Annual report and accounts 2016/17 West Suffolk NHS Foundation Trust – annual report 2016/17 Page 2 West Suffolk 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. West Suffolk NHS Foundation Trust – annual report 2016/17 Page 3 © 2017 West Suffolk NHS Foundation Trust West Suffolk NHS Foundation Trust – annual report 2016/17 Page 4 Contents Page 1. Performance report 1.1 Overview 1.1.1 A message from the chairman and chief executive 7 1.1.2 About our Trust – a summary 10 1.1.3 Principal risks and uncertainties 12 1.2 Performance analysis 1.2.1 Performance management framework 15 1.2.2 Principal activities and achievements 15 1.2.3 Future business plans 20 2. Accountability report 2.1 Governors’ report 2.1.1 Responsibilities 32 2.1.2 Composition 32 2.1.3 Register of interests 34 2.1.4 Governors and directors working together 34 2.1.5 Membership 35 2.1.6 Nominations committee 37 2.2 Directors’ report 2.2.1 Responsibilities 38 2.2.2 Composition 39 2.2.3 Register of interests 43 2.2.4 Appointment of chairman and non-executive directors 44 2.2.5 Evaluation of the board of directors’ performance 44 2.2.6 Audit committee 45 2.2.7 Quality governance framework 46 2.2.8 Details of consultation 47 2.2.9 Other disclosures 47 2.3 Foundation trust code of governance compliance 48 2.4 NHS Improvement’s single oversight framework 49 2.5 Statement of accounting officer’s responsibilities 50 2.6 Annual governance statement 51 2.7 Remuneration report 64 2.8 Staff report 2.8.1 Our staff 69 2.8.2 Staff costs 69 2.8.3 Average number of employees 70 2.8.4 Reporting of compensation schemes - exit packages 2016/17 70 2.8.5 Breakdown at year end of the number of male and female staff 70 West Suffolk NHS Foundation Trust – annual report 2016/17 Page 5 2.8.6 Sickness absence data 70 2.8.7 Equality and diversity 71 2.8.8 Health and safety report 73 2.8.9 Occupational health report / occupational health and wellbeing 74 service 2.8.10 Staff survey 75 2.8.11 Pension liabilities for ill health retirement 79 2.8.12 Policies and procedures for fraud and corruption 79 2.8.13 Off-payroll engagements 80 3. Quality report 3.1 Chief executive’s statement 81 3.2 Quality structure and accountabilities 83 3.3 Quality priorities for 2017/18 83 3.4 Statements of assurance from the Board 85 3.5 Performance against 2016/17 priorities 93 3.6 Other quality indicators 122 3.7 Development of the quality report 132 Annex A: Participation in clinical audit 133 Annex B: Nationally mandated quality indicators 138 Annex C: Comments from third parties 142 Annex D: Statement of directors’ responsibilities in respect of the quality report 145 Annex E: Independent auditor’s report to the council of governors of West 146 Suffolk NHS Foundation Trust on the quality report Annex F: Glossary 149 4. Accounts for 2016/17 152 Throughout this document the organisation West Suffolk NHS Foundation Trust is referred to as WSFT and West Suffolk Hospital as WSH. West Suffolk NHS Foundation Trust – annual report 2016/17 Page 6 1. Performance report 1.1 Overview The purpose of this overview is to give the reader a short summary that provides sufficient information to understand the organisation, its purpose, the key risks to the achievement of its objectives and how we performed during the year. 1.1.1 A message from the chairman and chief executive We are delighted to introduce our annual report for the year 2016/17. This year we faced some unprecedented challenges but were able to deliver some significant achievements thanks to our outstanding staff. We remain a high-performing hospital for the quality of our care and this is recognised in a number of national surveys of outcome data. Our latest accolades are described on page 16 and they are a tribute to the excellent staff who work tirelessly to continuously improve our services. A changing health economy The environment we operate in continues to change as NHS England seeks to develop new models of care that will strengthen and support the closer integration of hospital services with community- based teams, primary care, mental health and social care. The further development of sustainability and transformation plans (STPs) and the move towards integrated care systems (ICSs) are two of the national drivers that our Trust is already involved with and we remain fully committed to further integration of services for the benefit of our west Suffolk population. In December 2016 we were given permission to form an alliance of providers to develop and run community services for Suffolk for the longer term. This means that in partnership with Ipswich Hospital NHS Trust, Suffolk County Council, Suffolk GP Federation and Norfolk and Suffolk NHS Foundation Trust, we will be transforming community services so that they are fully aligned with the needs of their local populations. The aim is to provide a seamless integration between different types of care. We know there is much more to do to genuinely transform services and we are in a better position to get on with this work now that we have the support to develop long term plans. Maintaining financial balance The move towards new models of care is urgently needed because acute hospitals as well as other parts of the health economy are struggling to manage the growing cost of their services. This is driven by higher numbers of patients needing care and the increased expense of the drugs and technologies used to treat them. Like many hospitals across the country we came under significant financial pressure during the year which ended with us being £3.3 million in deficit (before adjusting for the Pathology Partnership (tPP) impairment of £4.8m). While this was better than our plan at the start of the year, we are working hard inside and outside the organisation to identify where whole system changes and productivity improvements can be made. Quality We are proud of the quality of our services and during 2016/17 we were benchmarked as being a top performing hospital in the NHS in a number of key areas. West Suffolk has the best rates of early cancer diagnosis in the country (NHS atlas of variation) and correspondingly good outcomes for treating the disease. This is a major benefit for our communities and a fantastic achievement by healthcare professionals in our hospital and primary care services. Stroke services have undergone major reconfigurations across the country and are under constant national scrutiny. Our service here was threatened with closure a number of years ago but has now delivered some of the best outcomes in the country according to the stroke sentinel national audit programme (SSNAP). West Suffolk NHS Foundation Trust – annual report 2016/17 Page 7 The care of patients with hip fracture has been transformed in recent years thanks to research that has identified the key things that we need to get right to get patients back on their feet and back to their best again. The national hip fracture database measures the success of services in this area and the 2017 report shows that we are the highest rated service in the east of England and one of the best in the country. Hip fracture is one of the most common serious injuries in older people and often results in long hospital stays and prolonged rehabilitation. Getting this service right is therefore vital for the people we serve in this part of the world and we are extremely proud to be leading the way in this area. Our patient surveys demonstrate that most of the time we do get things right and they have a good experience of our care. However this is not the case in every instance and we receive concerns and complaints that we work hard to address and resolve. You can read more about the quality of our services in our quality report (section 3). We demonstrated good performance against the national standards, meeting these targets in 2016/17 with the exception of: maximum waiting time of four hours in the emergency department (ED) from arrival to admission, transfer or discharge; 18 week maximum wait from point of referral to treatment (patients on an incomplete pathway); and two week wait from referral to date first seen comprising all urgent referrals for symptomatic breast patients (cancer not initially suspected). The pathology service delivered to the WSFT by The Pathology Partnership (tPP) has been a cause for concern during 2016/17 in terms of both quality and financial performance. A new clinically led structure has been implemented for services in the east of the partnership. The North East Essex and Suffolk Pathology Services (NEESPS) includes West Suffolk, Colchester and Ipswich hospitals and is managed locally as a stand-alone network. The Trust’s share of the loss incurred by tPP was £4.8m. Growing demand for services and our performance We are seeing significant growth in demand for our services particularly in the area of urgent and unplanned care. Over Christmas we experienced the highest level of pressure that we can remember with very high numbers of patients requiring urgent admission into an inpatient bed. This affected our ability to deliver the four hour standard for either admitting or discharging patients after arrival at ED and our performance this year is described on page 123 of this report.