as bleeding environment for patients who are mobile and which cannot be managed in a hospice environment medically stable to receive a range of procedures and the ability to stay on Yarty Ward even the last and treatments. Patients who attend the unit would phases of their illness is important to them. The room otherwise have required a hospital bed, either as has been used since its opening and already the an inpatient or day case. Patients now have their feedback is overwhelmingly positive with our patients treatment and can then be discharged to their own and their loved ones describing the difference this home, returning each day as required. Feedback from has made to them, even in the most traumatic of patients about this service has been positive and one situations. person has commented that it was life changing, not having to be confined to a hospital bed. This The room was recently used for a 42 year-old male has improved the pathway for the patient ensuring patient receiving end of life care and because of the quality and improved patient experience. facility and available space, he was able to have his whole family and close friends spend a significant amount of time with him.

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The patient and his family reported how important The pilot is now underway with trainees taking it was for them to remain together as a unit as the up posts in January 2017across Devon in different patient neared the end of his life, and how this NHS organisations. There are 69 trainee Nursing positively impacted on the support they were able to Associates across Devon employed as band 3 staff provide to the patient and to each other. The relatives during their training. On successful completion of also expressed how the family room allowed them training they will move into band 4 roles. During to provide the care they all wanted to give with the the pilot we will consider how these roles can best reassurance that there was expert nursing support compliment the current staff establishment to ensure available should they require it. that those using our services receive the right care. The Trust is employing 15 of the trainees who 7 Day Ultrasound Services will over the next two years undertake a level 5 The hospital has traditionally provided ultrasound qualification delivered by Petroc Further Education services Monday to Friday for all patients. At College whilst rotating through the Medical, Surgical weekends however the service has only been and Community divisions. In addition and to ensure available for clinically urgent patients. This resulted they are exposed to other healthcare settings, they in some patients waiting until the following week will all have placements within Devon Partnership for their ultrasound appointment. In 2016 a business Trust, Hospice Care, GP practices and private care case was developed to demonstrate the benefits to homes. The Trust is working closely with HEE and all patients of running an extended service over the the NMC to shape the future direction of this role; weekend. This was approved and following a formal considering aspects such as medicine administration, consultation with staff to change shift patterns, regulation and dovetailing with apprenticeship a seven day ultrasound service commenced in routes. September 2016. This exciting new initiative allows us to build a Patients who require an ultrasound scan can now sustainable plan within Devon STP to address the be seen on any day of the week, with the majority workforce challenges, particularly the shortage of of inpatient scans performed within 24 hours of band 5 nurses. Once employed in band 4 roles the the request. For outpatients, the ability to scan at Nurse Associates will be able to free up the registered the weekend has meant more appointment options band 5 nurses available to concentrate on the more during the week days and the service is looking at the complex nursing needs of our service users. The pilot potential to extend weekend provision to incorporate is being overseen by a Strategic Programme Board outpatient appointments. whose membership includes the Directors of Nursing/ Chief Nurses of the five employing organisations. Devon Nursing Associate Improvements Undertaken by the Collaborative – Building a Quality Improvement Academy Workforce for our Future 2016/17 In October 2016 the Trust, on behalf of Devon Sustainability and Transformation Programme (STP), The Quality Improvement Academy (QIA) is an submitted a bid to Health Education England (HEE) organisation run by Junior Doctors within the to be in the first wave of pilot sites to train 1000 Trust for Junior Doctors. It is supported by the Nursing Associates. Medical Education department to help support and encourage Junior Doctors with quality improvement The Nurse Associate role is a new role that will bridge (QI) projects. The use of a central organisation rather the gap between an unregistered health/support than individual doctors taking on smaller, self-led worker with a care certificate and a registered nurse. projects allows the participants’ attention to be The Trust was named as the lead employer in the focused on the project and on improving patient bid which means it is the main contact for HEE and safety. the Nursing Midwifery Council (NMC) in terms of monitoring and financial activities associated with the The Academy provide teams with both a Clinical pilot. In late October 2016, it was confirmed that the Mentor and a Management Sponsor who can advise bid was successful and that out of the 49 submitted the team on all elements of the project, support bids, we were one of only 11 pilot sites across the them when they get into difficulty and ensure a country. high quality of project. The QI Academy also offers a chance for individuals who may not already have an idea for a project or an already formed team to become involved in a variety of pre-formed groups.

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In addition to support with QI projects, the Academy The aim is to reduce the time spent by junior doctors also runs regular education sessions for Junior editing the list by 50% over six months and to reduce Doctors to learn about NHS management and culture clerical errors by 90% by integrating this process into as well as gain a deeper understanding of patient the ‘Doctors Whiteboard’ system. safety and quality. Key achievements What are the aims of the QIA? ● Meeting held with IT in order to discuss how ● To increase Junior Doctor involvement in QI the Doctors Whiteboard system could be projects through support and education optimised in order to be used to compile specialty/ward inpatient lists. ● To promote the publication and presentation of QI work from the RD&E ● Once the system is optimised, due for trial in Urology initially before rolling out to further ● To ensure all projects are of high quality specialties. ● To keep a central database of QIA projects Improving the handover of Specialty ward The following projects were undertaken in 2016-17: round jobs to AMU ward doctors QIA Project Information 2016-17 for current Background projects: summary sheets for a faster and This project looks at the handover of jobs produced safer patient handover from the Specialty ward rounds on AMU to the Objective allocated ‘ward doctor’ of the day on AMU. Jobs are often not handed over to the ward doctor, or it is not This project focuses on the time spent using patient clear who the job is to be completed by (specialty or notes by out of hours doctors to accurately assess ward doctor). This can lead to delays in a patients on- acutely unwell patients that are unknown to them. going care or their discharge from hospital. Patients notes can be vast and complicated which can make information gathering a very time-consuming The aim is to have in 100% of cases, a clear plan task. of which jobs are to be completed by the AMU doctors, and for this job allocation to have been The aim is a reduction in time of information communicated to AMU doctors by the time of AMU gathering by 50% over 6 months and ultimately to board round. improve patient care. Key achievements Key Achievements ● Introduction of a stamp placed on Post Take ● A summary sheet has been designed to be Ward Round page of medical clerking in order placed in patients notes and filled in by the to divide jobs between ‘Specialty to do’ and ward junior doctor looking after them; currently ‘AMU to do’ for better clarification this has been implemented in Cardiology. ● Since introduction of the stamp, job handover ● The average time taken to summarise a patients has improved from less than 50% to 100% at notes on the Cardiology wards has been best. reduced from 11 minutes to 3 minutes (n=24). ● Identification via qualitative feedback that Lost time and lost patients: a new approach further education about the stamp and its use to the patient list is required. Objective Standardisation of venepuncture/ cannulation equipment across wards This project focuses on the time taken to update the inpatient lists held by ward-based specialties Background within the Trust. This can be a very time-consuming process, especially in surgical specialties where the list This project focuses on the time taken to gather is expected to be updated with the two most recent equipment for venepuncture and cannulation sets of blood results. This transcribing can result in on the wards. Currently this time varies widely errors, for example patients being missed off of lists, between wards as there is no standard set-up for which could potentially have an impact on patient this equipment and often there will be equipment care. missing. This leads to delays in patient care and inefficient use of junior doctor time.

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The aim is to have a standard layout of venepuncture/ white card varied as did whether a phone call was cannulation equipment across wards and reduce the also required. This made it a very inefficient process time taken to gather this equipment on both medical for the junior doctor making the referral. and surgical wards by 50% by July 2017. Key achievements Key achievements ● Online referral system designed and integrated ● Plan to trial using a trolley borrowed from into the existing Doctors Whiteboard system. the Phlebotomy department to see how this Trialled within one medical and surgical improves the venepuncture/cannulation process specialty to identify further improvements required. Improving the prescription of schedule 2 and 3 controlled drugs on discharge ● Time taken to make a referral by junior doctor (i.e. from decision made by Consultant to make summaries referral to referral submitted) reduced from an Background average of 2 hours to 1.66 hours. This project is based around the prescription of ● Time taken to review by specialty (i.e. from schedule 2 and 3 controlled drugs on discharge referral submitted to specialty review) also summaries, an area that has very specific legal unexpectedly reduced from an average of requirements but where errors very commonly occur. 23.18 hours to 16.38 hours. There is a significant amount of time wasted by ● Qualitative feedback gained from both referrers pharmacists, nurses and junior doctors having to and specialties receiving referrals stated that make amendments to discharge summaries where the new system was felt to be more efficient these errors occur. and safe than the previous paper-based system. The aim is to increase by 50% over six months The system has a clear audit trail which was not the number of schedule 2 and 3 controlled drug present with the previous system. prescriptions on discharge summaries that comply ● Specialties currently involved include: with legal prescription requirements. ● Cardiology Key achievements ● Gastroenterology ● Intervention 1 trialled: informal education to ● Endocrinology/Diabetes junior doctors. ● Neurology ● Intervention 2 trialled: sticker detailing all the information needed on the prescription placed ● Haematology on the front of every clinical-facing computer in ● Healthcare for Older People the hospital. ● Urology ● Over the course of the project so far the ● ENT number of prescriptions that comply with legal requirements has improved from 36.6% to ● Upper GI Surgery 75%. ● Colorectal Surgery On-going projects from previous years: ● Vascular Surgery improving routine ‘white card’ inter- ● Continued liaison with other specialties is specialty referrals on-going with the eventual aim of rolling out across the Trust as the standard routine referral Background process. This project focused on improving the routine inter- specialty referral process. This is a process that happens daily and it is essential that this is reliable and efficient for patient flow and safety. There was anecdotal evidence that the paper-based system was causing delays in patient care and adversely affecting patient safety. The process also varied widely between specialties; the location for depositing the

Page 23 Quality Report 2016/17 OUR PRIORITIES 2017/18 Governor Priorities

Patient Discharge Packages of care How effective is the discharge of patients from the Experience of the patients/carer, who is responsible acute hospital to the community? for what and when along the patient pathway, how does the Trust measure effectiveness? Failed Discharge Information to patients on discharge – is this What is the process for involving careers/relatives sufficient, does it tell patients what to do if their in discharge where a package of care is required – condition or circumstances change or worsens? how is the Trust assured that this is effective, how What information is provided for Careers on is learning /feedback shared? What information do discharge? What information does the GP receive, careers/relatives receive, i.e. when to be concerned how timely is this? and what the correct route is for seeking help? Delayed Discharge Review of data – snap shot look into delays and reasons for delays – what problems have been identified, what actions are the Trust and other Stakeholders taking to reduce delays. How is the Trust measuring improvement?

Page 24 Quality Report 2016/17 OUR PRIORITIES FOR 2017/18 Trust Priorities

In hospital plan

● Rehabilitation/reablement

● Focus on discharge

● Ambulatory care

● Onward Care

In-Hospital Operational Capacity Removing waiting for hospital Planning inpatients Building upon the successes of last year, over the During a patient’s stay in hospital they will enter into forthcoming 12 months, a programme of further a number of hidden queues for different diagnostic service change is planned, with the aim of continuing tests, clinical reviews, therapeutic treatment and to streamline hospital care and reduce dependence administrative processes. Work to establish accepted on acute hospital beds. Within the main Wonford “internal professional standards” has been on-going Hospital, these projects include the following: to set timescales for various hospital processes. Over the next 12 months it is intended to improve these Cultural change timescales across a range of areas, with the aim of reducing the overall time patients stay in a hospital Shifting the culture towards care at home being the bed. ideal as opposed to a hospital bed is an essential part of the drive to reduce dependence on the Further development of Trust’s inpatient facilities. For staff, a number of initiatives are being progressed, such as the refresh ambulatory care and assessment of the “ward productivity” and “specialty pull” units programmes, which both aim to empower staff in supporting safe, timely transfer of patients out of The Trust currently has assessment units for medical hospital. patients, surgical patients and children, as well as the Ambulatory Care Unit, which provides day case In order to give patients as much ownership of treatment for patients who otherwise might require a their own care and discharge as possible, two hospital overnight stay. These services have radically complimentary pieces of work are being developed; improved the care we are able to provide, with some “#GetDressed 2Progress” #endPJparalysis, and a patients who might have required 5-day hospital patient video aimed at empowering patients to be stays to receive infusions for example, now being as active as possible, ask questions and work with able to attend hospital during the morning and then clinical staff to push their own discharge forward. return home for the rest of the day and night, greatly This video will be shown to approximately 30,000 improving their experience and saving valuable patients per year via the bedside TVs and it is hoped hospital resources. Over the next year, the Trust will give patients the information and confidence to will review its clinical pathways to identify further play a more active role in getting back home as soon opportunities to streamline hospital care and avoid as it is safe to do so. unnecessary hospital admission. These projects and others related to this Service Transformation are overseen by the Operational Capacity Steering Group, which is responsible for planning the use of bed capacity across the Trust. The team uses a range of metrics, such as admissions per day per area, length of stay and bed occupancy in order to guide the development and monitor the outcome of the various schemes.

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Out of hospital plan Community Connect – Urgent Response ● Comprehensive assessment The Trust invested £2.1 million into the enhancement ● Single point of access of community health and social care services in 2016/17 and the recruitment into these roles is ● Urgent community response almost complete. This has enabled health and social care teams to provide an enhanced community Out of Hospital Care response, with a focus on reablement. This aims to A key objective for the Trust is to lead the support people who have an urgent need in order to development of integrated health and social care reduce the risk of admission or to ensure that people across our community. The Trust has led a number of are supported swiftly in their transfer home after a pilots within the Integrated Care Exeter project from stay in hospital. The urgent response teams will be which we have taken the learning and have plans to further developed over 2017/18 to ensure that we implement across Eastern Devon. rely less on bed-based models of care and have the right capacity to support people in their own homes Community Connect – A Single to return to leading a well and independent life as soon as possible. Point of Access On the 14 March 2017, the Trust launched an Comprehensive Assessment exciting new service called Community Connect. As part of the work we are undertaking to ensure One of the key elements of this service is to ensure the health and social care service meets the needs that there is a single number that community staff, of the people within our communities, we plan to ambulance staff and our acute teams can call to set up a process of comprehensive assessment. This arrange community health and social care support for will ensure that we identify those people in our people who need it within Eastern Devon. The service communities that are most likely to need additional is operational 7 days a week and is the single contact support from our health and social care teams. point to ensure that the right support is in place for Once identified we will have multi-disciplinary teams people who may need urgent health or social care across primary care, mental health and community support to stay at home and avoid an unnecessary health and social care staff working together with admission to hospital. The same single point of the individual concerned to develop a plan that access will be used to plan services for those people is focussed on their needs, their priorities, as they who have had a stay in hospital and are ready to be see them. We will use the principle of ensuring transferred to their own home with some additional each person is able to express “What matters to support. me” and that this forms the basis of our planned The Single Point of Access is staffed by a range of co- response should the person need additional help and ordinators and clinical staff who work together with support. The plan will then form the basis for the the referring clinician to create a plan for admission agreed response of our services with the emphasis avoidance or discharge home. The clinical team has on keeping people well and maintaining their a mixture of skills across nursing and therapy which independence. will enable a multi-disciplinary approach to creating a plan of care for those people who need it. Clinical Conversations We will continue to build on the principle of ensuring Our teams have expressed the importance of having that there is a single point of contact to ensure that systems in place that provide an easy, swift and the right thing to do for a patient is the easiest thing effective way to ensure there is an opportunity for to do. This should avoid unnecessary visits to hospital clinical teams across primary, community and acute or admissions. Over 17/18 we will put additional care to talk to each other; get specialist advice and services through this single point of access, such generate a shared plan to meet the needs of a person as the provision of specialist advice and guidance within our community. through Clinical Conversations. We will set up a system whereby GPs will be able to access specialist opinion to manage an urgent need for a person within the community to avoid an unnecessary hospital attendance or admission.

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In addition we will set up a system to ensure that to expand the role of the Nurse Practitioner and where GPs may have in the past referred a person for increase the number in post, to help manage the a planned specialist opinion through an outpatient current workload and address some of the reduction appointment that is more routine in nature, they will in the junior doctors available. A further example have the opportunity to discuss the persons issues is the work undertaken in the neonatal unit where with a hospital specialist and receive appropriate advanced nurse practitioners have been trained to advice, guidance or access to diagnostics. This will cover the medical rotas thus ensuring sustained safe reduce the length of time that a person waits to cover 24 hours a day. These advanced roles provide get the treatment they need and reduce the need career development for the multi-professional team for people to travel to a hospital for unnecessary and offer a consistent quality service for our patients. appointments. Although this work has come from workforce challenges it is providing some exciting opportunities Focus on Well-being for our staff and ensuring that we continue to provide safe effective services. In addition to integrating our health and social care services to respond to people when they need us the The Clinical Workforce Development will be most, we believe that it is important to be a pro- detailed in the work programmes for the respective active partner within our communities to promote workforce groups, who will in turn report against and enable wellbeing, prevention of ill health and an overarching workforce programme which will be improve the opportunities for our citizens to live monitored by the Workforce Strategy Group which full and active lives. We will work within each of will report to the Senior Delivery Team Strategy our communities to ensure that we develop these Group. partnerships in order that the longer term benefits of Partnership Work with Exeter University keeping people well and in their communities are a priority. Over the years, the Trust and the University of Exeter have collaborated on a number of research projects The Out of Hospital plan is governed through a to benefit the health and care of our patients and steering group which is chaired by the Integration community. In late 2016, the two organisations Director and reports through to the Executive via the sought to strengthen their relationship and to this Strategic Delivery Group, chaired by the CEO. Each end, implemented a Joint Partnership Steering Group. project is monitored through action trackers and a The Trust is represented at the steering group by suite of key performance indicators are monitored Suzanne Tracey, Chief Executive; Em Wilkinson-Brice, on a monthly basis to ensure that each of these Deputy Chief Executive/Chief Nurse and Adrian improvement projects delivers the intended outcomes Harris, Executive Medical Director. and meet the intended aim of developing integrated health and social care across Eastern Devon. The aims of the steering group are: Recruitment ● To further strategic partnership working between the Trust and University of Exeter to benefit the Clinical Workforce Development care of patients in the region through health- related education & teaching, research and The approach the Trust is taking to meet the knowledge transfer. workforce challenges across all of the professions is to take a detailed bottom-up approach. Initially ● To promote workforce development in the reviewing those services with the more pressing healthcare professions and undertake joint needs, we are considering what tasks need to workforce planning at a strategic level be completed, identifying roles that we currently ● To embed research practices and to connect have in place that can deliver the care required as with University of Exeter academics to explore well as considering what new roles may need to healthcare innovations including through an be developed to ensure safe care provision for our expanded clinical trials function. patients. Current examples would include the use of Orthopaedic Practitioners who can enhance the ● To consider a shared approach to capital orthopaedic workforce specifically covering many development and infrastructure which will of the ward based aspects of care that would make best use of resources and bring benefits traditionally have been completed by junior doctors. to patients and research advancement through In the Emergency Department we are planning shared projects.

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● To consider the future healthcare needs of the Stop The Pressure: NHSI wider region including effective working and relationships with other partners in the region to Improvement Plan take advantage of opportunities and overcome Pressure ulcer prevention has been a key patient challenges. safety issue for the Royal Devon and Exeter NHS To share best practice in organisational effectiveness, Foundation Trust for several years and significant to promote joined-up ways of working and pioneer improvements to pressure ulcer acquisition rates have new processes and to facilitate greater synergies been achieved with year on year reductions in all between the two organisations. categories. A programme of work is being developed and In 2012, 421 hospital acquired pressure ulcers were priorities set, both of which will support the strategic reported. This reflects a rate of 2.02 per 1000 bed aims. The progress of the work will be monitored by days. Year on year reductions have been made and both the Trust Board of Directors and the University in 2017, 37 pressure ulcers were reported, a rate of Exeter Strategic Board through regular reporting of 0.15 per 1000 bed days. There have been no processes. category 4 pressure ulcers since September 2011. For the Acute Trust the target for 2017/ 2018 a further Em Wilkinson-Brice is also working in collaboration 25% is the target as we strive to eliminate hospital with the University of Exeter on the Development of acquired pressure ulceration for our patients a Nursing Academy, to support the development of the nursing profession across the region. A Nursing In October 2016, community services in East Devon Academy Board, chaired by Professor Dave Richards integrated with the Royal Devon and Exeter NHS of Exeter University, held its first meeting in March Foundation Trust. The inclusion of community services 2017. The work is very much in its infancy but there within the organisation provides new challenges with is an ambition to welcome a first cohort of nursing regard to pressure ulcer prevention. As a result, the students in September 2018. key objectives for 2017/18 are: ● To maintain high standards of pressure ulcer Patient Safety Programme Outline prevention practice and low rates of pressure damage in the acute in-patient services; The Trust has an annual Patient Safety Programme which is led by the Deputy Chief Executive/Chief ● To apply the pressure ulcer prevention strategies Nurse and delivered by the Patient Safety and proven to have been successful in acute hospital Mortality Group (a sub group of the Safety and Risk in-patient wards for in-patients in community Committee), chaired by the Head of Safety, Risk and hospital wards; Patient Experience. The Patient Safety Programme describes how we intend to achieve reductions in ● To establish a better understanding of the burden harm and mortality; improve ward / department posed by pressure ulcers for patients on the safety; improve patient experience and reliability of community nursing case load and, once this has care as well as support and empower our staff. been achieved, develop a strategy for prevention and management in patients’ own homes.

Acute Kidney Injury Care Bundle ● To review the provision of education and clinical support to patients and carers in residential and Acute Kidney Injury (AKI) is estimated to occur in nursing homes. around 13-18% of hospital admissions in the UK. Over the last year 5 ward areas having been testing The elements of the plan that are aimed at the application of an AKI care bundle in practice maintaining low rates or reducing rates of pressure alongside the practice education team providing damage will be measured through the use of education in practice on early recognition of AKI and pressure incident data on a monthly basis at clinical treatment. This approach will be rolled out through and executive levels as described above. A trajectory 2017/18 to see the impact on the number of severe for improvement is currently being set and will be AKI flags on our patients. monitored by the Patient Safety and Mortality Group on a quarterly basis.

Page 28 Quality Report 2016/17

Reducing Harm From Falls 2. Learning and best practice – Implementation of the Saving Babies’ Lives care bundle to Falls and reducing harm from falls has been a key reduce stillbirths area of focus. In-patient ward areas have been focusing on delivering enhanced patient observation ● Commitment to reducing smoking in by cohort bay nursing (minimum of one nurse visible pregnancy by introducing robust screening at all times in the bay) and supervising patient whilst and referral process toileting to prevent harm for patients from falls. ● Enhancing detection of fetal growth Over the last year the Trust (acute and community restriction – of the one in 200 babies that combined) has seen a reduction of 26.53% from are stillborn, growth restricted babies are the night time falls. The Falls Group over the last year single largest preventable group has combined with our community colleagues and the focus over the forthcoming year will be seeing ● Improving awareness of the importance of an overall reduction in the number of falls and a fetal movements in pregnancy by ensuring reduction in the number of avoidable harm from falls. effective patient information and ensure Baseline data is being collated to agree a trajectory robust process and audit for improvement over the year. ● Improving fetal monitoring during labour –to ensure effective annual training and Identifying and Treating Sepsis assessment for all staff The Trust has signed up to the National Sepsis CQUIN Public Health England (PHE) is leading the again this year as each year in the United Kingdom ‘improving prevention’ work stream. around 65,000 people survive a life-threatening brush with Sepsis (serious infection). The CQUIN will apply ● Best practice in whooping cough and flu to all patients in the emergency department and Immunisation acute in-patient settings to ensure there is screening and timely identification and treatment of sepsis in ● Advice on drinking alcohol in pregnancy the appropriate timeframes followed by appropriate ● Promoting healthy weight antibiotic review within 72hrs. ● Prevention and early help in perinatal mental Maternity health In November 2015 the government made an 3. Teams announcement to reduce the number of stillbirths, Training together is critical to effective neonatal deaths, maternal deaths and brain injuries multidisciplinary team working, review of current that occur during or soon after birth by 20% by 2020 training provision to provide assurance of and by 50% by 2030. continuous development of training programmes The Government has asked all maternity services to and robust team engagement commit to place a spotlight on safety and contribute 4. Data towards achieving the national ambition to improve maternity outcomes (DOH: 2016). A £8million New RAG rated dashboard launched to ensure Maternity Safety Training Fund was launched to robust transparent scrutiny of maternity data, support every NHS trust to improve their maternity currently shared externally via the South West safety training, a successful bid of £41,000 was Strategic clinical network. Report into key data confirmed. In return we were asked to commit to key sets by 2018, prioritising early submission where actions within a bespoke safety improvement plan. possible.

Key work streams ● Maternity Services Dataset

1. Leadership ● MBRRACE-UK

● To ensure Board level Maternity Champion ● Royal College of Obstetricians and Gynaecologists’ ‘Each Baby Counts’ ● To devise a Bespoke Maternity Safety programme Improvement Plan ● National Neonatal Dataset ● To appoint one obstetrician and one midwife jointly responsible for championing maternity ● National Maternity and Perinatal Audit safety in their organisation

Page 29 Quality Report 2016/17

5. Innovation Developing our Safety Culture Participate in the new national Maternal Safety Culture Questionnaires and Neonatal Health Quality Improvement Programme, RD&E requested 2018/19 phase. The Trust will continue its collaboration with the South West Academic Health Science Network and ● Maternity Safety Innovation Fund launched, further roll-out of the Score Survey in some clinical successful bid confirmed for a package of areas to continue to work with clinical teams and measures to evaluate blood loss prospectively influence positively the culture of what it feels like to at Caesarean Section to overcome this come to work every day, and the quality of care that important deficit in intra-operative care. is delivered. Working with Patients and Families Learning From Excellence to Learn Lessons Safety in healthcare has traditionally focused on avoiding harm by learning from error. This approach One of the key areas for focus over the forthcoming may miss opportunities to learn from excellent year is to further improve how we involve families, practice. The Trust will look to build on the work from carers and patients when things have gone wrong the pilot areas of the 2016/17 on the approach which and in doing so ensure that we address the concerns focuses on recognising excellence in practice. Core and questions that they may have about what did not to this will be moving away from a dedicated email go as well as it could or should have. inbox but integrating this approach into our Incident In addition we will revise the investigation process Reporting System for all Trust staff. to ensure that the patient, family and or carer have a named contact who they can access to before, Human Factors & Simulation Training during and following the investigation. They will be Building on the learning together for safety more involved in determining the terms of reference philosophy the Trust will continue to develop and regularly updated on the progress of the and expand its Simulation Service to deliver more investigation. multi- professional simulation training not only in our simulation suite but in situ on the in-patient wards and meet all the South West Simulation key standards. The focus will continue to be in relation to acute deterioration and AKI and Sepsis but also look to how we work with our mental health partners to deliver simulation scenarios in relation to acute mental health issues in our key admission areas.

Page 30 Quality Report 2016/17 Duty of Candour Participation in Clinical The Trust remains committed to being open and Audit honest with patients and their families when things go wrong. The Trust has implemented a process During 2016/17 37 national clinical audits and four for Duty of Candour from August 2013 which national confidential enquiries covered relevant was communicated and led through the Trust’s health services that the Royal Devon and Exeter NHS Governance system. Monitoring of compliance Foundation Trust provides. of Duty of Candour happens at different levels. During that period the Royal Devon and Exeter NHS The Trust uses its electronic incident reporting Foundation Trust participated in 97% (36)* national system Datix for overseeing the Duty of Candour confidential enquiries of the national clinical audits requirements. Duty of Candour compliance is and 100% (4) national confidential enquiries which it monitored through the Trust’s Incident Review Group. was eligible to participate in. This compliance is also reported through to the Safety and Risk Committee and is included in the monthly * The Trust was unable to participate in the National Integrated Performance Report to the Board. This Ophthalmology Audit due to challenges with data year we will engage with patients and relatives to collection. seek their views of what it is like to experience duty The national clinical audits and national confidential of candour from us to identify areas for improvement enquiries that the Royal Devon and Exeter NHS (please see page 37 ‘Working with patients and Foundation Trust was eligible to participate in during families to learn lessons’). 2016/17 are listed in Annex F. The national clinical audits and national confidential NHS Staff Survey Results enquiries that the Royal Devon and Exeter NHS Foundation Trust participated during 2016/17 are for indicators KF26 and listed in Annex F. KF21 The national clinical audit and national confidential enquires that the Royal Devon & Exeter NHS Percentage of staff experiencing harassment, bullying Foundation Trust participated in, and for which data or abuse from staff in the last 12 months – i.e. K26. collection was completed during 2016/17 are listed Trust score in 2016 20% (in 2015 – 20%). alongside the number of cases submitted to each audit or enquiry as a percentage of the number of Percentage believing that Trust provides equal registered by the terms of that audit or enquiry in opportunities for career progression or promotion for Annex F. the Workforce – i.e. KF21. Trust score in 2016 89% (in 2015 – 93%). The reports of 20 national clinical audits were reviewed by the provider in 2016/17 and the Royal Devon and Exeter NHS Foundation Trust intends to Review of Services take the following actions to improve the quality of healthcare provided as detailed in Annex F. During 2016/17 the Royal Devon and Exeter NHS Foundation Trust provided and/or sub-contracted 104 The reports of 31 local clinical audits were reviewed relevant health services. by the provider in 2016/17 and the Royal Devon and Exeter NHS Foundation Trust intends to take the The Royal Devon and Exeter NHS Foundation Trust following action to improve the quality of healthcare has reviewed all the data available to them on the provided as detailed in Annex F. quality of care in 104 of these relevant services. The income generated by the relevant health services reviewed in 2016/17 represents 100% per cent of the total income generated from the provision of relevant health services by the Royal Devon and Exeter NHS Foundation Trust for 2016/17.

Page 31 Quality Report 2016/17

● Clinicians, clinical scientists and researchers Participation in Clinical collaborated to reduce the number of local Research pregnant mothers routinely given a blood product (Anti-D) they do not need. Anti-D is offered Participation in clinical research demonstrates the to mothers with a RhD-negative blood type to Trust’s commitment to improving the quality of care reduce the risk of problems if they are carrying a we offer and to contributing to implementation of RhD-positive fetus. However, up to 38% of these evidence-based patient care. Our clinical staff stay mothers carry a RhD-negative fetus so this Anti-D abreast of the latest possible treatment possibilities is not needed. By verifying the diagnostic accuracy and active participation in research leads to successful of a new system to identify the fetal RhD status patient outcomes. from a sample of mothers blood taken in early pregnancy, the Trust can now offer a new service The high quality of the research undertaken in the to target Anti-D prophylaxis to women who need Trust is demonstrated by the level of external grant it. funding which in 2016/17 exceeded £7million. The number of Chief Investigators with successful ● A study in paediatric diabetes has led to improved external grants increased during the year. quality of life for children with type 1 diabetes. The Beagle Study demonstrated the accuracy of In 2016 there were 324 publications in peer- new sensor-based glucose monitoring technology reviewed journals, demonstrating our commitment to compared with finger stick blood glucose readings transparency and desire to improve patient outcomes in children aged 4-17 with type 1 diabetes and experience across the NHS. on insulin therapy. Children using the glucose The Trust is consistently the highest recruiting NHS monitoring system benefit from reduced finger organisation to clinical trials in the South West prick tests and parents are able to scan young Peninsula. The Trust was involved in conducting 394 children at night without waking them to check network clinical research studies in a wide range they are not becoming hypoglycaemic whilst of specialties during 2016/17. Over 96% of studies asleep. were approved within 30 days of receiving valid ● The cardiology department became the only application. centre outside the United States to join the The Trust collaborates with the University of Exeter OPTALYSE study, looking at the use of a new Medical School, hosting the NIHR Clinical Research technology to treat cases of pulmonary embolus Facility for experimental medicine. The number of where the heart is under strain and the patient’s patients receiving relevant health services provided life is at risk. Pulmonary Embolus is a serious by the Royal Devon and Exeter NHS Foundation condition, where a blood clot deposits within Trust during 2016/17 that were recruited during the lungs, obstructing the circulation. It can be that period to participate in research approved by a life-threatening condition and is within the the Research Ethics Committee is 3,600. Research top five causes of in-hospital death in the world. focuses on understanding mechanisms of disease and Patients within that study were successfully introducing improvements into patient care. treated, embedding the training and technology within our department. As a consequence of this Research highlights that have positively impacted on new technology when a patient who needed patient care: urgent life-saving abdominal surgery suffered a large pulmonary embolus, rendering her unfit ● A consultant specialising in Neurogenetics has for surgery, we were able to successfully and played a pivotal role in the discovery of a new safely treat her pulmonary embolus and enable genetic form of childhood-onset dystonia, a the surgery to go ahead. Without this ground- rare progressive muscle disorder that can leave breaking technology, it is unlikely that she would patients wheelchair-bound and causes speech and have survived. swallowing problems. The discovery has paved the way for clinicians to spot this form of childhood- onset dystonia more rapidly and accurately than before and direct patients more quickly to a form of treatment for the disease called Deep Brain Stimulation, which if successful can dramatically improve patients’ mobility and quality of life and reduce the need for trials of medication with side effects.

Page 32 Quality Report 2016/17 Goals Agreed with Commissioners A proportion of the Royal Devon and Exeter NHS Foundation Trust income in 2016/17 was conditional on achieving quality improvement and innovation goals between the Royal Devon and Exeter 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 www.rdehospital.nhs.uk. The 2016/17 NHS Planning guidance continued the potential for Trust to earn additional income, conditional upon achieving quality improvement and innovation goals. The Trust agreed a suite of schemes for which the Trust could earn an additional £6.8m of income in 2016/17. In 2015/16 the Trust received payment to the value of £6.9m. The number of patients receiving relevant health services provided by Royal Devon and Exeter NHS Foundation Trust in 2016/17 that were recruited during that period to participate in research approved by a research ethic committee was 6700.

Page 33 Quality Report 2016/17 COMMISSIONING FOR QUALITY AND INNOVATION SCHEMES 2016/17

Name of Scheme – NHS Staff Health and ● Work with the sponsors of the Great West Run Wellbeing: Introduction of Health and (GWR) generated 12 ‘free’ places being offered Wellbeing Initiatives to staff. All were taken up, with participants running in the 2016 GWR. Objective ● The Royal College of Midwives (RCM) campaign The objective of this CQUIN is to encourage the continues to be implemented. Activities have introduction of Health and Wellbeing initiatives for included various staff surveys looking at rest NHS staff, including initiatives for physical health, and breaks, bullying and harassment. Work for mental health and for improved access to continues to implement the findings from these physiotherapy for staff with musculoskeletal issues. surveys, working in partnership with our Staff Key Achievements Side colleagues. ● Staff Physiotherapy service has been expanded Name of Scheme – NHS Staff Health and to include a proactive service looking into Wellbeing: Healthy Food for NHS Staff, Musculo Skeletal (MSK) issues. Visitors and Patients ● Stress management courses have Objective recommenced, with two courses being provided during 2016-17. This CQUIN encourages the review of the food that is offered within the hospital to NHS staff, visitors and ● Group Mindfulness courses have commenced, patients, including through food and retail outlets. It provided by Staff Support and Counselling. is intended that this CQUIN will support a change in ● Staff mental health now being included within food provision on hospital premises to include healthy a strategic Trust work stream re; patient facing options including for staff working night shifts, to mental health summit. ban sugary drinks and foods high in fat, sugar and salt from checkouts and banning the advertisement ● Mental health awareness training sessions for on NHS premises of sugary drinks and foods high in managers have continued to be provided and fat, sugar and salt. have increased understanding of mental health. Key Achievements ● Running clubs have excelled; with three beginners groups commencing during 2016- ● An action plan has been developed and 17. This has led to a further running group agreed with commissioners, and subsequently being established to support those who have implemented whereby price promotions on all successfully attended the beginners groups and high fat, sugar and salt (HFSS) items have been who wish to go on to continue running with a removed in the agreed food outlets group. ● For other commercial outlets within the ● Personal training (circuits) have also expanded hospital, outside the agreed formal scope of and are now provided on Mondays and the CQUIN, discussions have taken place to Thursday nights. Both are well attended and encourage the removal of promotions on foods supported by staff. high in fat, sugar or salt. These promotions have been removed and replaced with new ● A staff member has started up a Yoga group on promotions that are driving healthier options. Wednesday evenings, which is well attended by staff. ● A review of promotional material within the Trust’s Oasis Restaurant which now only ● Work with Active Devon continues, with both advertises themed events. calendar of events being co-ordinated to ensure maximum coverage and support. Events ● Removal of sugary drinks and foods high in fat, have included Big Devon March. Discussion sugar and salt from all till points. Whilst this continues with Active Devon to see how we has been particularly challenging as some food can roll out activities to community colleagues outlets within the hospital are very small, every based in East Devon. effort has been made to position HFSS foods as far away from the tills as possible.

Page 34 Quality Report 2016/17

● All food outlets and vending machines provide ● 75% of patients who presented with severe healthy options. sepsis, red flag sepsis or septic shock were administered IV antibiotics within 60 minutes ● A new vending machine offering frozen meals (Q3) is now available for staff at night from mid- March 2016. This includes WeightwatchersTM ● 67% of patients who presented with severe products. sepsis, red flag sepsis or septic shock and were administered IV antibiotics, had an empiric ● Links to additional healthy eating information review within 3 days of the prescribing of on the intranet have been provided for staff antibiotics (Q3)

Name of Scheme – NHS Staff Health and ● Sepsis training has been delivered via Wellbeing: Improving the Uptake of Flu e-presentation and at communication cell Vaccinations Amongst Front Line Staff meetings to over two hundred staff, including all matrons, on the five identified wards. Objective Training has been supplemented with micro- teaching by the AKI / sepsis educational This CQUIN scheme intends to encourage NHS facilitator providers to achieve an uptake of the flu vaccination by frontline clinical staff of 75%, by 31 December ● Data capture mechanisms created and 2016. trajectory for improvement agreed Key Achievements Name of Scheme – Antimicrobial Resistance ● By the end of December 2016, 76% of front and Antimicrobial Stewardship line staff had been vaccinated. This represents 3548 staff. Objective This CQUIN scheme seeks to reduce the consumption Name of Scheme – Sepsis of all antibiotics, particularly broad-spectrum Objective carbapenems and piperacillin-tazobactam, and to encourage a focus on antibiotic stewardship by The objective of this CQUIN scheme is to ensure ensuring antibiotic prescriptions are reviewed within that patients presenting with the criteria for severe 72 hours of initiation. Antibiotic use is a key driver sepsis screening are screened for sepsis, and that in the spread of antibiotic resistance and measures those patients who present with severe sepsis, to address unnecessary or inappropriate prescribing red flag sepsis, or septic shock via the Emergency are crucial to minimise this unintended consequence. Department, or by direct admission to the Acute Reviewing antibiotics after 24-72 hours of treatment Medical Unit or Surgical Assessment Unit, are allows clinicians to change therapy in light of new administered intravenous antibiotics within the information e.g. new blood, microbiology and appropriate timeframe and have a review of the imaging results and depending on the patient’s prescribing of antibiotics within three days of their clinical improvement. This helps to ensure treatment initial prescription. For patients who develop red flag is tailored to the individual/infection and that no sepsis or septic shock whilst already an inpatient, unnecessary antibiotics are prescribed. this CQUIN scheme seeks to ensure that patients are prescribed and receive intravenous antibiotics Key Achievements within 90 minutes of identification of red flag sepsis ● Data submitted regarding antibiotic or septic shock, and that the prescription is reviewed consumption (Q1 – Q3) within 3 days. This element of this CQUIN scheme is being initially implemented on five wards within the ● Empiric review performed in 90% of cases hospital in 2016-17 prior to roll-out more widely in within 72 hours (Q1), 89% of cases within 2017-18. 72 hours (Q2), and 91.3% of cases within 72 hours (Q3) Key Achievements (performance against the targets in this scheme were locally agreed and ● Data submitted regarding Trust antibiotic cannot be compared nationally) consumption (Q1 – Q4)

● 97% of patients meeting the criteria for severe ● Empirical antibiotic therapy was reviewed within sepsis screening, were screened for sepsis (Q3) 72 hours for 90% of prescriptions (Q1), 89% of prescriptions (Q2), 91.3% of prescriptions (Q3)

Page 35 Quality Report 2016/17 NHS England CQUIN Schemes

Name of Scheme – Clinical Utilisation Name of Scheme – Spinal Surgery Networks Review (CUR) (Data, MDT Oversight) Objective Objective This CQUIN scheme seeks to improve patient flow This CQUIN scheme supports the creation and within the hospital, through the adoption of the operation of a spinal surgery network, the Clinical Utilisation Review process to provide real-time identification of appropriate data flows, and the evidence based clinical decision support to ensure establishment of a multi-disciplinary team (MDT) that patients are in the most appropriate setting for meeting for spinal surgery patients with data the clinical needs. reported to the British Spinal Registry. This CQUIN aims to ensure that patient selection for specialised Key Achievements surgery is carefully discussed and the optimum ●● Use of Clinical Utilisation Review process piloted treatment option is chosen in all cases. on four wards Key Achievements ●● Deep dive approach implemented on each ward ●● Peninsula Regional Spinal Network established to enable detailed examination and resolution with representation from all acute Trusts in of implementation issues Devon and Cornwall ●● Consideration of rollout in 2017-18 being ●● Terms of Reference agreed and Network Host developed established

Name of Scheme – Enhanced Supportive ●● Four Network meetings held to discuss pre- Care – Access for Advanced Cancer Patients operatively both complex and non-complex cases, with further discussion of cases post- Objective operatively where there is identified learning There is growing evidence that good supportive care provided early to patients with advanced cancer can Name of Scheme – Adult Critical Care improve quality of life, possibly lengthen survival Objective and reduce the need for aggressive treatments near the end of life. This CQUIN scheme seeks to ensure This CQUIN seeks to reduce delays in transferring that patients with advanced cancer are, where adult inpatients from Critical Care environments appropriate, referred to a Supportive Care Team. (including Intensive Care) to an inpatient ward, by improving bed management in ward based care, Key Achievements thereby removing delays and improving flow ●● A fixed term supportive and palliative care team Key Achievements has been established ●● A revised process for communicating and ●● The national palliative care holistic tool (IPOS) recording that patients were fit to discharge has been introduced for this group of patients from ICU was agreed with ICU and the Site using the technology from the “Living With and Practitioner team Beyond Cancer” project ●● A thematic analysis of reasons for delayed ●● Over one hundred patients (so far) have discharges was undertaken, which indicated benefited from this initiative with many more further actions to reduce delays in transferring patients who might benefit from it being patients from ITU to inpatient wards identified ●● An improvement in the percentage of patients discharged within 4 hours of being declared medically fit to transfer from ICU and has been seen in Q2 and Q3 data compared to Q1

Page 36 Quality Report 2016/17

Name of Scheme – Blueteq Implementation Name of Scheme – Armed Forces CQUIN for Clinical Devices Objective Objective This CQUIN scheme encourages the adoption of This CQUIN encourages the implementation of processes to support the embedding of the Armed Blueteq – a web-based “prior approval” system Forces Covenant and NHS Constitution, ensuring whereby for high cost devices, instant approval can that members of the Armed Forces Community, who be provided by NHS England. for operational reasons may need to move home frequently during their military service, suffer no The expected benefits are: disadvantage in accessing health services. ● Assurance is provided that patients are being Key Achievements treated according to NHS England commissioned policies, including NICE technology appraisals. ● An Armed Forces Covenant Lead identified from Executive Team ● The on line forms provide the opportunity to undertake a prospective audit, rather than a ● Plan developed and implemented for retrospective audit after expenditure has been operationalisation of the Armed Forces incurred. Covenant including communication of Armed Forces Covenant commitments to staff ● The Blueteq system enables the provider invoices to be reconciled to the patient’s on line form. ● Face to face training delivered to 131 staff (97%) identified as requiring it. Staff have ● Patients meeting the criteria stipulated by Blueteq received training via face to face briefings and will be automatically approved for use with meetings, with messages reinforced through subsequent financial flows being ensured. the provision of Standard Operating Procedures Key Achievements and an extract from the RTT Supervisor User Guide (as referenced above) to all appropriate ● A Trust lead for Blueteq use in devices has been staff assigned ● Communication has also been sent to ● A Trust standard operating procedure for all Administration Line Managers and Blueteq use for both drugs and devices has Administration Service Managers to reinforce been developed this message regarding the management of inter-provider transfers, including those covered ● Blueteq forms will now be completed for by the Armed Forces Covenant, through its devices as directed by NHS England inclusion at “Comm Cell” briefing to admin ● The Contracts team will now monitor Blueteq teams approval before claims for devices are made Name of Scheme – Increasing Participation Name of Scheme – Systemic Anticancer in NHS Screening Programmes Therapy (SACT) Dose Banding Objective Objective This CQUIN scheme focusses on the identification This CQUIN scheme incentivises the standardisation and delivery of initiatives to improve uptake in NHS of chemotherapy doses for cancer patients in order Screening (Cervical Screening, and Diabetic Eye to increase safety, improve efficiency and support Screening) programmes amongst sections of the parity of care across all providers of chemotherapy in population where historically uptake has been low. England. Key Achievements Key Achievements Diabetic Eye Screening Programme

● Approval by Drugs and Therapeutics Committee ● Patient questionnaire established, and GP of principles of dose banding practice focus groups created to explore ● More than 70% of patients received their reasons for low uptake in diabetic eye screening chemotherapy using the dose banding programme amongst working age adults, approach. The remaining patients received their and patients in areas of high socio-economic treatment on an individualised basis. deprivation

Page 37 Quality Report 2016/17

● Distribution of media material, including posters and videos for GP practices and creation of education material on Trust website, emphasising importance of retinal screening programme

● Fixed appointments trialled in a small surgery to reduce patient waiting times

● Trial established of evening appointments to encourage increased uptake amongst working age adults

● Appointment reminder service established

● “Easy read” patient letters to be created to support improved uptake amongst those with learning disabilities Cervical Screening Programme

● Education and training programmes across Devon being created for administration and practice staff at GP surgeries with low participation rates in cervical screening programme to support consistent approach to cervical screening, and thereby improved access and increased uptake.

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The Trust has submitted an action plan to the CQC. The Trust’s Governance Committee will monitor the action 23planNotR oythroughesal Devon to & Excompletion;eter Hospital the (Wonf targetord) Quality date is R eport1 April 09/02/2016 2017.

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8 Mardon Neuro-rehabilitation Centre Quality Report 09/02/2016 Quality Report 2016/17 NHS Number and General Information Governance Medical Practice Code The Royal Devon and Exeter NHS Foundation Trust Information Governance Assessment Report overall Validity score for 2016/17 was 74% and was graded green. The Royal Devon and Exeter NHS Foundation Trust submitted records during 2016/17 to the Secondary Users Service for inclusion in the Hospital Episodes Clinical Coding Statistics which are included in the latest published The Royal Devon and Exeter NHS Foundation Trust data. was not subject to the Payment by Results Clinical Coding Audit during 2016/17. The percentage of records in the published data:

● Which included the patient’s valid NHS number Data Quality was: The Royal Devon and Exeter NHS Foundation Trust ● 99.7% for admitted patient care will be taking the following actions to improve data quality: ● 99.9% for outpatient care 1. Ensure correct calculation of Commissioner ● 97.9% for accident and emergency care for outpatient care, admitted patient care and ● Which included patient’s valid General Medical accident and emergency care. Practice Code was: 2. Ensure correct speciality is recorded for outpatient ● 100% for admitted patient care care.

● 100% for outpatient care 3. Ensure referral date is recorded in all cases for outpatient care. ● 99.9% for accident and emergency care 4. Ensure correct Health Resource Group calculation for outpatient care.

Page 40 Quality Report 2016/17 Definition National Definition Source Source of measure NHS Digital Indicator Portal Internal Audited? Clinical Coding Audit (part of IG toolkit) The Trust monitors this The Trust via the data regularly Patient Safety Group, Safety & Risk Committee and the monthly Board Report. The Royal Devon and Exeter NHS Foundation intends to take/ Trust has taken the following this actions to improve percentage/proportion/ and score/rate/number, so the quality of its services, by: There is a nine There The SHMI 1. over month cross between each period. reporting 2. values are comparable to those calculated independently by the University Hospitals Birmingham Foundation Healthcare Trust Evaluation Data (HED) system. The Royal Devon and Exeter NHS Foundation considers Trust that this data is as described for the following reasons: July 2015 - June 2016 SHMI: 1.0182 (as expected) (11 trusts higher than expected, 110 as expected and 15 lower than expected) Data: Previous reporting period October 2015 - September 2016 SHMI: 1.0305 (as expected) (10 trusts higher than expected, 111 as expected and 15 lower than expected) Data: Most recent reporting period SHMI The Summary Hospital-level Mortality on mortality at trust Indicator (SHMI) reports the NHS in England. The SHMI level across is the ratio between actual number of patients who die following hospitalisation at the trust and number that would be expected to die on the basis of average given the characteristics of England figures, It covers all deaths there. the patients treated admitted to of patients who were reported non-specialist acute trusts in England and either die while in hospital or within 30 days of discharge. published SHMI values for each trust are along with bandings indicating whether a SHMI is ‘1 – higher than expected’, ‘2 trust’s – as expected’ or ‘3 – lower than expected’. For any given number of expected deaths, to a range of observed deaths is considered be ‘as expected’. If the observed number of deaths falls outside of this range, the trust to have a higher or in question is considered advised are lower SHMI than expected. Trusts to use the banding descriptions i.e. ‘higher than expected’, ‘as or ‘lower expected’ rather than the numerical codes to these bandings. This is which correspond because, on their own, the numerical codes not meaningful and cannot be readily are understood by readers. Indicator Description Summary Hospital- level Mortality Indicator (SHMI) Indicator Domain 1 – Preventing people dying from prematurely Indicator Group CORE INDICATORS to monitoring performance, approach of Directors the Board and patient experience indicators which reflect effectiveness has chosen the safety, The Trust assurance of cause and effect. provide and outcome measures of process A mixture approach. card adopting a balanced score

Page 41 Quality Report 2016/17 National Definition Definition NHS Digital Indicator Portal Source Source of measure No Audited? The Trust monitors this The Trust via the data regularly Patient Safety & Mortality Review Group. The Royal Devon and Exeter NHS Foundation intends to take/ Trust has taken the following this actions to improve percentage/proportion/ and score/rate/number, so the quality of its services, by: There is a There The coding in Increases 1. nine month over cross between each reporting period. 2. rates are comparable to those calculated independently by the University Hospitals Birmingham Foundation Healthcare Trust Evaluation Data (HED) system. 3. the palliative coding rate were figures seen following completion of specific interventions intended to improve recording. The Royal Devon and Exeter NHS Foundation considers Trust that this data is as described for the following reasons: July 2015 - June 2016 Palliative Coding: 19.2% (Highest 54.8%, Lowest 0.6%, National average 29.2%) Data: Previous reporting period October 2015 - September 2016 Palliative Coding: 19.1% (Highest 56.3%, Lowest 0.4%, National average 29.7%) Data: Most recent reporting period Palliative Coding The SHMI methodology does not make any adjustment for patients who are palliative care. as receiving recorded is considerable This is because there variation between trusts in the coding to in order However, of palliative care. of the SHMI, support the interpretation published various contextual indicators are alongside it, including indicators on the coding. Reported topic of palliative care of patient deaths is the percentage here, coded at either with palliative care diagnosis or specialty level for the trust period. the reporting Indicator Description Indicator Indicator Group

Page 42 Quality Report 2016/17 National Definition Definition NHS Digital Indicator Portal Source Source of measure No Audited? The data is reviewed The data is reviewed by the regularly Surgical Services their Division through Governance structure. The Royal Devon and Exeter NHS Foundation Trust intends to take/has taken the following actions to improve this percentage/ proportion/score/ and rate/number, so the quality of its services, by: Results for some not the metrics are published due to the small number of procedures undertaken within and the the Trust need to maintain patient confidentiality. These PROMs scores comparable are or better than the national average and consistent with other patient satisfaction results. measure The Royal Devon and Exeter NHS Foundation Trust considers that this data is as described for the following reasons: April 2015 - March April 2015 - March 2016 Hernia Groin EQ-5D: 0.130285 (England 0.0878582, Lowest 0.0213379, Highest 0.157388) 2.09831 EQ-VAS: (England -0.804931, Lowest -4.74623, Highest 4.97083 Vein Varicose EQ-5D: 0.132489 (England 0.0951698, Lowest 0.0182181, Highest 0.148773) Data: Previous Data: Previous period reporting April 2016 - September 2016 Hernia Groin EQ-5D: N/A* (England 0.0892652, Lowest 0.016173, Highest 0.161799) N/A* EQ-VAS: (England -0.115698, Lowest -4.64603, Highest 3.11488) Vein Varicose EQ-5D: N/A* (England 0.0994836, Lowest 0.0161098, Highest 0.151918) Data: Most recent Data: Most recent period reporting Patient Reported Measures Outcome a (PROMs) are means of collecting information on the of care effectiveness to NHS delivered patients as perceived by the patients themselves; reported / at NHS Trust independent sector and CCG provider for: level as scores (i) hernia Groin surgery (ii) vein Varicose surgery (iii) Hip replacement surgery (iv) Knee surgery replacement Indicator Description PROMS; patient reported outcome measures Indicator Domain 3 - Helping people to recover from episodes of ill health or following injury Indicator Group

Page 43 Quality Report 2016/17 Definition Source Source of measure Audited? The Royal Devon and Exeter NHS Foundation Trust intends to take/has taken the following actions to improve this percentage/ proportion/score/ and rate/number, so the quality of its services, by: The Royal Devon and Exeter NHS Foundation Trust considers that this data is as described for the following reasons: EQ-VAS: 3.50102 EQ-VAS: (England -0.451703, Lowest -8.0714, Highest 4.85902) Varicose Aberdeen Questionnaire: Vein -11.415 (England -8.59664, Lowest -18.0196, Highest 3.05957) Hip replacement primary EQ-5D: 0.442533 (England 0.438304, Lowest 0.320382, Highest 0.510117) Data: Previous Data: Previous period reporting EQ-VAS: N/A* EQ-VAS: (England 1.37183, Lowest -0.788634, Highest 5.01629) Varicose Aberdeen Questionnaire: Vein N/A* (England -8.47694, Lowest -14.5166, Highest 1.33495) Hip replacement primary EQ-5D: 0.445908 (England 0.448974, Lowest 0.329827, Highest 0.524997) Data: Most recent Data: Most recent period reporting EQ-5D Index - a combination of five key criteria concerning self- patient’s general reported health comparing and post- pre- operative scores - the EQ-VAS state of current self- the patient’s general reported health comparing and post- pre- operative scores Hip Score/ Oxford Knee Oxford Score/Aberdeen Vein Varicose The casemix- adjusted average heath gain scores are: ● ● ● Indicator Description Indicator Indicator Group

Page 44 Quality Report 2016/17 Definition Source Source of measure Audited? The Royal Devon and Exeter NHS Foundation Trust intends to take/ has taken the following actions this to improve percentage/ proportion/score/ and rate/number, so the quality of its services, by: The Royal Devon and Exeter NHS Foundation Trust considers that this data is as described for the following reasons: EQ-VAS: 12.4469 (England EQ-VAS: 12.4049, Lowest 4.95667, Highest 18.7153) 22.427 Hip Score: Oxford (England 21.6166, Lowest 16.8924, Highest 24.9728) revision Hip replacement EQ-5D: 0.300685 (England 0.284568, Lowest 0.225136, Highest 0.372465) 5.68063 (England EQ-VAS: 6.418, Lowest 1.55674, Highest 11.751) 14.7712 Hip Score: Oxford (England 13.2058, Lowest 9.51028, Highest 16.1863) Knee replacement primary EQ-5D: 0.362676 (England 0.320198, Lowest 0.198277, Highest 0.397955) 7.82057 (England EQ-VAS: 6.22569, Lowest 1.50513, Highest 12.6294) Data: Previous reporting reporting Data: Previous period EEQ-VAS: 13.6088 (England EEQ-VAS: 13.7327, Lowest 3.94363, Highest 19.514 23.4489 Hip Score: Oxford (England 22.0185, Lowest 17.8378, Highest 25.2044) EQ- revision Hip replacement 5D: N/A* (England 0.285013, Lowest N/A*, Highest N/A*) N/A* (England EQ-VAS: 7.83838, Lowest N/A*, Highest N/A*) N/A* Hip Score: Oxford (England 13.1373, Lowest N/A*, Highest N/A* primary Knee replacement EQ-5D: 0.430254 (England 0.336978, Lowest 0.26064, Highest 0.430254) 12.0994 (England EQ-VAS: 8.07544, Lowest 0.797542, Highest 15.0858) 20.1335 Knee Score: Oxford (England 16.8772, Lowest 12.6468, Highest 21.3485) Data: Most recent reporting reporting Data: Most recent period Questionnaire Questionnaire - comparison and of pre- post- operative to response condition- specific questions Indicator Description Indicator Indicator Group

Page 45 Quality Report 2016/17 Definition Source Source of measure Audited? The Royal Devon and Exeter NHS Foundation Trust intends to take/ has taken the following actions this to improve percentage/ proportion/score/ and rate/number, so the quality of its services, by: The Royal Devon and Exeter NHS Foundation Trust considers that this data is as described for the following reasons: Oxford Knee Score: Knee Score: Oxford 18.6175 (England 16.3679, Lowest 11.9602, Highest 19.9198) Knee replacement EQ-5D: 0.242968 revision (England 0.257762, Lowest 0.188252, Highest 0.334586) 1.95034 (England EQ-VAS: 2.0314, Lowest -5.86552, Highest 6.15525) Knee Score: Oxford 11.4022 (England 11.9351, Lowest 8.34144, Highest 14.1481) * to values that N/A refers due have been suppressed to low patient numbers Data: Previous reporting reporting Data: Previous period Knee replacement revision revision Knee replacement EQ-5D: N/A* (England 0.288512, Lowest N/A*, Highest N/A*) N/A* (England EQ-VAS: 5.15063, Lowest N/A*, Highest N/A*) N/A* Knee Score: Oxford (England 13.6245, Lowest N/A*, Highest N/A*) * to values that N/A refers due to have been suppressed low patient numbers Data: Most recent reporting reporting Data: Most recent period Indicator Description Indicator Indicator Group

Page 46 Quality Report 2016/17 National Definition National Definition Definition NHS Digital Indicator Portal NHS England Source Source of measure No Internal audit 2013/14 Audited? The Patient Experience the committee reviews and oversees full report any actions required. The Trust The Trust Communications & have Engagement Team at several work streams Corporate, Divisional and local levels including leadership training engagement and staff meetings. The Royal Devon and Exeter NHS Foundation intends to take/ Trust has taken the following this actions to improve percentage/proportion/ and score/rate/number, so the quality of its services, by: Picker Institute that oversaw the 2016 staff an survey are Survey approved Contractor having met the necessary data quality They standards. have expertise in this field as the The Trust The Trust continues to ask these questions as part of the quality care assessment tool (a time audit). real organisation that runs the survey co-ordination which centre oversees survey for programmes acute, mental health and for primary care the CQC. The Royal Devon and Exeter NHS Foundation Trust considers that this data is as described for the following reasons: 2015 Staff 2015 Staff Survey 81% (All 69%, Trusts Acute Trusts 70%) April 2013 - 2014 March 72.7 (England 68.9, Lowest 54.4, Highest 84.2) Data: Previous reporting period 2016 Staff 2016 Staff Survey 85% (All 69%, Trusts Acute Trusts 70%) April 2014 - 2015 March 74.0 (England 68.9, Lowest 59.1, Highest 86.1) Data: Most recent reporting period The percentage of staff of staff The percentage or under employed by, contract to, the trust during period who the reporting the trust would recommend to their of care as a provider family or friends. The Trust’s score with regard with regard score The Trust’s to the to its responsiveness personal needs of its patients period during the reporting out of 100). (score The indicator value is based of five on the average score the National questions from which Inpatient Survey, the experiences measures of people admitted to NHS hospitals. Due to a sampling error, RD&E inpatient survey data is not available for 2015/16. Indicator Description Staff who Staff would recommend the trust to their family or friends Responsiveness to the personal needs of patients Indicator Domain 4 - Ensuring people have a positive experience of care Domain 4 - Ensuring people have a positive experience of care Indicator Group

Page 47 Quality Report 2016/17 National Definition National Definition Definition Public Health England NHS England Source Source of measure No No Audited? The Trust will continue The Trust striving to eliminate avoidable C.difficile the infection, however, rate of infection is now and below the regional national rate and given the aging population served by this hospital may a further reduction not be possible. On-going work with clinical teams to strive for 100% risk assessment. Monthly performance at ward is reviewed the ward level through framework to board and at divisional level the Performance through Assurance Framework meetings. The Royal Devon and Exeter NHS Foundation intends to take/ Trust has taken the following this actions to improve percentage/proportion/ and score/rate/number, so the quality of its services, by: Antimicrobial Stewardship hygiene Environmental including an annual deep clean programme Hand hygiene Hand hygiene Rapid laboratory diagnostics of written Provision guidance and policy supported by education to implement effectively to implement effectively to proven measures the risk of reduce C.difficile infection, namely: ● ● ● Isolation of symptomatic patients on a designated ward ● ● ● The focus has been on sustaining performance against this target. This has been achieved focus a relentless through clinical teams by ward that all eligible to ensure risk assessed patients are in a timely manner. has continued The Trust The Royal Devon and Exeter NHS Foundation considers that this Trust data is as described for the following reasons: July 2016 - September 2016 (Q2 16/17) 95.13% (England 95.45%, Lowest 72.14%, Highest 100%) April 2014 - 2015 March 13.8 (England 15.0, Lowest 0, Highest 62.6) Data: Previous reporting period October 2016 - December 2016 (Q3 16/17) 95.39% (England 98.16%, Lowest 65.92%, Highest 100%) April 2015 - 2016 March 8.6 (England 14.9, Lowest 0, Highest 66.0) Data: Most recent reporting period The percentage The percentage of patients who admitted to were hospital and who risk assessed were for venous thromboembolism (VTE) during the reporting period. The rate per 100,000 bed days of trust apportioned cases of C. difficile infection that have within occurred the trust amongst patients aged 2 or over during the period. reporting Indicator Description Patients admitted to hospital who risk assessed were for venous thromboembolism Rate of C.difficile infection Indicator Domain 5 - Treating and caring for people in a safe environment Domain 5 - Treating and caring for people in a safe environment Indicator Group

Page 48 Quality Report 2016/17 National Definition Definition Source Source of measure Internal audit 2013/14 Audited? The Trust has targeted The Trust of lower reporting areas a consistent to ensure culture open reporting This all areas. across work is on-going. The Royal Devon and Exeter NHS Foundation intends to take/ Trust has taken the following this actions to improve percentage/proportion/ and score/rate/number, so the quality of its services, by: The data is directly The data is directly Datix and uploaded from data subject to vigorous quality checks by the and NRLS. Trust The Royal Devon and Exeter NHS Foundation considers that this Trust data is as described for the following reasons: April 2015 - September 2015 Total Incidents: 5760 in % resulting harm severe or death: 0.16% (England 0.56%) Data: Previous reporting period October 2015 - 2016 March Total Incidents: 5487 in % resulting harm severe or death: 0% (England 0.55%) Data: Most recent reporting period The number and where available, rate of patient safety incidents that within occurred the trust during the reporting period, and the of percentage such patient safety incidents that in severe resulted harm or death. A patient safety incident is defined as ‘any unintended or unexpected incident(s) that could have, or did, lead to harm for one or more person(s) receiving NHS funded healthcare’. Indicator Description Patient safety incidents and the that percentage in severe resulted harm or death Indicator Domain 5 - Treating and caring for people in a safe environment Indicator Group

Page 49 Quality Report 2016/17 Single Oversight Framework Quality Account Part 3 Indicators

Indicator for disclosure (limited to 2016/17 2015/16 Source of Definition Audited? those that were included in both Measure RAF and SOF for 2016/17) Maximum time of 18 weeks from 91.6% 93.0% Unify2 National KPMG 2017 point of referral to treatment (RTT) in submission Definition aggregate - patients on an incomplete pathway A&E: maximum waiting time of four 92.5% 94.8% Unify2 National KPMG 2017 hours from arrival to admission/ submission Definition transfer/discharge All cancers: 62-day wait for first treatment from: ● urgent GP referral from suspected 79.7% 81.1% Open Exeter National PWC 2012/13 cancer Definition Internal Audit 2013/14

● NHS Cancer Screening Service 93.1% 91.7% Open Exeter National PWC 2012/13 referral Definition

Page 50 Quality Report 2016/17 STATEMENT FROM THE COUNCIL OF GOVERNORS Annex A This is the first time that I have authored the quality statement on behalf of the Council of Governors. The quality report is a comprehensive document demonstrating not only the breadth of the services provided by the Royal Devon and Exeter NHS Foundation Trust but also the many and varied initiatives that have been undertaken to improve those services. 2016/17 has been a period of great uncertainty and change for the NHS in general and the Trust in particular. The Trust is moving forward under the direction of a new Chief Executive while progressing into new territory in joining acute and community services with the integrated Care Exeter Project, ICE Uncertainties are brought about for the Trust and its staff by changes due to the Sustainability and Transformation Plan, Brexit and the acute services review. This has required the staff at all levels to respond to these challenges while ensuring a safe and quality service is maintained for all those people who use the service. Throughout the year the Governors were updated with the status of service initiatives which were being taken to maintain a high quality service by the Chief Executive, members of the Board and the teams working within the hospital. When there have been problems or potential problems the Governors have been briefed when possible in advance. A comprehensive dissertation on the preparedness of the Trust for winter pressures was given to the Governors demonstrating the ways the Trust was changing its working practices to meet the challenges. The plan resulted in a reduction in the number of days in which the Trust had to restrict its normal working throughout the winter. The Governors’ priorities for 2016/7 focused on two areas. The patient experience of the referral and booking process, including the management of cancellations, postponement and amendment of appointments. This is the time when the patients first come into contact with the Trust and form their initial opinions and before they enter the excellent clinical pathways. The Trust will systematically review and improve outpatient booking processes in 2017/18. Mental Health Services focusing on maternity and young people A Trust priority is focused across the mental health services It is clear the perinatal mental health team was well embedded within the maternity department in an innovative way, planning a comprehensive prediction and a detection pathway alongside their midwifery colleagues in order to bring services to women who were pregnant or contemplating pregnancy who required them. The community perinatal mental health team are to be congratulated for winning the ‘positive practice in mental health’ award. The mental health services for young people provided by CAMHS give a wide range of excellent services for those with specific mental health issues and long-term physical conditions. The Trust is served by a highly motivated staff and score highly in the staff survey. The nominations to the Extraordinary People awards this year show the appreciation of the staff by the patients, their relatives and their managers. The Trust was one of the first providers in the UK to be accredited under the ‘Gold Standards Framework’ for end-of-life care and the first Trust to be fully accredited by the prestigious UNICEF UK Baby Friendly Initiative. The Committee of Governors thanks the staff for their hard work and dedication and congratulates them on their achievements. Dr Tony Ducker TD FRCP FRCPCH Public Governor for Exeter and South Devon

Page 51 Quality Report 2016/17

STATEMENT FROM THE NEW DEVON CCG Annex B Thank you for the opportunity to comment on the 2016/17 Quality Report for the Royal Devon and Exeter NHS Foundation Trust (RDEFT). The report describes the quality of services delivered by your Trust and demonstrates how quality and safety clearly remain at the top of your agenda. The following briefly outlines some of the key quality and safety successes we have also identified through working closely with you during 2016/17. Emergency Care: RDEFT have clearly experienced an increase in services and this includes the Emergency Department. Ensuring emergency care and pathways have been, and continue to be, addressed and improved assures us of your on-going commitment to patient quality and safety. CQUIN: RDEFT continue to take part in Commissioning for Quality and Innovation schemes (CQUINs). As well as schemes that further improved patient care, RDEFT also demonstrated their commitment to caring for staff; 75% of staff vaccinated against flu (Health &Staff Health & Wellbeing CQUIN). Cancer: RDEFT continue to work with NEW Devon CCG to reduce the breaches in waiting times. When challenged, RDEFT has quickly put action plans in place to ensure safe care is delivered. Maternity: RDEFT have clearly supported their maternity team to continue to learn together and further improve on the excellent care they provide women and babies. Undertaking simulation training as well as safety culture questionnaires (SCORE) are just two ways this has been encouraged. We would also like to congratulate the Perinatal Mental Health Team for their award, ‘Positive Practice in Mental Health’. Community: The launch of Community Connect in March 2017 has ensured a joined up approach between community, ambulance and acute staff to enable patients who are safe to remain at home the right support. Moving into the coming year, such services will continue to ensure safe care for patients across the community setting. Looking ahead, NEW Devon CCG continues to supports the Trust priorities for 2017/2018:

● Emergency Pathways

● Improving discharge processes across local care economy

● Supporting mental health needs for people

● Patient Safety Programme We look forward to our continued collaborative working to deliver safe and high quality care across Devon. Lorna Collingwood-Burke Chief Nursing Officer/Caldicott Guardian

Page 52 Quality Report 2016/17

STATEMENT FROM HEALTHWATCH DEVON Annex C Healthwatch Devon welcomes the opportunity to provide a statement in response to the quality account produced by the RD&EFT for the year 2016/17. Progress on 2016/17 priorities Our statement this year focusses on the Trust’s progress in relation to the governors priorities of patient experience of the referral and booking process, and Mental Health Services focusing on young people. These are particularly relevant to the patient experiences shared with Healthwatch Devon, and the recent report that we published ‘Children and Young People: Speaking out on health and care services’.

● Patient experience of the referral and booking process and how the Trust manages the cancellation / postponement and amendment of appointments. The work done to reduce waiting times for ophthalmology services is to be commended. We can confirm that the feedback shared with Healthwatch Devon regarding experiences regarding the ophthalmology department has all been positive, with patients praising the quality of treatment received. Patients are still reporting issues with appointments, including long waits for referrals, in other areas.

● Mental health services focusing on young people. We read with interest that “recent statistics highlight Devon as having the second highest number of referrals for young people (aged 10-24) who have self-harmed in the country”. This is fully supported by our key findings from our ‘Children and Young People: Speaking out on health and care services’ report. We used a set of questions that enabled us to find out what health and social care issues matter most to young people. The top 3 healthcare issues that respondents indicated were most important to them included; Depression and anxiety, Sexual health and Self-harm. Key areas for improvement identified from the feedback provided by children and young people included better access to healthcare services in a timely manner, particularly mental health services. We support the Trust’s priority of improving discharge process and the continued programme of work undertaken. Priorities for 2017/18 We are committed to supporting the work in relation to the Trust’s priorities in 2017/18:

● Clinical conversations. We would support work that prevents the need for unnecessary hospital admissions and referral appointments. We have received patient experiences relating to these services and which we have shared with the Trust throughout the year.

● Working with patients and families to learn lessons. We will continue to report patient experience data to the Trust on a regular basis. We welcome any opportunity to work with the Trust to ensure any further feedback we receive relating to patients, relatives, friends or carers helps to inform the work of the Trust.

Page 53 Quality Report 2016/17

STATEMENT FROM THE HEALTH AND WELLBEING SCRUTINY COMMITTEE Annex D Devon County Council’s Health and Wellbeing Scrutiny Committee has been invited to comment on the Royal Devon and Exeter NHS Foundation Trust Draft Quality Report 2016/17 which includes the priorities for 2017/18. All references in this commentary relate to the reporting period 1st April 2016 to 31st March 2017 and refer specifically to the Trust’s relationship with the Scrutiny Committee and its members. The Scrutiny Committee believes that the Quality Report 2016-17 is a fair reflection and gives a comprehensive coverage of the services provided by the Trust, based on the Scrutiny Committee’s knowledge. The scrutiny committee welcomes the new Chief Executive of the Foundation Trust and commends the proactive approach she has already taken with regard to briefings and meetings with the Chair of the Committee. Across the year the RD&E has provided ad-hoc briefings for the Chair as required and has endeavoured to work with Health Scrutiny with an informed and positive relationship to change. The RD&E presented to the scrutiny committee in June 2016 as a follow up session on cancer waiting times. The scrutiny committee was content with the progress that had been made as recognised by the CQC and welcomed the innovation in cancer care initiatives. The Committee is impressed with overall RD&E performance and would like to commend the RD&E on resolving the outstanding backlog of patients from 900 to zero for Glaucoma. In the next year the committee particularly looks forward to receiving information on the success of the redesign of the booking/appointments service, welcomes the focus on mental health and will be watching with interest the work on social prescribing to change demand streams on traditional services. Looking at the coming year the Committee will wish to continue to have an engaged relationship with the RD&E as the STP moves into the results of the review of acute services in the South West. Following the Health and Wellbeing Scrutiny Committee’s spotlight review on Quality, the Committee very much hopes that regular quality and performance information will be shared via the CCG in a regular reporting cycle. The committee welcomes a continued positive working relationship with the RD&E in 2017/18 and beyond.

Page 54 Quality Report 2016/17 STATEMENT OF DIRECTORS’ RESPONSIBILITIES FOR THE QUALITY REPORT Annex E The directors are required under the Health act 2009 and the National Health Service (Quality Accounts) Regulations to prepare Quality Accounts 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 NHS foundation trust boards should put in place to support the data quality for the preparation of 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 2016/17 and supporting guidance

● The content of the Quality Report is not inconsistent with internal and external sources of information including: ● board minutes and papers for the period April 2016 to March 2017 ● papers relating to quality reported to the board over the period April 2016 to March 2017 ● feedback from commissioners dated 12 May 2017 ● feedback from governors dated 12 May 2017 ● feedback from local Heathwatch organisations dated 12 May 2017 ● feedback from Overview and Scrutiny Committee dated 12 May 2017 ● the trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated 25 January 2017 ● the national patient survey 18 January 2017 ● the national staff survey 7 March 2017 ● the Head of Internal Audit’s annual opinion of the trust’s control environment dated 19 May 2017 ● CQC inspection report dated 9 February 2016

● The Quality Report presents a balance 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 measures 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 manual and supporting guidance (which incorporates the Quality Accounts regulations) as well as the standards to support data quality for the preparation of the Quality Report. 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 24 May 2017 James Brent, Chairman and Suzanne Tracey, Chief Executive

Page 55 Quality Report 2016/17 CLINICAL AUDIT Annex F The national clinical audits and national confidential enquiries that Royal Devon and Exeter 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 that audit or enquiry (where known).

Name of audit / Clinical Outcome Review Trust Trust Participation rate Programme eligible? participated? Acute Adult Asthma Yes Yes 21* Case Mix Programme (CMP) Yes Yes 100% (967/967) Major Trauma: The Trauma Audit & Research Yes Yes 119% (365/305)** Network (TARN) National emergency laparotomy audit (NELA) Yes Yes 67% (177/264)*** National Joint Registry (NJR) Yes Yes 1655* Moderate & Acute Severe Asthma (care in Yes Yes 50* emergency departments) Severe Sepsis and Septic Shock (care in emergency Yes Yes 50* departments) Blood and Transplant National Comparative Audit of Blood Transfusion Yes Yes 84% (38/45) programme Cancer Bowel cancer (NBOCAP) Yes Yes 102% (293/288) Head & Neck Cancer (HANA) Yes Yes 302* Lung cancer (NLCA) Yes Yes 98% (1224/1247) Oesophago-gastric cancer (NAOGC) Yes Yes >90% (195) Heart Acute coronary syndrome or Acute myocardial Yes Yes On-going data submission infarction (MINAP) Cardiac Rhythm Management (CRM) Yes Yes 907* National Audit of Percutaneous Coronary Yes Yes 709* Interventions (PCI) (Coronary Angioplasty National Cardiac Arrest Audit (NCAA) Yes Yes 81* National Heart Failure Audit Yes Yes On-going data submission Long term conditions Inflammatory bowel disease (IBD) Yes Yes 52* National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme: ● Pulmonary Rehabilitation Yes Yes On-going data submission ● Secondary Care National Diabetes Core Audit (Adult) Yes Yes 167*

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Name of audit / Clinical Outcome Review Trust Trust Participation rate Programme eligible? participated? National Diabetes Foot Care Audit (NDFA) Yes Yes 194* National Diabetes Inpatient Audit Yes Yes 107* National Pregnancy in Diabetes Audit Yes Yes 58* Renal Replacement Therapy (Renal Registry) Yes Yes 100% National Ophthalmology Audit Yes No 0% UK Cystic Fibrosis Registry Yes Yes 163* Older People National Audit of Dementia Yes Yes 83% (83/100) National Hip Fracture Database (NHFD) Yes Yes 594* Sentinel Stroke National Audit Programme (SSNAP) Yes Yes >90% (701) Other Elective surgery (National PROMs Programme) Yes Yes 75% (1601/2130) Cystectomy Audit (BAUS) Yes Yes >95% Radical Prostatectomy Audit (BAUS) Yes Yes >95% Nephrectomy Audit (BAUS) Yes Yes 100% Percutaneous nephrolithotomy (PCNL) (BAUS) Yes Yes 100% Endocrine and Thyroid National Audit Yes Yes 116* Women’s & Children’s Health National Diabetes (Paediatric) (NPDA) Yes Yes 202* Neonatal intensive and special care (NNAP) Yes Yes 42* Outcome Review Programmes Medical and Surgical Clinical Outcome Review Programme (NCEPOD): ● Mental Health Yes Yes 100% (5) ● Acute Pancreatitis 100% (6) ● Acute Non Invasive Ventilation 100% (5) Child Health Clinical Outcome Review Programme (NCEPOD): ● Chronic Neurodisability Yes Yes Studies still open – on- ● Young Peoples Mental Health going data submission Maternal, Newborn and Infant Clinical Outcome Yes Yes 100% Review Programme (MBRRACE-UK) Learning Disability Mortality Review Programme Yes Yes 12* (LeDeR)

* No case requirement outlined by national audit provider/unable to establish baseline. ** Case submission greater than national estimate from Hospital Episode Statistics (HES) data *** Provisional, data not yet finalised/cleansed

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The reports of 20 national clinical audits were reviewed by the provider in 2016/17, and the Royal Devon & Exeter NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided:

National Clinical Actions Audit/Confidential Enquiry Title National Diabetes Discuss and review number of “medication errors” (e.g. diabetes drugs at wrong times Inpatient Audit or wrong doses) with pharmacy. 2015 National Care for The audit results and recommendations to be widely disseminated across the Trust. the Dying in Acute Hospitals Audit ● End of Life specific training to be adopted as mandatory for all patient facing staff and delivered in a format appropriate to their roles

● Communication Skills Training to be prioritised for all clinical staff and a funding stream identified to provide training and release staff.

● The Opening the Spiritual Gate training programme to be promoted by Matrons and Clinical and Education leads for all clinical staff groups.

● An annual survey or contemporaneous electronic survey of relative experience to be conducted by the Bereavement Team and presented to the End of Life Steering Group.

● 7 day face to face specialist palliative care to be introduced.

● To consider increasing Medical Specialist Palliative Care provision particularly to non-cancer wards which may require a change in referral pathway.

● The individualised care plans to be adapted to become more succinct, less educational and routinely used by all staff groups for patients in the last few days of life.

● All patients who have a nil by mouth decision made to have the reasoning for doing so clearly documented by a senior clinician. The decision should be regularly reviewed particularly when it is established that the patient is in the last few days of life.

● All clinical specialties to consider Advance Care Planning a component of good clinical practice.

● The care of patients for whom an individualised plan of care has not been agreed and followed to be reviewed by the responsible team and form part of reflective practice for revalidation and appraisal.

● All ward areas to be trained in the use of EPACCS which should be accessed on admission and care plans proactively uploaded for all patients thought to be in the last year of life.

● The Trust to commit to future participation in this important audit.

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National Clinical Actions Audit/Confidential Enquiry Title National Audit of ● Ensure consistency between Falls and Delirium and Dementia policies Inpatient Falls 2015 ● Nursing Admission assessment to be updated to include history of blackouts, lying and standing blood pressure. Further audit to be carried out late 2016.

● Therapy Admission assessment to include physiotherapy assessment of mobility, falls risk and fear of falling

● Information leaflet providing falls information to be provided for patients (part of the Nursing Falls Care Plan).

● Medication reviews for at-risk patients to include a trial of pharmacist medication reviews in relation to falls prevention.

● Regular audit of bed rail use is to be completed.

● Regular audit to take place to ensure that the call bell is in sight and reach. Sentinel Stroke ● To review bed availability and reduce inappropriate use of trolley beds on the Acute National Audit Stroke Unit (ASU). Programme ● Audit clerks to prompt at board round if no NIHSS available for admission or 24 hours post-thrombolysis.

● To improve numbers of patients who received a CT within 1 hour of arrival by the consultant/Stroke Nurse Practitioner (SNP) to expedite scan if not done overnight and highlight at morning Acute Care of the Elderly (ACE) meeting.

● To improve efficiency of treating patients with alteplase by educating ED to refrain from undertaking unnecessary tasks (i.e. undressing patient etc.).

● Thrombolysis doctor and SNP to actively consider diagnosis of large artery occlusion stroke in ED and investigate and manage accordingly.

● Discuss all outlier strokes early with SNPs. Bring all stroke cases, even short stay patients, to the ASU.

● Reconfigure consultant input to the ASU.

● Work with the Southwest CV Clinical Network on a region-wide solution to service availability.

● Continue to increase the amount of face to face Speech and Language therapy time, including Lunch Clubs, and increase the use of volunteers.

● Discuss access to a clinical psychologist as core member of the MDT with Devon Partnership Trust .

● Plan for and provide a stroke-skilled early supported discharge service for the whole of the RD&E catchment population.

● Review diagnostic pathway for suspected TIA out of hours, not involving ABCD2 triage; consider means of diagnosing carotid stenosis out of hours.

● Increase patient and carer representation within the governance structure; provide additional means for patients and carers to feed back.

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National Clinical Actions Audit/Confidential Enquiry Title National UK ● Access to the community Parkinson’s Nurse (PN) is to be improved. Parkinson’s Audit ● Exeter community based PN post to be advertised.

● Non motor symptom enquiry to be improved further.

● The Non-motor questionnaire to be put in clinic waiting rooms.

● The need to enquire about hypersomnolence (in relation to driving) during the clinic consultation is to be highlighted.

● Community nurses to follow up patients 6 – 8 weeks post diagnosis. National Audit ● To improve diabetes control in women planning pregnancy. Education of patients of Diabetes in and healthcare professional involved in management of diabetes in patients of Pregnancy reproductive age through the departmental governance meeting, discussion of the results in the multidisciplinary meetings, departmental educational sessions, virtual clinics and educational sessions for GPs and practice nurses.

● To improve diabetes control during pregnancy. To prioritise more complex type 1 diabetes pregnant women in the joint antenatal clinic. To make this possible, a midwife lead telephone follow-up service for pregnant women with hypothyroidism has commenced. National Neonatal ● Implementation of a neo-therm multidisciplinary project to raise awareness of the Audit Project importance of thermoregulation at birth by monitoring babies’ temperatures at Annual Report birth, on departure from labour ward, on arrival in the NNU and temperature when 2016 based on in incubator. 2015 calendar year data ● To improve documentation of parental consultation with senior member of NNU team within 24 hours. Royal College ● Promote in-house video to highlight importance of vital signs at triage and use in of Emergency teaching sessions/triage study day and staff induction sessions. Medicine Paediatric Vital ● Highlight and review Paediatric triage times at Clinical Governance meeting and Signs consultant meeting to identify further improvements ● Improve triage interface on Patient First to enable staff to record vital signs with more ease.

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The reports of 31 local clinical audits were reviewed by the provider in 2016/17 and the Royal Devon & Exeter NHS Foundation Trust intends to take the following action to improve the quality of healthcare provided:

Specialty Local Clinical Audit Title & Actions Aim Acute Thunderclap Headaches The audit findings were as follows: Medicine (TCH)Audit ● All patients had imaging and lumbar puncture (LP) as Aim: To identify all the recommended by Sign guidelines. patients who presented to the ● Thunderclap headache is non-specific and can be caused RD&E hospital with suspected by a number of conditions other than Subarachnoid thunderclap headache and haemorrhage (SAH) examine whether they had appropriate management ● An initial negative CT head scan could potentially rule out and investigations as major SAH. recommended by the Sign guidelines. ● INR check may not be needed in patients who are not on To examine the outcome warfarin or are not known to have blood disorders. in patients who had an ● In the absence of signs of a central nervous system initial negative CT head by infection a CT angiography/ magnetic resonance retrospectively examining angiography may be considered as a first line imaging their clinical notes. modality in patients with TCH and suspected SAH as a more effective way of diagnosing SAH and reducing the need for in patient LP. The below actions have been put in place to improve future compliance by April 2017:

● To develop a care pathway for TCH, followed by a re-audit Anaesthetics Pro Ultra – Audit of The audit found that: Consent Process for Upper Limb Regional Anaesthesia ● Full data regarding consent was seen on 28 patients (RA) across South West although the documentation was variable and generally Peninsula (Exeter Data) poor and it is evident from patient recall that most patients have some form of discussion prior to block Aim: Evaluate consent performance. for upper limb block, and ask patients if they felt ● Patient satisfaction with RA is generally very good with informed about RA and what almost everyone being happy to undergo RA in the future information they valued/ Improvements to be made to the documentation of the would have liked to know. consent process:

● Tick boxes would appear to improve documentation - this could be appropriated into the anaesthetic chart in the next redesign

● Documentation of the block itself could also be improved, again manageable in the next chart redesign

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Specialty Local Clinical Audit Title & Actions Aim Anaesthetics An audit to evaluate This audit showed checking of the first haemacue when perioperative blood transfusion of packed red cells is anticipated is performed transfusion practice well. 2 unit transfusions were common based upon the initial haemacue value without an intervening haemacue check. Aim: to evaluate current Post transfusion haemoglobin analysis suggests that in several transfusion practice of of these cases a 1 unit transfusion may have sufficed. postoperative patients within the various recovery The actions agreed are as follows: units at the Royal Devon & Exeter Hospital and instigate ● Present findings at the clinical governance meeting of the improvements in adherence blood management group to current guidelines ● Liaise with the matron of the recovery units to:

● Disseminate educational material to the recovery staff regarding transfusion triggers and the need to check an haemoglobin value prior to the administration of each unit of packed red cells

● Put visual cues onto the haemacue boxes and the blood track scanners to remind staff of the need to check an haemoglobin value prior to transfusion

● Re-audit in early 2017 Cancer The Peninsula Multicentre The audit found that a number of delays in treatment course services Head & Neck Cancer Audit: were unavoidable namely prolonged post-operative surgical Time from Surgery to and medical issues; and the introduction of a streamlined Adjuvant Radiotherapy pathway is required. Aim: To identify the causes of Following the audit the following actions were taken: delay in South West Peninsula network (Exeter, Plymouth, ● “The Peninsula Initiative” was created encompassing a Truro) and to formulate an number of targets. Time from surgery to MDT is set to improved multidisciplinary within 2 weeks. pathway for the network with ● Patients are pre-booked into clinic for timely oncology minimal extra resources consultation.

● Dedicated dental service is provided for post-operative patients.

● Patients needing post-operative RT are identified pre- operatively, allowing forward radiotherapy booking and planning.

● Current prospective audit in Plymouth shows considerable improvement.

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Specialty Local Clinical Audit Title & Actions Aim Dermatology Biologics audit The audit findings were as follows:

Aim: To ensure we comply ● Generally good compliance with NICE Guidance with NICE guidance when treating patients with ● Improved documentation of PASI and DLQI pre-treatment. psoriasis, with biologics Following actions in place to improve compliance:

● Better documentation of PASI scores and adherence to this policy by all doctors

● Awareness of ‘Understanding NICE Guidelines booklet’ to be improved and documentation and ordering a stock of this document

● Audit will be repeated in 12 months Dermatology An audit of the patch test The audit found that: clinic in Dermatology ● Standards were met for referral indications and prick Aim: to determine and testing. establish the patch test service against UK suggested ● Standards were not met for wait time of 6 weeks from standards. referral to patch testing, visits Day 0 and 4, investigation of 200 cases per annum

● It was felt that the current service is felt to be satisfactory. The following actions were recommended:

● To re-audit in 12 months

● Referring clinicians should track their referral outcomes to assess number of positive results versus negative, plus relevance of results to patient’s current complaint Dermatology An audit of alopecia areata 14 patients in total were given a new diagnosis or likely diagnosis & management diagnosis of alopecia areata within the timeframe. In all parameters except documentation of co-morbidities, the Aim: To re-assess the re-audit demonstrates maintenance or improvement in assessment of alopecia areata performance. diagnosis and management based on BAD guidelines The action from the report is to continue to educate and 2012 remind colleagues of standards required. Ear, Nose A re-audit on The re-audit sample was smaller than the initial cycle. and Throat Dexamethasone Dosing in It was found that there were no firm conclusions. The Day Case Tonsillectomies snapshot samples initial audit shows standard routine is for Prevention of not in compliance to SIGN but rather in keeping with local Postoperative Nausea and guidelines. Overall good compliance to local guidelines in Vomiting adult population but room for improvement in regards to paediatric population. Aim: To improve compliance of dexamethasone dosing in An action plan was agreed to improve future compliance: accordance to guidelines in day case tonsillectomy. ● Audit results to be disseminated to encourage better compliance to set dosages in local guidelines

● Re-audit to be considered in the future is required

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Specialty Local Clinical Audit Title & Actions Aim Emergency An audit of antimicrobial The audit finds were: Medicine management of animal bites admitted to the ● Compliance with guidelines was 90.3%. Emergency Department ● Only a small number of patients had received antibiotics Aim: To review the empirical prior to admission. antimicrobial management of ● The method of collecting data may have missed a patients admitted with dog or significant proportion of those who did receive antibiotics cat bites. prior to admission as it relied on documentation by the admitting clinician. An action plan was agreed, to improve future compliance:

● Staff education

● Highlight guidelines within ED

● Re-audit October 2016 Intensive Snapshot audit of current The audit findings were: Care practice in the screening and management of ● No patients were screened within 24 hours or during delirium in intensive care admission for clinical contributing risk factors for delirium. Of the patients included in the audit, 100% had risk Aim: To evaluate current factors for delirium. practice and improve care of patients at risk of and ● 95% of patients received daily he Richmond Agitation and suffering with delirium within Sedation Scale (RASS) screening the RD&E NHS Trust Intensive ● No patients received daily Confusion Assessment Method care unit against the Local for the Intensive Care Unit (CAM-ICU) screening, and only and National guidelines 9.5% received CAM-ICU screening during their admission Following the completion of the audit, an action plan was agreed, to improve compliance:

● All patients to be screened for delirium daily on morning ward round.

● Re-launch of education package regarding CAM-ICU screening tool

● Review indication for CAM-ICU screening in all patients daily ward round

● Add CAM-ICU to neurology module on carevue

● Education and clarification of appropriate use of RASS / Glasgow Coma Score (GCS) assessments on ward round

● Raise awareness of audit findings at safety brief and add to hot topics notice board

● Adaptation of ‘this is me’ form to clarify type of glasses worn by patients

● Further evaluation of noise levels during day and night hours. In short term offer awake patients ear plugs

● Re-audit to be undertaken by September 2017

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Specialty Local Clinical Audit Title & Actions Aim Maternity Appropriate care for The main findings of the audit were: primiparous patients with ● 40% had evidence in their medical notes that the midwife a Body Mass Index (BMI) ≥ 35kg/m² at booking had requested the GP to prescribe Aspirin. Aim: The aim of the ● 3% did not have fundal height measured. audit was to ensure that ● 45% were felt to have concerning fundal height appropriate care was being measurements. given to primiparous patients with a BMI ≥ 35kg/m² at ● 100% who had concerning fundal height measurements booking, as outlined in the were referred for a growth scan. relevant guidelines ● The signature of the doctor or midwife was entered in the health record in 100% of cases, however in 1 case the name of the staff member was not clearly recorded, and in 2 cases some entries were illegible. The following actions were agreed to improve future compliance:

● Newsletter and email to all midwives to raise awareness of guidance surrounding Aspirin in Pregnancy

● Develop BMI guideline and pathway, with explicit risk factors

● Re-audit January 2017 Neurology Audit into the use of The audit found that 70.4% of patients were maintained dimethyl fumarate on the Tecfidera at the time of sampling. The predominant (Tecfidera) for multiple reason for stopping the medication was side effects and only sclerosis at the Royal three patients stopped due to relapses. Devon and Exeter Hospital The following recommendations were made: Aims: ● Request baseline MRI scans when commencing a new ● To inform prescribing disease modifying treatment to make it easier to assess if practice with the there is no evidence of disease activity (NEDA). experience gained from the patients receiving ● Reminders to patients and GPs at clinic appointments of dimethyl fumarate. the importance of on-going blood monitoring. ● An automated system of reminders when patients have ● To assess tolerability of the medication missed blood tests, which may also highlight abnormal blood tests that may lead to changes to treatment. ● To assess the monitoring system in place for blood tests.

● To assess current practice with regards to monitoring of radiological disease progression with MRI.

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Specialty Local Clinical Audit Title & Actions Aim Neuro- Physiologists Nerve The results of the audits showed 100% compliance on physiology Conduction Studies (NCS) 10 of the 14 recommended National Standards for nerve against National Standards conduction studies being assessed during this audit. The audit Audit data highlighted issues with generic standards 1 and 2. Aim: To assess whether Actions following the audit were: as a department the physiologists’ are achieving ● To make amendments to the NCS equipment main the recommended national screen to allow for the recording of the checking and standards for CTS, Ulnar documenting patient details and the recording and and PN studies on every documenting of limb temperature. test performed within the ● To review current protocols, ensuring all members of staff department. are familiar with current practice and update these if required before re-auditing.

Nutrition Accuracy of the The audit findings were as follows: malnutrition Universal Screening Tool (MUST) at ● 78% of patients had an accurate MUST score. the Royal Devon & Exeter ● The greatest areas for inaccuracies were in the steps Hospital looking at the patient’s weight (both usual and actual). Aim: To assess the accuracy 48% of patients had the same weight recorded for both of MUST screening performed their usual and actual weight. on the wards so a training Following the completion of the audit, the below actions package can be developed were put in place: to aid ward screening. The overall aim of this is to ● Results to be presented at Nutrition Steering Groups to improve the appropriateness raise awareness to senior staff of referrals received by the ● Ward based training package to be developed and rolled Dietetic Department out within the Trust

● Re-audit to be completed once training has been provided to ensure accuracy has improved Nutrition Audit of dietetic nutrition All standards had a compliance rate of 100% of eligible support standard subjects and the current audit shows that it is only achieved for weight at initial assessment otherwise none of the other Aim: The aim of the audit standards achieved full compliance. is to monitor the Trust’s compliance with its Food & To improve future compliance, the action plan below was Nutrition policy. agreed:

● Design specific Oncology standard

● Re-audit to be completed by March 2017

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Specialty Local Clinical Audit Title & Actions Aim Obstetrics Placental Examination The audit found that although all of the placentas should Audit have been sent to the lab, either for immediate examination or for saving for 7 days, only 58% of placentas were sent. Aim: To establish whether The standard for sending placenta’s that require histological the standard for placental examination to the laboratory was not met. Of those examination is being met placenta’s that were sent, some were not examined in full and were only saved for 7 days, this was due to the lack of a request form or the correct information. A histological report of the examination was not available in the hospital notes in all cases. The following action plan was agreed, to improve future compliance:

● Reminders on to midwives on Comms Cell around placental histology criteria

● Report results to be added to Maternity Newsletter

● Reminders to be added to sluices within labour wards and theatres regarding sending placentas being sent to the laboratory Obstetrics Audit of appropriate It is clear from the audit that a proportion of women who location of mid-cavity undergo delivery in the room would fit the criteria of deliveries ‘consideration of a trial in theatre’, however there is clear indication (in all but 10% of cases) as to why to the delivery Aim: To ensure that was expedited. All deliveries performed in the room were Obstetricians are conducting successful. mid cavity instrumental deliveries in the most Following the audit the following actions were agreed: appropriate location according to the presence ● Clinicians to be contacted from lead clinician to remind or absence of relevant risk them to document why a patient wasn’t taken to theatre factors and the indications Ophthal- Screening for uveitis in The audit findings were as follows: mology juvenile inflammatory arthritis (JIA) ● 64% underwent the initial screening for uveitis within 6 weeks as per guidelines, 17% took longer than 6 weeks, Aim: The aim is to audit while it was unclear from the notes in 19%. practice against guidelines, and to identify any areas for ● Counselling of patents about the condition was done improvement. A secondary in only 20%. However, it was noted that in reality more aim would be to develop parents are being counselled about the condition, but local guidelines and to be documenting the discussion should be improved. adopted by all MDT involved Following the completion of the audit the action below was in providing this care. agreed:

● Present report and results to Rheumatology, Paediatrics and Ophthalmology teams with the aim of developing of a local protocol / pathway for referral and follow up of these patients.

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Specialty Local Clinical Audit Title & Actions Aim Ophthal- Pan-retinal The audit findings are as follows: mology photocoagulation (PRP) laser therapy in diabetic ● 31% of patients did not have baseline fundus fluorescein patients angiography (FFA) before or during treatment. Aim: to establish whether ● In patients who had FFA done there was adequate interval the service is following the in 72% of them, between initial clinical diagnosis of PDR appropriate proliferative and performing the FFA. diabetic retinopathy (PDR) ● 19% had PRP within the recommended 2 weeks period. treatment guidelines published by the Royal ● 41% of patients do not have the recommended number College of Ophthalmologists of laser burns. with regard to the ● 83% of patients were seen within 6 weeks after laser recommended treatment time treatment for their follow up appointment. frames and protocols The actions following the audit were:

● To ensure that all PDR patients-unless contraindicated- have FFA and preferably to be done within 2 weeks of the clinical diagnosis.

● To ensure that all patients start their laser treatment within 2 weeks of initial diagnosis.

● To ensure that all patients have the recommended and applied numbers of laser burns documented.

● Maintain the current good time frame of follow up post treatment.

● Re-audit to be conducted in 1 years’ time. Orthopaedic Adult Orthopaedic Surgical The audit findings were as follows: Antibiotic Prophylaxis Audit ● High standards throughout audit and specialities Aim: To see if the current ● All patients being prescribed second doses of Teicoplanin standards stipulated by and further antibiotics if required are receiving them on the Trust Guidelines on the ward at the correct time Orthopaedic Surgical ● Good communication with Microbiology when required Prophylaxsis are being met ● Excellent compliance with Time Out Before Skin Incision and Sign Out To improve future compliance the following actions were agreed to be completed before the next cycle:

● Education to be provided at MDT meetings regarding antibiotic doses based on patient weight and second dose prescribing

● Improve documentation

● Ensure all anaesthetic rooms have guidelines available and visible

● Re-audit in 6 months

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Specialty Local Clinical Audit Title & Actions Aim Orthopaedics VTE Prophylaxis in Lower Following the re-audit, the following actions were agreed: Limb Immobilisation Audit ● Risk stratification of VTE risk for immobilised patient to be Aim: a re-audit to ensure completed. an improvement in compliance following a recent ● Leaflet for DVT vigilance to be produced and given to intervention. patients on discharge from the Emergency Department. Orthopaedics Pharmacological venous Following the re-audit, the following actions were agreed: thromboembolism (VTE) prophylaxis prescribing ● Look into getting VTE assessment as a compulsory item to in elective arthroplasty complete on the e-discharge summaries patients ● To update the app and Trust guidelines highlighting that Aim: a re-audit to ensure aspirin should be prescribed even if a patient is routinely an improvement in on clopidogrel compliance following a recent ● Re-audit – after the introduction of the hip fracture intervention. operation note, which includes post-op VTE prophylaxis and to assess the change in way discharge summaries are generated Orthopaedics Pharmacological venous Following the re-audit, the following actions were agreed: thromboembolism (VTE) prophylaxis prescribing in ● Look into getting VTE assessment as a compulsory item to hip fracture patients complete on the e-discharge summaries Aim: a re-audit to ensure ● To update the app and Trust guidelines highlighting that an improvement in aspirin should be prescribed even if a patient is routinely compliance following a recent on clopidogrel intervention. ● To update the app and Trust guidelines highlighting that hip fracture patients should be assessed as high or low risk like the elective arthroplasty patients

● Re-audit – after the introduction of the hip fracture operation note, which includes post-op VTE prophylaxis and to assess the change in way discharge summaries are generated Paediatrics Paediatric Emergency The main findings of the audit were: Appendicectomy ● 87% were operated on within 12 hours of decision to Aim: To assess the emergency operate (median 18.5 hours) appendicectomy service against the RCS/ BAPS ● The negative appendicectomy rate was 18% standards and local standards ● 49% were seen by a doctor within 1 hour of admission to the Paediatric Assessment Unit

● 100% were admitted to a paediatric ward To improve compliance, the following actions were agreed:

● Increased priority for CEPOD list

● Discuss findings with clinical lead and surgeons

● Complete a re-audit by December 2017

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Specialty Local Clinical Audit Title & Actions Aim Paediatrics Specialist prescribing in The data showed a rapid increase in the prescriptions of Cow’s milk protein allergy specialist formulas in the last 5 years, with more than double the amount of prescriptions in the 2015-2016 period Aim: to investigate whether compared with the 2011-2012 period. or not this stand-alone programme was effective in To improve this in the future, the following actions were altering prescribing practices agreed:

● Educational programme to be introduced

● Re-audit to be completed by August 2017 Pain Pain Assessment and the The audit findings were as follows: Management Prescription of Analgesics ● Documentation of pain scores as the fifth vital sign on Aim: To identify areas of the Early Warning Score (EWS) chart once every 24 hours good practice in managing is excellent and has been maintained since 2011 and is pain and areas for greatly improved since an audit in 2004. improvement ● There is room for improvement in documenting pain scores with every set of vital signs. However it may be inappropriate in some cases to document pain score as frequently as the other vital signs if, for example, the patient is on hourly observations. The actions below were agreed to improve future compliance:

● Review Trust guidance and refer back to Matrons, plan for audit of documentation of weight as future anaesthetic project if necessary

● Review frequency of pain assessment with clinical team leaders

● Disseminate results of reports to medical teams

● Additional audit projects to be completed to improve compliance Pain Inclusion of muscle A total of 96 patients were included in the audit. 79% of Management at first resection for patients had a separate base specimen with muscle included, Endoscopic treatment with and 74% of patients who did not have a separate base transurethral resection of specimen had muscle included within the specimen. bladder tumour (TURBT)/ appropriate use of The following actions were put in place to improve future Mitomycin compliance: Aim: To audit compliance ● Every specimen to have a separate base specimen at first with NICE and bladder cancer TURBT. guidelines ● Re-audit to confirm improvement

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Specialty Local Clinical Audit Title & Actions Aim Radiology Re-audit of hip image The audit found that whilst the department has extremely quality in Developmental high standards, they had not achieved 100% compliance dislocation of the hip against the standard of accurate measurement of the alpha (DDH) screening angle, in DDH screening, according to peer review. Aim: The aim of the audit To improve future compliance the following actions were was to assess the quality of agreed: the ultrasound images taken at screening for DDH in the ● Workshop on image requirements and accurate ultrasound department, measurement ensuring that they fulfil the ● on-going attendance to update course and feedback to criteria for measurement and peers evaluation according to the GRAF technique ● Re-audit over 6-12 months to increase both time frame and number of images addressed Renal Phosphate Binder The audit findings were as follows: management of inpatients on Creedy ward and Exeter ● Binders are not being sent with patient ton dialysis unit Dialysis Unit when eating a meal off ward Aim: To ensure that patients ● Nursing staff do not appear to understand need to for are taking their phosphate patients to have binders outside of drug rounds and with binders at the correct times meals and with meals on and off ● Nursing staff and patients often not able to identify if they the ward when an inpatient are taking a binder A risk assessment and action plan were completed following the audit. The below actions were put in place to improve future compliance:

● Education on ward, display to be produced.

● Addition to food record chart to include comment on binders

● Identify strategy to improve compliance with binders – coloured pill pot to have binders outside of medicine round

● All patients should be assessed re suitability of self- administration of meds especially binders – engagement with nursing staff and medics on ward

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Specialty Local Clinical Audit Title & Actions Aim Renal Audit of Renal Nutrition The audit found that: services ● The team has positively incorporated the assessment of Aim: To provide a benchmark outcomes into their day to day working and the results of the numbers of patients identified by this audit will help concentrate efforts in seen by the Renal Dietetic areas where targets are not being achieved. team, look at what is being achieved of outcomes with ● All patients seen within the low clearance clinic had seen a patients and whether time dietician within first 3 appointments. frames for initially seeing ● 65% of patients were seen according to all standards for and reviewing patients are haemodialysis. meeting standards An action plan was agreed to improve future compliance:

● Increase liaison with the covering Consultant for Peritoneal Dialysis Clinic in Torbay, complete telephone reviews where appropriate

● Re-audit to be completed by June 2017 Stroke Post Stroke Cognition The findings of the audit were that screening is done well by Rehabilita- therapy team. However, further actions were required to: tion Aim: To audit the performance of the Stroke ● follow up concerns with regard to cognition - to be Unit in terms of measuring discussed at MDT and recorded in the patients case notes cognition formally in patients who have had a stroke. ● improve information on the discharge summaries which will be discussed with the junior doctors

Page 72 Quality Report 2016/17 INDEPENDENT AUDITOR’S REPORT TO THE COUNCIL OF GOVERNORS OF ROYAL DEVON AND EXETER NHS FOUNDATION TRUST ON THE QUALITY REPORT We have been engaged by the Council of Governors We read the Quality Report and consider whether of Royal Devon and Exeter NHS Foundation Trust to it addresses the content requirements of the NHS perform an independent assurance engagement in Foundation Trust Annual Reporting Manual and respect of Royal Devon and Exeter NHS Foundation consider the implications for our report if we become Trust’s Quality Report for the year ended 31 March aware of any material omissions. 2017 (the ‘Quality Report’) and certain performance indicators contained therein. We read the other information contained in the Quality Report and consider whether it is materially Scope and subject matter inconsistent with: ● Board minutes and papers for the period April The indicators for the year ended 31 March 2017 2016 to May 2017; subject to limited assurance consist of the following two national priority indicators (the indicators): ● papers relating to quality reported to the board over the period April 2016 to May 2017; ● percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the ● feedback from commissioners, dated 12 May end of the reporting period; 2017;

● A&E: maximum waiting time of four hours ● feedback from governors, dated 12 May 2017; from arrival to admission, transfer or discharge; ● feedback from local Healthwatch organisations, We refer to these national priority indicators dated 11 May 2017; collectively as the ‘indicators’. ● feedback from Overview and Scrutiny Committee, Respective responsibilities of the dated 11 May 2017; directors and auditors ● the Trust’s complaints report published under regulation 18 of the Local Authority Social The directors are responsible for the content and Services and NHS Complaints Regulations 2009; the preparation of the Quality Report in accordance ● the latest national patient survey, dated 18 with the criteria set out in the NHS Foundation January 2017; Trust Annual Reporting Manual issued by NHS Improvement. ● the latest national staff survey, dated 7 March 2017; Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything ● Care Quality Commission Inspection, dated has come to our attention that causes us to believe February 2016; and that: ● the 2016/17 Head of Internal Audit’s annual ● the Quality Report is not prepared in all material opinion over the trust’s control environment. respects in line with the criteria set out in the NHS We consider the implications for our report if we Foundation Trust Annual Reporting Manual and become aware of any apparent misstatements or supporting guidance; material inconsistencies with those documents ● the Quality Report is not consistent in all material (collectively, the ‘documents’). Our responsibilities do respects with the sources specified in the Detailed not extend to any other information. requirements for quality reports for foundation trusts 2016/17 (‘the Guidance’); and We are in compliance with the applicable independence and competency requirements of the ● the indicators in the Quality Report identified as Institute of Chartered Accountants in England and having been the subject of limited assurance in Wales (ICAEW) Code of Ethics. Our team comprised the Quality Report are not reasonably stated in assurance practitioners and relevant subject matter all material respects in accordance with the NHS experts. Foundation Trust Annual Reporting Manual and the six dimensions of data quality set out in the This report, including the conclusion, has been Detailed Requirements for external assurance for prepared solely for the Council of Governors of Royal quality reports for foundation trusts 2016/17. Devon and Exeter NHS Foundation Trust as a body,

Page 73 Quality Report 2016/17 to assist the Council of Governors in reporting the measurements and can affect comparability. The NHS Foundation Trust’s quality agenda, performance precision of different measurement techniques may and activities. We permit the disclosure of this report also vary. Furthermore, the nature and methods within the Annual Report for the year ended 31 used to determine such information, as well as the March 2017, to enable the Council of Governors to measurement criteria and the precision of these demonstrate they have discharged their governance criteria, may change over time. It is important to read responsibilities by commissioning an independent the quality report in the context of the criteria set assurance report in connection with the indicator. To out in the NHS Foundation Trust Annual Reporting the fullest extent permitted by law, we do not accept Manual and supporting guidance. or assume responsibility to anyone other than the Council of Governors as a body and Royal Devon The scope of our assurance work has not included and Exeter NHS Foundation Trust for our work or this governance over quality or the non-mandated report, except where terms are expressly agreed and indicator, which was determined locally by Royal with our prior consent in writing. Devon and Exeter NHS Foundation Trust. Assurance work performed Basis for qualified conclusion We conducted this limited assurance engagement Our sample testing for the percentage of incomplete in accordance with International Standard on pathways within 18 weeks for patients on incomplete Assurance Engagements 3000 (Revised) – ‘Assurance pathways for the year ended 31 March 2017 Engagements other than Audits or Reviews of identified three instances from a sample of 20 where Historical Financial Information’, issued by the clock start dates could not be corroborated back International Auditing and Assurance Standards to a date stamped referral letter. However, of these Board (‘ISAE 3000’). Our limited assurance three instances, none would change the patient from procedures included: a non-breach to a breach if the date of the referral Theletter scope was of taken our asassurance the clock work start has rather not thanincluded the governance over quality or the non- ● evaluating the design and implementation of the mandateddate the indicator, Trust received which thewas letter.determined locally by Royal Devon and Exeter NHS Foundation key processes and controls for managing and Trust. reporting the indicator; BasisConclusion for qualified conclusion ● making enquiries of management; OurBased sample on thetesting results for the of percentageour procedures, of incomplete except for pathways within 18 weeks for patients on ● testing key management controls; incompletethe effects pathways of the matters for the describedyear ended in the31 March‘Basis 2017 identified three instances from a sample of 20 where clock start dates could not be corroborated back to a date stamped referral for qualified conclusion’ section above, nothing has ● limited testing, on a selective basis, of the data letter. However, of these three instances, none would change the patient from a non-breach to come to our attention that causes us to believe that, used to calculate the indicator back to supporting a breach if the date of the referral letter was taken as the clock start rather than the date the for the year ended 31 March 2017: documentation; Trust received the letter. Conclusion●● the Quality Report is not prepared in all material ● comparing the content requirements of the NHS respects in line with the criteria set out in the NHS Foundation Trust Annual Reporting Manual to the Based on the results of our procedures, except for the effects of the matters described in the Foundation Trust Annual Reporting Manual; categories reported in the Quality Report; and ‘Basis for qualified conclusion’ section above, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2017: ●● the Quality Report is not consistent in all material ● reading the documents. • therespects Quality with Report the is sources not prepared specified in all in material the respects in line with the criteria set out in A limited assurance engagement is smaller in theGuidance; NHS Foundation and Trust Annual Reporting Manual; scope than a reasonable assurance engagement. • ● thethe Quality indicators Report in isthe not Quality consistent Report in all subject material to respects with the sources specified in the The nature, timing and extent of procedures for Glimiteduidance; assurance and have not been reasonably stated gathering sufficient appropriate evidence are • thein indicatorall materials in respectsthe Quality in Reportaccordance subject with to limitedthe assurance have not been reasonably deliberately limited relative to a reasonable assurance statedNHS Foundationin all material Trust respects Annual in Reporting accordance Manual with the NHS Foundation Trust Annual engagement. Reportingand the sixManual dimensions and the ofsix data dimensions quality ofset data out qualityin set out in the Guidance. Limitations the Guidance. Non-financial performance information is subject to Jonathan Brown more inherent limitations than financial information, KPMG LLP given the characteristics of the subject matter and the JonathanCharter Browned Accountants methods used for determining such information. 66 Queen Square KPMG LLP The absence of a significant body of established CharteredBristol BS1 Accountants 4BE practice on which to draw allows for the selection 6624 Queen May Square2017 of different, but acceptable measurement Bristol techniques which can result in materially different BS1 4BE 24 May 2017 Page 74

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