Annual Report & Accounts 2015/16 Putting you first West Suffolk NHS Foundation Trust Annual Report and Accounts 2015/16 Presented to Parliament pursuant to Schedule 7, paragraph 25(4)(a) of the National Health Service Act 2006. West Suffolk NHS Foundation Trust – annual report 2015/16 Page 3 © 2016 West Suffolk NHS Foundation Trust 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 13 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 18 2. Accountability report 2.1 Governors’ report 2.1.1 Responsibilities 25 2.1.2 Composition 25 2.1.3 Register of interests 27 2.1.4 Governors and directors working together 27 2.1.5 Membership 28 2.1.6 Nominations committee 31 2.2 Directors’ report 2.2.1 Responsibilities 33 2.2.2 Composition 33 2.2.3 Register of interests 36 2.2.4 Appointment of chairman and non-executive directors 37 2.2.5 Evaluation of the board of directors’ performance 37 2.2.6 Audit committee 38 2.2.7 Quality governance framework 39 2.2.8 Details of consultation 40 2.2.9 Foundation trust code of governance compliance 41 2.2.10 Other disclosures 41 2.3 Regulatory ratings 43 2.4 Statement of accounting officer’s responsibilities 46 2.5 Annual governance statement 47 2.6 Remuneration report 56 West Suffolk NHS Foundation Trust – annual report 2015/16 Page 5 2.7 Staff report 2.7.1 Our staff 61 2.7.2 Average number of employees 62 2.7.3 Breakdown at year end of the number of male and female staff 62 2.7.4 Sickness absence data 62 2.7.5 Equality & diversity 63 2.7.6 Health and safety report 65 2.7.7 Occupational health report / occupational health & wellbeing 66 service 2.7.8 Staff Survey 68 2.7.9 Pension liabilities for ill health retirement 72 2.7.10 Policies and procedures for fraud and corruption 72 2.7.11 Off-payroll engagements 72 2.7.12 Expenditure on consultancy 73 3. Quality report 3.1 Chief executive’s statement 74 3.2 Quality structure and accountabilities 76 3.3 Quality priorities for 2016/17 76 3.4 Statements of assurance from the board 79 3.5 Performance against 2015/16 priorities 87 3.6 Other quality indicators 111 3.7 Development of the quality report 121 Annex A: Participation in clinical audit 122 Annex B: Nationally mandated quality indicators 133 Annex C: Comments from third parties 137 Annex D: Statement of directors’ responsibilities in respect of the quality report 140 Annex E: Independent auditor’s report to the council of governors of West 141 Suffolk NHS Foundation Trust on the quality report 143 Annex F: Glossary 4. Accounts for 2015/16 147 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 2015/16 Page 6 1. Performance report 1.1 Overview 1.1.1 A message from the chairman and chief executive We are delighted to introduce our annual report for the year 2015/16. The year brought significant challenges and changes to the organisation and you can read more about them and how we have responded throughout this report. We remain a high-performing hospital and our achievements this year have once again been publicly recognised with further awards to add to our growing trophy cabinet. Our latest accolades are described on page 17 and they are a tribute to the excellent staff who work in our services. A changing health economy The environment we operate in continues to change with our clinical commissioning groups (CCGs) and NHS England seeking 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. Here in Suffolk our two CCGs (east and west) are now working closely together with a single accountable officer and are moving towards further integration of services for our populations. In October 2015 we took a significant step towards integration when we were awarded a one-year contract to run Suffolk community healthcare services as part of a joint venture with The Ipswich Hospital NHS Trust. Other partners are involved in providing these services with us and our success so far in delivering quality care for patients has been recognised with a one-year extension to the contract. The challenges of achieving this transition and making the new arrangements work make this a significant achievement for the Trust. We know there is much more to do to genuinely transform services and we are in a better position to start this work now that we have the agreement that the current arrangement will stay in place until October 2017. 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 £9.8m in deficit. This was slightly worse than we had expected and we are working hard inside and outside the organisation to identify where whole system changes and productivity improvements can be made to bring us back into balance. Quality We are proud of the quality of our services and at the same time determined to keep improving wherever we can. We know from benchmarking data that many of our services offer among the best safety and outcomes recorded anywhere in the country. Our patient surveys demonstrate that most of the time we get it right for them and that 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 on page 74. 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. During March 2016 we had two days of record-breaking attendances at our emergency department when the number of patients turning up needing assistance was nearly 40 per cent above the average levels. This has affected our ability to deliver the four hour standard for either admitting or discharging patients after arrival at our emergency department (ED) and our performance this year is described on page 111 of this report. West Suffolk NHS Foundation Trust – annual report 2015/16 Page 7 In our elective services we are measured against a target of treating patients within 18 weeks of their referral to us by either a GP or another hospital. We have performed consistently well in this area and continue to meet all targets. Similarly we have met all the targets set for our performance in treating patients with cancer who need to be diagnosed and treated within safe timeframes. Our excellent staff Our staff remain our greatest asset and this year they have risen to the challenge of growing demand for our services while continuing to provide care that is outstanding for its quality. Our staff survey provides solid evidence that our staff are positive about working here and feel well engaged in the organisation. More staff recommend us as a place to work and as a place to receive treatment that at any other acute hospital in East Anglia. This is something we are proud of and want to build on and you can read more about our staff survey including the areas where we need to improve on page 68 of this report. We recognise that our staff deliver change and improve our services, not management. This year we launched Freedom to Speak Up, a campaign to encourage and support staff to speak up and act whenever they see anything that can be improved, an issue that needs resolving or an area where praise can be given for exceptional achievement. Hundreds of staff have now signed our pledge ‘never to walk by’ and we are now continuing to develop the campaign with staff and also patients who we have also asked to speak up. In a recent patient feedback day patients were able to talk to us around the hospital about their thoughts about our services and how they can be improved. Updating our IT system If we are to transform and improve services we need to modernise the infrastructure that we are working with. During the year we have undertaken extensive work to prepare for the implementation of e-Care, a single integrated electronic patient record, to improve the quality and safety of services and support the delivery of our vision. The new system will enable us to manage demand more effectively and provide safer, more effective care for patients. Implementation of these systems is notoriously challenging, however we feel that we have prepared as well as we can for all eventualities and are confident of the benefits the system will bring once it is fully rolled out and established with our staff.