annual report 2016/17 The Hillingdon Hospitals NHS Foundation Trust

Transcription

1 annual report 2016/17 The Hillingdon Hospitals NHS Foundation Trust

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3 The Hillingdon Hospitals 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.

4 2017 The Hillingdon Hospitals NHS Foundation Trust

5 Table Of Contents Introduction from Chair and Chief Executive Challenges, Achievements and Trust Strategy 1. Performance Report 2. Accountability Report 2.1 Directors Report 2.2 Remuneration Report 2.3 Staff Report 2.4 Compliance with NHS Foundation Trust Code of Governance 2.5 Single Oversight Framework 2.6 Statement of Accounting Officer s Responsibilities 2.7 Annual Governance Statement 3. Quality Report 4. Annual Accounts Statement of Directors Responsibilities in Respect of the Accounts 6. Independent Auditor s Report 7. Foreword to the accounts

6 Introduction from the Chair and Chief Executive

7 Annual Report and Accounts 2016/17 Introduction from the Chair and Chief Executive The Trust faced the most challenging time in its history during 2016/17 as the increase in demand for services continued to impact on the whole of the NHS. We provided more care to more people up by 7.9% on the previous 12 months resulting in more than 516,200 patient contacts. This presented the Trust with the most significant performance challenges it has ever experienced. Demand for services, particularly in A&E and across the whole of the Emergency Department, was unprecedented. Between October and December we saw a 14% increase in patients visiting A&E, compared to the year before, and an increase of 32% arriving by blue-light ambulance, meaning more of the very sickest patients needed caring for. There were also longer delays in the transfer of our most elderly and frail patients and this had the knock-on effect of causing delays in the time it took to see patients in A&E. It meant we missed the four-hour waiting time target more often than we hoped to. We have, however, performed well on our referral to treatment times and cancer treatment targets. We have addressed all of the urgent recommendations made by the Care Quality Commission following their inspection in 2014/15. However, full implementation, particularly on recommendations about our estate, will take longer to resolve. The poor condition of many of our buildings remains a key issue of concern for the Trust s Board. Significant capital investment is required and we continue to explore options to find a solution. We are working with a range of partners, including local MPs and NHS Improvement to secure the necessary funding. Over the year, our hospitals experienced the largest ever increase in patient numbers. Despite being under relentless pressure, our staff worked diligently to provide them with the best possible care. Their dedication is unwavering and we are extremely proud of their tenacity in such a challenging climate. A shared commitment to improving patient outcomes has enabled us to achieve some real successes over the last 12 months. This year we completed the 4 million upgrade of our Paediatric Services. The new Children s A&E department was transformed to provide a light, bright, welcoming space. And the new bigger bed-bays, built to modern-day standards, provide greater privacy for our youngest patients and their families and carers. We also opened a brand new extension to our Peter Pan children s ward which now boasts a dedicated teen-room for our older young patients. In addition we appointed seven new paediatric consultants to provide additional 24/7 specialist support for children. We also invested in the refurbishment and upgrading of vital services and facilities. This included building a new extended Clinical Decision Unit to care for and observe patients while evaluating if they need to be admitted or are well enough to go home. We created two new A&E triage rooms to help speed up the time patients 7

8 The Hillingdon Hospitals NHS Foundation Trust need to wait in the busiest area of the hospital. Behind the scenes we upgraded electrical, heating and ventilation services for our Maternity building and spent almost 1 million to make significant improvements to our water supply at Hillingdon. Elsewhere, working with Hillingdon CCG, we expanded patient services by opening a brand new Outpatient Pharmacy, meaning patients attending our clinics can now immediately get the medicines they need without having to visit their GP. We also established a dedicated Frailty Unit to help us better assess the needs of our more vulnerable older patients. To ensure that patients admitted are as comfortable as possible, we carried out a hospitalwide bed and mattress replacement programme at both hospital sites, spending more than 1.1m on 400 state-of-the-art cots, cribs and electric beds. We work hard to achieve the highest standards in patient safety and this year saw us establish a Patient Safety Champions Network this will ensure that we work more closely with patients and carers to further improve patient safety. We also updated our strategy for carers following their feedback at specially hosted events. Throughout the year we continued to strengthen our partnership working and, in particular, made great progress with the formation of an Accountable Care Partnership known as Hillingdon s Health and Care Partnership (HHCP). The partners are already pooling resources, and will eventually share their entire budgets for the over-65 age group, to increase spending power and ensure we get the best value for money. This year HHCP established Hillingdon s first Care Connection Teams. Based in GP surgeries across the borough, they play a crucial role in providing seamless, joined-up care for the over- 65s. Although newly established they are making a significant difference to people s lives and demonstrate just how effective good partnership working can be. This year also saw us launch the North West London Pathology Partnership with Imperial and Chelsea and Westminster Trusts. This consolidates pathology services across all three organisations to better manage demand for services, improve value for money and make the best use of technology. It will save an estimated 96 million over 10 years that will be ploughed back into the NHS. Throughout the year we continued to strengthen our partnership working and, in particular, made great progress with the formation of an Accountable Care Partnership known as Hillingdon s Health and Care Partnership (HHCP). 8

9 Annual Report and Accounts 2016/17 We are currently working in collaboration with other NW London trusts to save money by collectively improving our procurement, as well as exploring how we can provide back office services more efficiently. Our Hospital Charity has been successful in forging new partnerships with local groups and businesses that want to support its fundraising activities to provide additional equipment for Trust patients. In the last year, two of our services attracted national recognition by being shortlisted for prestigious awards; IT were recognised for developing the Hillingdon Care Record a system that enables clinicians to access electronic patient records at the bedside; our HomeSafe Team were acknowledged for their work in ensuring everything in place before the discharge of elderly patients. This year we have updated our Vision and Strategy to ensure it aligns with Hillingdon s Sustainability and Transformation Plan (STP). The STP was developed by all local health and care providers, in liaison with the local community, to address the specific future health and wellbeing needs of the borough. Our CARES Values Communication, Attitude, Responsibility, Equity and Safety continue to be at the heart of our approach to patient care and fully support an improved patient and staff experience. We have maintained high standards of care as demonstrated by our good patient outcomes, key quality performance indicators and positive feedback from patients. The Trust was rated green (compliant) throughout the year for NHS Improvement s key performance reporting, apart from the A&E four-hour target where high levels of patient activity and demand for the service have stretched existing resources within a very restricted environment. We maintained our high performance for Referral to Treatment waiting time standards and we performed better than the London and national averages for the key cancer performance indicators waiting time standards. Patient mortality rates have been maintained within the as expected range. For the aggregate Hospital Standardised Mortality Ratio (HSMR); we are below national average, which is an improvement on the previous year. We received more than 33,800 responses to the Friends and Family test (FFT) during the year with 95.6% of patients saying they were happy to recommend our services to their friends and family. And we once again performed well in the national staff survey, with above average results in 17 out of 32 areas and 12 of those being ranked in the top 20% of all acute trusts in England. While this feedback is reassuring it is not something we take for granted and we will continue to strive for further improvement. 2016/17 was a very difficult year for the Trust financially. While we delivered on our financial targets, this was largely dependent on one-off items which masked an underlying deterioration in our finances overall - largely brought about by increasing demand. Recognising that additional support is needed to recover the Trust s financial position, the Board is working in partnership with NHS Improvement and a specialist contractor to deliver a Financial Improvement Programme. We remain optimistic about the future as we broaden and strengthen our partnerships, and pilot a range of initiatives to support the delivery of care in new ways. We will continue to manage challenges with the same positive attitude that has seen us through past difficulties. As ever, we are grateful to our staff, governors, volunteers, and fellow Board members for their hard work and commitment to the Trust and the people who depend on us. Shane DeGaris Chief Executive The Hillingdon Hospitals NHS Foundation Trust 30th May 2017 Richard Sumray Chair The Hillingdon Hospitals NHS Foundation Trust 30th May 2017 In the last year, two of our services attracted national recognition by being shortlisted for prestigious awards. 9

10 The Hillingdon Hospitals NHS Foundation Trust Challenges, Achievements and Trust Strategy 10

11 Annual Report and Accounts 2016/17 Key challenges Increasing demand for services Increasing demands on staff The demand for services has continued to increase with the Trust seeing an overall increase of 7.9%. Delays in the transfer of elderly patients has also had a detrimental impact on our ability to free up beds and improve the speed that we are able transfer patients from A&E. We had to rely far more heavily on agency staff that we wanted to. Our staff are working under greater pressure as the level of demand and activity continues to increase. There is also real competition for good staff in the region and a greater number of options open to them. Poor condition of our estate Many of our main buildings have been operational well beyond their expected life cycle and are continuing to deteriorate. Much of our estate would require significant investment to bring it up to modern-day standards. The Trust s modest capital investment programme means that we are unable to address the most substantial estates issues. The demand for services has continued to increase with the Trust seeing an overall increase of 7.9% The Trust s modest capital investment programme means that we are unable to address the most substantial estates issues. 11

12 The Hillingdon Hospitals NHS Foundation Trust Key achievements Improving patient safety As part of our commitment to the national Sign up to Safety Campaign, we established a Safety Champions network to implement safety improvement projects across the Trust. Improving patient comfort We carried out a hospital-wide bed and mattress replacement programme at both hospital sites, spending more than 1.1 million on 400 state-of-the-art cots, cribs and electric beds, ensuring patients are as comfortable as possible during their stay. Expanding patient services This year we opened a brand new 400k Outpatient Pharmacy at Hillingdon Hospital, meaning patients get the medicines they need more quickly, reducing the need to visit their GP. Importantly this also saves the NHS money. More than 4.5 million was spent on refurbishing and upgrading services and facilities This included building a new extended Clinical Decision Unit, new A&E triage rooms and staff offices Friends and Family Test We received more than 33,800 responses to the FFT 95.6% of patients would recommend our services to their friends and family higher than the England and London score. Caring for our staff In the annual NHS Staff Survey 63% of our staff said they would recommend the Trust as a place to work - 1% higher than the average for acute trusts. Overall, we scored above average in 17 areas with 12 of these being in the top 20% of all acute trusts in England. We also launched a new staff Leadership training programme and established a BAME forum for nurses. Gaining national recognition Two of our services were shortlisted for prestigious national awards; the HomeSafe Team ensures everything is in place for elderly patients who are being discharged, while the IT Team were praised for the Hillingdon Care Record which provides clinicians with electronic access to patient records at the bedside. One of our midwives also received a top national award for her work in raising awareness of Female Genital Mutilation. Increasing partnership working We launched the North West London Pathology Partnership with Imperial and Chelsea and Westminster Trusts. This consolidates pathology services to better manage demand for services, improve value for money and make best use of technology. 12

13 Annual Report and Accounts 2016/17 Trust History and Purpose Improving women s and children s services The Trust spent more than 3 million on improving and expanding children s services. This included completing a major refurbishment of Children s A&E and building a brand new four-bed extension wing on Peter Pan Ward. We also appointed seven new paediatric consultants to provide additional 24/7 support for children. Refurbishing and improving facilities More than 4.5 million was spent on refurbishing and upgrading services and facilities This included building a new extended Clinical Decision Unit, new A&E triage rooms and staff offices. We also upgraded electrical and heating services for Maternity as well as carrying out works to improve the water quality on the Hillingdon site. Performing well The Trust again rated green (compliant) throughout the year in all but one (A&E four-hour target) of Monitor s performance targets. Key cancer indicators are well maintained for all the national waiting times standards, and were better than the London and national average. The Hillingdon Hospitals NHS Foundation Trust was established on 1 April 2011 when Monitor authorised the organisation as an NHS Foundation Trust. The Trust provides health services at two hospitals in North West London: Hillingdon and Mount Vernon. Hillingdon Hospital is the only acute hospital in the London Borough of Hillingdon and offers a wide range of services including Accident and Emergency, inpatient care, day surgery, outpatient clinics and maternity services. The Trust s services at Mount Vernon Hospital include routine day surgery at a modern treatment centre, a minor injuries unit, and outpatient clinics. The Trust also acts as a landlord to a number of other organisations that provide health services at Mount Vernon, including East and North Hertfordshire NHS Trust s Cancer Centre. The Trust s income in 2015/16 was over million and we employed over 3,400 staff. The majority of our patients live in the London Borough of Hillingdon but as part of our strategy we are seeking to provide healthcare to a wider area. In 2016/17 (increase/decrease from 2015/16): 92,520 (8% increase) attendances were made to our Accident and Emergency department and Minor Injuries Unit 4,900 (3.7% increase) babies were born in our Maternity Unit 368,884 (9.4% increase) attendances were made as outpatients 23,129 (9% decrease) admissions were made for emergency treatment across all parts of the Trust 26,827 (6.2% increase) admissions were made for planned operations and day surgery. 13

14 The Hillingdon Hospitals NHS Foundation Trust Overview of the Trust s strategy The Trust s Strategy and Business Model During 2016/17, the Trust s strategy was refreshed in light of the North West London Sustainability and Transformation Plan (STP). The STP changes the landscape in which the Trust operates, and it is important that our longer-term efforts are geared towards the new context with a particular focus on achieving shared objectives. Overview of the STP The STP aims to transform the way that care will be experienced in 2020/21. It is a plan to implement system-wide changes which seek to improve population health and wellbeing, together with care and quality for patients. This ambition is clearly explained in the STP check-point submission, of June The shift in emphasis is illustrated below: Although there is no regulatory obligation to produce a strategic plan, we consider it helpful to articulate our ambitions and collate our key strategies in one document. The Strategic Plan permits us to do this; and, it sets out how we intend to address the clinical and financial performance challenges which we face, in common with other acute trusts. Most notably: Demand for acute services is rising at an average of 4% each year, as the population ages. The Trust is experiencing year on year increases in non-elective activity Funding is growing at a slower rate than demand for services. This is reflected in the deficit of 800million that NHS providers are expected to deliver in FY 2016/17. Current System Reactive care, often responding to crises, under resourced and capacity pressures. Future System Pro-active care focusing on self-care, wellbeing and community interventions. 14

15 Annual Report and Accounts 2016/17 Summary of our refreshed strategy The Strategic Plan provides a framework within which a number of supporting strategies and plans are referenced. It represents a high-level document, which avoids duplicating the more detailed information contained within Operational Plans. It articulates how we will deliver the quality, safe, acute services required by the STP, by implementing the following priority agendas over the medium term: 1 Deliver more joined-up, community-based care to make best use of available resources. We will do this by working in partnership with other organisations who deliver care, locally. These include Central and North West London NHS Foundation Trust (CNWL), the Hillingdon GP Federation, and H4all (a consortium of voluntary sector providers). Together, we have formed Hillingdon Health and Care Partners to be commissioned by Hillingdon Clinical Commissioning Group (CCG) as an Accountable Care Provider (ACP). 2 Implement transformation schemes to manage demand whilst also making best use of available financial and staffing resources. These include national initiatives like the The Model Hospital and efficiency improvements recommended by Lord Carter s review, together with sub-regional schemes like the NWL productivity programme. 3 Develop an Academic Centre for Health Sciences with Brunel University London and CNWL. This will bring together academics, health and social care professionals in a shared agenda of education and research to shape the NHS and care workforce. It represents an initial step in developing an Academic Health Campus to improve population health and patient care in Hillingdon. 15

16 The Hillingdon Hospitals NHS Foundation Trust Refreshed vision and mission statements Throughout 2016/17, the Board devoted considerable time to strategy development. This includes a session at the Board awayday in May 2016; and a facilitated workshop at Board away-day in September to agree new Vision and Purpose statements. Vision To be an outstanding provider of healthcare through leading health and academic partnerships, transforming services to provide best care where needed. Purpose To provide high quality, safe and compassionate care, improving the health and wellbeing of the people that we serve. This statement acknowledges a commitment to changing our operational model over the planning period. We recognise that transformational change is required to continue providing highquality care to the growing number of older people we serve; whilst also supporting many others who now live with long-term conditions. We recognise that evidence-based innovation will play a key role in fulfilling our aspirations, and so we intend to strengthen our relationship with local academic health partners like Brunel University London, Bucks New University, and the Academic Health Services Network which is based at Imperial College Healthcare Partners. Our focus is to improve health outcomes, and we will adopt the most efficient approaches to deliver effective care this means extending our reach beyond the footprint of our hospitals, and working with community-based partners in responding to local needs. This statement of purpose is informed by the dual nature of our role. We will continue treating people when they are ill, by providing the best available acute care as has been our focus to date. Looking forward, we will be more forthright in helping people to stay healthy, so that they do not become ill in the first place this will represent an increased focus on prevention. 16

17 Annual Report and Accounts 2016/17 Key Issues and Risks The key issues and risks facing the Trust can be summarised as: The Trust may fail to achieve the 95% A&E target leading to a breach of its License The Trust is working with Hillingdon Clinical Commissioning Group, Hillingdon Borough Council, Hillingdon Community Health and the third sector to integrate care and ensure that admissions to hospital are avoided where possible; and, that time spent in the A&E department is reduced. Action will be taken, following a recent independent review of patient flows to and through the A&E department and into the Acute Medical Unit, to improve patients waits in A&E. Suboptimal staffing issues in relation to potential risk of inadequate nursing levels due to a combination of vacancies, national shortages and additional capacity being opened to meet surge in demand This risk is mitigated in real-time by proactive review of staffing by senior nurses and midwives to ensure each area is staffed in line with actual need. Average shift-fill rates are also reviewed retrospectively alongside patient-centred outcome 17

18 The Hillingdon Hospitals NHS Foundation Trust indicators. There has, and continues to be, ongoing and frequent recruitment, with each divisional team working in partnership with the recruitment manager to progress plans specific to the needs of their specialities. In addition to the international recruitment campaign to the Philippines during 2016, more flexible working arrangements and recruiting overseas nurses already working in the UK, supporting them to achieve registration with the Nursing and Midwifery Council, are some of the additional initiatives the Trust has employed to improve the recruitment of nurses. Failure to deliver high quality patient care as a result of inadequate staffing provision and specifically inadequate staffing provision to meet the 7-day workforce initiative The Trust is reviewing its clinical and support service workforce using acuity and dependency tools and other mechanisms; to improve frontline clinical staff numbers and care at the bedside seven days a week. The Trust will continue to drive forward a robust recruitment and retention work programme to reduce the number of vacancies and to support the increased activity that the Trust has seen during this past year. Failure to comply with the expected standards set out by our regulators which could impact on the Trust achieving a good rating with the CQC The Trust continues to strengthen its governance arrangements and its compliance with the Health and Social Care Act regulations through a programme of internal peer reviews and mock inspections. This will ensure there is evidence of improvement against a refreshed CQC action plan for 2017/18. Core services are undertaking self-assessment against the inspection frameworks to support critical review of compliance against the CQC standards. There is increased scrutiny of operational performance and quality data and an accountability framework to ensure compliance with policy and delivery of statutory targets is 18

19 Annual Report and Accounts 2016/17 being progressed. Particular attention is focused on areas of outstanding compliance notices, most notable of which is infection control. investment in equipment, training for nursing and medical staff and review of escalation processes. Failure to remain within hospitalacquired infection thresholds Clostridium difficile infection (CDI). In 2016/17 the Trust exceeded the trajectory of eight with a total of 12 cases. Only two cases were deemed to constitute a Lapse in Care as agreed with our commissioners; the other 10 cases were deemed treated appropriately and there was no evidence of cross-infection or inappropriate infection control practice. Actions continuing to be taken to mitigate risk include delivery of the Infection Prevention and Control annual action plan and completion of key actions to embed the Start Smart, Then Focus antimicrobial prescribing guidance. Lack of interventional radiology on call This could lead to a delay in diagnosis or treatment. A business case has been developed to support a joint post with Northwick Park Hospital (NPH) to provide robust day-time cover and on-call cover for Hillingdon as part of an interventional radiology rota with our partners. Clinical pathways have been reviewed with NPH and Imperial Healthcare Trust to agree the most suitable arrangements for vascular and other emergency cases. Lack of commissioned service to deliver high dependency care for children This level of medical care and treatment is not commissioned for delivery at the Trust. This poses a risk to children who are admitted to the Trust with complex needs and require high dependency medical and nursing care. With limited provision of Level 1 critical care paediatric services regionally, a business case has been prepared and submitted to our commissioners for the commissioning of this level of service. Actions already taken to mitigate the current risk include improvements to medical cover, environmental upgrade with a new four-bedded unit, Effectiveness of the financial control system or failure to achieve the financial plan The Trust has a challenging savings target in 2017/18 of 4%, but this still leaves a deficit of 15.3 million. The 2017/18 financial plan has been developed and approved by the Board of Directors, and submitted to the regulator. There is robust monitoring in place via the Board, Audit and Risk Committee, Finance Committee and Transformation Committee. To give the Trust the very best opportunity of delivering its savings, a Project Management Office (PMO) is in place to support managers and clinicians to achieve identified savings plans. Throughout the year weekly/fortnightly risk assessment allows early signs of potential areas of non-delivery to be identified and ensure mitigating actions are put in place to prevent slippage or nondelivery. To further strengthen the PMO, the Trust is participating in a Financial Improvement Programme run by NHS Improvement. External consultants experienced in delivering financial improvements have been engaged to add capacity to the PMO and help strengthen the governance arrangements for QIPP delivery. To manage the service risk as robustly as possible all savings schemes have a project initiation document that requires risk assessment. Any significant risks identified need a comprehensive Quality Impact Assessment (QIA) that is reviewed by the Clinical Assurance Panel (CAP) led by the Medical Director. The CAP reviews, approves or rejects any schemes, thereby assuring the organisation that change and transformation programmes do not pose a material risk to the delivery of safe, high quality care. The CAP also reviews quality KPIs related to projects to track any changes alongside key changes to service delivery. 19

20 The Hillingdon Hospitals NHS Foundation Trust The scale of investment required to improve the Trust s fragile estate infrastructure exceeds the Trust s financial capacity Failure to maintain the estate comes under Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010: Safety and Suitability of Premises. The condition of key building systems is assessed by a five yearly survey, and is risk assessed and rated against available capital. The annual capital investment available for the estate is targeted at addressing specific extreme risks, and although the level of funding is insufficient to remove the risks it does enable a risk reduction. However, the available funds are insufficient to keep pace with the scale of backlog maintenance and the Trust continues to have high-risk estates issues on its Risk Register. The need for investment in our infrastructure has been highlighted through the Shaping a Healthier Future (SaHF) business case. The case identifies the need for investment, but also flags that though investment would help, it would not resolve all our issues with the current infrastructure. In addition, the Trust is working with partners to develop a longer term solution to the estates issues through the development of a new facility on a university health campus at Brunel University. Failure to modernise and reconfigure the estate and facilities to meet the needs of our clinical services The estate has suffered from under-investment over an extended period and many building services have failed or are beyond their economic and design life cycle. Key facilities such as Theatres, Critical Care and many wards are of a design and condition that does not lend itself to the delivery of modern high quality healthcare. A waste incinerator that provides the majority of heat to the Hillingdon acute site has a remaining operational life of only two years. Investment in energy efficiency has been very low and a major replacement energy centre will be needed. The Trust is appraising the benefits of an Energy Performance Contract (EPC) programme which may help the Trust to meet its medium to longterm heat and power strategy, and to identify and implement commercially viable energy efficiency options on both sites. Overall, the Trust will remain focused on the tension between quality, safety, financial efficiency and risk to ensure that patient care remains uncompromised. The Trust will do this by having regular Board and Executive reviews of progress and delivery of agreed, plans and check that all schemes are quality impact assessed. Going Concern After making enquiries, the directors have not had any communication indicating that necessary support funding will not be made available to allow the NHS FT to continue into operating existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. Further commentary can be found in section 5.2 of the annual governance statement contained within this report. 20

21 Annual Report and Accounts 2016/17 01 Performance Report 21

22 The Hillingdon Hospitals NHS Foundation Trust Operational Performance Report Approach to measuring performance The Trust has in place an established performance framework supported by an integrated approach to monitor and track all the performance standards. The weekly meetings include detailed operational reviews of constitutional standards covering both emergency and planned care led by the Chief Operating Officer and Director of Operational Performance. The monthly divisional reviews form a core part of the framework led by the Executive Team to ensure there is effective support and controls to deliver high quality services to patients. The meetings report by exception to the respective sub-committees of the board, where further scrutiny is applied to ensure continuous improvement of the Trust s delivery on quality and operational performance. Overview of performance key targets The overall Trust position remains strong in all the areas except for the four-hour emergency care transit time standard of 95%. The Trust has worked closely with staff and external agencies to ensure sustained improvements in this key delivery area. Whilst the year end position for the four-hour transit time standard was at 84%, the month of March ended with 86.3% of our patients being discharged, admitted or transferred within fourhours. This meant the Trust met its improvement trajectory agreed with the regulators and the commissioners for March The performance for this standard is being monitored through the A&E Delivery Board which represents a whole care system agency collaboration, highlighting the dependency of achievement across all the agencies involved in providing care for the residents of Hillingdon and the neighboring boroughs. The Performance table below provides a three year comparative for each of the performance standards. A monthly integrated quality and performance report is presented to the Board which covers the five key domains based on the Care Quality Commission (CQC) framework: Safe, which includes infection control, falls, maternity indicators, safety thermometer, Serious Incidents/never events, patient safety and mortality standards. Effective, this covers readmissions and DNAs as well as monitoring performance on the use of Electronic Referral Service (ERS). Caring, this domain monitors outputs and delivery of Friends and Family surveys, as well as complaints and feedback from the Trust s Patient Advice and Liaison Service (PALS). Responsive, focuses predominantly on the constitutional standards reporting on Emergency Care, Cancer and RTT Well Led, monitors recruitment and retention as well as sickness rates and PDR performance. 22

23 Annual Report and Accounts 2016/17 Performance Table: Three year comparator (2014/15 to 2016/17) Indicator Performance In 2014/15 Performance In 2014/15 Performance in 2015/2016 Performance in 2016/17 Target Achieved Clostridium difficile (total) n/a Clostridium difficile (Lapses of Care) All cancers: 31 days for second or subsequent treatment (surgery) All cancers: 31 days for second or subsequent treatment (anticancer drug treatments) All cancers: 62 days for first treatment from urgent GP referral for suspected cancer All cancers: 62 days for first treatment from NHS Cancer Screening Service referral All cancers: 31 days diagnosis to first treatment Cancer: two week wait from referral to date first seen for all urgent referrals (cancer suspected) Cancer: two week wait from referral to date first seen for symptomatic breast patients (cancer not initially suspected) Maximum time of 18 weeks from point of referral to treatment admitted patients Maximum time of 18 weeks from point of referral to treatment non admitted patients Maximum time of 18 weeks from point of referral to treatment patients on an incomplete pathway A&E: Total time in A&E less than 4 hours (Accident & Emergency, Minor Injuries Unit, Urgent Care Centre) 8 n/a % 100.0% 100% 100% 96% 100.0% 100% 100% 85% 92.2% 92.2% 88.4% 90% 97.8% 98.4% 95.0% 96% 99.3% 99.3% 98.7% 93% 98.0% 98.0% 95.5% 93% 95.7% 95.7% 97.9% 90% 95.2% n/a n/a 95% 98.4% n/a n/a 92% 97.4% 96.1% 92.4% 95% 94.1% 92.0% 84.0% Self-certification against compliance with requirements regards access to healthcare for people with a learning disability N/A Fully Compliant Fully Compliant Fully Compliant 23

24 The Hillingdon Hospitals NHS Foundation Trust 1.1 Clostridium difficile As illustrated by the graph below the Trust continued with its good performance in reducing the incidence of reported Clostridium difficile Infection (CDI). There were two cases due to a lapse in care in 2016/17; these were determined via robust root cause analysis in partnership with the Clinical Commissioning Group (CCG). The learning from this has been incorporated into practice. 1.2 Cancer Performance The Trust successfully achieved all of the cancer access targets for the fifth successive year. The close tracking of each patient at tumor site level with a strong multi-disciplinary approach has been a key enabler for this success. The Trust remains committed to delivering a sustained performance for our patients in this area. 1.3 Referral to Treatment The Trust continues to perform well against this standard and ended the year with a performance of 92.4%. The services continue to increase capacity at specialty level in response to demand mainly through waiting list initiatives. The Trust demand and capacity model is being developed further in light of the increasing levels of demand in 2017/18 to support the delivery of the 18-week referral to treatment standard. 1.4 A&E four-hour Standard The Trust did not meet 95% performance for the four-hour Emergency Care transit time standard achieving 84%. However, due to the improvements put in place over the year, the March 2017 position was at 86.3% therefore achieving the set trajectory by the regulators for the month. This progress is expected to continue with a robust system-wide plan for improving emergency care across the borough. The plan continues to be monitored by the A&E Delivery Board which represents a whole care system agency collaboration, ensuring a strong partnership approach. The A&E attendance (Type 1) increased by 9.3% compared to the previous year, with blue-light conveyances up by 19.5% and non-blue-light conveyances up by 5.9%. Paediatric attendances also continue to increase seeing a 15.4% rise during 2016/17. The graphs on page 26 demonstrate the trend in all these areas over the year. The Trust saw an increase of 6.3% in the number of emergency admissions. This was 1.8% higher than the national average. All these factors culminated in additional demands on the service and an increasing need for resources overall. The Trust continues to make progress against the five key areas of improvement set out in the joint Clinical Commissioning Group (CCG) and Trust recovery programme, which will continue into 2017/18. The work stream areas are System Demand Management, Emergency Clostridium difficile Toxin Positive Source: PHE / / / / / / / / / /17 24

25 Annual Report and Accounts 2016/17 Department Process, Patient Flow, SAFER Care Bundle and Discharge Process. Some of the key improvement areas include: The ambulance handover time is improving and this has been shared through the A&E Operational Group and London Ambulance Service (LAS). This is due to ambulance streaming in place within a dedicated handover area The Clinical Decisions Unit is functioning well particularly with the improvement in bed flows within specialty wards enabling a quicker transfer of admitted patients The staff shift pattern leadership focus around the overall co-ordination of the department continues to improve incrementally and remains work in progress Early First Assessment and Management (EFAM) for self-presenters have strengthened ensuring timely clinical decision making in patient management Patient flows are improving with the Homesafe Frailty Unit in place ensuring earlier and proactive management of patients within a 72-hour period The Trust has put in place a 24-hour clinical operating rhythm including two patient safety huddles a day throughout the week with ward managers. This has enabled the teams to focus on safe care whilst maximising discharges over a 24-hour period Ensuring the SAFER Care Bundle, including the visual patient management system red to green, is maintained with further plans to strengthen the core elements, which will provide a consistent application at ward level Initiatives such as Discharge Home to Assess and Discharge to Assess are progressing well with partner organisations. The aim is to reduce medically optimised and delayed transfer of care patients in the hospital The daily conference calls for case-managing both groups of patients continues with partner agencies which will be further supported by the ECIP whole systems diagnostics completed in March 2017 Further focus on hospital-wide management of emergency care flows continues including the active management of the four hour breaches with the expectation of incremental improvements to achieve the set trajectory per month The second Clinical Leads evening meeting has taken place and outline Internal Professional Standard has been agreed. 25

26 The Hillingdon Hospitals NHS Foundation Trust A&E Attendances 2015/16 to 2016/17 A&E Attendances Type Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Type 1 attendances increased by 9.3%. A&E Blue Light Ambulance Attendances 2015/16 to 2016/17 A&E Attendances Blue Light Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Blue light ambulances increased by 19.5% A&E Paediatric Attendances 2015/16 to 2016/17 A&E Attendances Paediatrics (excl UCC) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Paediatric attendances increased by 15.4% 26

27 Annual Report and Accounts 2016/17 Financial performance analysis Overall performance The 2016/17 financial year proved to be the most challenging since becoming a Foundation Trust. Activity levels significantly exceeded plan and the income received for the extra activity did not meet the costs of delivery. In addition, the impact of the quality investments and increased staffing levels following the 2015 Care Quality Commission inspection exceeded the funding allocated. Finally, the Trust failed to deliver the level of planned savings for the year, only delivering its planned financial position through an accounting benefit to the value of its investment properties. Despite the financial pressures on the Trust it nevertheless still managed to deliver a 10.9 million programme of much-needed capital investment. Trading for the year The Trust ended the 2016/17 financial year with a financial surplus of 5.9 million. This was an improvement on the position in 2015/16 ( 1.5 million deficit) and better than the plan for the year ( 4.8 million surplus). However, this position was only delivered due to an unplanned accounting benefit of 11.3 million relating to the revaluation of the Trust s investment properties. The on-going increase in demand for the Trust s services led to a 7 million increase in its clinical income in 2016/17 when compared with the previous year. This included the transfer of some paediatric activity from Ealing, along with the full year impact of the transfer of Ealing maternity activity that started in 2015/16. Pay costs increased by more than the growth in clinical income. This reflects the fact that the marginal increase in clinical income does not cover the additional costs of undertaking the activity. It also reflects the Trust s efforts to reduce the numbers of nursing shifts remaining uncovered through increased recruitment. Non-pay costs increased by a greater rate than the growth in pay. Excluding the gain on investment properties, the Trust achieved 4.4 million of savings in 2016/17. This fell short of the 9 million target the Trust had set, thus contributing to the worsening financial position. Cash flow The Trust generated 9 million cash during the financial year, predominantly from direct healthcarerelated activities. In addition, to maintain liquidity the Trust drew down the full 6 million cash from its working capital facility with the Department of Health. Of this, 5.2 million was utilised to service outstanding debt and interest commitments from loans and leases, and to pay 4 million Public Dividend Capital to the Department of Health. The remaining 8.8 million of cash was used to finance the Trust s capital investment programme. The year-end retained cash balance of 1.1 million was a reduction of 3 million compared to 2015/16, reflecting the impact of the Trust s underlying financial position. Capital investment During the financial year the Trust invested in a capital programme totalling 10.9 million on the facilities, equipment and technology used by the Trust to deliver healthcare. The Trust s physical estate infrastructure again remained by far the largest area of investment. This was targeted toward prioritised risk-based investment to ensure operational buildings remained safe, fit for purpose, and compliant with statutory legislation. 27

28 The Hillingdon Hospitals NHS Foundation Trust The Trust received funding through the North West London Shaping a Healthier Future programme to invest in a Paediatric A&E Department ahead of the reconfiguration of Paediatric services in Ealing. With financial support from Hillingdon CCG, the Trust invested in a new Outpatient Pharmacy Department to improve the service for patients. Apart from the physical infrastructure, the Trust also continued to invest in updating its medical equipment impacting on a wide range of clinical services, and on information technology infrastructure and capability. Looking ahead Given the underlying 2016/17 deficit position, the Trust will face a particularly challenging 2017/18. In addition to the national efficiency requirement of 2%, the Trust faces a number of other cost pressures in 2017/18. The target savings from the Quality, Innovation, Productivity and Prevention (QIPP) plan are 9.6 million. The QIPP plan is supported by national work streams on agency cost reduction; Getting it Right First Time initiatives and the work of Lord Carter of Coles to improve operational productivity. There is also coordinated work across North West London to maximise savings across a wider footprint where this is practicable. Over the medium term, the Trust will achieve financial balance as the acute services reconfiguration in North West London is completed. However, the pace of these changes is not sufficient to deliver financial balance over the next three years. As a consequence of the planned deficit for 2017/18 and in the absence of a plan to get back to balance in the next few years, the Trust asked NHS Improvement (NHSI) for support. As part of this support, NHSI have put the Trust on to the national Financial Improvement Programme to support the development of a clinically-led sustainable financial recovery plan. Given its age and condition, managing the Trust s estate infrastructure is an ever increasingly difficult and expensive task. The cost of maintaining current facilities to meet compliance standards and service requirements remains high. 28

29 Annual Report and Accounts 2016/17 Environmental Issues The Trust recognises the need to operate as a financially and socially responsible organisation, minimising its impact on the environment in order to deliver the highest quality healthcare to the communities we serve, now and in future. In line with the Sustainable Development Management Plan work has been undertaken to continue to minimise the organisation s impact on the environment and reduce the Trust s energy use. The Carbon Reduction Commitment Energy Efficiency Scheme (often referred to as the CRC ) is a mandatory scheme aimed at improving energy efficiency and cutting emissions in large public and private sector organisations. The scheme features a range of reputational, behavioral and financial drivers, which aim to encourage organisations to develop energy management strategies that promote a better understanding of energy usage. The Trust has undertaken risk assessments and has Carbon Reduction Delivery Plans in accordance with emergency preparedness and civil contingency requirements, as based on UKCIP 2009 weather projects, to ensure that the Trust s obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with. Extensive audits have been carried out on both sites to identify opportunities to reduce energy consumption and associated carbon emissions. Water surveys were also conducted on both sites to understand usage profiles and patterns better, and to pinpoint areas where consumption can be optimised. With increased electrical demand from rising clinical activity, the electricity consumption for the period 2016/17 increased to 16,542,524 kwh from 16,355,687 kwh in 2015/16, an increase of 1.14%. In addition, total gas consumption for the year rose by 0.01%% against 2015/16 figures. The Trust s contract with SRCL (Part of Stericycle Inc.) to operate the incinerator based on The Hillingdon Hospital site ensures our clinical waste travels a minimal distance before entering the incinerator process. It helps minimise the impact on the environment in that the steam created from burning clinical waste is used to provide 70% of the energy needed to heat the radiators and provide hot water at Hillingdon Hospital, therefore significantly reducing our need for energy sources such as gas and oil. The incinerator takes most of the waste from Hillingdon, and clinical waste from Mount Vernon Hospital. The Trust s procurement contracts now require suppliers to demonstrate that they minimise any impact on the environment with the products and services they provide. The Trust has undertaken risk assessments and has Carbon Reduction Delivery Plans in accordance with emergency preparedness and civil contingency requirements, as based on UKCIP 2009 weather projects, to ensure that the Trust s obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with. 29

30 The Hillingdon Hospitals NHS Foundation Trust Looking ahead Investment in energy efficiency has been very low and a major replacement energy centre will be needed. Work is underway to appraise the benefits of an Energy Performance Contract (EPC) programme which may help the Trust to meet its medium to long term heat and power strategy and identify and implement commercially viable energy efficiency options on both sites. The projects being considered include, but are not limited to: Feasibility of a combined heating and power plant Lighting upgrades Electrical system enhancements Metering strategy and associated energy monitoring and targeting software These initiatives will help the Trust become a more efficient user of energy and thereby lower its associated carbon emissions. In addition, the Trust will benefit from a reduction in both direct energy costs and non-energy charges in the form of lower carbon levies, operational, maintenance, and service costs. Waste reduction and minimisation The Trust s Waste Group has met on a regular basis during the year. Part of its role is to ensure waste is segregated, managed, recycled and disposed of effectively in line with the Department of Health publication Safe Management of Healthcare Waste and Waste Hierarchy of the Department for Environment, Food & Rural Affairs. The Facilities waste & recycling service provides the safe collection, management and disposal of materials from our sites. Overall there has been a reduction in the amount of clinical and domestic waste since 2015/16. Waste minimisation efforts have been focused on reducing reliability on plastic-based packaging and replacing with either cardboard-based or biodegradable alternatives. All takeaway food in the Trust restaurants is now served in compostable packaging. There was a continuing decrease in the amount of waste sent to landfill in comparison to the previous year. During the year there has been considerable focus on improving waste segregation and processing, and an increased drive to improve our recycling and reduce landfill, working in partnership with the local authority. Green travel The Trust has continued to promote green travel for staff and service users. The Trust Travel Plan Coordinator has been undertaking a range of initiatives to encourage green travel in liaison with the local authority including cycle-to-work schemes. A major survey of how people travel to the Hillingdon Hospital site was undertaken using a nationally recognised standard system for data collection and analysis. The Trust was also successful in locating and leasing an increased number of local off-site parking spaces for staff. 2012/ / / /16 Total waste generated at Hillingdon and Mount Vernon Hospitals 1,476 tonnes 1,881 tonnes 1,736 tonnes 1,710 tonnes Waste recycled 437 tonnes (30%) 441 tonnes (23%) 409 tonnes (24%) 420 tonnes (25%) Clinical waste incinerated to produce steam that generated heat and hot water at Hillingdon Hospital 537 tonnes (36%) 574 tonnes (31%) 659 tonnes (38%) 688 tonnes (40%) Waste sent to landfill 502 tonnes (34%) 866 tonnes (46%) 668 tonnes (38%) 602 tonnes (35%) 30

31 Annual Report and Accounts 2016/17 02 Accountabiility Report 31

32 The Hillingdon Hospitals NHS Foundation Trust 2.1 Directors Report 2016/17 Board of Directors The Board was comprised of a Non-Executive Chair, six Non-Executive Directors and six Executive Directors (one non-voting). There were two non-executive vacancies that arose during the year. There were no Executive vacancies. Richard Sumray: Trust Chair Richard Sumray was appointed in November Richard has been involved for over 30 years as a Non-Executive Director in the NHS and is an experienced Chair. He chaired NHS Haringey (Primary Care Trust) for ten years from 2001 to 2011 and during that period also chaired the Joint Committee of London PCTs that supported Healthcare for London and the significant reforms to stroke and trauma services. He was also a member of the London Health Commission for eight years. Richard is a magistrate and has been chairing family and youth courts for 25 years in inner London. He was Chair of the London 2012 Forum working with the London Organising Committee of the Olympic Games and was a leading figure in sport in London, starting the work on an Olympic bid in the early 1990s. He currently chairs Alcohol Concern and recently stood down from the Chair of The National Centre for Circus Arts. He was also a member of the Metropolitan Police Authority for eight years. In addition to chairing the Board of Hillingdon Hospitals, he chairs the Trust s Charitable Funds Committee and the Board of Directors Nominations Committee. His term of office expires on 31 October Carol Bode: Non-Executive Director and Deputy Chair Carol Bode was appointed in April Carol s professional background is in organisational development and governance and she has 35 years experience operating in the commercial sector, public sector and not for profit sector in retail, customer services, financial services, health housing and education. Previous Directorships have included Non-Executive Chair at Southern Health NHS FT, Trustee of Foundation Trust Network Board, Corporate Director with a General Motors Company, Director of The Costello School (an Academy Trust). Currently, Carol is Non-Executive Chair of Radian Housing Group, Independent Chair of Hampshire Safeguarding Adults Board, Associate Trainer with NHS Providers, Associate Director with The Rialto Consultancy and Senior Adviser to Newton Europe. Carol is also a serving magistrate in North Hampshire. Carol was appointed Deputy Chair in March 2016, Chair of Remuneration Committee and the Board s Quality & Safety Committee. Carol left the Board in April

33 Annual Report and Accounts 2016/17 Professor Soraya Dhillon MBE: Non-Executive Director Soraya Dhillon was appointed in February Soraya retired from her full time role as Dean of the School of Life and Medical Sciences at the University of Hertfordshire at the end of October Health Sciences and Academic Manager University of Hertfordshire. Soraya was appointed Chair of the Board s Transformation Committee from October 2016, a member of the Board s Audit and Risk Committee and Quality and Safety Committee. Soraya s term of office expired on 31 January 2017 and has been further extended to 31 January Soraya has a PhD in Clinical Pharmacology and has held a number of key senior academic and clinical posts. Her research interests are in chronic disease management, prescribing, medicines optimisation and patient safety. Soraya is the former Non- Executive Chair of Luton and Dunstable Hospital NHS Foundation Trust and a member of the General Pharmaceutical Council. Soraya is a fellow of the Royal Pharmaceutical Society and was awarded an MBE for her contribution to health services in Bedfordshire. Soraya brings expertise in strategic leadership, academia and patient safety to the Board. Her current appointments are Non-Executive Director NHS Digital, Independent Chair Improvement Steering Group, Eastern Academic Professor Elisabeth (Lis) Paice OBE: Non-Executive Director and Senior Independent Director Lis Paice was appointed in February Lis trained as a doctor at Trinity College Dublin and Westminster Medical School before being appointed as a Consultant Rheumatologist at the Whittington Hospital. For 15 years Lis was Dean Director of London Deanery, overseeing the postgraduate training of doctors. Previously Chair of the Inner and Outer North West London Care Programmes and Co-Chair of the Integrated Care Programmes. Lis co-chairs the SelfCare workstream of North West London and has special responsibility for encouraging partnerships with people using health and social care services. Lis 33

34 The Hillingdon Hospitals NHS Foundation Trust holds the ILM Diploma in Executive Coaching and Leadership Mentoring, and was named NHS Mentor of the Year In 2011 she received an OBE for services to Medicine. Lis is a Fellow of the Royal College of Physicians. Lis term of office expired on 31 January 2017 and has been further extended to 31 January Richard Whittington: Non-Executive Director Richard Whittington was appointed on 1 October Richard is a chartered accountant (FCA) who was a Senior Partner at KPMG, where he was latterly in charge of the Infrastructure, Government and Healthcare Audit Group which provided services to the health and public sectors and building and construction companies. Until May 2016 Richard was a Non-Executive Director and Chairman of the Audit Committee of ISG Plc, a 1.4 billion turnover international construction services group. He was also Chairman of the ISG Middle East businesses. Richard is a Director, Trustee and Honorary Treasurer of the Community Foundation of Surrey and Chair of the Governors and Director of the Gordon s School Academy Trust Limited and a Trustee of the Gordon Foundation. He is also a Director of two small property management companies. Richard was installed as High Sheriff of Surrey in April 2016 for twelve months. Richard brings senior financial, audit and corporate governance experience to the Board, together with estates and capital investment expertise. Until early December 2016 Richard was Chair of the Capital Investment Committee (CIC). At that time he became Chair of the Audit and Risk Committee, of which he was already a member. Until the end of the financial year he remained a member of the CIC and of the Transformation Committee. Richard s term of office expires on 30 September Carl Powell: Non-Executive Director Carl Powell was appointed on 1 May Carl is the former Chief Executive of Pell Frischmann Limited (PF), a firm of consulting engineers providing financial and management services. 34

35 Annual Report and Accounts 2016/17 He continues to work with PF. Previous positions include Director of Planning and Transportation for Westminster City Council and Managing Director of two financial services companies. He has also served as a Non-Executive Director at CNWL and East London and City Mental Health Foundation Trust. Carl s term of office expires on 30 April Keith Edelman: Non-Executive Director Keith Edelman was appointed on 1 May Keith is also currently Chairman of Revolution Bars Group Plc, Chairman of Bullion by Post Limited, Senior Independent Director of Supergroup Plc, a Non-Executive Director of the London Legacy Development Corporation, and a Director of Stonebury Properties Ltd. In his executive career he was a Director of Ladbrokes, Managing Director of Carlton Communications Plc and Chief Executive of Storehouse Plc. His most recent executive appointment was Managing Director of Arsenal Football Club where he was responsible for the development of Emirates Stadium and the attendant regeneration of the area including Highbury Square. Keith s term of office expires on 30 April Katey Adderley: Non-Executive Director Katey Adderley was appointed in December Katey is a former Director and Partner of Charterhouse Capital Partners, one of Europe s largest private equity companies, where she worked for 11 years. Katey is also a Non-Executive Director of BPP University. She has a first class Honors degree in Economics from Cambridge University and a Master s degree (distinction) in Economic Evaluation in Healthcare. Katey is a Chartered Management Accountant. Katey is Chair of the Trust s Audit & Risk Committee. Her term of office expired on 30 November Shane DeGaris: Chief Executive: Executive Director Shane DeGaris was appointed Trust Chief Executive in March 2012 having previously been the Trust s Deputy Chief Executive & Chief Operating Officer. Shane is an experienced NHS Director having worked in a number of London Trusts in senior management roles including as Director of Operations at Barnet & Chase Farm Hospitals NHS Trust and as Deputy Chief Executive at Epsom & St Helier University Hospitals NHS Trust. Australian by birth, he began his healthcare career in 1990 after training as a Physiotherapist in Adelaide, South Australia. Shane is a Board Director of Imperial College Health Partners, a Board member of the London & South East LETB (a sub-committee of Health Education England) and Chair of a National Expert Reference Group for evidence-based treatment pathways for integrated Mental and Physical healthcare. Dr Abbas Khakoo: Medical Director: Executive Director Abbas Khakoo was appointed as sole Medical Director in October 2014 having held the position on a job-share basis since in January Abbas is a Consultant in Paediatrics and the care of new born babies. Abbas also runs a children s allergy service at Hillingdon Hospital and at St Mary s Hospital, part of Imperial College Healthcare NHS Trust. Since July 2015, Abbas has been the Chair of the Paediatric Project Delivery Board and Joint Senior Responsible Officer for the Paediatric Transition, Shaping a Healthier Future. In 2016 he agreed to be a medical advisor to PA Consulting for a single overseas tender but which was unsuccessful, and there is no ongoing relationship. Professor Theresa Murphy: Director of the Patient Experience & Nursing: Executive Director Theresa Murphy joined the Trust in May 2013 having been the Director of Nursing at North Middlesex University Hospital NHS Trust. Theresa qualified in general nursing in 1987, before specialising in Neuroscience and Critical Care nursing. Theresa has also held a number of clinical and managerial posts in both teaching and general hospitals. Theresa was awarded the Florence Nightingale leadership scholarship for 2012, and is an Honorary Professor for the City of London University, and has an LLB. Theresa holds Board level responsibility for nursing, governance and risk management, infection prevention and control, safeguarding people, patient experience and engagement. 35

36 The Hillingdon Hospitals NHS Foundation Trust David Searle: Director of Strategy & Business Development: Executive Director David Searle was appointed in David had a 20 year career in the Royal Navy as a Fleet Air Arm Pilot, where senior roles included second in command of a major Air Defence warship and the Commanding Officer of a large front line Naval Air Squadron. David subsequently worked in the aerospace and defence industries where he held senior positions in procurement, commercial management, business development and marketing. He was latterly Director, Wider Markets in the Defence Aviation Repair Agency before joining the Trust. David has Board level responsibility for strategy, business planning, business development, estates and facilities and communications. He is a Trustee of St David s Care Home for ex-servicemen and women. Joe Smyth: Chief Operating Officer: Executive Director Joe Smyth was appointed Chief Operating Officer in March 2015; having previously been the Trust s Director of Operational Performance. Joe has over 20 years senior managerial healthcare experience, including Deputy Chief Operating Officer at Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust and Director of Service Improvement at Epsom and St Helier University Hospitals NHS Foundation Trust. Joe holds Board level responsibility for the management of the clinical divisions, emergency planning, integration and the QIPP programme (Quality, Innovation, Productivity and Prevention). One of Joe s key responsibilities is to ensure that the Trust meets and exceeds all national and local patient access standards. Trevor Mayhew: Acting Finance Director Trevor Mayhew was appointed Acting Finance Director from 15 February to 3 April Trevor is a member of the Association of Chartered Certified Accountants, and has spent all his working life within the NHS, with previous positions at Royal Free and Great Ormond Street Hospitals. Trevor has worked at the Trust since April 2000, and has been the substantive Deputy Director of Finance since May Trevor also held Board level responsibility for purchasing and supplies; the Trust s information services and information technology functions, which includes the clinical coding team; health and safety; and is the Trust s Senior Information Risk Owner (SIRO). Matthew Tattersall: Director of Finance: Executive Director Matthew Tattersall was appointed Director of Finance in April He has spent all his working life in NHS Finance joining as a graduate trainee in the North Thames Region and going on to qualify as a Chartered Public Finance Accountant. He also has an MSc in Healthcare Leadership and a NHS Leadership Academy Award in Senior Healthcare Leadership. His roles have included Director of Finance at Dacorum and Watford PCTs and Deputy Director of Finance at Homerton University Hospital. Matthew also holds Board level responsibility for Purchasing and Supplies, the Trust s Information Services and Information Technology functions, Health and Safety and is the Trust s Senior Information Risk Owner (SIRO). Terry Roberts: Director of People and Organisational Development: Executive Director Terry Roberts joined the Trust in March 2016 as Director of People and Organisational Development and attends Board meetings in a non-voting capacity. Prior to this post he was the Director of Workforce at Kingston Hospital Foundation Trust and has held senior HR positions at Bart s Health, Ealing Hospital, St Mary s Hospital and North West London Hospital as well as working at the Department of Health as a National HR Advisor. Terry holds a Master s Degree in Human Resources Management and is a Fellow of the Chartered Institute of Personnel and Development (FCIPD). He has completed the Top Managers Programme with the Kings Fund and is a certified Coach and Mediator. Terry is also a Director of Transform Ltd company. Terry has Board level responsibility for human resources (including recruitment, employee relations and temporary staffing), occupational health, nurse training, and workforce and organisational development. 36

37 Annual Report and Accounts 2016/17 Board member Register of Interests and Gifts and Hospitality Company directorships and other declarations of interest or gifts and hospitality were declared by all Board members. The full register of declarations is available from the Trust Secretary. Statement on the balance, completeness and appropriateness of the membership of the Board The Board of Directors Nominations Committee is responsible for reviewing the structure, size and composition of the Board and makes recommendations to the Council of Governors on the skills required for any upcoming Non- Executive Director appointments. As outlined in the biographies of Board members, the Board comprises individuals with senior level experience in the public and private sectors, across a range of disciplines including clinical and patient care; health service leadership; commercial development; business transformation and change management; finance; governance; risk management; and human resources. The Board therefore confirms that the current composition is considered to be appropriate. Taking account of the NHS Foundation Trust Code of Governance published by Monitor, the Board considers the current Chair and all of the Non-Executive Directors to be independent. Performance evaluation of the Board Committees The Board had already reviewed its Committee structure in October 2015 and implemented revisions from that time. Consequently there were no revisions to its Committee structure in 2016/17. 37

38 The Hillingdon Hospitals NHS Foundation Trust Meetings of the Board, its Committees and the Council of Governors in 2016/17 The Board The Board met 12 times during 2016/17 comprises of a Non-Executive Chair, six Non- Executive Directors, and six Executive Directors although the Director of People is a non-voting member. In order to make Board meetings accessible to the public and Governors, four Board meetings were held at Mount Vernon Hospital and eight at Hillingdon Hospital. Two of the meetings at Hillingdon Hospital were held at 5pm and one meeting held at Mount Vernon at 5pm. The Board set the strategic vision and direction of the Trust for the year 2016/17, agreeing the annual Operating Plan, the Budget and Capital Programme at an early point in the year. The Board also acted as the body which was able to provide assurance that the Trust s statutory obligations, as well as its overall performance (including safety and quality), was of the standards expected or that appropriate action was being taken to ensure compliance with those standards, either directly or through its Committee structure. Committees of the Board The Board had seven Committees, each chaired by a Non-Executive Director in 2016/17; Audit & Risk Committee Quality and Safety Committee Transformation Committee Capital Investment Committee Board of Directors Nomination Committee Board of Directors Remuneration Committee Charitable Funds Committee Audit & Risk Committee The Audit & Risk Committee met five times during 2016/17. As at 31 March 2017, the Trust s Audit & Risk Committee comprises four Non-Executive Directors; the Committee Chair having recent and relevant financial experience. The Committee is usually attended by the internal and external auditors, the Director of Finance and the Director of Patient Experience & Nursing as the Executive Director responsible for clinical and corporate governance. The Local Counter Fraud Specialist attends at least two meetings a year, and other Directors and senior managers attend when invited by the Committee. The Committee is responsible for providing an independent and objective review of the Trust s systems of internal control (both financial and non-financial) and the underlying assurance processes in place at the Trust. The Committee is also responsible for ensuring that the Trust has independent and effective internal and external audit functions. The Committee is responsible for providing an independent and objective review of the Trust s systems of internal control (both financial and non-financial) and the underlying assurance processes in place at the Trust. 38

39 Annual Report and Accounts 2016/17 External audit The Audit & Risk Committee (ARC) is responsible for making recommendations to the Council of Governors on the appointment and removal of the external auditor. In October 2013 the Council of Governors appointed Deloitte as the Trust s external auditors for a three year period starting with the 2013/14 audit with an option for two one year extensions. In line with the Code of Governance this reappointment is subject to annual review. This annual review involves the Audit & Risk Committee (ARC) members completing a structured review of external audit against the areas of work set out in Monitor s Audit Code: Financial statements Annual governance statement The Trust s arrangements for securing economy, efficiency and effectiveness in the use of resources; and The quality report. Plus review of external audit against 46 criteria across the following domains: The audit partner The audit team The audit approach planning and then execution Communications by the auditor to the ARC External audit s support to the work of the ARC Insights and adding value Formal reporting by the auditors. The Chair of the ARC then presents a report to the July meeting of the Council of Governors on the outcomes of this review and whether external audit s appointment should be confirmed. The audit fee for 2016/17 was 81,300 plus VAT ( 66,400 plus VAT for the financial statement audit and 14,900 plus VAT for work on the quality report). In October 2013 the Council of Governors agreed an updated policy on the engagement of the external auditors to undertake additional services. Under this policy, any such work is reported to the Council of Governors. No such additional work was commissioned in 2016/17. Internal audit The Trust s internal audit service is provided by KPMG. Internal audit provides an independent and objective opinion on risk management, control and governance by measuring and evaluating the effectiveness by which organisational objectives are achieved. Through detailed examination, evaluation and testing of the Trust s systems, internal audit play a key role in the Trust s assurance processes. The scope and work of the Trust s internal auditors, is set out in a charter approved by the Audit & Risk Committee. The Audit & Risk Committee agree a work plan for internal audit at the start of each financial year, taking account of the risk assessment undertaken by internal audit. The Committee review the findings of internal audit s work against this plan at its quarterly meetings. Audits undertaken in 2016/17 included: risk management; data quality; business cases and financial controls. The Head of Internal Audit reports to the Committee and is managed by the Director of Finance. The Head of Internal Audit has a right of direct access to Committee members. Key issues considered by the Committee Key elements of the Committee s work include reviewing the Board Assurance Framework, the Risk Register and reviewing the findings of the Trust s internal and external auditors and Local Counter Fraud Specialist. The Committee is responsible for reviewing the annual financial statements, with particular focus given to major areas of judgement and changes in accounting policies, determining that the Trust remains a going concern, and reviewing the draft annual report including the annual governance statement. The Committee also reviews the assurance in place in respect of data quality. In addition the Committee monitored estates compliance, compliance with information governance standards, reviewed contingent liabilities, reviewed debtors and examined the Trust s status as a going concern. 39

40 The Hillingdon Hospitals NHS Foundation Trust Quality and Safety Committee The Quality and Safety Committee met six times during 2016/17. As at 31 March 2017, the Trust s Quality & Safety Committee comprises of three Non-Executive Directors and four Executive Directors. The Committee s remit is to provide the Trust Board of Directors with assurance that quality and safety within the organisation is being delivered to the highest standards and that there are appropriate processes in place to identify gaps and manage them accordingly. The Committee combines the three themes that define quality: Effectiveness of the treatment and care provided to patients measured by both clinical outcomes and patient-related outcomes Safety of treatment and care provided to patients safety is of paramount importance to patients and is the bottom line when it comes to what services must be delivering Experience that the patients have of the treatment and care they receive how positive an experience people have on their journey through the organisation can be even more important to the individual than how clinically effective care has been. The Committee has actively participated in the development of the Trust s five year Quality and Improvement Strategy to treat and care for people in a safe environment and protect them from avoidable harm which is one of the five outcome domains outlined in the NHS Outcomes Framework. The Committee also monitors the Trust s compliance with Care Quality Commission registration requirements. Transformation Committee The Transformation Committee met three times during 2016/17. As at 31 March 2017, the Trust s Transformation Committee was comprised of four Non-Executive Directors and six Executive Directors. The Committee s remit is to shape, challenge and review the development and implementation of the Trust s transformation programme with a particular focus on schemes that improve quality whilst reducing cost. Key issues considered by the Committee The work of the Committee has focused on the challenge to ensure the Trust continually transforms its services, using four strategic workstreams to measure that this was taking place; Responsible Accessible Services, Emergency Care Improvement, Accountability, Workforce. The Committee was also responsible for reporting to Board on the achievement of its savings programme as well as setting the savings targets for 2017/18. Against a target total of million the Committee oversaw a total saving of million although 11.5 million of this total related to savings generated by property revaluation. Capital Investment Committee The Capital Investment Committee met nine times during 2016/17. As at 31 March 2017, the Trust s Capital Investment Committee comprises of four Non-Executive Directors and four Executive Directors. The Committee s primary remit is to shape, challenge and review the development and implementation of the Trust s strategic redevelopment programme. Key issues considered by the Committee The Capital Investment Committee monitored the capital investment programme for 2016/17 and identified priorities for capital spending for 2017/18. Given a woefully small available budget the Committee was charged with continually having to make recommendations on competing schemes as well as seek innovative solutions to attract the maximum funding possible for the Trust. The Committee was however able to oversee some key deliverables; a 4 million upgrade of our paediatric services, building a new extended Clinical Decision Unit, the creation of two new A&E triage rooms, upgrades to electrical, heating and ventilation services for our Maternity building and significant improvements to our water supply at the Hillingdon site. 40

41 Annual Report and Accounts 2016/17 Nominations Committee The Board of Directors Nomination Committee met twice during 2016/17. As at 31 March 2017, the Trust s Board of Directors Nomination Committee comprises of seven Non-Executive Directors and one Executive Director (Chief Executive) with the Director of People and Organisational Development in attendance. The Board of Directors Nominations Committee leads the process for Executive Board appointments, Non-Executive and Executive succession planning and evaluating that the Board has the right skills mix and training to lead the organisation. Key issues considered by the Committee During 2016/17 the Committee had no Executive appointments to make and focused on Executive succession planning as its key area of business. Remuneration Committee The Board of Directors Remuneration Committee met twice during 2016/17. As at 31 March 2017, the Trust s Board of Directors Remuneration Committee comprises of seven Non-Executive Directors with the Chief Executive and the Director of People and Organisational Development in attendance. The Committee sets Executive annual objectives, reviews performance and then sets pay based on a thorough appraisal of that performance. Charitable Funds Committee meetings 2016/17 The Charitable Funds Committee met three times during 2016/17. As at 31 March 2017, the Trust s Board of Directors Charitable Funds Committee comprises of three Non-Executive Directors, two Executive Directors and the Lead Governor. The Charitable Funds Committee assists the Trust in its role as corporate trustee for The Hillingdon Hospitals NHS Foundation Trust charity and has been established to make and monitor arrangements for the control and management of the Trust s charitable funds. Key issues considered by the Committee The Committee actively reviewed income and expenditure within the fund and the performance of the fund managers, Brewin Dolphin. An Annual Report and Accounts was produced, reviewed and lodged with the Charity Commission. The Committee approved a new strategy to take the Charity forward over the next three years. The strategy includes an ambitious target to significantly increase income through traditional fundraising initiatives and also developing corporate partnerships and enhancing the Charity s profile in the local community. The Committee also reviewed bids for allocation of funds. Key issues considered by the Committee The Committee formally appraised the Chief Executive and all Executive Directors, agreed their pay and set targets for 2016/17. 41

42 The Hillingdon Hospitals NHS Foundation Trust Attendance at Board and Board Committee meetings 2016/17 The following table outlines Board members attendance at Board and Committee meetings during 2016/17 against the total possible number of meetings for which an individual was a member. Committee attendance is shown in relation to those Committees of which a Director is a formal member. Board of Directors (12 meetings) Audit & Risk Committee (6 meetings) Board Nominations Committee (2 meetings) Board Remuneration Committee (2 meetings) Charitable Funds Committee (3 meetings) Quality & Safety Committee (5 meetings) Transformation Committee (3 meetings) Capital Investment Committee (9 meetings) Katey Adderley 9 of 9 4 of 4 1 of 1 1 of 1 1of 2 4 of 4 Carol Bode 9 of 12 2 of 2 2 of 2 3 of 3 5 of 5 3 of 3 Shane DeGaris 12 of 12 2 of 2 4 of 5 2 of 3 9 of 9 Soraya Dhillon 12 of 12 6 of 6 2 of 2 2 of 2 5 of 5 3 of 3 Abbas Khakoo 11 of 12 5 of 5 3 of 3 Theresa Murphy 8 of 12 3 of 5 1 of 3 Lis Paice 10 of 12 2 of 2 1 of 2 5 of 5 David Searle 11 of 12 3 of 3 9 of 9 Joe Smyth 9 of 12 3 of 5 2 of 3 5 of 9 Richard Sumray Richard Whittington 12 of 12 2 of 2 2 of 2 3 of 3 9 of 9 11 of 12 6 of 6 1 of 2 1 of 2 7of 9 Carl Powell 8 of 11 2 of 3 2 of 2 1 of 2 1 of 1 1 of 3 6 of 8 Keith Edelman 7 of 11 2 of 3 2 of 2 1 of 2 6 of 8 Matthew Tattersall 12 of 12 6 of 6 3 of 3 3 of 3 9 of 9 Terry Roberts 11 of 12 1 of 3 42

43 Annual Report and Accounts 2016/17 Governors report Council of Governors The role and powers of the Council of Governors statutory duties are set out in the Health and Social Care Acts of 2006 and and in summary are: To hold the Non-Executive Directors to account for the performance of the Board Appoint the Non-Executive Directors of the Trust, including the Chair and agree their remuneration Approve the appointment of the CEO as recommended to them Appoint the Trust s auditor Approve changes to the Constitution Receive the Trust s Annual Report Approve significant transactions and may choose to set out the definition(s) in the Trust s Constitution. The composition of the Council of Governors is determined by the Trust s Constitution. As at 31 March 2017 there were 24 positions on the Council of Governors: 13 elected to represent the public members, seven elected to represent the staff members, and four appointed by partner organisations (Hillingdon Council, Hillingdon Clinical Commissioning Group, the London Ambulance Service, and the Trust s Joint Negotiating & Consultative Committee). Governors are normally appointed for a term of three years. By having publically elected governors and appointed governors representing the local area, the Trust ensures the public interests of patients and the community is represented. 43

44 The Hillingdon Hospitals NHS Foundation Trust The members of the Council of Governors who served during 2016/17 are: Public Governors Name Date took office and method (see key below) Term of office expires North (4) Graham Bartram 01/04/2014 (CE) 31/03/2017 Ian Bendall 01/04/2014 (CE) 31/03/2017 David Bishop 01/04/2014 (CE) 31/03/2017 Tony Ellis 01/04/2014 (CE) 31/03/2017 Central (4) Harkishan Chander 01/04/2014 (CE) 31/03/2017 Donald Dakin 01/04/2014 (CE) 31/03/2017 Terry Thompson 01/07/2015 (CE) 30/06/2018 Roger Shipton 01/04/2014 (CE) 31/03/2017 South (4) Raymond Smith 01/03/2016 (CE) 28/02/2019 Keith Saunders 01/04/2014 (CE) 31/03/2017 Doreen West 01/04/2014 (CE) 31/03/2017 Rekha Wadhwani 01/04/2014 (CE) 31/03/2017 Rest of England (1) Daphne Magidi 01/07/2015 (CE) 30/06/2018 Staff Governors Doctors & Dentists (1) Alvan Pope 01/04/2014 (UE) 31/03/2017 Nurses, Midwives, Healthcare Assistants (3) Sheila Bacon 08/04/2014 (UE) 31/03/2017 Sheila Kehoe 08/04/2014 (UE) 31/03/2017 Amanda O Brien (resigned 31/3/2016) 01/04/2014 (UE) 31/03/2017 Allied Health Professionals (1) Graham Coombs 01/04/2014 (CE) 31/03/2017 Support Staff (2) Paul Cornford 01/04/2014 (UE) 31/03/2017 Jack Creagh 01/04/2014 (UE) 31/03/2017 Appointed Governors Hillingdon Clinical Commissioning Group (1) Dr Mayur Nanavati 01/04/2014 (A) 01/04/2017 London Borough of Hillingdon (1) Mary O Connor 01/04/2014 (A) 01/04/2017 London Ambulance Service (1) Pauline Cranmer 01/04/2014 (A) 01/04/2017 Joint Negotiating & Consultative Committee (1) Nicola Batley 01/07/2015 (A) 30/06/2018 Key: CE contested election UE uncontested election A appointed by partner organisation 44

45 Annual Report and Accounts 2016/17 In 2016/17 the Council of Governors formally met four times. Governor attendance at these meetings is outlined below. Where a Governor was not in office for all four meetings, the maximum possible attendance is shown. Governor Meetings attended Graham Bartram (Public) 4 of 4 Ian Bendall (Public) 2 of 4 David Bishop (Public) 4 of 4 Tony Ellis (Public) 3 of 4 Harkishan Chander (Public) 4 of 4 Donald Dakin (Public) 4 of 4 Raymond A Smith (Public) 2 of 2 Roger Shipton (Public) 4 of 4 Keith Saunders (Public) 4 of 4 Rekha Wadhwani (Public) 4 of 4 Doreen West (Public) 4 of 4 Terry Thompson (Public) 3 of 4 Daphne Magadi (Rest of England) 0 of 4 Alvan Pope (Staff) 4 of 4 Sheila Bacon (Staff) 3 of 4 Sheila Kehoe (Staff) 4 of 4 Graham Coombs (Staff) 4 of 4 Paul Cornford (Staff) 3 of 4 Jack Creagh (Staff) 2 of 4 Dr Mayur Nanavati (Appointed) 1 of 4 Mary O Connor (Appointed) 3 of 4 Pauline Cranmer (Appointed) 1 of 4 Nicola Batley (Appointed) 0 of 4 45

46 The Hillingdon Hospitals NHS Foundation Trust Governors are required to declare any relevant interests which are then entered into the publicly available Register of Governors Interests. The Register is formally reviewed by the Council of Governors annually and is available from the Trust Secretary. Contact with individual governors can be made by request through the Trust Secretary. Lead Governor In line with Monitor s Code of Governance, the Council of Governors elects one of the Public Governors to be the Lead Governor. The main duties of the Lead Governor are to: Act as a point of contact for Monitor should the Regulator wish to contact the Council of Governors on an issue for which the normal channels of communication are not appropriate Be the conduit for raising with Monitor any Governor concerns that the Foundation Trust is at risk of significantly breaching its Licence, having made every attempt to resolve any such concerns locally Council of Governors Nominations & Remuneration Committee The Committee met three times during 2016/17. The Committee comprises of the Chair of the Trust, three public Governors and two staff Governors. The Council of Governors Nomination & Remuneration Committee leads the process for appointing or terminating the role of the Chairman and all Non-Executive Directors, making recommendations to the full Council of Governors; it is also responsible for recommending their remuneration, appraising their performance and setting their targets. The Committee s main areas of work during the year were: To appoint two new Non-Executive Directors in April 2016 To approve the Chair and Non-Executive Director appraisals and review their remuneration in June 2016 To consider two Non-Executive Director extensions of appointment in November Chair such parts of meetings of the Council of Governors which cannot be chaired by the Trust Chair or Deputy Chair due to a conflict of interest in relation to the business being discussed. Rekha Wadhwani was Lead Governor for the 2016/17 financial year. The Committee met three times during 2016/17. The Committee comprises of the Chairman of the Trust, three public Governors and two staff Governors 46

47 Annual Report and Accounts 2016/17 The Board s liaison with Governors and members All Board members have a standing invitation to attend Council of Governors meetings in order to ensure they understand the views of Governors and members. Throughout the year the Chairman and each Non-Executive Director has addressed the Council Governors, outlining their experience and what they are focusing on at the Trust. In addition a monthly briefing session for Governors is held with the Chairman where Governors are updated on matters at the Trust and have the opportunity to ask questions of the Executive Directors. The Council of Governors meetings are held in public and there is an opportunity for members of the public to ask Governors and members of the Board questions. Governors and members of the Board also attend the Trust s People in Partnership meetings and Annual Members Meeting to liaise with members and Governors. Attendance by Non-Executive members at the four meetings of the Council of Governors and the joint meeting between the Board and Council of Governors in 2016/17 is outlined below: Non-Executive Board Member No of Council of Governor meetings attended in 2016/17 (4 meetings held) Katey Adderley (Non-Executive Director) 2 of 3 Carol Bode (Non-Executive Director and Deputy Chair) 3 of 4 Soraya Dhillon (Non-Executive Director) 3 of 4 Lis Paice (Non-Executive Director and Senior Independent Director ) 4 of 4 Keith Edelman (Non-Executive Director) 1 of 2 Carl Powell (Non-Executive Director) 3 of 4 Richard Whittington (Non-Executive Director) 2 of 4 47

48 The Hillingdon Hospitals NHS Foundation Trust Membership The Foundation Trust membership is divided into two categories: public membership and staff membership. 48

49 Annual Report and Accounts 2016/17 Public membership There are four public constituencies, which are collectively known as the Public Constituency. The majority of the public members are drawn from the three public constituencies which cover the electoral wards in Hillingdon borough together with several neighbouring electoral wards. The fourth public constituency covers all other electoral areas in the rest of England. Public membership is open to individuals aged 16 years or over living within the Public Constituency, who are not eligible to be a staff member of the Foundation Trust. The Constitution includes two further disqualifications on public membership. 1 Staff membership The staff constituency is a single constituency divided into the following classes: Doctors and dentists Nurses and midwives (including health care assistants) Allied Health Professionals Support staff. Staff membership is open to all those employed by the Trust on a permanent basis, those who have a fixed term contract of at least 12 months, and those who have been working at the Trust for at least 12 months. These staff are automatically members of the staff constituency unless they opt-out from membership. In addition, those working at the Trust through the temporary staffing bank become staff members providing they have been registered on the Trust s bank for at least 12 months and continue to be registered. So far no staff has opted out from being a member of the Foundation Trust. Staff membership will cease at the point that the member leaves the service of the Trust. Anyone eligible to be a staff member of the Foundation Trust cannot be a public member. Public Membership as at 31 March 2017 As at 31 March 2017, the Trust had 6,820 public members. The table below illustrates the number of public members for each constituency compared to the total population. During 2016/17, the Foundation Trust recruited 90 new public members and lost 246 public members due to bereavement, moving away without providing a new address or cancelling their membership. The Trust established a Council of Governors Membership Development and Engagement Group to enable Governors to become engaged in a programme of focused recruitment and engagement with members. Key actions agreed by the group included setting up Governor surgeries in the hospital, identifying community events for the Governors to attend, redesigning the membership leaflet and encouraging Governors to suggest content for the Pulse Foundation Trust newsletter. Discussions also focused on using social media to engage with young people and exploring opportunities for attracting students from Brunel University to undertake a placement at the Trust. 31 March 2017 % of membership Population Base % of area Central 2, , North 1, , South 2, , Rest of England Total 6, , An individual may not become or remain a member of the Trust if during the five years prior to their application, they have demonstrated aggressive or violent behaviour at any hospital or towards any person working for a health service body and following such behaviour has been excluded from any hospital or other health service body under either the Trust s or other health service body s policy for withholding treatment from violent/aggressive patients, or equivalent. Nor can anyone become or continue as a member of the Trust if they have been confirmed as a vexatious complainant in accordance with the Trust s complaints handling policy. 49

50 The Hillingdon Hospitals NHS Foundation Trust Staff Membership as at 31 March 2017 As at 31 March 2017 the Trust had 3398 staff members. The following table provides a breakdown by staff group. Each staff group includes bank staff who meet the Trust s eligibility criteria for staff membership: Doctors and Dentists 330 Nurses, Midwives and 1,592 Healthcare Allied Health 375 Professionals, Scientific and Technical Support staff 1,101 Total 3,398 Number of members Membership Development and Engagement Strategy The Trust with the Council of Governors updated and approved the Membership Development and Engagement Strategy at its meeting in February The Strategy describes the Trust s objectives for the membership and the approach we will use to ensure the Trust develops and engages with a representative membership. It outlines our plans for raising awareness about membership and for the recruitment, retention and involvement of members. It also defines how we will measure the success of the strategy. The strategy was produced with the guidance and input of the Council of Governors. A high level action plan to deliver the Membership Development and Engagement Strategy has been developed each year with progress periodically reported to the Council of Governors and the Board. The Hillingdon Hospitals NHS Foundation Trust is committed to recruiting members from the diverse population served by the Trust. Membership is open to all those eligible to be a member regardless of gender, race, disability, ethnicity, religion or any other groups covered under the Equality Act The membership base is regularly reviewed to ensure that the membership is representative of those eligible to be members. Specific groups that appear to be under-represented are targeted in recruitment campaigns in order to seek to increase membership representation in these areas, such as young people between the ages of 16 and 39. A summary of these details can be requested from the Membership Office. 50

51 Annual Report and Accounts 2016/17 Key actions to grow membership and improve engagement: Encourage Governors to attend local groups and events (e.g. Resident Associations and Community Voice) to engage with the public and recruit new members Support fundraising events organized by the Trust or other local organisations Attract new members visiting the hospitals during monthly Governor/member surgeries Organise membership recruitment events at Hillingdon and Mount Vernon Hospitals Encourage Governors and members to sign up family, friends and members of the public Insert a membership form into new patient appointment letters Invite ex-staff, their family and friends to become public members Utilise existing networks in promoting membership with staff and students at local universities and schools Encourage all volunteers to sign up as public members Use social media (e.g. Twitter) to attract new members. Engagement between Governors and members The Trust organises People in Partnership meetings which enable the Governors, particularly the Public Governors, to engage with the members they represent. The meetings are held either at Hillingdon or Mount Vernon Hospital during the year and are chaired by a Governor. They are preceded by an opportunity for members and Governors to meet over refreshments. The Trust encourages and facilitates linkages between the Council of Governors and groups and organisations which represent patients, public and the wider community. During 2016/17 Public Governors attended various community events throughout the year, including the May Fair in West Drayton. Many Governors participate in activities unrelated to health i.e. local churches, volunteer driving and education, and are therefore able to communicate with local residents and public members at these events and report back to the wider Council of Governors in order to ensure that the Council of Governors is aware of public comments and concerns which have been raised. The Trust provides Governors with information on the Trust s strategy and performance at various meetings such as the formal quarterly Council of Governors meetings, monthly informal meetings with the Chair and Chief Executive, and the joint meetings between the Board and Council of Governors. The Trust provides Governors with information on the Trust s strategy and performance at various meetings such as the formal quarterly Council of Governors meetings, monthly informal meetings with the Chair and Chief Executive, and the joint meetings between the Board and Council of Governors. Governors can then feed this information back to the members and organisations they represent. These meetings also provide the opportunity for Governors to feed back issues of concern raised by members. During 2016/17 such issues included car parking at the Hillingdon site, staffing levels, facilities for patients and the quality of the estate. Governors are also able to communicate with members through the quarterly members newsletter The Pulse which regularly features a Governor article. The Membership Development & Engagement Strategy outlines the Trust s policy on the involvement of members, patients and wider public, including a statement on the Trust s approach to consultation, and addressing the overlap and interaction between the Governors and other consultative and representative groups. The strategy is available on the Trust s website. Political Donations The Trust has not made any donations to political parties. 51

52 The Hillingdon Hospitals NHS Foundation Trust Payment of Creditors The Trust aims to comply with the Better Payment Practice Code which is that 95% of invoices in terms of numbers and value are paid by the due date of payment, though it has been unable to achieve the target in 2016/17. Details of the Trust s compliance in this matter can be found in note 7.1 of the accounts. The Trust paid out 13k in 2016/17 for interest on late payments under the Commercial Debts (Interest) Act 1998 ( 3k in 2015/16). Annual Quality Report The Trust s commitment to quality improvement and quality governance is clearly outlined in its Quality and Safety Improvement Strategy ( ); this describes a system of quality performance management, and a clear risk management process. Having the right structures and processes in place allied to an appropriate culture with supporting values and behaviours is strongly emphasised. The 2016/17 Quality Report, contained within this report, provides evidence of progress against our key quality and safety indicators and outlines our priorities for improvement for the forthcoming year. It is aligned to our Quality and Safety Improvement Strategy ( ) objectives and our overall Trust Strategy. As part of its consultation on priorities for improvement for the Annual Quality Report the Trust has liaised with clinical and managerial staff via divisional governance Board meetings and divisional review meetings. Key stakeholders, such as our FT membership, our Governors, our local Healthwatch and local organisations from the third sector have been engaged via a stakeholder event to discuss the current year s progress and priorities for the forthcoming year. The Information Team has also undertaken a triangulation exercise examining data sources that they regularly analyse for potential underlying issues of quality related to performance or data, not otherwise identified. All of the above has assisted the Trust be clear on its priorities and quality targets. The Trust uses its systems for quality performance management to assess its performance in relation to regional and national comparators for the key quality indicators and associated narrative in the Quality Report. Information on quality is supplied to the Board, its committees and the management team by the Information and the Clinical Governance teams who collect and maintain an overview of quality information. Alongside key quality indicators as part of the integrated quality and performance report, information is also included on clinical audit, clinical incidents, SIs and the learning from them, complaints and claims. This flow of information ensures that key risks to quality are identified. The Trust has a comprehensive clinical audit work plan covering both national and local audits. Regular updates on clinical audit are reported to the CCG on a quarterly basis with exception reporting to the Quality and Safety Committee. Progress against national and local audits and actions being taken are detailed in the Quality Report to ensure transparency on our performance against these. The Trust aims to comply with the Better Payment Practice Code which is that 95% of invoices in terms of numbers and value are paid by the due date of payment, though it has been unable to achieve the target in 2016/17. A quarterly meeting with our local Healthwatch has supported discussion on the progress of our quality priorities and key quality indicators alongside hearing feedback from service users who access our services and who interact with Healthwatch. This assists in informing our quality improvement work. Care Quality Commission The Trust was inspected by the CQC in October 2014 as part of its planned and more detailed inspection regime. The final reports were 52

53 Annual Report and Accounts 2016/17 published on 10 February The Trust was rated as Requires Improvement overall. The Trust received a good rating for the caring domain across all of its services; staff were observed to be kind and had a caring and compassionate manner. The Trust has been working through a detailed improvement plan since this inspection and this continues to be presented to the Trust s Quality and Safety Committee on a quarterly basis. A recent review by the Trust s internal auditors, KPMG against the CQC s Key Lines of Enquiry will support the Trust in refreshing its action plan in A more detailed account is provided in the Quality Report. Quality Governance There are key quality governance and leadership structures that support the Trust in ensuring that the quality of care is being routinely monitored across all services. These are outlined in the Trust s Quality and Safety Improvement Strategy. There is monthly reporting to the Board via an integrated quality and performance report with exception narrative. The Quality and Safety Committee (QSC), a sub-committee of the Board chaired by a Non-Executive Director, receives more detailed information on safety and quality to ensure there is robust discussion and Board-level scrutiny. This includes a rotational programme where each clinical division presents on clinical and quality governance issues, including discussion on areas of risk, performance against key quality indicators and progress of work in relation to learning from clinical incidents and clinical audit. There is also a deep dive review at each QSC meeting on the key aims of the Quality and Safety Improvement Strategy. Clinical divisions review their quality data in relation to patient safety, patient experience and clinical effectiveness on a monthly basis at their divisional governance boards; divisional exception reports are received by the Patient Safety Committee (PSC) and any concerns on patient safety are escalated to the QSC. Similarly the Regulation and Compliance Committee (RCC) receives bi-monthly updates from the divisional governance boards on their compliance with the CQC standards and other quality and regulatory requirements, reporting by exception to the QSC. More detailed information on the Trust s quality governance arrangements are outlined in the Annual Governance Statement as part of the Annual Report. Income Disclosure Section 43(2A) of the NHS Act 2006 (as amended by the Health and Social Care Act 2012) requires that the Trust s income from the provision of goods and services for the purposes of the health service in England must be greater than its income from the provision of goods and services for any other purposes. In 2016/17, the Trust met this requirement, with 96.3% ( 243,706k) of the Trust s income generated by activities for the purpose of the health service in England. As the vast majority of Trust income is categorised as generated by activities for the purpose of the health service in England, it is the Board s view that other income does not detract from NHS provision to any material extent. Where other income is generated it supports the Trust to make optimum use of its assets and is used to directly support principal patient care activities. Directors Disclosure to Auditors For each individual who was a director at the time that this report was approved: so far as the director was aware, there was no relevant audit information of which the NHS Foundation Trust s auditor was unaware and the director has taken all the 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 NHS Foundation Trust s auditor was aware of that information. 53

54 The Hillingdon Hospitals NHS Foundation Trust 2.2 Remuneration Report The Trust s pay policy is to set executive remuneration between the median and upper quartile of comparator Trusts when individuals have a demonstrable track record of high performance against agreed objectives and in their overall contribution to the Trust over a sustained period of time. In making decisions on executive remuneration the Remuneration Committee will also consider the organisation s performance, and the individual s experience, marketability and likelihood of moving elsewhere. Executive remuneration does not currently include provisions for bonus payments linked to the delivery of performance targets. No executive pay should be below the maximum scale for Agenda for Change Band 9. In March 2017 the Remuneration Committee agreed the to use the NHSI Comparator for medium Acute NHS Trusts and Foundation Trusts and to pay each of the executive directors between the lower quartile and median of the NHSI Comparator for medium Acute NHS Trusts. In addition, it was agreed that the Director of Finance pay award should be phased in over a two year period in order to reach the lower quartile. The first portion paid in 2016/17 and the second is due to for implementation in 2017/18 subject to continued good performance. A recent benchmarking exercise undertaken by Capita suggests that there are variations in the competitive positioning of the salaries paid to individual post holders when roles are benchmarked with comparable posts in Foundation Trusts. While the current salary levels paid for some roles are around the median level paid by Foundation Trusts that are of a similar size to the Trust, other salary levels were found to be less competitive. Service contracts and payments for loss of office Neither the Chief Executive nor the Executive Directors are currently appointed for fixed term contracts. The Board believes that such contracts would make it harder to attract and retain highquality Executives in a competitive recruitment environment, and can lead to uncertainty affecting service delivery towards the end of the contract. The Trust s policy on notice periods and termination payments for Executive Directors is six months, in line with generally accepted practice at this level in the NHS. Any decision to allow an Executive Director to leave the Trust s employment without this full notice period is subject to a risk assessment by the Board of Directors Nominations Committee, in line with the Code of Governance. This risk assessment will include consideration of the individual s performance and the succession planning arrangements in place. Non-Executive appointments are not within the jurisdiction of Employment Tribunals and there is no entitlement for compensation for loss of office through employment law. The expiry of the terms of office for the Chair and Non-Executive Directors are outlined earlier in the annual report in the section relating to the Board. The Chair and Non-Executive Directors can resign at any time by giving three month s written notice. 54

55 Annual Report and Accounts 2016/17 All Executive Directors are entitled to sick pay in line with the following table: Length of NHS Service During the first year of service: During the 2nd year of service: During the 3rd year of service: During the 4th and 5th years: After 5 years service Full Pay Half Pay 1 month 2 months 2 months 2 months 4 months 4 months 5 months 5 months 6 months 6 months In terms of loss of office, all Executive Directors will be entitled to the same redundancy terms associated with Agenda for Change (AfC) and Medical & Dental (M&D) staff i.e. after two years qualifying service, the entitlement for redundancy pay will be one month s salary for each year s service, capped at 24 months payment. For the purposes of redundancy, under the amended Section 16 of AfC salary, redundancy payments will be capped at 80K where relevant. Furthermore, all Executive Directors will be entitled to any annual leave which has been accrued and not taken at the point of a loss of office. Where more annual leave has been taken than already accrued, the Director will need to pay this back to the Trust (payment will be recovered through monthly pay). As mentioned earlier, all Executive Directors will be entitled to a six months notice period in relation to a loss of office, the only exception to this would be an immediate dismissal, whereby notice periods would not be applicable. Payments made to Directors at the point when there will be a loss of office would in usual circumstances be in line with contractual rights i.e. redundancy, annual leave etc. Any payments outside of these would be subject to the relevant approval process, which may include NHS Improvement. Further changes to loss of office payments may be made in response to the forthcoming Public Sector Exit Payment Regulations Non-Executive Directors are not entitled to redundancy pay, holiday pay or sick pay, as they are Office Holders, and not employees of the Trust. Details on senior manager pay, the future policy table and fair pay multiple are in tables 1-4. Shane DeGaris Chief Executive The Hillingdon Hospitals NHS Foundation Trust 30th May

56 The Hillingdon Hospitals NHS Foundation Trust Table 1 Senior Managers (The Chair, Executive and Non-Executive Directors) Remuneration Current Year Ending 31 March 2017 Previous Year Ending 31 March 2016 NAME AND TITLE Salary and fees 2016/17 Taxable Benefits 2016/17 (Note 6) Annual Performance Related Bonuses 2016/17 Long Term Performance Related Bonuses 2016/17 Pension Related Benefits 2016/17 Total Remuneration 2016/17 Salary and fees 2015/16 Taxable Benefits 2015/16 (Note 6) Annual Performance Related Bonuses 2015/16 Long Term Performance Related Bonuses 2015/16 Pension Related Benefits 2015/16 Total Remuneration 2015/16 Notes (bands of 5000) (To the nearest 100) (bands of 5000) (bands of 5000) (bands of 2500) (bands of 5000) (bands of 5000) (To the nearest 100) (bands of 5000) (bands of 5000) (bands of 2500) (bands of 5000) 000s s 000s 000s 000s 000s 000s s 000s 000s 000s 000s Executive Directors Shane Degaris, Chief Executive N/A N/A N/A N/A Abbas Khakoo, Medical Director N/A N/A N/A N/A Trevor Mayhew, Interim Director of Finance N/A N/A N/A N/A Theresa Murphy, Director of Emergency Care N/A N/A N/A N/A Terry Roberts, Director of People N/A N/A N/A N/A N/A 5-10 David Searle, Director of Strategy & Business Development N/A N/A N/A N/A Joe Smyth, Chief Operating Officer N/A N/A N/A N/A Matthew Tattersall, Director of Finance N/A N/A N/A N/A N/A N/A N/A N/A 5 Jacqueline Walker, Director of the Patient Experience and Nursing N/A N/A N/A N/A N/A N/A N/A N/A 56

57 Annual Report and Accounts 2016/17 Current Year Ending 31 March 2017 Previous Year Ending 31 March 2016 NAME AND TITLE Salary and fees 2016/17 Taxable Benefits 2016/17 (Note 6) Annual Performance Related Bonuses 2016/17 Long Term Performance Related Bonuses 2016/17 Pension Related Benefits 2016/17 Total Remuneration 2016/17 Salary and fees 2015/16 Taxable Benefits 2015/16 (Note 6) Annual Performance Related Bonuses 2015/16 Long Term Performance Related Bonuses 2015/16 Pension Related Benefits 2015/16 Total Remuneration 2015/16 Notes (bands of 5000) (To the nearest 100) (bands of 5000) (bands of 5000) (bands of 2500) (bands of 5000) (bands of 5000) (To the nearest 100) (bands of 5000) (bands of 5000) (bands of 2500) (bands of 5000) 000s s 000s 000s 000s 000s 000s s 000s 000s 000s 000s Non Executive Directors Richard Sumray, Chair N/A N/A N/A N/A N/A N/A Katey Adderley, Non-Executive Director (to 30/11/2016) N/A N/A N/A N/A N/A N/A Carol Bode, Non- Executive Director N/A N/A N/A N/A N/A N/A Soraya Dhillon, Non- Executive Director N/A N/A N/A N/A N/A N/A Keith Edelmanb, Non-Executive Director (from 1/5/2016) N/A N/A N/A N/A N/A N/A 0 Lis Paice, Non- Executive Director N/A N/A N/A N/A N/A N/A Carl Powell, Non- Executive Director (from 1/5/2016) N/A N/A N/A N/A N/A N/A 0 Richard Whittington, Non-Executive Director N/A N/A N/A N/A N/A N/A Notes on Table 1 Annual and Long Term Performance Related bonuses have not been paid by the Trust and are not applicable (N/A) Pension Related Benefits have been calculated using the HMRC method advised by Monitor in the Annual Reporting Manual. There were no taxable benefits paid in the year. 57

58 The Hillingdon Hospitals NHS Foundation Trust Table 2 Senior Managers Pension Entitlements NAME AND TITLE Real increase in pension at age 60 at 31 March 2017 Real increase in pension lump sum at age 60 at 31 March 2017 Total accrued pension at age 60 at 31 March 2017 Lump Sum at age 60 related to accrued pension at 31 March 2017 Cash Equivalent Transfer Value at 1st April 2016 Real Increase in Cash Equivalent Transfer Value Cash Equivalent Transfer Value at 31 March 2017 Employer's contribution to stakeholder pension Executive Directors (Bands of 2500) (Bands of 2500) (Bands of 5000) (Bands of 5000) 000s 000s 000s 000s 000s 000s 000s Shane Degaris, Chief Executive N/A Abbas Khakoo, Medical Director N/A Trevor Mayhew, Interim Finance Director N/A Theresa Murphy, Director of Emergency Care N/A Terry Roberts, Director of People N/A David Searle, Director of Strategy & Business Development N/A Joe Smyth, Chief Operating Officer N/A Matthew Tattersall, Director of Finance N/A Jacqueline Walker, Director of the Patient Experience and Nursing N/A Notes on Table 2 The Trust is a member of the NHS Pension Scheme which is a defined benefit Scheme, though accounted for locally as a defined contribution scheme. The Trust does not operate nor contribute to a stakeholders pension scheme. This is therefore shown as not applicable (N/A). Non Executive Directors are not members of the Trust pension scheme. CETV (Cash Equivalent Transfer Value) is the value of a members pension fund at 31 March if he/she were to transfer that pension fund on that date. 58

59 Annual Report and Accounts 2016/17 Table 3 Fair Pay Multiple 2016/ /2016 Band of Highest Paid Director s Total Remuneration ( 000) Median Total Remuneration 32,731 30,501 Ratio Notes on Table 3 The HM Treasury Financial Reporting Manual (FReM), requires the Trust to disclose the median remuneration of the Trust staff and the ratio between this and the mid-point of the banded total remuneration of the highest paid director. The calculation is based on full-time equivalent staff of the Trust at 31 March 2017 on an annualised basis. In 2016/17 and 2015/16 no employee received remuneration in excess of the highest paid director. Remuneration in table 3 excludes pension related benefits in accordance with NHSI/Monitor instructions. Table 4 Senior Managers earning more than the Prime Minister 2016/ /2016 (Bands of 5000) (Bands of 5000) Shane Degaris, Chief Executive Abbas Khakoo, Medical Director Notes on Table 4 The Annual Reporting Manual (ARM) for NHS Foundation Trusts from 2016/17 requires the Trust to disclose all Senior Managers receiving greater remuneration than the Prime Minister (currently 142,500). For the purpose of table 4 Prime Minister comparatives, the average of the banding of Total Remuneration in Table 1 is used. The remuneration in table 4 must be disclosed on a full time, part time, or any other pro rata basis. Furthermore the Trust must disclose what steps it has taken to satisfy itself that the remuneration is reasonable. The process the Trust follows is explained below: The Trust s exec pay policy is to set executive remuneration between the median and upper quartile of comparator Trusts when individuals have a demonstrable track record of high performance against agreed objectives and in their overall contribution to the Trust over a sustained period of time. In making decisions on executive remuneration the Remuneration Committee will also consider the organisation s performance, the individual s experience, marketability, the pay of senior managers on Agenda for Change terms and conditions and the likelihood of them moving elsewhere. Executive remuneration does not currently include provisions for bonus payments linked to the delivery of performance targets. Executive pay was last benchmarked in 2015 by Hay Group who examined data from annual reports and a national survey conducted by the Foundation Trust Network. The Remuneration then considered all executives and the CEO s salary against the benchmark report and in accordance with the pay policy as set out above. Remuneration in table 4 excludes pension related benefits in accordance with Monitor instructions. Notes Changes in Office Holders 2016/17 1 Clinical work in band of 35-40k, Director work in band of k Recharges out to NHS Central London CCG and Imperial College not included in above Included in salary was a Clinical Excellence Award in band of 35k to 40k which was funded by the NHS Commissioning Board CCG. 2 Trevor Mayhew was employed as Interim Director of Finance from 22 February 2016 to 3 April Theresa Murphy became Director of Emergency care on 30/1/17. Before that Director of the Patient Experience and Nursing. 4 Matthew Tattersall commenced employment as Finance Director on 4 April Jacqueline Walker became Director of the Patient Experience and Nursing on 30 January 2017 Shane DeGaris Chief Executive The Hillingdon Hospitals NHS Foundation Trust 30 May 2017 Detailed staff costs are now included in the staff report in the annual report, rather than the accounts. 59

60 The Hillingdon Hospitals NHS Foundation Trust 2.3 Staff Report A breakdown at the end of the year of the number of male and female directors, senior managers and employees. The Trust Board has fourteen members, ten male and four female. Women represent 70% of senior staff at band 8 and above. This is above the representation within the workforce and London Borough of Hillingdon population. As at 31 March 2017, the Trust employed over 3,200 staff (headcount). Of this 77.5% of staff were female and 22.5% male. We have a growing female workforce which is consistent with the health sector. Since 2015/2016, our female workforce increased by 2.5% to 77.5% of our overall workforce with female staff dominating professional groups such as nursing and midwifery (91% female) and Allied Health Professionals (81% female). There was an almost equal balance of gender representation within Medical and dental workforce which although historically male, has over the last six years seen an increase in female medical doctors to 54%. See Appendix A. Whilst our male workforce is declining, there continues to be stronger gender representation of male staff within admin & clerical and estates & ancillary groups. 60

61 Annual Report and Accounts 2016/17 The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts Employee costs and numbers Employee costs 31 March March 2016 Total Permanently employed Other Total Permanently employed Other Salaries and wages 128, ,192 8, , ,483 6,781 Social security costs 13,353 12, ,403 10, Employer contributions to NHS Pension 14,343 13, ,621 13, scheme Temporary staff - agency/contract staff 14,194 14,194 14,725-14,725 Recoveries from DH Group bodies in respect of staff cost (1,410) (1,410) - (1,465) (1,465) - Employee benefits expense 169, ,363 23, , ,247 22,301 Of the total above: Charged to capital , Charged to revenue 168, ,538 23, , ,282 22, , ,363 23, , ,247 22,301 Directors aggregate remuneration 31 March 2017 Remuneration 31 March March March 2016 Number of Directors ** Remuneration Number of Directors ** Executive Directors 1, ,054 9 Non Executive Directors* Total 1, , Analysis of Directors Remuneration ( 000) Gross pay 1, Employer Pension Contributions Employer National Insurance Contributions Total 1,239 1,185 *Non Executive Directors are not members of the NHS pension scheme. ** The number of directors denotes the number of individuals employed in a director position at some point during the financial year, not the number of directors simultaneously employed. 61

62 The Hillingdon Hospitals NHS Foundation Trust Analysis of Average Staff Numbers Average number of people employed 31 March March 2016 Total Permanently employed Other Total Permanently employed Other Number Number Number Number Number Number Medical and dental Administration and estates Healthcare assistants and other support staff Nursing, midwifery and health visiting staff 1, Scientific, therapeutic and technical staff Healthcare science staff Total 3,476 2, ,269 2, Of the above: Number of whole time equivalent staff engaged on capital projects

63 Annual Report and Accounts 2016/17 Sickness absence data The Trust completed the financial year with a YTD sickness rate of 3.22% - although this rate is higher than the Trust target of 3%, it was less than the 15/16 YTD figure of 3.53%, a decrease for the second consecutive year. The Women s & Children s Division completed the year with the highest YTD sickness rate (4.27%), followed by CCSS (3.33%), Corporate (3.10%), Medicine (2.97%), and Surgery (2.86%). The estimated YTD cost of sickness to March 2017 was 2,868,697. The overall reduction in the sickness rate for 16/17 (3.22% compared to 3.53%), can be partly attributed to the greater focus on sickness within the Divisions and the delivery of sickness absence training to managers. Furthermore, there was greater joint working between the Human Resources (HR) team and the Occupational Health (OH) team in relation to complex sickness cases. The HR and OH team have also been reviewing the current sickness absence policy, with a view to close down loopholes and making it more robust. The revised policy will go out to consultation with key stakeholders and Staff Side colleagues in May Staff policies and actions applied during the financial year: Policies were applied during the financial year for giving full and fair consideration to applications for employment made by disabled persons, having regard to their particular aptitudes and abilities. In line with the policies governing recruitment, selection, disability and the Guaranteed Interview Scheme, disabled candidates for any selection process, who meet the essential criteria, will be shortlisted for interview. The following policies apply in relation to the above question; Recruitment & Selection Policy, Equality & Human Rights Policy, Employment Checks Policy The Trust has a positive approach to disability and subscribes to the Two Ticks Scheme. We aim to encourage and support the inclusion of disabled people in accessing the full range of opportunities open to staff, and to promote greater participation in public life. In line with the policies governing recruitment, selection, disability and the Guaranteed Interview Scheme, disabled candidates for any selection process, who meet the essential criteria, will be short-listed for interview. Managers responsible for conducting any selection or assessment processes are also responsible for ensuring that reasonable adjustments are made for any candidates who require them, in line with the Trust s Recruitment and Selection Policy/Resourcing Policy. Policies applied during the financial year for continuing the employment of, and for arranging appropriate training for, employees who have become disabled persons during the period. The following policies apply in relation to the above question; Equality & Human Rights Policy. Managers are responsible for ensuring that staff are able to carry out their work in appropriate conditions, including participation in learning and development initiatives and local induction processes. Where necessary, reasonable adjustments must be made to equipment, working or learning arrangements and the physical environment to ensure that disabled staff can carry out their work, and access the full range of learning and development opportunities. These adjustments will be carried out with advice from the occupational health department. In certain circumstances the Equality Act 2010 provides that a reasonable adjustment can include treating disabled staff more favourably, such as appointing a disabled member of staff into a role without undergoing a competitive selection process. 63

64 The Hillingdon Hospitals NHS Foundation Trust Policies applied during the financial year for the training, career development and promotion of disabled employees. The following policies apply in relation to the above question; Recruitment & Selection Policy, Equality & Human Rights Policy. The Trust has a positive approach to disability and subscribes to the Two Ticks Scheme. We aim to encourage and support the inclusion of disabled people in accessing the full range of opportunities open to staff, and to promote greater participation in public life. be taken into account in making decisions which are likely to affect their interests. These forums include; the JNCC (Joint Negotiating Consultative Committee), JLNC (Joint Local Negotiating Committee), Terms & Conditions Committee and subgroups such as the PDR Working Group. The Trust also acts upon information received from the results of the Staff Survey and Staff Friends & Family Test. Other initiatives include the monthly Chief Executive briefing and the Team Brief. Where appropriate the principles of the Managing Organisational Change Policy are also applied, especially in relation to changes which impact on working arrangements. In line with the policies governing recruitment, selection, disability and the Guaranteed Interview Scheme, disabled candidates for any selection process, who meet the essential criteria, will be short-listed for interview. Where appropriate the principles of Positive Action are applied to support the career development and promotion of disabled employees. Actions taken in the financial year to provide employees systematically with information on matters of concern to them as employees. The Trust sends out regular bulletins to staff to keep them informed of matters which may be of concern to them. Managers are encouraged to disseminate such information at Team Meetings and/or 1:1 meetings as appropriate. Should employees have concerns which they wish to raise, a number of channels are open to them to do so. These include but are not limited to the following; Raising Concerns at Work Policy, Dignity at Work Policy, Grievance Policy, SpeakInConfidence, escalating concerns to their manager or manager s manager. Actions taken in the financial year to consult employees or their representatives on a regular basis so that the views of employees can be taken into account in making decisions which are likely to affect their interests. The Trust has a number of forums in place to consult with employees or their representatives on a regular basis, so that the views of employees can Actions taken in the financial year to encourage the involvement of employees in the NHS Foundation Trust s performance. The Trust has a culture of engagement and routes through which it involves and listens to its workforce. The senior team is actively involved in welcoming new employees. The CEO uses his monthly briefings to listen to and engage with the workforce. These briefings are held at both the Hillingdon and Mount Vernon sites. Trust employees are involved and contribute to clinical decision making at all levels of the organisation through representation on various committees particularly clinical audit committees. These provide a forum for discussion, problem solving, action planning and review of Trust performance. The Trust has a culture of regular 1:1 meetings between managers and direct reports and their teams. The Performance Development Review meetings provide an additional forum through which staff are involved in decisions about their work, service and performance of the Trust. Staff are encouraged through our Bright Ideas scheme to submit ideas and activities for improving the quality of the workplace and patient care. This is actively promoted through and via the Trust Bulletin. In addition, staff governors take a full part in the governors role and will bring matters forward from staff to governors meetings. 64

65 Annual Report and Accounts 2016/17 We continue to use the findings from the annual staff survey report to engage our staff. With the involvement of staff and teams, action plans are developed from its findings and taken forward for the benefit of staff and patients. The Trust has a culture of partnership working with its staff and staff side colleagues. This relationship is supported via three main forums through which staff are consulted in decisions about the organisation. The Trust has an Occupational Health Department which provides information and support to staff. In addition the Trust has an Employee Assistance Program in place, which is open to all Trust Employees details are published on the Trust intranet page. Occupational Health and managers will refer staff to the service as appropriate. The Trust also promotes Occupational Health services at internal health promotion events and the Trust s New Joiners Event. Health and safety Through its Health and Safety Strategy the Trust continues work towards best practice standards of health and safety for all our staff in the workplace, for members of the public, patients, and others who come in to our premises. Health and safety governance: The Health and Safety Committee have met quarterly and the Board has received reports on health and safety issues and performance throughout the year. Training: All new members of staff receive health and safety training during their corporate induction. Fire safety training has been completely reviewed and as a result, attendance has increased. Performance: During this reporting period there were a total of 1,607 incidents reported indicating a slightly increased trajectory in incident reporting. Information on policies and procedures with respect to countering fraud and corruption The Trust has a Counter Fraud Policy in place which highlights to staff what they should do in the event that they suspect fraud or corruption. The Trust also has in place a Raising Concerns at Work Policy (Whistleblowing), and an anonymous dialogue system called SpeakInConfidence, which can also be used for the purposes of raising concerns. Staff survey results The Trust received a positive staff survey with a 12% increase from our 2015 response rate (34%). Therefore 1442, Trust staff took part in the survey (46% response rate). Our 2016 response rate was 2% above the average for acute trusts in England (44%). This means that many more of our staff have been engaged in having their say and putting forward their views. We scored above average for more than 50% of all Key Findings (17 out of 32) with 12 Key Findings (more than a third) in the top 20% of all acute Trusts. This is also two more Key Findings in the top 20% than we achieved in The Staff Survey National Report highlights the five Key Findings for which the Trust compares most favourably with other acute trusts in England and the five Key Findings for which we compare least favourably with other acute trusts in England. This has been compared with what was reported in

66 The Hillingdon Hospitals NHS Foundation Trust Top Five Ranking Findings Benchmarking group (trust type) average Trust Improvement Deterioration Staff motivation at work (Key Finding 4) 4.06% 4.03% 3.94% Decrease Staff feeling unwell due to work related stress in the last 12 months (Key Finding 17) 30% 31% 35% Increase Staff appraised in last 12 months (Key Finding 11) 93% 92% 87% Decrease Staff / colleagues reporting most recent experience of violence (Key Finding 24) Recognition and value of staff by managers and the organisation (Key Finding 5) 64% 72% 67% Increase 26% 29% 31% Increase Bottom Five Ranking Findings Benchmarking group (trust type) average Trust Improvement Deterioration Action Plan to address areas of concern Staff experiencing discrimination at work in last 12 months (Key Finding 20) Staff believing that the organisation provides equal opportunities for career progression or promotion (Key Finding 21) Staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months (Key Finding 25) Staff reporting errors, near misses or incidents witnessed in the last month (Key Finding 29) Fairness and effectiveness of procedures for reporting errors, near misses and incidents (Key Finding 30 14% 17% 11% Increase Discrimination falls within the remit of the Equality, Diversity and Inclusion Committee who direct the action plan in response to the WRES data. 83% 83% 87% Same A programme of actions has been agreed with an external training provider (EWG) to design an assessment centre model with a roll out planned for May Actions will align to the EDI Committee s WRES action plan 29% 30% 27% Increase Data will be looked at a divisional level, identify the hot spots and look at focused action plans to address this issue. Disseminate results to the Equality, Diversity & Inclusion committee Launch a zero tolerance communications campaign 90% 88% 90% Decrease Findings reported to the Quality and Safety committee for investigation and any appropriate action. 3.69% 3.68% 3.72% Decrease Findings reported to the Quality and Safety committee for investigation and any appropriate action. 66

67 Annual Report and Accounts 2016/17 Staff motivation at work (KF4) Staff motivation at work has remained in the top 5 Key Findings for another year and the result puts Hillingdon Hospitals in the top 20% of all acute trusts. This Key Finding combines questions about whether staff look forward to work, are enthusiastic about their job and whether time passes quickly. The result is only 0.04 less than the best score in 2016 for acute trusts. Staff appraised in last 12 months (KF11) This Key Finding has remained in the top 5 ranked findings and is 5% higher than the average for acute trusts, putting Hillingdon in the top 20% of acute trusts. This is anticipated with local reporting from the PDR window showing that 97% of staff completed their appraisal. The amount that staff feel recognised and valued by the organisation is the final new finding within the top 5 ranked this year. This places Hillingdon Hospitals in the top 20% of all acute trusts. Staff experiencing discrimination at work in last 12 months (KF20) The percentage of staff experiencing discrimination at work has not only remained in our bottom 5 ranked findings but has also increased by 3%. This places us at 6% above the national average and in the worst 20% of acute trusts. When looking into this further by protected characteristics, the results show that staff from a black and minority ethnic group or disabled staff are more likely to experience discrimination at work (8% and 12% respectively) compared to their white or not disabled colleagues. Analysis of the questions which relate to this Key Finding show that ethnicity was the biggest reason given for discrimination experienced and that discrimination was higher from managers/colleagues (11%) than from the public/service users (9%) Suggested action: This survey shows a worsening picture and a clear need for further action. Discrimination falls within the remit of the Equality, Diversity and Inclusion Committee who direct the action plan in response to the WRES data. This action plan should be progressed at pace. 67

68 The Hillingdon Hospitals NHS Foundation Trust Staff believing that the organisation provides equal opportunities for career progression or promotion (KF21) This Key Finding has remained in our bottom 5 ranked findings and is the second finding under the equality and diversity theme. This means that both the equality and diversity findings have been in the bottom 5 ranked findings for the past two years and in the worst performing 20% of acute trusts. When looking at the breakdown by ethnicity, there is a 10% difference in the number of white staff (87%) who believe the Trust provides equal opportunities for career progression or promotion compared to BME (78%). This indicates a levelling between the two groups through a slight decrease for white staff (3%) but a 4% increase for BAME staff. This indicates that some of the BAMEfocused actions from the WRES action plan, such as mentoring for BAME staff, may be having some impact but there has been a negative change in perception from white staff. Suggested action: As with KF20, these actions will align to the EDI Committee s WRES action plan and again, should be progressed at pace. Part of this action will be to develop a development centre for BAME staff within the organisation. Staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months (KF25) The final new finding in the bottom five for 2016 is the amount of staff experiencing harassment, bullying or abuse from patients/public in the last 12 months. This has increased by 1% and indicates that the Trust is now 3% above national average. Further detail shows that 5% of the responding staff experienced bullying/harassment/ abuse from the public more than six times in the past year, an increase of 2% on last year. Suggested action: It is recommended that these results should be reported to the EDI Committee for investigation and action. Staff reporting errors, near misses or incidents witnessed in the last month (KF29) Staff reporting errors has declined by 2% since 2015 and has placed the finding in the bottom 5 ranked scores. Although not a statistically significant change for the Trust, it has placed the Trust in the worst performing 20% of acute trusts for this Key Finding. Suggested action: It is recommended that the result is reported to the Quality and Safety committee for investigation and to take forward any appropriate action. 68

69 Annual Report and Accounts 2016/17 Fairness and effectiveness of procedures for reporting errors, near misses and incidents (KF30) Although this Key Finding is now within the Trust s bottom 5 ranked findings, there has been only a minimal decrease since 2015 (0.01). This result is below average (0.04) but not in the worst 20% of acute trusts. Consultancy The Trust expenditure on consultancy services was 105k. This was for a range of activities including recruitment searches, advice and benchmarking. Off payroll engagements See appendix B. Suggested action: It is recommended that the result is reported to the Quality and Safety committee for investigation and to take forward any appropriate action. Exit packages The Trust did not use or issues any exit packages within this year. Further analysis at a Directorate and Staff Groups level will be undertaken in partnership with divisional leads and the People & Development team. Working collaboratively with People & Development and other support services as needed, divisional leads will be asked to develop action plans to improve areas of concern and promote ownership of these within their teams. Staff Engagement Our Staff Engagement score has remained steady from 2015 and continues to exceed the average: despite the additional pressures we were under in 2016 and the increased response rate, we continue to promote and build on the two new recognition schemes introduced at the Trust this year (Pay It Forward and CARES monthly). Reporting of high paid off-payroll arrangements As per the Trust s Standing Financial Instructions, off-payroll or non-standard contract employment arrangements are only be considered by exception and where there is no practical alternative to the Trust employing directly. Before any off-payroll engagements are agreed with an individual, a tax status questionnaire must be completed and sent to the Director of People before any engagement is finalised. It is the responsibility of the Director of People to approve all off-payroll engagements or non-standard contract employment arrangements prior to commencement. In addition there is further work in place to look at why staff feel valued as part of the employer of choice branding project. This overall strategy aims to improve levels of staff engagement, reduce vacancy and turnover rates and improve our time to hire. In line with Our the Staff policies governing Engagement recruitment, selection, disability score has remained steady and the Guaranteed Interview Scheme, disabled candidates for any from 2015 and continues to selection process, who meet the exceed the average. essential criteria, will be shortlisted for interview. 69

70 The Hillingdon Hospitals NHS Foundation Trust Appendix A Workforce Breakdown by Staff Group and Gender Staff Group split by Gender Staff Group Female Male Total Students % 0.00% % Healthcare Scientists 94.44% 5.56% % Nursing and Midwifery Registered 90.74% 9.26% % Additional Clinical Services 87.82% 12.18% % Allied Health Professionals 81.28% 18.72% % Administrative and Clerical 78.90% 21.10% % Add Prof Scientific and Technic 73.68% 26.32% % Medical and Dental 53.98% 46.02% % Estates and Ancillary 53.04% 46.96% % Gender split by Staff Group Staff Group Female Male Nursing and Midwifery Registered 33.70% 11.82% Administrative and Clerical 22.01% 20.24% Additional Clinical Services 17.38% 8.29% Medical and Dental 9.64% 28.26% Estates and Ancillary 7.59% 23.10% Allied Health Professionals 6.01% 4.76% Add Prof Scientific and Technic 2.77% 3.40% Healthcare Scientists 0.67% 0.14% Students 0.24% 0.00% Total % % 70

71 Annual Report and Accounts 2016/17 Appendix B Off Payroll Arrangements Table 4B: For all off-payroll engagements as of 31 Mar 2017, for more than 220 per day and that last for longer than six months 2016/17 Number of engagements Number Number of existing engagements as of 31 Mar Of which: Number that have existed for less than one year at the time of reporting 3 Number that have existed for between one and two years at the time of reporting Number that have existed for between two and three years at the time of reporting Number that have existed for between three and four years at the time of reporting Number that have existed for four or more years at the time of reporting 3 Confirmation: Please confirm that 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 4C: 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 reached six months in duration between 1 Apr 2016 and 31 Mar 2017 Number of the above which include contractual clauses giving the trust the right to request assurance in relation to income tax and national insurance obligations Yes 2016/17 Number of engagements Number 4 4 Number for whom assurance has been requested 0 Of which: Number for whom assurance has been received 0 Number for whom assurance has not been received * 0 Number that have been terminated as a result of assurance not being received Table 4D: For any off-payroll engagements of board members, and/or senior officials with significant financial responsibility, between 1 Apr 2016 and 31 Mar 2017 Number of off-payroll engagements of Board members and/or, senior officials with significant financial responsibility during the financial year. Number of individuals that have been deemed "Board members and/or senior officials with significant financial responsibility". This figure should include both off-payroll and on-payroll engagements /17 Number of engagements Number

72 The Hillingdon Hospitals NHS Foundation Trust 2.4 Compliance with NHS Foundation Trust Code of Governance The Hillingdon Hospitals NHS Foundation Trust has applied the principles of the NHS Foundation Trust Code of Governance on a comply or explain basis. The NHS Foundation Trust Code of Governance, most recently revised in July 2014 is based on the principles of the UK Corporate Governance Code issued in Following review, the Board confirms it is compliant with the Code. 72

73 Annual Report and Accounts 2016/ Single oversight framework NHS Improvement s Single Oversight Framework provides the framework for overseeing providers and identifying potential support needs. The framework looks at five themes: Quality of care Finance and use of resources Operational performance Strategic change Leadership and improvement capability (well-led). Based on information from these themes, providers are segmented from 1 to 4, where 4 reflects providers receiving the most support, and 1 reflects providers with maximum autonomy. A Foundation Trust will only be in segments 3 or 4 where it has been found to be in breach or suspected breach of its licence. The Trust is currently in segment 2. This segmentation information is the Trust s position as at May Current segmentation information for NHS Trusts and Foundation Trusts is published on the NHS Improvement website. The Single Oversight Framework applied from Quarter 3 of 2016/17. Prior to this, Monitor s Risk Assessment Framework (RAF) was in place. Information for the prior year and first two quarters relating to the RAF has not been presented as the basis of accountability was different. This is in line with NHS Improvement s guidance for annual reports. Finance and use of resources The finance and use of resources theme is based on the scoring of five measures from 1 to 4, where 1 reflects the strongest performance. These scores are then weighted to give an overall score. Given that finance and use of resources is only one of the five themes feeding into the Single Oversight Framework, the segmentation of the Trust disclosed above might not be the same as the overall finance score here. Due to the deteriorating underlying financial position of the Trust, NHS Improvement undertook an investigation into the Trust s finances. Following this review the Trust asked NHSI for support and was accepted on to their national Financial Improvement Programme (FIP). NHSI did not require the Trust to formally respond to the findings of their investigation, but asked that the recommendations were reflected in the FIP. Area Metric 2016/17 Q3 score 2016/17 Q4 score Financial sustainability Capital service capacity 2 2 Liquidity 4 4 Financial efficiency I&E margin 1 1 Governance rating Distance from financial plan 1 1 Agency spend 2 3 Overall scoring

74 The Hillingdon Hospitals NHS Foundation Trust 2.6 Statement of the Chief Executive s responsibilities as the Accounting Officer of The Hillingdon Hospitals NHS Foundation Trust The NHS Act 2006 states that the Chief Executive is the accounting officer of the NHS Foundation Trust. The relevant responsibilities of the Accounting Officer, including their responsibility for the propriety and regularity of public finances for which they are answerable, and for the keeping of proper accounts, are set out in the NHS Foundation Trust Accounting Officer Memorandum issued by NHS Improvement. NHS Improvement, in exercise of the powers conferred on Monitor by the NHS Act 2006, has given Accounts Directions which require The Hillingdon Hospitals 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 [name] NHS foundation trust and of its income and expenditure, total recognised gains and losses and cash flows for the financial year. In preparing the accounts, the Accounting Officer is required to comply with the requirements of the 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 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 financial statements ensure that the use of public funds complies with the relevant legislation, delegated authorities and guidance prepare the financial statements on a going concern basis. The Accounting Officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the NHS Foundation Trust and to enable him/her to ensure that the accounts comply with requirements outlined in the above mentioned Act. The Accounting Officer is also responsible for safeguarding the assets of the NHS Foundation Trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities. To the best of my knowledge and belief, I have properly discharged the responsibilities set out in the NHS Foundation Trust Accounting Officer Memorandum. Shane DeGaris Chief Executive The Hillingdon Hospitals NHS Foundation Trust 30th May

75 Annual Report and Accounts 2016/ Annual Governance Statement Scope of responsibility As Accounting Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the NHS Foundation Trust s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the NHS Foundation Trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum. The purpose of the system of internal control The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of The Hillingdon Hospitals NHS Foundation Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place in The Hillingdon Hospitals NHS Foundation Trust for the year ended 31 March 2017 and up to the date of approval of the annual report and accounts. Capacity to handle risk The Board is responsible for reviewing the effectiveness of the system of internal control including systems and resources for managing all types of risk. The Trust Board approved Risk Management Strategy and Policy (including Board Assurance Framework) ensures that the Trust approaches the control of risk in a strategic and organised manner. It sets out the responsibilities of Executive Directors and Senior Managers in relation to their leadership in risk management and makes it clear that all employees have a role to play in risk management appropriate to their level. The Board has established a committee structure to provide assurance on, and challenge to, the Trust s risk management process. Each of these committees are chaired by a Non-Executive Director to enhance this challenge, and the Chairs report formally to the Board to escalate issues that require further Board discussion. The main Board committee for risk management is the Audit & Risk Committee (ARC). The ARC provides assurance that there is a sound system of internal control and governance, and ensures that risks to the delivery of the Trust s services are identified and addressed. Corporate risks are reported to the Board/ARC via the Trust Management Executive. Local risks are reported and escalated to the corporate risk register via Divisional Governance Boards and Trust Committees such as the Patient Safety Committee, Health and Safety Committee, Information Governance Steering Group etc., as outlined in the Trust s Risk Management Strategy and Policy. The Board has established a committee structure to provide assurance on, and challenge to, the Trust s risk management process. 75

76 The Hillingdon Hospitals NHS Foundation Trust The structure of each divisional team is designed to provide the most coherent possible leadership. Clinical oversight is provided by a triumvirate, which comprises a Divisional Director, an Assistant Director of Operations and an Assistant Director of Nursing. This divisional team is supported by operational management, business development, nursing, financial management and HR. The Divisional Directors, (who are Medical Consultants) are accountable to the Chief Operating Officer and responsible for the safe and efficient management of the clinical divisions within the Trust. Divisional Directors are professionally accountable to the Medical Director. The Director of Patient Experience and Nursing (DPEN) provides professional accountability and support to the Assistant Directors of Nursing. Risk management and awareness training is mandatory to all Trust employees and is included in the New Employees Week programme. The Trust s Corporate Governance and Health and Safety team deliver risk management training appropriate to all levels across the Trust including the Trust Board. Risk Control Framework Risk Management Strategy The Trust Board approved the Risk Management Strategy and Policy (including Board Assurance Framework) ensuring that the Trust approaches the control of risk in a strategic and organised manner. It sets out the responsibilities of Executive Directors and Senior Managers in relation to risk management and makes it clear that all employees have a role to play in risk management appropriate to their level. Risk management requires participation, commitment and collaboration from all staff. The process starts with the systematic identification of risks via structured risk assessments. Identified risks are documented on risk registers. These risks are analysed in order to determine their risk score using a risk scoring matrix and assigning a local or corporate management level dependant on their relative importance and mitigating actions required. A target risk score and target mitigation date is assigned to ensure that risks are controlled in a timely manner and to an acceptable level of risk. Risk control measures are identified and implemented via action plans to achieve the target level of risk. Local risks are managed by the area in which they are found whilst corporate level risks are managed at progressively higher levels within the organisation. Achieving control of the higher scoring risks is given priority over lower scoring risks. The Trust has a Board Assurance Framework (BAF) which seeks to provide reasonable assurance that management and the Board in its oversight role are made aware in a timely manner of the extent to which the Trust is managing the key risks to achieving its strategic objectives. The BAF provides information and assurance, cross references the corporate risk register, and highlights where the Board may need to intervene or make decisions. The BAF is reviewed quarterly by the ARC and Board. Quality Governance Arrangements There are key quality governance and leadership structures that support the Trust in ensuring that 76

77 Annual Report and Accounts 2016/17 the quality of care is being routinely monitored across all services; the governance arrangements to review and challenge performance and variation are as follows: There is monthly reporting to the Board via the integrated quality and performance report with exception narrative. At each Quality and Safety Committee (QSC) meeting a clinical division presents on clinical and quality governance issues, discusses areas of risk, reviews performance against key quality indicators and progress of work in relation to learning from clinical incidents and clinical audit. There is now a deep dive review at each QSC meeting on the key aims of the new Quality and Safety Improvement Strategy. Any external quality and safety intelligence is presented at the QSC on a bi-monthly basis, and a summary of performance against KPIs in the Annual Quality Report Look forward section are also reported with escalation to the Board where required. Clinical divisions review their quality data in relation to patient safety, patient experience and clinical effectiveness on a monthly basis at their divisional governance boards; divisional exception reports are received by the Patient Safety Committee (PSC) and any concerns on quality are escalated to the QSC. The Board has developed a structured process of reporting the investigation of Serious Incidents and the follow up of outcomes and action plans resulting from Serious Incidents (SIs). SIs have a named Executive/Divisional lead and Executiveled panel reports are presented to the Board. Root cause analysis is used and forms the basis of the report together with the creation of action plans which are monitored by divisional governance boards through to completion. There are regular visits to clinical departments by the DPEN, Chief Executive Officer and other Board members giving them the opportunity to talk to staff and patients about their experience. Clinical Fridays allow the corporate nursing team and divisional senior nurses, alongside the DPEN, to work with clinical staff on wards and in departments to experience the environment and delivery of care, engaging with staff and patients and their carers. Any issues or concerns are escalated accordingly to the Executive Team and Trust Board. There is a robust framework to ensure that all service changes have a Quality Impact Assessment (QIA) which is then reviewed by the Medical Director. Any schemes where there are quality concerns are reviewed at a multi-professional Clinical Assurance Panel (CAP), with the project leads presenting the scheme and the actions being taken to mitigate any associated risks to quality. Listening to Patients/Governors: it is important that there is a range of opportunities to support patients in providing feedback and raising their concerns. This is welcomed by the Trust as a learning organisation which is always striving for quality improvement. Patients can complete local patient experience surveys, including the Friends and Family Test, provide feedback via NHS Choices, in person directly to department managers and matrons or via the PALS/Complaints offices. There is opportunity for patients and members of the public to attend the Trust s People in Partnership (PiP) meetings, Council of Governors meetings and the Trust Board meetings. There are also specialty-based focus and support groups where patient feedback can be obtained. The Board receives patient stories as part of understanding the patient experience; this ensures that the voice of the patient and their families/ carers is heard first hand by Board members; stories are captured directly from patients via 1:1 interviews, complaints and PALS feedback. Quality of Performance Information The Trust s Data Quality Improvement Steering Group (DQISG) reports into the Audit and Risk Committee (ARC) on a quarterly basis to provide assurance on accuracy of information provided to the Board. In addition, the Elective Performance Meeting (EPM) reviews data quality risks on a monthly basis and reports to DQISG on progress and actions to address them. Through these groups risks are actively reviewed and addressed through the data quality framework that has been established. Care Quality Commission (CQC) Compliance The Trust continues with a rating of Requires 77

78 The Hillingdon Hospitals NHS Foundation Trust Improvement as judged by the CQC as a result of its comprehensive inspection in October In May 2015, the CQC re-inspected the Trust and noted the many improvements made from its previous visit. A requirement notice against regulation 12; safe care and treatment was, however, issued at this time; this will remain outstanding until further inspection takes place. It is focused, specifically, on infection and prevention and control. The Trust will continue to strengthen its governance arrangements and its compliance with the Health and Social Care Act regulations via its programme of internal peer review and mock inspection ensuring there is evidence of progress of improvement with the aim of achieving a minimum of a good rating in future inspections. The Trust s internal auditor, KPMG, has recently undertaken a review of the Trust s compliance against the CQC s Key Lines of Enquiry (KLOE), as part of the Trust s internal audit programme. The audit report acknowledges the overall quality improvements made by the Trust since its last inspection and outlines recommendations for further improvement to support compliance in some key areas of practice to support patient safety. The Trust s CQC action plan will be refreshed in line with the KPMG review recommendations and monitored by the Regulation and Compliance Committee with escalation to the Quality and Safety Committee. The Trust Board declared compliance against Monitor s Well-Led Framework in January 2017 and is committed to continuing compliance with the governance requirements outlined in this framework, and as part of its annual selfassessment on quality governance and the well-led domain in the CQC standards. Data Security The Trust s various security systems are monitored continuously and the applications are patched regularly to remove security vulnerabilities. At least once a year the Trust undertakes penetration testing of its systems to detect vulnerabilities that may have been unwittingly introduced and these are rectified to ensure the systems are not at undue risk of cyber-attack. Incidents are reported and monitored at the Information Governance Steering Group, which meets a minimum of four times a year and is chaired by the Trust s Senior Information Risk Owner. Relevant incidents are also reported via the Information Governance Incident Reporting Tool. At least once a year the In line with Trust undertakes penetration the policies governing testing recruitment, of selection, its systems disability to detect vulnerabilities and the Guaranteed that Interview may have Scheme, disabled candidates for any been unwittingly introduced and selection process, who meet the these are rectified to ensure the essential criteria, will be shortlisted are for not interview. at undue risk of systems cyber-attack. The risk to the security of the Trust s systems from computer viruses and malware is persistent and always changing. The Trust monitors new and emerging threats and introduces countermeasures in a timely manner. The organisation s major risks The Board oversees the management of all major risks, which are actively addressed by the Audit and Risk Committee. Key controls and assurances, and any identified gaps are continually reviewed and action plans developed and progressed accordingly. Outcomes are confirmed via this process and reported to the Board. During 2016/17 the Board ensured on-going assessment of in year and future risks and full reference to all major risks is contained within the quarterly Board Assurance Framework paper available via the Trusts public website. 78

79 Annual Report and Accounts 2016/17 The key financial and non-financial risks faced by The Hillingdon Hospitals NHS Foundation Trust moving forward into 2017/18 include: Failure to achieve 95% A&E target leading to breaching its Licence. Suboptimal staffing issues in relation to potential risk of inadequate nursing levels due to a combination of vacancies, national shortages and additional capacity being opened to meet surge in demand. Failure to remain within hospital acquired infection thresholds. Failure/delay in escalation of deteriorating patients. Lack of interventional radiology on call. Lack of commissioned service to deliver high dependency care for children. Failure to deliver high quality patient care as a result of inadequate staffing provision and in line with the 7-day workforce initiative. Failure to meet compliance with the expected standards set out by our regulators. Failure to achieve the financial plan. The scale of investment required to improve the Trust s fragile estate infrastructure exceeds the Trust s financial capacity. Failure to modernise and reconfigure the estate and facilities to meet the needs of our clinical services. Overall, the Trust will remain focused on the tension between quality, safety, financial efficiency, and risk to ensure that patient care remains uncompromised. The Trust will do this by having regular Board and Executive reviews of progress and delivery of agreed plans, and check that all schemes are quality impact assessed. Compliance and Validity of the NHS Foundation Trust condition 4 (FT Governance): Corporate Governance Statement The Trust has assessed compliance with the NHS Foundation Trust condition 4 (FT governance). Assurances to support the validity of the conditions are reviewed in detail bi-annually by the Executive team and the ARC (October 2016 and March 2017) and were agreed by the Board in May All statements were confirmed. The Trust believes that effective systems and processes are in place to maintain and monitor the following: The effectiveness of governance structures. The responsibilities of Directors and subcommittees. Reporting lines and accountabilities between the board, its sub-committees and the executive team. The submission of timely and accurate information to assess risks to compliance with the Trust s licence. The degree and rigour of oversight the board has over the Trust s performance. Equality, Diversity and Human Rights Control measures are in place to ensure that all the organisation s obligations under equality, diversity and human rights legislation are complied with. Equality impact analysis/assessments (EIA) are carried out as standard procedure for all Trust policies and new developments/service changes. An equality and diversity toolkit is available for staff on the Trust s intranet to support them with completing an EIA. The Trust has an Equality and Diversity Steering Group and an annual report is presented to the Trust Board. The Trust has published its statutory equality & diversity report providing assurance that the Trust is compliant with equality legislation. Engagement with Stakeholders The Trust works with its key public stakeholders to manage its risks. This is done through the following mechanisms: Engagement with the local External Services Scrutiny Committee. Engagement with the local Healthwatch. The Council of Governors is consulted on key issues and risks as part of the annual plan. Regular People in Partnership Forums enables the Trust to listen to the views and opinions of the communities we serve, share information about what the Trust is doing, and planned future developments, and provides an opportunity for members to meet and communicate with staff, Governors and fellow members. Annual Members Meeting. Engagement with user and support groups e.g. 79

80 The Hillingdon Hospitals NHS Foundation Trust Fighting Infection Together, Maternity Services Liaison Committee, People Improving Cancer Services, Lay Strategic Forum and the Patient-led Assessment of the Care Environment (PLACE). Inviting public members and local stakeholders to identify priorities for our Quality Report. In addition the Trust has established a Lay Strategic Forum made up of patients and carers who use our services providing them with an opportunity to improve the health and wellbeing of the local population, the quality and safety of care and the efficiency and productivity of Trust services. Representatives from this group have joined committees and other groups providing a public viewpoint to discussions. The Trust has continued to engage with patients and the public on the patient safety and quality agenda and required improvements as part of its Quality and Safety Improvement Strategy. This work continues with the recruitment of patients to our Patient Safety Champion network. Incident Reporting There are structured processes in place for incident reporting, the investigation of Serious Incidents and following up outcomes from Board commissioned external reports. The Trust Board, through the Risk Management Strategy & Policy (including BAF) and the Incident Policy (including Serious Incident (SI)), promotes open and honest reporting of incidents, risks and hazards. The Trust has a positive culture of reporting incidents enhanced by accessible online reporting systems available across the Trust. The latest available National Reporting Learning System (NRLS) report (covering 1st April th September 2016) has shown the Trust to be in the middle 50th percentile for incident reporting. 80

81 Annual Report and Accounts 2016/17 Registration with the Care Quality Commission (CQC) The Trust is fully registered with the CQC. The Trust has been issued with its certificate for 2016/17. Pension Scheme As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employer s contributions and payments into the Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations. Assessing our Impact on the Environment The Hillingdon Hospitals NHS Foundation Trust has undertaken risk assessments and Carbon Reduction Delivery Plans are in place in accordance with emergency preparedness and civil contingency requirements, as based on UKCIP 2009 weather projects, to ensure that this organisation s obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with. The Trust is fully registered with the CQC. The Trust has been issued with its certificate for 2016/17. The Trust recognises the need to operate as a financially and socially responsible organisation, minimising its impact on the environment in order to deliver the highest quality healthcare to the communities we serve, now and in future. Extensive audits have been carried out on both sites to identify opportunities to reduce energy consumption and associated carbon emissions. Water surveys were also conducted on both sites to understand usage profiles and patterns better and to pinpoint areas where consumption can be optimised. Waste minimisation efforts have been focused on reducing reliability on plastic based packaging and replacing with either cardboard based or bio degradable alternatives. All takeaway food in the Trust restaurants is now served in compostable packaging. The Trust s procurement contracts now require suppliers to demonstrate that they minimise any impact on the environment with the products and services they provide. Review of economy, efficiency and effectiveness of the use of resources Despite reporting a surplus for 2016/17, the recurrent underlying position of the Trust is a deficit. This trajectory is forecast to continue through 2017/18. This underlying deficit was articulated in the North West London Shaping a Healthier Future strategy. It showed how the Trust would not return to financial balance until this strategy had been fully implemented and the consequent efficiency benefits realised. Since that strategy was agreed, the Trust has seen growth in activity significantly in excess of the levels planned for by commissioners. This has increased the Trust s costs in excess of the funding provided and thereby increased the deficit. The board of directors are clear about the financial challenges in the local health economy and recognise that a system wide approach will be required alongside the measures being taken by the Trust. Whilst the Trust has a range of measures in place to obtain value for money, it has not been able to set a balanced budget. Consequently, the Trust is not securing the overall economy, efficiency and effectiveness of the available resources. As a result, the trust is taking the following steps to rectify the position: 81

82 The Hillingdon Hospitals NHS Foundation Trust Working with partners to secure additional funding in 2017/18. Participating in the NHS Improvement Financial Improvement Programme to increase the delivery of savings in 2017/18 and 2018/19. Discussing with NHS Improvement changes to the Trust s Control Total and access to Sustainability and Transformation Funding. Working with partners to establish an Accountable Care Partnership across Hillingdon to provide more effective care for the over 65s. Working across the North West London Sustainability and Transformation Plan footprint on sector wide productivity opportunities. Whilst the Trust is not currently living within the resources available, it still has key processes in place to ensure that resources are used economically, efficiently and effectively as follows: Scheme of Delegation and Reservation of Powers approved by the Board sets out the decisions, authorities and duties delegated to officers of the Trust. Standing Financial Instructions detail the financial responsibilities, policies and procedures adopted by the Trust. They are designed to ensure that an organisation s financial transactions are carried out in accordance with the law and Government policy in order to achieve probity, accuracy, economy, efficiency and effectiveness. Robust competitive processes are used for procuring non-staff expenditure items. Above 25k, procurement involves competitive tendering. All procurement tendering activities are published within nominated publications and in line with Public Contracts Regulations Saving schemes are assessed for their impact on quality with local clinical ownership and accountability. Use of National and London benchmarking for non-clinical support functions. Use of Lord Carter review and Model Hospital Information for Clinical specialties and support services. The Trust Board has gained assurance from the ARC that financial and budgetary management is robust across the organisation. The ARC also receives quarterly reports regarding losses, special payments and compensations (with high value over 50K approved by the Board), write-off of bad debts and contingent liabilities. The value of losses and special payments has remained at an immaterial level (0.12% of Trust turnover in 2016/17).The Trust has a Transformation Committee that meets quarterly to review the Trust s transformation programme and major strategic service change business cases. This includes the use of information technology to lever change. Value for money discussions take place at a management group chaired by the Chief Operating Officer where the discussion is based on service line reporting reviewing how much a service costs to run versus the income it generates and how it is performing both clinically and operationally. There are a range of internal and external audits that provide further assurance on the quality of financial data, economy, efficiency and effectiveness; these include internal audit reports on financial controls, cost improvement programmes, and business cases. These are all reported to ARC. In February 2017 NHSI conducted an investigation in to the financial position of the Trust in response to the underlying financial deficit. The findings of this review raised concerns about the Trusts governance of the QIPP process as well as the Trusts financial position more generally. The Board have noted the concerns, are making changes where relevant and a financial recovery plan is being developed to reflect the impact of these changes. Compliance with the Code of Governance The Board has reviewed itself against the NHS Foundation Code of Governance. The Board has made the disclosures required by the Code in the governance section of the Directors Report, including explanations for non-compliance with provisions of the Code. Attendance records and coverage of work for each Board committee is also included in this section of the annual report. Going Concern In concluding the annual accounts for 2016/17, the Board of Directors is required to formally consider whether it regards the Trust as a going concern. The directors have considered the 82

83 Annual Report and Accounts 2016/17 application of the going concern concept based upon the continuation of service provide by the Trust. NHS Improvement (NHSI), the sector regulator for health services in England, states that anticipated continuation of the provision of a service in the future is sufficient evidence of going concern, on the assumption that upon the dissolution of a foundation trust the service will continue to be provided. The directors consider that there will be no material closure of NHS services currently run by the Trust in the next business period (considered to be 12 months) following the publication of this report and accounts. For this reason the directors continue to adopt the going concern basis in preparing the accounts. Given the deteriorating financial context within the Trust and the wider NHS, the directors have also given serious consideration to the financial sustainability of the Trust as an entity in relation to the Trust s available resources and note that: Despite reporting a surplus for 2016/17, the recurrent underlying position of the Trust is a deficit. The Operational Plan for 2017/18 & 2018/19, approved in December 2016, show the Trust delivering deficits of 15.3m in each year. As a consequence, the Trust is deemed to be in distress and will receive interim cash support from the Department of Health up to the value of the revenue deficit. The deficit and requirement for support is consistent with the Trust s original planning trajectory agreed with commissioners. The support was planned to continue until such time as the efficiency benefits are realised from the North West London Shaping a Healthier Future (SaHF) strategy. The Trust recognises the need to reduce its deficit ahead of the full implementation of SaHF. As a consequence, it is working with partners to increase funding in 2017/18 whilst also participating in a Financial Improvement Programme to reduce the cost base. At the time of writing, the Trust has proposed a plan to the regulator that shows a reduced deficit in 2017/18 of 8.8m. Should the Trust receive the full Sustainability and Transformation Funding in 2017/18, the deficit would reduce further to 2.9m. The Trust have an agreed financial plan for 2017/18 and 2018/19 and signed contracts from commissioners. The Trust has significant risk mitigation against unplanned activity pressures that materially impacted the 2016/17 financial position. Unlike in 2016/17 where the Trust had financial liability for delivery of commissioner savings, in 2017/18 and 2018/19 the commissioner bears the financial risk. Should activity exceed plan, the Trust will be reimbursed at 70% of the relevant tariff (or 100% of tariff where activity levels are below 2016/17 outturn). The Trust has had consistent and ongoing dialogue with, and reporting to, the regulator in relation to the need for Interim Support from 2017/18. The Trust Board is implementing the findings of the latest review conducted by the regulator. This includes strengthening the Trust s approach to financial grip and control ; clarifying the roles and responsibilities of the Programme Management Office, and establishing clear executive level responsibility for each key financial savings workstream. At the suggestion of the regulator, the Trust is participating in their national Financial Improvement Programme. Interim cash support will be made available to the level of the Trust s revenue deficit, albeit, the actual cash required must be applied for, and approved by the Department of Health (DH), on a monthly basis. The directors acknowledge that, given the mechanism the DH is using for agreeing cash support on a month by month basis, this creates a material uncertainty that may cast significant doubt on the Trust s ability to continue as a going concern and, that it may be unable to realise its assets and discharge its liabilities in the normal course of business. There is currently no indication from the regulator or the DH that the support will not be provided. Furthermore, the regulator has not placed particular conditions on the Trust or required further action not already included within the Financial Improvement Programme. The directors 83

84 The Hillingdon Hospitals NHS Foundation Trust continue to work with partners across Hillingdon and the wider North West London Sustainability & Transformation Plan footprint, to develop and implement a strategy consistent with the resources available. member had not adhered to Trust policies and procedures to safeguard information and advised the Trust to add an explicit paragraph on working in the community to the Code of Conduct for Employees regarding Confidentiality Policy. Information Governance The Trust had one information governance incident categorised at level 2 in 2016/17, which was investigated by the Information Commissioners Office (Case Reference Number COM ). A Trust encrypted laptop and diary containing personal data belonging to patients (name, address and blood result required to undertake community visits) was left locked overnight in a vehicle belonging to a member of staff. The vehicle was subsequently stolen and the personal data contained within the vehicle was not located. This incident was reported to the Police and via the Information Governance Toolkit to the ICO. A formal investigation was undertaken by the Trust and the data subjects informed of this data breach. The ICO reviewed the information provided by the Trust and concluded that the staff Annual Quality Report The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended) to prepare Quality Accounts for each financial year. NHS Improvement (in exercise of the powers conferred on Monitor) has issued guidance to NHS foundation trust boards on the form and content of annual Quality Reports which incorporate the above legal requirements in the NHS Foundation Trust Annual Reporting Manual. In 2016/17 the Trust launched a new Quality and Safety Improvement Strategy ( ). The strategy provides a structure for high quality clinical governance, to ensure on-going improvement in the quality and safety of patient care and supports our purpose To provide high 84

85 Annual Report and Accounts 2016/17 quality, safe and compassionate care, enhancing the health and wellbeing of the people that we serve. It defines our aims and is informed by the Trust Quality and Safety Committee s own review of effectiveness, national and local priorities and CQC recommendations. It sets out how we create a culture of continuous improvement to increase and sustain the quality of our services for our patients, people and stakeholders. It also takes into account lessons learnt from within the Trust and from others, emerging best practice and national quality improvement initiatives, in particular The Health Foundation guidance on measuring and monitoring safety and work being taken forward by Imperial College Health Partners on patient safety and quality improvement, regulatory and other inspections, as well as the national and local priorities. The 2016/17 Quality Report provides evidence of progress and priorities for improvement and is aligned with our quality and safety improvement strategy objectives and our overall Trust Strategy. As part of its consultation on priorities for improvement for the Annual Quality Report the Trust has liaised with clinical and managerial staff via divisional governance board meetings and divisional review meetings. Key stakeholders, such as our FT membership, our Governors, our local Healthwatch and local organisations from the third sector have been engaged via a stakeholder event to discuss current year s progress and priorities for the forthcoming year. The Information Team has also undertaken a triangulation exercise examining data sources that they regularly analyse for potential underlying issues of quality related to The directors continue to work with partners across Hillingdon and the wider North West London Sustainability & Transformation Plan footprint, to develop and implement a strategy consistent with the resources available. performance or data, not otherwise identified. All of the above has assisted the Trust be clear on its targets. Determining SMART objectives against our priorities is underway. The Trust uses its systems for quality performance management to assess its performance in relation to regional and national comparators for the key quality indicators and associated narrative in the Quality Report. Information on quality is supplied to the Board, its committees and the management team by the Information and the Clinical Governance teams who collect and maintain an oversight of quality information. Alongside key quality indicators as part of the integrated quality and performance report, information is also included on clinical audit, clinical incidents, SIs and the learning from them, complaints and claims. This flow of information ensures that key risks to quality are identified. The Trust s external auditors are required to undertake testing on several aspects of the Quality Report and this will be included as a limited assurance report in the Trust s annual report. This work includes reviewing the content of the Quality Report against the requirements of NHS Improvement s guidance, reviewing the content of the Quality Report for consistency with other sources of information and having the external audit undertake testing on several indicators in the Quality Report. The Trust continues to have a comprehensive clinical audit work plan covering both national and local audit priorities; this plan has final agreement at the Quality and Safety Committee (QSC). The Clinical Audit and Effectiveness Committee is the working group to drive audit work across the Trust, chaired by a Consultant Anesthetist. Regular updates on clinical audit are reported to the Regulation and Compliance Committee with exception reporting to the QSC. Progress against national and local audits and actions being taken are detailed in the Quality Report to ensure transparency on our performance against these. A quarterly meeting with our local Healthwatch has supported discussion on the progress of our quality priorities and key quality indicators alongside hearing feedback form service users who access our services and who interact with 85

86 The Hillingdon Hospitals NHS Foundation Trust Healthwatch. This assists in informing our quality improvement work. A framework exists for the management and accountability of quality of performance data and data quality. This is supported by a comprehensive audit programme, the Data Quality Policy, and an overarching data quality group chaired monthly by the Director of Operations. This group reports to an Executive Director-led data quality steering group which sends a quarterly report to the ARC. These quarterly data quality and performance quality reports cover the Monitor compliance data, reported to the Board, and other key data sets used at key committees. This, together with the data audit results, and the use of Data Quality Badges which are included in each monthly performance report, provides assurance to the Board on data quality and data performance issues and strength of internal control. The integrated performance report gives indications over quality metrics, early warning and trends to enable swift intervention to keep performance on track. The quality of elective waiting time data in particular will continue to be reviewed monthly at the elective performance meeting, ensuring all elective lists are managed and assessed on electronic systems. Areas that have been identified this year where further actions are being implemented include: 1) NHS Number coverage on clinical systems. 2) Trust Board Indicator assurance regular review and local auditing. Review of effectiveness As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, clinical audit and the executive managers and clinical leads within the NHS foundation trust who have responsibility for the development and maintenance of the internal control framework. I have drawn on the content of the quality report attached to this Annual report and other performance information available to me. My review is also informed by comments made by the external auditors in their management letter and other reports. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the board, the Audit and Risk Committee, the Quality and Safety Committee and a plan to address weaknesses and ensure continuous improvement of the system is in place. The Trusts Board Assurance Framework itself provides me with evidence that the effectiveness of controls that manage the risks to the organisation achieving its principal objectives have been reviewed. Internal Audit provides me with an opinion about the effectiveness of the assurance framework and the internal controls reviewed as part of the internal audit plan. Work undertaken by internal audit is reviewed by the Audit and Risk Committee. The Board Assurance Framework and Corporate Risk Register is presented to the Audit and Risk Committee on a quarterly basis and all significant risks are presented to the Board quarterly. This provides me and the Board with evidence of the effectiveness of controls in place to manage risks to achieve principal objectives. The Council of Governors plays an integral part in the governance structure within the Trust, ensuring through regular interaction with the Board of Directors, the interests of the Trusts members, and the public, are at the fore when reviewing the risks to, and performance with respect to the principal objectives. The cost improvement plan is always a challenge, however the CAP and appropriate KPI s provide assurance that clinical quality should not be compromised. My review is also informed by External Audit opinion, inspections carried out by the Care Quality Commission and other external inspections, accreditations and reviews. The processes outlined below are well established and ensure the effectiveness of the systems of internal control through: Audit and Risk Committee review of the Board Assurance Framework and Corporate Risk Register. Audit and Risk Committee scrutiny of controls in place. Board oversight of all significant risks. Review of serious incidents and learning at the Quality and Safety Committee and Board. Review of progress in meeting the Care Quality 86

87 Annual Report and Accounts 2016/17 Commissions Fundamental Standards by the Regulation and Compliance Committee. Internal audits of effectiveness of systems of internal control. On balance, I therefore conclude that the Board has conducted a review of the effectiveness of the Trust s system on internal control and found them to be effective. I am satisfied that the measures that have been put in place following the CQC inspection findings addresses the issues raised with respect to regulatory compliance. Given the National and London position with regard to the A&E 4 hour target, if the current levels of high demand continue into 2017/18 this will remain a significant challenge for our Trust alongside the condition of the Trust estate, and the threshold for C. difficile, which has been set at 8 cases for 2017/18. The Trust also has a challenging savings target in 2017/18 of 4%, but this still leaves a deficit of 15.3m. The Trust Board continues to proactively drive forward agreed actions to ensure compliance with CQC regulations. I can also confirm that, having taken all appropriate steps to be aware of any relevant audit information that should be communicated, and to the best of my knowledge, there is no relevant audit information of which our external auditor, Deloitte LLP has not been made aware. Shane DeGaris Chief Executive The Hillingdon Hospitals NHS Foundation Trust 30th May 2017 Conclusion My review confirms that The Hillingdon Hospitals NHS Foundation Trust has a generally sound system of internal control that supports the achievement of its policies, aims and objectives. The Board has extensive and effective governance assurance systems in place. These systems enable identification and control of risks reported through the Board Assurance framework and Corporate Risk Register. Internal and external reviews, audits and inspections provide sufficient evidence to state that no significant internal control issues have been identified during 2016/17 and that these control systems are fit for purpose. A requirement notice against regulation 12; safe care and treatment, specifically focused on infection and prevention was applied to our Trust in 2015 and this will remain until further inspection takes place. 87

88 The Hillingdon Hospitals NHS Foundation Trust 3 Quality Report 2016/17 To provide high quality, safe and compassionate care, improving the health and wellbeing of the people that we serve 88

89 Table Of Contents About the Trust s Quality Report Executive summary Part 1: Statement from the Chief Executive Part 2: Priorities for improvement and statements of assurance from the Board 2.1 Review of Quality Priorities for Improvement Key Quality Achievements for 2016/17 Quality priorities for improvement 2016/17 How did we do? Quality priorities for improvement in 2017/ Formal Statements of assurance from the Board Information for our regulators Provision of NHS Services Participation in clinical audit Commitment to research as a driver for improving the quality of care and patient experience Lessons Learned from the Investigation of Serious Incidents Duty of Candour Commissioning for Quality and Innovation (CQUIN) targets Care Quality Commission (CQC) registration Data quality Information Governance Toolkit Clinical coding error rate Action taken to improve data quality 2.3 Performance against Core Quality Indicators 2016/17 Part 3: Other key quality improvements we have made in 2016/17 Annex 1: Statements from our stakeholders Statement from External Services Scrutiny Committee Statement from Hillingdon Clinical Commissioning Group (CCG) Statement from our local Healthwatch The Hillingdon Hospitals NHS Foundation Trust s response to its key stakeholders Independent Auditor s Report Annex 2: Statement of Directors responsibilities in respect of the Quality Report Glossary 89

90 The Hillingdon Hospitals NHS Foundation Trust About the Trust s Quality Report What is the Quality Report? The Quality Report is produced by NHS healthcare providers to inform the public about the quality of services they deliver. As a Trust we strive to achieve high quality care for our patients. The Quality Report provides an opportunity for us to demonstrate our commitment to quality improvement and show what progress we have made in 2016/17 against our quality priorities and national requirements. The Quality Report is a mandated document which is laid before Parliament before being made available on the NHS Choices website and our own website ( As well as a glossary being available at the back of the report, each abbreviation and term will initially be written in italics in the main body of the report to indicate that further explanation is available. What is included in the Quality Report? The Quality Report is a statutory document that contains specific, mandatory statements and sections. There are also three categories mandated by the Department of Health (DH) that give us a framework in which to focus our quality improvement programme. These are patient safety, patient experience and clinical effectiveness. The Trust undertook extensive consultation in developing this report to ensure that the quality improvement priorities reflect those of our patients, our staff, our partners and the local community. Part 2 of the report highlights the Trust s quality priorities and includes: the areas identified for improvement in 2016/17 how we performed against these improvement targets what this means for our patients. There is also a section in Part 2 on the quality priorities that have been identified for improvement projects in 2017/18. 90

91 Annual Report and Accounts 2016/17 Executive summary This Executive Summary provides a brief overview of the information in this year s report. The Quality Report provides a summary of performance during 2016/17 in relation to quality priorities and national requirements. Overall, the Trust has performed very well in 2016/17 across a wide range of quality indicators. Particular successes that are noted in the Report and demonstrate compliance with performance and quality targets include: Improving compliance for patients being assessed for risk of developing Venous Thromboembolism (VTE). The Trust is now performing better than the London and national average Patient mortality rates being in the as expected range. For the aggregate Hospital Standardised Mortality Ratio (HSMR); we are below national average, which is an improvement from the previous year Clostridium difficile (C. diff) infection rates remaining below the London and national average; this means patients are less likely to contract this infection in our hospitals. The Trust continuing to maintain good performance against the 18 week Referral to Treatment (RTT) standard and better than the London and national average Key cancer performance indicators being well maintained for the national waiting times standards, performing better than the London and national average Performing better than the England and London average for percentage of respondents recommending the service in the Friends and Family Test (FFT) An improved patient safety incident reporting rate which is better than the London average. This demonstrates an improved safety culture A reduction in emergency readmissions within 28 days compared to last year; reducing the number of avoidable readmissions improves the overall patient experience of care and releases hospital beds for new admissions Recruiting 50 staff safety champions as part of our Sign up to Safety Campaign. These staff members are now taking forward safety improvement projects in their clinical areas and are coming together as a support network to share and learn from each other 63% of our staff saying they would recommend the Trust as a place to work ; this is 2% higher than the average for acute Trusts, as part of the Annual NHS Staff Survey Achieving a score of 3.85 out of 5 for staff engagement as part of the NHS Staff Survey this is above the national average. Overall, we scored above average in 17 areas with 12 of these being in the top 20% of all acute Trusts in England. In addition, 2016/17 has been a notable year for our staff and teams receiving nominations and winning awards. For example, our nurses winning an Excellence in Education Award at the Health Education England North West London (HEENWL), Excellence in Education and Training Awards and the Trust s HomeSafe and IT Teams being shortlisted in two categories in the prestigious Health Service Journal Awards. Finally, one of our midwives was honoured with a top nursing award for her work in raising awareness of Female Genital Mutilation and working with victims, their partners and families. Despite these successes it has been a very challenging year in being able to achieve all of our access and quality targets. We have struggled with 91

92 The Hillingdon Hospitals NHS Foundation Trust our Accident and Emergency (A&E) Department performance with only 83.9% of patients being seen within the four-hour A&E target. This was due to high levels of patient activity exceeded by our physical capacity within A&E and the rest of the hospital. This has resulted in patients having to wait for a longer time in A&E and our having to reduce the amount of operations we were able to provide patients. Other areas of challenge have included the condition of the Trust estate and the impact this has on being able to deliver effective modern day healthcare services. The financial savings targets that the Trust has had to achieve in the past year and into 2017/18, alongside the reduction in social care funding, have impacted severely on the delivery of effective streamlined pathways for patients to minimise their time in hospital and to ensure they are receiving care in the right place at the right time. Disappointingly, the FFT response rate for A&E only achieved 8.7% compliance against a target of 20.0%; in relation to patient complaints, only 67.7% of complaints received were completed within the timescale agreed with the complainant. This performance is lower than achieved last year. Underlying reasons for this include staffing challenges due to sickness absence in the Complaints Management Unit and competing priorities within clinical divisions impacting on ability to respond to complaints in a timely manner. Areas of performance that require improvement in the forthcoming year are outlined in more detail in the main report. The information below provides high-level progress overview for our priority areas for 2016/17: Priority 1: Achieving National Early Warning Score (NEWS) compliance to support early escalation of the deteriorating patient NEWS is now an integral aspect of mandatory training and additional Deteriorating Patient study days are now being delivered by the Critical care Outreach Team. A pilot of seven day services on a Care of the Elderly ward, which included increased consultant presence and consultant board rounds of all patients seven days per week, demonstrated a halving of NEWS calls put out during the pilot period. Overall performance achieved for all indicators measured for NEWS policy compliance was 83%. Priority 2: Achieving improvement in relation to seven day working priorities All emergency admissions must be seen and have a thorough clinical assessment by a suitable consultant as soon as possible but at the latest within 14 hours from the time of admission to hospital. September 2016 survey data shows that the time taken to seek a first consultant review is 74% for weekday compliance and 63% for weekends. Breaches were within acute internal medicine, which fits with the admission pattern of the hospital. Hospital inpatients must have scheduled seven-day access to diagnostic services. A business case will be presented to Trust Management Executive in 2017/18 in order to provide weekend magnetic resonance imaging (MRI) and ultrasound slots; further consideration is taking place on positive impact on patient flow and reduction in length of stay. Once a clear pathway of care has been established, patients should be reviewed by a consultant at least once every 24 hours, seven days a week, unless it has been determined that this would not affect the patient s care pathway. The September 2016 audit showed that 99% of emergency admissions were reviewed daily during weekdays but only 74% at the weekend, both above the national average. 92

93 Annual Report and Accounts 2016/17 Priority 3: Delivering compassionate care and improving communication During 2016/17, complaints relating to communication and staff attitude reduced by 47% and 56% respectively compared to 2015/16. This is a dramatic improvement however there were changes in the Complaints Team that may have affected data recording. Staff were briefed about the Accessible Information Standard (AIS) and a bespoke AIS leaflet was published. The Trust website includes AIS information and an application form. AIS launched on 1 August Priority 4: Safer staffing improved recruitment and retention to ensure delivery of safe care International recruitment established as the most viable method of filling hard to fill medical and dental posts. Agencies have been commissioned to fill long term vacancies with overseas candidates. A&E recruited to full establishment in January 2017 and its nurse staffing is reviewed daily, and continues to be increased during times of high demand to ensure a safe environment for patients and staff. While the A&E paediatric area has fully recruited to establishment, recruitment challenges in the Acute Medical Unit (AMU) continue. Three pre-registration pharmacists have been successfully recruited to join the Trust in August We have set out our quality priorities for 2017/18 and we aim to achieve the following: 1. Improving the discharge process 2. Improvements to End of Life Care (EoLC) 3. Continuing to deliver the seven-day working priorities 4. Improving the care of patients with dementia The key indicators that we are aiming to achieve under these priorities are outlined in the main report. During 2016/17 the Trust implemented a revised Quality and Safety Improvement Strategy for 2016 to 2021 as informed by the Trust Quality and Safety Committee s own review of effectiveness and recommendations arising from the Trust s Care Quality Commission (CQC) inspection in October The strategy clearly articulates our ambitious aims across the domains of patient safety, clinical effectiveness and patient experience. Our quality improvement work has been informed by working with our partners, including our patients and collaboration with the Patient Safety Partnership as part of Imperial College Healthcare Partners Academic Health Science Network. Despite the significant operational challenges, mostly relating to increased emergency care volume and complexity of patients, there has been continued progress with the Sign up to Safety Campaign to strengthen patient safety in the NHS. In the latter part of 2016/17 the Trust committed to implementing the SAFER patient flow bundle as well as improving compliance with the Seven Day Service standards both of which include the importance of senior medical review supported by access to specialised diagnostic tests and interventions. We continue to work closely with our partners in community and primary care and the voluntary sector to deliver improvements in patient care through the whole systems integration model supporting new care models to ensure an improved quality of person-centred care. The mandated sections within this Quality Report include information on our participation in national audits and our research activity during 2016/17. In addition, information is provided on our registration as a healthcare provider with the CQC and the progress we have made in response to the findings of their inspection of October 2014 and their re-visit of May This Quality Report and the priorities for 2017/18 are presented as a result of consultation and engagement with Foundation Trust members, our Governors, patients and the public, our staff, our local Healthwatch and our Commissioners. 93

94 The Hillingdon Hospitals NHS Foundation Trust Part 1: Statement from the Chief Executive This Quality Report provides the Trust with an opportunity to demonstrate its commitment to delivering high quality care and outlines the improvements that have been made during 2016/17. At The Hillingdon Hospitals NHS Foundation Trust we are led by our dedication to delivering good clinical care and a high standard of patient experience. Thanks to the professionalism of our staff, volunteers and partners we are making great achievements in many areas. However, we are always aware that improvements can be made and continually look to adopt best practice and to learn and improve wherever we can. It has been a difficult year for NHS Trusts up and down the country and with high levels of demand in emergency and planned care. The Trust has struggled to meet some key performance and access targets. Nevertheless, the dedication of our staff has continued to drive through local quality improvements and ensure that our patients receive high quality and safe care, which are outlined in this report. Ensuring our patients receive a positive experience of care is important to our staff and for us as an organisation and we are pleased with our results in our local patient experience surveys and the positive feedback from a number of patients stating that they would recommend our services to a relative or friend. Likewise, the percentage of our staff who would recommend the Trust as a place to work is assuring although we continually strive to improve upon this figure. The Trust also made great investments last year in new and improved services. These have included: The Trust spent more than 4 million on improving and expanding children s services. This included a major refurbishment of children s A&E and building a brand new four-bed extension wing on Peter Pan Ward. Seven new Paediatric consultants were also appointed to provide additional 24/7 support for children Refurbishing and upgrading emergency care facilities. This included building a new extended Clinical Decision Unit, new A&E triage rooms and staff offices At a cost of 812k, developing a brand new outpatient pharmacy at Hillingdon Hospital means patients now get the medicines they need more quickly, reducing the need to visit their GP The Trust spent more than 300k on 400 stateof-the-art cots, cribs and electric beds as part of a hospital-wide bed replacement programme at both hospital sites. A new Quality and Safety Improvement Strategy also saw many improvements being made across areas of patient safety including Safety Huddles as part of clinical handovers, safety ward rounds and the appointment of Patient Safety Champions through our staff and patients. 94

95 Annual Report and Accounts 2016/17 Easing the carer and patient journey played a key role in the improvements made this year with the implementation of national initiatives such as John s Campaign. This enables carers to support their loved ones outside of visiting times in accordance with their wishes and can provide a significantly improved patient experience. The Trust also implemented the Accessible Information Standard which ensures that people can access information in different formats, where needed, such as large print, braille, easy read or accessing a British Sign Language interpreter. Our Sign up to Safety Campaign, now in its second year, has continued to grow stronger with significant achievements including an improvement in incident reporting on medication errors, raised awareness for our staff on malnutrition in hospital with ongoing education for our nutritional link nurses, and further measures to reduce inpatient falls and pressure ulcers. Substantial progress has also been made with the Shaping a Healthier Future programme and Whole Systems Integrated Care as we work closely with our partners in health and social care and key stakeholders to continue to deliver improvements in the services delivered across North West London and through Hillingdon Health and Care Partners that sees an even closer integration between health providers as well as the Third and Voluntary Sectors. This report details our progress with our quality improvement work and outlines our key priorities for the coming year. I am confident that our planned quality priorities can be achieved. I would particularly like to thank our staff who continuously work to improve the quality of the services we deliver to ensure that patient safety and the quality of care provided to our patients remains at the forefront of everything we do. There are a number of inherent limitations in the preparation of this Quality Report which may impact the reliability or accuracy of the data reported. These include: Data is derived from a large number of different systems and processes. Only some of these are subject to external assurance, or included in the internal audits programme of work each year Data is collected by a large number of teams across the Trust alongside their main responsibilities, which may lead to differences in how policies are applied or interpreted. In many cases, data reported reflects clinical judgement about individual cases, where another clinician might reasonably have classified a case differently National data definitions do not necessarily cover all circumstances, and local interpretations may differ Data collection practices and data definitions are evolving, which may lead to differences over time, both within and between years. The volume of data means that, where changes are made, it is usually not practical to reanalyse historic data The Trust s Board and management have sought to take all reasonable steps and exercise appropriate due diligence to ensure the accuracy of the data reported, but recognises that it is nonetheless subject to the inherent limitations noted above. Following these steps, to my knowledge, the information in the document is accurate, except for the matters detailed under the heading: Definitions of the two mandated indicators for substantive sample testing by the Trust s auditors in Part 2 of this Quality Report. Shane DeGaris Chief Executive The Hillingdon Hospitals NHS Foundation Trust 30th May

96 The Hillingdon Hospitals NHS Foundation Trust Part 2: Priorities for improvement and statements of assurance from the board 2.1 Review of Quality Priorities for Improvement In this part of the report we tell you about the quality of our services and how we have performed in the areas identified for improvement in 2016/17. These areas are called our quality priorities and they fall into the three areas of quality as mandated by the DH: patient safety, patient experience and clinical effectiveness; we are required to have a minimum of one priority in each area. Firstly, the information below provides an overview of some of our key quality achievements in 2016/17. These are important indicators for the public and our key stakeholders to provide assurance on the quality of care and services that are delivered at the Trust: Key Quality Achievements in 2016/17 Improving compliance for patients being assessed for risk of developing VTE from 94.6% (49,310 out of 52,118 admissions) between 1 April 2015 to 31 March 2016 to 96.2% (35,646 out of 37,027 admissions) between 1 April 2016 to 31 December 2016, performing better than the London and national average Patient mortality figures being as expected within the Summary Hospital-level Mortality Indicator (SHMI) band. Aggregate HSMR 94.5 below national average, improvement on 2014/15 (101.5) Key cancer performance indicators being well maintained for all the national waiting times standards and performing better than the London and national average Better than the England and London average for percentage of respondents recommending the service in the FFT An improved patient safety incident reporting rate (better than London average). This demonstrates an improved safety culture A reduction in emergency readmissions within 28 days of 7.0% (3,063 out of 43,766 emergency readmissions) for year to date 2016/17, compared with 7.6% (3,345 out of 44,115 emergency readmissions) during 2015/16. Reducing the number of avoidable readmissions improves the overall patient experience of care and releases hospital beds for new admissions Recruiting 50 staff safety champions as part of our Sign up to Safety Campaign. These staff members are now taking forward safety improvement projects in their clinical areas and are coming together as a support network to share and learn from each other 63% of our staff saying they would recommend the Trust as a place to work (1% higher than the average for acute Trusts) within the Trust s Annual NHS Staff Survey 96 C. diff infection rates remaining below the London and national average. This means patients are less likely to contract this infection in our hospitals The Trust continued to maintain its high 18 week RTT performance against this standard - better than London and national average Achieving a 3.85 out of 5 staff engagement score, within the annual NHS Staff Survey which was above the national average (3.81). Overall, we scored above average in 17 areas with 12 of these being in the top 20% of all acute Trusts in England.

97 Annual Report and Accounts 2016/17 LOOKING BACK Quality priorities for improvement 2016/17 How did we do? of the escalation and response process including when it is appropriate to make physiological parameter changes dependent on the patient s condition. Priority 1 Achieving NEWS compliance to support early escalation of the Deteriorating Patient We said: NEWS (National Early Warning Score) audits conducted during 2015/16 showed that staff were not fully compliant with our Trust NEWS policy in fully documenting the evidence of escalation and the review of the acutely unwell patient. It was agreed that we would improve patient safety in this area and that there needed to be increased training to ensure staff had a better understanding This requirement is set against a background of the Trust seeing more of the higher acuity (measurement of the intensity of nursing care required by a patient) patients and such patients not always being placed on the appropriate ward with regard to capacity and activity demands. As a consequence, staff may not have the right skills and knowledge to look after the patients special needs. This can result in patients acute needs not being identified at the earliest opportunity which may lead to deterioration in their condition. It is important for staff to report these cases to ensure the Trust learns from these types of patient safety incidents; the trust had seen such cases reported as Serious Incidents in the past year. How did we do? The specific goals that we set and the performance during 2016/17 are outlined below: Quality Priority indicators Review NEWS education programme re-visit what is taught, how it is taught and by whom. Explicit learning outcomes to be made transparent and ensure that evaluation of education reflects learning outcomes. Continue NEWS audits of NEWS charts and compliance with escalation policy via monthly 24 hour snapshot audits. Aim to achieve more than 90% in all audited criteria as a minimum. Reduction in number of patient safety incident forms completed of moderate severity or higher. 2016/17 performance NEWS is now an integral aspect of mandatory training and is incorporated into our Basic Life Support training. The Trust has also started to run non-mandatory monthly Deteriorating Patient Study days, which incorporate the NEWS process, escalation and trouble-shooting and from September 2016 until March 2017, approximately 50 nurses and six doctors have attended this. Feedback from the sessions has been positive and as result we are encouraging greater attendance from clinicians to encourage multi-disciplinary team learning. During 2016/17 nine monthly NEWS snapshot audits were conducted over 12 months. During 2017/18, we have allocated time each month for these audits to be undertaken consistently and shared accordingly. Overall performance achieved for all indicators measured for NEWS policy compliance was 83%. The results indicate there has been some improvement in the recording of the key requirements in line with Trust policy, such as calculation of NEWS scores (160 out of 180 sets of medical notes indicate a correct calculation was made) and medical review (154 out of 188 sets of medical notes indicate a review was undertaken) as part of the escalation response. However, ongoing education is still required to achieve more than 90% compliance in all areas that we test. In 2015/16, six patient safety incident forms were completed involving failure or delay in using the NEWS call or where NEWS was described in the incident description or immediate action sections. In 2016/17, this increased to 13. On the one hand, the information supplied via incident forms allows us to determine if care could have been improved where a patient s condition has deteriorated and what learning is required in order to improve. On the other hand, further work is required to embed NEWS and heighten staff awareness in this aspect of care via training and ongoing encouragement to report policy deviation and poor documentation of care delivered. 97

98 The Hillingdon Hospitals NHS Foundation Trust What does this mean for our patients? NEWS enables early recognition of patients on general adult wards and the within A&E who are at risk of clinically deteriorating and enables staff to escalate their concerns by contacting the team for a patient review in a time-measured way. Early recognition, early intervention, early decision making and early escalation of care to other healthcare professionals and other clinical teams may be identified before a serious adverse event occurs. This timely interpretation and escalation of recognised deterioration is of crucial importance in minimising the likelihood of serious and adverse events including cardiac arrest and death. The Trust regularly audits the various aspects of the process of NEWS and also patient outcome; in particular, we audit whether the patient was reviewed, whether the appropriate grade of doctor reviewed the patient and whether the patient s management was escalated. There are also senior clinical nurses who also respond to these NEWS calls and who can review patients, initiate treatment and escalate care, who work collaboratively with the healthcare team. The NEWS audits which are undertaken monthly are a snapshot of a twenty-four hour period. The results are variable and are fed back to each of the individual departments, with comments whereby positive practice is highlighted. However, deficits in our practice, when compared with the standards set, are also highlighted and sometimes there is often a narrative to help with the context. These results are variable and this is due to a variety of reasons. Out of hours, the medical staff ratio is reduced and whilst most patients are seen in a timely manner, they are not always seen by the appropriately graded doctor. There are regular examples whereby when patients trigger the NEWS, they are reviewed but there is not always a documented account within the notes of this review. Ongoing education of all staff remains a priority as well as understanding how we can address new ways in achieving the standards set. There is work currently being undertaken within the Trust to look at electronic monitoring systems which can enable some remote vigilance and observation of patients, as well as enabling medical and other healthcare professionals to clinically prioritise their caseloads. However, it is recognized that we need to continue to educate and empower our staff to improve and ensure a patient focused approach as well as to improve and ensure patient safety. Pertinently, when there are concerns about patient deterioration, and concerns with our service delivery and environment, we raise these concerns via our incident reporting system and actively try to understand what happened. This helps us to establish whether our systems and processes need to be reviewed or whether there is a requirement for further education for our staff. Priority 2 Achieving improvement in relation to seven day working priorities We said: NHS England committed to offering a much more patient-focused service moving towards routine NHS services being made available seven days a week. We agreed this as a priority because evidence shows that the limited availability of some hospital services at weekends can have a detrimental impact on outcomes for patients, including raising the risk of mortality. North West London (NWL) as a sector accepted the opportunity to be a national First Wave Delivery Site for the new seven day services programme. As part of this programme, all acute trusts agreed to achieve delivery of four prioritised Clinical Standards by April These four standards were selected with the Academy of Medical Royal Colleges as having the most impact on reducing weekend mortality. 98

99 Annual Report and Accounts 2016/17 How did we do? The specific goals that we set and the performance during 2016/17 are outlined below: Quality Priority indicators Standard 2: Time to First Consultant Review (All emergency admissions must be seen and have a thorough clinical assessment by a suitable consultant as soon as possible but at the latest within 14 hours from the time of admission to hospital) Standard 5: Access to Diagnostics (Acute trusts should use their clinical governance processes and discussions with their commissioners to judge which diagnostic tests their patients require access to seven days a week, and whether these are delivered on site or via a formal networked arrangement) Standard 6: Access to Consultant Directed Interventions (Patients should receive urgent interventions within a timeframe that does not reduce the quality of their care) Standard 8: Ongoing Review (Once a clear pathway of care has been established, patients should be reviewed by a consultant at least once every 24 hours, seven days a week, unless it has been determined that this would not affect the patient s care pathway) 2016/17 performance The survey data from September 2016 shows that most non-compliance with the 14 hour review standard was in acute medicine, which fits with the admission pattern of the hospital. Overall, this review took place in 74% of our patients during weekdays and 63% at weekends against a standard of 90%. The Trust is disappointed with performance against this important standard for high quality patient care. Although it is comparable to National data, we will be making it a priority for 2017/18 (See Looking Forward section for key actions) and to help drive improvement, we will also be reviewing our next set of results by specialty. Good progress was made against this standard, with the exception of routine weekend MRI / ultrasound. Whilst not essential to patient safety, weekend delays in ordering these tests increases decision making time and length of stay for some patients. A business case will be presented in 2017/18. Routine cardiac echo is currently not formally offered at the weekend. There is an informal arrangement that it may be available ad hoc, provided by the echo technicians. The Trust has agreed that the demand is insufficient to justify further investment; any urgent cases can still be referred elsewhere as at present. The Trust is compliant with this important standard. All pathways have been agreed in consultation with North West London Collaboration of Clinical Commissioning Groups. This Standard was also amended slightly during the year. There should be consultant-led board rounds on every acute in-patient ward every day, and that the consultant will clearly decide with the rest of the team which member of staff needs to review each patient that day. There are clear criteria for this review being a consultant, other doctor, senior nurse / nurse specialist, or therapist. In certain areas, such as the Acute Medical and Surgical Units and high dependency areas, which accommodate the highest risk patients, there is a default twice daily consultant review. The September 2016 audit showed that 99% of emergency admissions have the appropriate reviews daily during weekdays and 74% at the weekend, both above the national average. Acute patients requiring twice daily review were seen twice a day 95% of the time during the week, but a disappointing 13% of the time at the weekend, this last figure being below the national average. As with Standard 2, The Trust believes this is an important standard for safer patient care, and has made it a priority for 2017/18 (See Looking Forward section for key actions). 99

100 The Hillingdon Hospitals NHS Foundation Trust What does this mean for our patients? NHS Improvement (NHSI) is supporting all trusts to meet the four standards identified as being must do by This will ensure patients: do not wait longer than 14 hours to initial consultant review get access to diagnostic tests within an appropriate timeframe based on clinical need. For urgent requests, this should be within 12 hours and for critical patients, more rapidly get access to specialist, consultant-directed interventions with high-dependency care needs receive twicedaily specialist consultant review, and all those patients admitted to hospital in an emergency will experience daily consultant-directed ward rounds. Significant progress has been made at both Trust and Sector level to deliver these standards, but a number of gaps remain. Filling these gaps may come at a cost and there is very limited evidence that this investment will deliver reduced patient mortality, but more evidence that in some cases decision making and patient flow may be increased. Priority 3 Delivering compassionate care and improving communication We said: We had received feedback from patients and their families that indicated this was an area that we needed to continue to focus on. Listening to feedback, as part of our communication with patients, enables our staff to gain a real insight into the patient s experience of care and to make further improvements. Ensuring staff were responsive to patients needs and communicating effectively was a key priority. What does this mean for our patients? During 2016/17, we achieved our FFT response rate target in one out of three areas. That was in Maternity, which achieved a response rate of 24.2% against a target of 20.0%, which is an improvement on 2015/16 when the area achieved 16.4%. With respect to A&E and inpatients, which had response rate targets of 20.0% and 30.0% respectively, the Trust fell short by achieving 8.7% and 27.3%, respectively. This compares to 2015/16, when A&E achieved a response rate of 9.6% and inpatients achieved a response rate of 21.0%. It has been identified that the poor response rate of A&E in particular, may be linked to only offering the survey in paper based format. The survey administration provider has now made the survey available on the ios operating system and Information Technology is procuring an ipad with trolley for use in A&E. It is hoped this will have impact, however, greater volume would be anticipated from proceeding with SMS texting service; the business case for this is now with finance for final additions prior to presentation at Trust Management Executive. Although response rates in the A&E department are not entirely where we would wish, the FFT does still provide a valuable source of patient feedback alongside other mechanisms the Trust has in place to hear about the patient s experience. Regarding complaints, we have monitored the progress of our complaint responses on a weekly basis and there has been an overall reduction in the number of complaints received by the Trust. Furthermore, we have achieved a significant reduction in complaints related to targeted key themes, which include communication and staff attitude. We are focussed on improving our patient experience and we run a quarterly snapshot survey for current inpatients that include a set of questions drawn from the CQC Inpatient Survey. However, the CQC Inpatient Survey, with a more extensive suite of questions is sent to those inpatients three months after discharge. The two surveys are based on different methodologies and different results may be achieved. National initiatives such as the John s Campaign, which was implemented at the Trust enables carers to support their loved ones outside of visiting times in accordance with their wishes. This provides for a better patient experience and can alleviate patient 100

101 Annual Report and Accounts 2016/17 anxiety during a hospital stay. In March 2017, we also held a carers listening event to help form a new carer s strategy that is due for publication in June 2017 and to further support carers who need to stay overnight at the Hillingdon Hospital we have ordered five new folding beds for carers staying overnight with the person they support. The aim of the indicator focussing on patients being delayed by more than 20 minutes in the outpatient department is to improve patient experience. Written comments obtained from patients during surveys indicate that patients appreciate the effort made in keeping them informed of delays and the reasons for the delays. They commented that this reduced their anxiety and made them feel like they were not forgotten. Those not informed of delays generally commented on how dissatisfied they were with the service. The number of patients not seen on time is gradually reducing and the departments are working to continue with this trend. With regard to improving communication and accessibility to information all organisations that provide NHS or adult social care had to implement the AIS by law from 31 July This includes making sure that people get information in different formats if they need it, for example in large print, braille, easy read or via . The standard also includes providing support from a British Sign Language interpreter, deaf-blind manual interpreter or an advocate. How did we do? The specific goals that we set and the performance during 2016/17 are outlined below: Quality Priority indicators To achieve more than 96% satisfaction in the FFT survey by March Realise a 5% reduction in complaints related to key themes including communication and staff attitude by March Improvement in CQC Inpatient Survey metrics for areas related to compassionate care and communication target 90% by March Patients delayed by more than 20 minutes for an outpatient appointment will be updated on the waiting times and informed of the reason for delay - target 80% by March /17 performance The following FFT results for patient satisfaction were achieved: Inpatients % A&E % Maternity % Complaints are logged by themes identified during review and investigation. One complaint can generate a number of themes. However, during 2016/17, complaints relating to communication and staff attitude reduced by 47% and 56% respectively, compared with 2015/16. There was however an overall reduction in complaints, but also changes within the Complaints Team may have contributed to such a reduction with variation in the actual coding of complaint themes. The Trust needs to strengthen this area of learning from the patient experience and triangulate with other sources of feedback*. In-house surveys are run on a quarterly basis using key questions from the annual CQC Inpatient Survey. Scores are calculated on a percentage basis. Quarter 4 results for communication, respect and dignity, privacy, pain control, support from staff to patients during mealtimes, confidence and trust in doctors and nurses treating the patient all exceeded the 90% target for year end. Up until March 2017, 85% of patients attending appointments were seen on time. Analysing the data for the patients not seen on time, 51.4% of these patients reported being informed of the waiting times and reason for the delay. The main challenge to achieving the 80% target has been specifically the environment of the eye clinic. Multiple waiting areas/pathways make it difficult to ensure patients are updated on the waiting times. 101

102 The Hillingdon Hospitals NHS Foundation Trust Quality Priority indicators Work towards implementing the AIS via review of current processes and a gap analysis to fully deliver the standard in 2016/ /17 performance Prior to AIS launch on 1 August 2016, the Trust undertook a gap analysis by configuring its patient database to identify those patients who registered for AIS so that patient letters and specific communications could be reviewed and individually tailored to suit their needs. Furthermore, staff were briefed about the concept of AIS, a bespoke AIS leaflet was published and the Trust website was updated to include AIS information and a patient application form to request information be provided in a different format. Patient communications from the Trust can now be made using large print, , easy read and British Sign Language. Presently, no patients have requested their communications in braille. However, this service can be provided on request by an outsourced supplier until later this year, when a new provider will include braille as a standard option, if requested. *Information on the patient experience is outlined in more detail in Part 3 of this Report Priority 4 Safer staffing improved recruitment and retention to ensure delivery of safe care We said: We need to ensure that we have safe staffing levels for medical, nursing and allied health professional (AHP) staff groups. This allows for improved continuity of care, effective communication and improved quality and safety of care. There are significant recruitment challenges with these staff groups across London and nationally. The Trust needs to agree a more effective and robust recruitment and retention strategy to meet these challenges and to be employer of choice for staff. We also need to reduce our reliance on agency staffing. We also wanted to ensure that staff are recruited to our values and deliver safe and compassionate care. This is a priority as it assists with staff morale and ensures a higher quality of care. It also improves retention and offers a better staff experience with their environment of work and the teams they work within. This was a safety priority identified by our stakeholders at the Quality Report consultation event. However, providing high quality services, while attracting and retaining sufficient skilled workforce has resulted in the Trust experiencing a significant financial challenge in 2016/17, and in future years. 102

103 Annual Report and Accounts 2016/17 How did we do? The specific goals that we set and the performance during 2016/17 are outlined below: Quality Priority indicators 2016/17 performance Nurse Staffing To significantly reduce vacancy levels in specific clinical areas: A&E, AMU and Fleming ward (surgery and gynaecology). Although the vacancy rate on Fleming ward has improved significantly in 2016/17, staff turnover remains high. The retention of staff remains a challenge across the surgical division and evidence from exit interviews show that staff are leaving due to family and personal reasons. The division however, is leading on a pilot project to improve recruitment of nurses by employing Pre-Registration Nurses who are supported with achieving registration with the Nursing and Midwifery Council (NMC). These are nurses with a nursing qualification from outside the European Union and are already resident in the UK. There has been a lot of interest in these posts and the first cohort of 17 pre-registration nurses has been recruited with a view to their gaining NMC registration within three months. If successful, the programme will be rolled out to the rest of the Trust. This, alongside traditional recruitment approaches is expected to move the Trust closer to achieving the target. In January 2017, A&E recruited to full establishment. A&E nurse staffing is now reviewed daily, and continues to be increased during times of high demand; to ensure a safe environment for patients and staff. Further, the introduction of Nurse Navigator posts has improved service quality and clinical safety of the department; improving monitoring of London Ambulance Service queues, improving their handover times, facilitating overall emergency care flows and providing clearer co-ordination and leadership in the department. The A&E nursing leadership structure is currently under review to further improve management of service delivery. Organisational Development has been engaged in work with the department towards developing a cultural development programme for 2017/18. Furthermore, a senior nurse away day has been held, with a follow-up day in a month s time, which aims to improve engagement and empower senior nursing in the department. The A&E paediatric area has fully recruited to establishment. A Paediatric Practice Development Nurse has been recruited for one year supported via HEENWL funding. This nurse started in February 2017 and is also undertaking her third year study as an Advanced Nurse Practitioner, which will really support skill development of the other paediatric nurses in the area. The AMU recruitment challenge continues. An increased number of strategies are being utilised to improve recruitment and retention including (but not limited to): more visible, rolling local and national recruitment; continuing with international recruitment; internal development opportunities such as Advanced Nurse Practitioner training and collaboration with surgical services in the context of joint appointments for the Surgical Assessment Unit / AMU. 103

104 The Hillingdon Hospitals NHS Foundation Trust Quality Priority indicators To develop a peripatetic (flexible, responsive and targeting gaps) nursing team to respond to additional short-notice staffing requirements To embed a proactive recruitment programme based on anticipated clinical demand To recruit internationally from the Philippines in July To achieve a vacancy rate for nursing of no more than 8% in line with the Trust target and a staff turnover rate no more than 10% 2016/17 performance Peripatetic nursing was trialled in the small pool of Registered Mental Health Nurses in the first instance to test its viability. 12 candidates applied, which is currently in the interview stage. A roster will be finalised once the nurses have been appointed. 112 Filipino candidates were originally offered nursing employment of which 91 are still in the recruitment process (21 having withdrawn from the process). These candidates are currently undertaking the prerequisites required for NMC registration, including passing the International English Language Testing Standard exam. The first cohort of nurses are expected to be deployed in late Summer An update to the Trust Board in March 2017 showed that our overall vacancy rate had reduced from 11.5% to 10.8% and our staff turnover had reduced from 17.0% to 15.8%. The Trust Board agreed in September 2016 that our target vacancy rate would be 8.0% and our turnover would be 13.0%. The Trust calculates staff turnover rate as the number of staff leaving in a month divided by the average number of staff across the year. A low staff turnover rate is desired. However, nil staff turnover can be detrimental so the Trust employs further measures (retention rate, voluntary turnover, exit interviews and such like) to inform its recruitment and retention initiatives. The Trust calculates vacancy rate by dividing the number of staff in a month against the staffing budget (establishment) for that month. As with staff turnover, a lower vacancy rate is preferred so that jobs are not left unfilled. To continue to develop and implement retention initiatives The three year Recruitment and Retention Strategy was approved in September 2016 and includes a wide range of retention initiatives. Implementation of the strategy is well underway, and has delivered on a number of these elements, namely the introduction of our end to end recruitment system; TRAC, and the implementation of the new Service Level Agreement for recruitment. Medical staffing Medical Locums bank in place where gaps are filled with own Trust doctors reducing need for agency workers and be within caps for agency usage aim to achieve phased launch by July Booking staff currently being recruited. Medical locum bank fills are being rolled out and now cover the majority of our clinical divisions. The aim of the centralised service is to increase our internal bank pool to contribute to a reduction in agency spend. Work is continuing to ensure coverage of the remaining clinical areas by the end of April

105 Annual Report and Accounts 2016/17 Quality Priority indicators Recruit to outstanding vacancies once divisions have developed their recruitment plan and shared this with Medical Staffing. 2016/17 performance International recruitment established as a viable method of filling specific hard to fill medical and dental posts. Agencies have been commissioned to fill long term vacancies with overseas candidates. Allied health professionals (AHPs) Workforce review to be completed within sonography; radiographers to complete sonography training - aim to achieve review by end of August 2016 and two trainee sonographers to complete course by September Radiology has generally maintained its six week performance target. It had significant capacity issues in MRI but managed to improve the waiting lists by outsourcing some of the demand. Ultrasound capacity remains an issue due to workforce and increasing volume of referrals. Recruitment and retention measures are being reviewed to reduce vacancies. Performance however, remains good when benchmarked against London and National figures. A workforce review has been done which included re-banding of certain roles. One sonography student completed the course in September 2016 and filled a vacant position. The Trust currently has four students undertaking the post graduate ultrasound course, two of which will finish in September The aim is to continue growing the number of sonographers with two more students starting in September By increasing the number of sonographers up to establishment the Trust will be able to increase its overall capacity which will reduce waiting times for patients. Currently there are two student sonographers who are due to complete their training in September. Agency sonographers are currently being used to ensure turnaround times but having the Trust s own sonographer s means it will be able to ensure the quality of service remains high. 105

106 The Hillingdon Hospitals NHS Foundation Trust Quality Priority indicators Shared competency framework to be established for Occupational Therapists and Physiotherapists on acute wards aim to achieve by end of August /17 performance Following a successful bid for HEENWL funding, project completed including skills gap analysis for Occupational Therapists and Physiotherapists on AMU / Integrated Discharge Team and bespoke training programme developed to enable staff to use the blended therapy assessment model for noncomplex patients seen at the weekend. This was supported by a competency framework to evidence broader skill development including clinical reasoning and governance. The blended therapy assessment model is now used by Therapists working at the weekend, the Occupational therapist working in the Integrated Discharge Team and the HomeSafe. A reduction in the average number of patients needing to be seen by both Occupational Therapists and Physiotherapists at the weekend has been observed and staff report less requirement for referring to their colleague of the other profession, as they feel more confident in assessing the patient holistically and in the context of the patient s home environment and acting on the findings. For example, issuing walking aids or small pieces of assistive equipment appropriately to the patient. The average duration of the initial assessment has also been reduced with the use of the integrated assessment pro-forma and skillset training while patients have reported high quality communication with the therapist. Development programme to support junior Occupational Therapists and Physiotherapists to move to higher-grade posts within the Trust aim to achieve this by end of October 16. Pharmacy to be pilot for central recruitment of pre-reg. pharmacists to improve recruitment. To participate in the HEE centralised recruitment for intake in August 2017 with interviews being held in September recruitment fayre in July Development programme established as planned with increased focus on non-clinical skill development added to existing clinical development via rotational posts, supervision and in-house training. Each clinical rotation now incorporates development in a specific non-clinical area (delegation, communication, difficult conversations, multi-disciplinary team working, Audit). To help embed learning, group supervision sessions have been established for junior staff, supplemented by peer support sessions. Physiotherapist rotations have been adjusted to expand the breadth of experience gained in each six month rotation. This year, three junior Occupational Therapists moved into higher-grade posts within the Trust, indicating successful development of the skills required for career progression and helping with a local solution to the London-wide Occupational Therapist recruitment challenges. Currently there are no higher-grade Physiotherapist vacancies. Three pre-registration pharmacists have been successfully recruited to join the Trust in August They will complete a year of vocational training prior to registration with the General Pharmaceutical Council. 106

107 Annual Report and Accounts 2016/17 What does this mean for our patients? The three year Recruitment and Retention Strategy approved by the Trust Board in September 2017 includes a wide range of initiatives to support safer staffing. We can see that through the interventions we have put in place in Year One of the Strategy that we are having a positive impact on the key metrics: Our staff turnover rate has decreased from 17.0% to 15.8% Our staff vacancy rate has decreased from 11.46% to 10.82% The Time to Recruit has decreased from 67 days to 55 days. We are continuing to implement further recruitment and retention initiatives as part of the Strategy in order to achieve the targets we have set ourselves for these key metrics. Regarding the pilot for central recruitment of registered pharmacists to improve recruitment, this will mean that the Trust attracts high calibre trainees often with opportunities to stay with the Trust as a qualified pharmacist. This enhances the quality of care provided to our patients. The shortage of applicants with the right skills, abilities and experience in many professions has created a more competitive market, coupled with an ageing workforce and increasing staff turnover due to retirement. The ability to deliver high quality, compassionate care depends upon recruiting and retaining the right people with the right skills. Therefore, an effective recruitment and retention strategy that complements the Trust s workforce strategy and Trust objectives and vision is essential. However, the Trust is at significant risk due to the inability of being unable to attract, recruit and retain sufficient staff to ensure a high calibre and skilled workforce in areas which are hard to recruit to roles in areas such as medical staff, registered nurses, sonographers and therapists. Our quality indicators relating to recruitment and retention will aid in informing actions to be implemented to mitigate these risks. A range of innovative developmental opportunities have been implemented to support development of our existing staff alongside a strong focus on recruitment. The partnership working with Central and North West London NHS Foundation Trust and Brunel University London around the new Academic Centre for Health Sciences will support development of knowledge, skills and research to underpin provision of evidence-based care to our patients. 107

108 The Hillingdon Hospitals NHS Foundation Trust LOOKING forward Our Quality and Safety Improvement Strategy During 2016/17 we have continued to focus on measuring and monitoring the quality of our services and the care that is delivered to our patients and their families. During this year the Trust developed a Quality and Safety Improvement Strategy for 2016 to 2021 which will support this work and help us to achieve our vision To provide high quality, safe and compassionate care improving the health and wellbeing of the people that we serve. The strategy provides a structure for ensuring strong clinical governance and ongoing improvement in the quality and safety of patient care. A clinical quality strategy action plan is reviewed on a quarterly basis at the Quality and Safety Committee (Board committee). Clinical divisions develop local quality actions plans based on the overarching Trust action plan. These form part of their business plans and were used to monitor progress at their divisional performance reviews. The Quality and Safety Improvement Strategy 2016 to 2021 puts Trust staff at the heart of delivering our aims and is supported by our culture and values framework: CARES (Communication, Attitude, Responsibility, Equity and Safety). This framework embraces a culture that empowers staff to report incidents and raise concerns about quality and patient safety in an open, blamefree working environment. This is supported by the statutory Duty of Candour and best practice guidance such as Freedom to Speak. The development of the Quality and Safety Improvement Strategy for 2016 to 2021 was guided by the Trust Quality and Safety Committee s own review of effectiveness; recommendations arising from the Trust s CQC inspection in October 2014; key reports such as Francis, Berwick and Keogh and other relevant data sources. The strategy clearly articulates our ambitious aims across the domains of patient safety, clinical effectiveness and patient experience. Our quality improvement work will be informed and supported by the learning from and collaboration with colleagues from across the North West London sector as part of the Imperial College Healthcare Partners Academic Health Science Network. Our seven quality aims as part our new strategy are as follows: 1. Developing a safety culture in which safety is everyone s business 2. Safer staffing 3. Working towards no preventable deaths 4. Proactively improving systems to reduce harm 5. Improving patient experience as defined by our patients 6. Achieving the best possible outcomes for patients 7. Ensuring people receive care in the right place. Our Sign up to Safety Campaign Sign up to Safety is a campaign to strengthen patient safety in the NHS. Its three year objective is to reduce avoidable harm by 50% and save 6,000 lives across the NHS in England. The Trust has supported this national patient safety campaign since its launch in Over the past two years the Trust has developed a detailed action plan outlining the work the Trust is taking forward to reduce harm and save lives; this work is aligned with the Trust s Quality and Safety Improvement Strategy. As part of this work the Trust has committed to: listen to patients, carers and staff, learn from what they say when things go wrong and take action to improve patients safety. We want to give patients confidence that we are doing all we can to ensure that the care they receive will be safe and effective at all times. A steering group has been meeting regularly to review progress against the Trust action plan; some of the actions are listed below: Following the success of our Sign up to Safety launch event and two patient and staff engagement events in 2015/16, 50 staff safety champions have been recruited. These members of staff are now taking forward safety improvement projects in their clinical areas and are coming together as a support network to share and learn from each other 108

109 Annual Report and Accounts 2016/17 A patient champion event was held in March 2017 to recruit patients who wish to engage with us on patient safety and support our improvement agenda We have seen an improvement in some key areas of focus which include improved incident reporting on medication errors this supports learning and safety improvement actions, raised awareness for our staff on malnutrition and ongoing education for our nutritional link nurses and further measures to reduce inpatient falls and pressure ulcers. Whole Systems Integrated Care and Partnership working We continue to work closely with our partners in community and primary care and the voluntary sector to deliver improvements in patient care through the whole systems integration model supporting new care models to ensure an improved quality of person-centred care. This has been expanded for an ever larger group of elderly patients providing care where it is needed, breaking down barriers and improving communication at all levels. We have also been working closely with our partners in health and social care and key stakeholders to continue to deliver improvements in the services delivered across North West London (NWL) with regard to the Shaping a Healthier Future programme. This aims to concentrate specialist hospital services into fewer sites allowing us to provide more senior consultants expertise more of the time at those sites, leading to better results and safer services for our area s two million patients. In the forthcoming year the Trust will be working with its partners do deliver the NWL Sustainability and Transformation Plan (STP) designed to address the three gaps identified in the government s Five Year Forward View. The three areas are: health and wellbeing, care and quality, finance and efficiency. For NWL nine emerging priorities have been identified, with work to meet these priorities split into key delivery areas. The Hillingdon Accountable Care Partnership (ACP) Shadow Board was established during 2016, functioning with an agreed set of principles to deliver better quality integrated services for older people in Hillingdon. These partners are: The Hillingdon Hospitals NHS Foundation Trust Central and North West London NHS Foundation Trust H4All is a federation of voluntary sector partners Hillingdon Age UK, Harlington Hospice, DASH, MIND Hillingdon and Hillingdon Carers Hillingdon four GP networks, due to become Hillingdon GP federation from April Together as an ACP they are now named Hillingdon Health and Care Partners: (HHCP). The next step is to agree an Alliance Contract. Under the umbrella of an Alliance partnership during 2017/18 the providers and commissioners have agreed to initially pool a range of service budgets which are specifically targeted at the over 65s that totals approximately 32m. A Clinical Design Group is overseeing the development of a more joined-up approach to the way that the HHCP partners work. Through a range of task and finish works streams, work is underway to change care models which will reduce duplication, identify gaps and put the patient at the centre of their proactive care plan. Work continues to ensure service users and carers are involved in this planning work and HHCP are going out to listen to people in Hillingdon whenever the opportunities present. A few key objectives assigned to the Model of Care redesign include: Improve access to primary care in hours and deliver extended seven day care. Thereby ensuring patients admitted as an emergency, receive high quality consistent care, whatever day they enter hospital. Reduce variation in practice and duplication across the system Share clinical information effectively and in a timely way Improve patient outcomes experience and quality of care Reduce reliance on A&E and hospitals Create empowered patients who effectively self-manage. 109

110 The Hillingdon Hospitals NHS Foundation Trust Recognising staff for improving the quality of care We have also performed well in other areas including our nurses winning an Excellence in Education Award at the HEENWL Excellence in Education and Training Awards. The award recognised the team s work on the junior nurse development pathway. The Trust entered the awards for the work that has progressed on the junior nurse development pathway and apprenticeship opportunities within the pathway. The pathway that has been developed builds on the Care Certificate allowing the Healthcare Assistant to progress through level two and three with associated apprenticeship levels attached to the qualification. We were also shortlisted in two categories in the prestigious Health Service Journal Awards. The Trust s HomeSafe Team was shortlisted in the Acute, Community and/or Primary Care Services Redesign category. The team is responsible for making sure everything is in place before elderly patients are discharged from hospital to home or another place of care. This could be arranging home visits with social services, setting up regular therapy sessions or making sure that a community nurse calls round. The Trust s IT Team also made the shortlist for their Hillingdon Care Record initiative in the category for Enhancing Care by Sharing Data and Information. The Hillingdon Care Record is a digital care record system that enables clinical staff to view patient records on mobile tablets at the bedside. This helps to speed-up care as it reduces the need to wait for patient records to be retrieved. Finally, a Community Midwife Team Leader in our Trust was honoured by the Royal College of Nursing with a Mary Seacole Scholar Award, to help her continue her work raising awareness of Female Genital Mutilation and working with victims, their partners and families. The Midwife plans to finish a therapy certification she is working on; her aim for an integrated Female Genital Mutilation service in Hillingdon, of specialists working together to meet the complex needs of victims, both physical and psychological; and to keep spreading the educational message both here and in the countries where Female Genital Mutilation still happens. 110

111 Annual Report and Accounts 2016/17 Quality priorities for improvement in 2017/18 In this section of the report, we tell you about the areas for improvement for the next year in relation to the quality of our services and how we intend to assess them. To develop these priorities, the Trust held an engagement exercise with key stakeholders (Foundation Trust members, Healthwatch, Governors, local voluntary organisations) on 21 November This event included a review of our current position against this year s priorities and a discussion on the quality priorities for the forthcoming year. Results from the discussions on the day show that some areas of improvement that we have focused on during 2016/17 still need further work including continuing to deliver the seven-day working priorities. An outline of the key results from the consultation is included in the table below: Quality Report 2017/18 Consultation Respondent Category Quality Priority Topic 2017/18 Patient Safety Staff Healthwatch The recruitment and retention of staff Reduce reliance on agency staff Improved communication at clinical handover including with the patient. Governors and Foundation Trust (FT) members Clinical Effectiveness Staff Healthwatch Governors and Foundation Trust (FT) members Staff Healthwatch Governors and Foundation Trust (FT) members Improvement to the physical environment of care Improve the discharge process medications, transport, communication with GP Empower nursing staff to communicate medical information and treatment plans Improve patient pathway through the hospital and reduce delays in care Improve admission process and care of patients with dementia Improvements required in relation to EoLC Reduce duplication and improve efficiency. For example, clinical documentation requirements. Importance of the patient perspective in treatment/care discussions Improved communication in relation to urgent tests/possible delays More hearing loops to be made available across both sites Better communication from staff to patients/carers e.g. discharge process and plans Improve experience for patients who currently feel under pressure to be discharged Improved facilities for patients with disabilities Improved information of availability of services within and outside of the Trust Better access to interpreting services. 111

112 The Hillingdon Hospitals NHS Foundation Trust In addition, the Trust triangulated data from several sources to identify themes and recurring trends. The Trust has engaged with clinical and management staff via divisional governance board meetings and divisional reviews to establish priorities. During the last year there has continued to be active engagement with our local Healthwatch including its members on several of our Trust working groups. The Trust has also met with Healthwatch on a quarterly basis to review quality and patient safety data and progress on the quality report priorities. This engagement has proved invaluable in being able to hear the feedback that Healthwatch receives from people with which it engages. The Board has considered all of the suggestions put forward and the review of data and the priorities below have been recommended for inclusion in the Quality Report for 2017/18. These have been identified as falling under the three domains of safety, clinical effectiveness and patient experience as follows: No. Priority Safety Clinical Effectiveness Patient Experience 1 Improvements to End of Life care 2 Continuing to deliver the seven-day working priorities 3 Improving the care of patients with dementia 4 Improving the discharge process 112

113 Annual Report and Accounts 2016/17 PRIORITY 1 Improvements to End of Life care (EoLC) Why is this one of our priorities? EoLC has been recognised as an important national issue: in 2016 NHS England cited EoLC as one of the top three areas for future focus and relates to our STP priority of improving the overall quality of care for people in their last phase of life and enabling them to die in their place of choice and achieving better outcomes and experiences for older people. Increased frailty during the last phase of life is inevitable, but often care services responses to these increasing health and social care needs are reactive rather than proactive, which can mean that people in the last year of life attend A&E more often and stay longer in hospital than fitter people. Focus on formal Advance Care Planning - a system of proactively and sensitively discussing an individual s wishes and agreeing a plan of care in the event of deterioration has been shown to improve the quality of care, and reduce inappropriate A&E attendance, hospital admissions and length of stay. It also increases the likelihood of an individual dying in the place that they wish. Nearly half of all deaths in England take place in hospital. 54% of Hillingdon Borough resident deaths occur in hospital. Compassionate care with an emphasis on dignity, respect and symptom control in the last days of life is an essential service that a hospital provides to its community. How are we doing so far? The Trust s CQC rating for EoLC was Requires Improvement. We have undertaken a baseline assessment of EoLC across the Trust, which has included an independent review of care by Macmillan (2016), taking part in a National Audit of Care of Dying in Hospital in order to benchmark our hospital performance against other Trusts (2015), a staff confidence questionnaire (2016), a review of advance care planning practices in the inpatient setting (2016) and a gap analysis of services using the NHSI Transformation Programme for Improving EoLC in Hospitals (2016). In addition, a multi-professional and crossdivisional project team with an Executive Sponsor and Clinical Lead has been developed to drive forward improvement in EoLC. This includes: Care in the last days of life Advanced care planning Writing a formal EoLC Trust strategy Within each of the above areas a range of distinct pieces of work have been identified and are being directed by front-line and specialist staff. Our aims for 2017/18 are: Standards of measurement for recognising improvements to EoLC will be implemented To improve the process of advance care planning with patients by enhancing the Trust s electronic palliative care coordination system used by healthcare professionals across primary and secondary care (that is, General Practitioner, district nurse, care homes and care of the elderly team in the first instance) and to enable healthcare professionals to recognise patients approaching the last phase of life through bespoke teaching sessions for staff on showcase wards To improve care in the last days of life by agreeing individualised compassionate care plans with patients and their loved ones, which ensure dignity and symptom control. This will be rolled out in two wards in the first instance To develop a Trust wide EoLC strategy that ensures sustained improvement across all ward areas and links with partners in primary care and care homes so that best care is given, whatever the care setting. 113

114 The Hillingdon Hospitals NHS Foundation Trust PRIORITY 2 Continuing to deliver the seven-day working priorities Why is this one of our priorities? The purposes of the standards are: to deliver safer patient care to improve patient flow through the acute system to enhance patients experience of acute care to reduce the variation in appropriate clinical supervision at weekends and potentially, to mitigate the excess mortality that has been shown in large studies to be associated with weekend admission to hospital. How are we doing so far? With respect to emergency admissions only, our aims for 2016/17 were: Clinical assessment for patients by a suitable consultant within 14 hours of admission to hospital (Standard 2) Seven day access to diagnostic services, consultant-directed tests and completed reporting will be within one hour for critical patients and within 12 hours for urgent patients (Standard 5) 24 hour seven day a week access for patients to consultant directed interventions; onsite or through formally agreed networked arrangements (Standard 6) All patients in high dependency areas must be seen and reviewed by a consultant twice daily. Patients should be reviewed by a consultant at least once every 24 hours, seven days a week unless this would not affect the patient s care pathway (Standard 8). Our aims for 2017/18 are: In addition to embedding and building on the achievements from 2016/17, these will be reviewed following receipt of the outcomes from 2016/17 that are due on 31 May We believe that there will be improved compliance especially with weekend delivery of standards 2 and 8 as a result of more focussed consultant input already in place in acute medical and surgical specialties, along with more robust board rounds and better documentation / data capture. If improved compliance is demonstrated then we will continue to build on and embed practices. If not, then we will need to align job plans with increased weekend senior doctor presence and where this is not possible due to scheduled elective work then submit appropriate business cases. Our ambition needs to, and will, remain to achieve 90% compliance with Standards 2 and 8 with no weekday and weekend variation, improve weekend compliance with standard 5 (particularly MRI / ultrasound) and continue to be compliant with Standard 6. Complete compliance with the Standards will have an associated cost. This has been presented at the North West London Program Executive Board to discuss and agree a sector-wide delivery approach. There have already been a number of successful pilot projects, two of which were hosted at the Trust, which showed how investment of resources (not just in more doctors) may improve compliance and better patient care. 114

115 Annual Report and Accounts 2016/17 PRIORITY 3 Improving the care of patients with dementia Why is this one of our priorities? It is estimated that there are more than 900,000 people living with dementia in the UK, with this due to reach over one million by The DH estimates that 25% of hospital beds are occupied by someone with dementia. Inpatients with dementia are some of the frailest, most vulnerable patients, with research demonstrating that they have higher rates of complications. Being in hospital can be a frightening experience for someone with dementia who has memory loss and problems with orientation and communication. In 2013, the Trust signed the National Dementia Declaration, committing the organisation to becoming dementia friendly. Our goal is to provide high quality, person-centred care to our patients by ensuring our staff are well trained, have senior specialist support available and work within a care pathway designed for patients with dementia. Furthermore, of the nine emerging priorities that were identified in the NWL STP, one priority involves improving the overall quality of care for people in their last phase of life and enabling them to die in their place of choice. A key delivery area is to achieve better outcomes and experiences for older people including approximately 5,000 people with advanced dementia and Alzheimer s disease. How are we doing so far? We are committed to developing a dementiaaware workforce to support person-centred care and to date 95% of our staff clinical, nonclinical and voluntary - have completed dementia awareness training. There are dementia champions across the Trust, many of whom have completed the Alzheimer s Society Foundation Certificate in Dementia Awareness. Specialist advice and support is available from the Clinical Lead (Consultant) and the Dementia Nurse Specialist. However, over 1,500 people were screened and 100% of all patients identified as possibly having dementia were highlighted to their GP for referral to memory services We have a visual indicator system in place to alert staff that a patient has dementia and clinical guidelines and nursing care plans are available to support staff to deliver appropriate, patientcentred treatment and care. As a signatory of John s Campaign we welcome carers to stay with the person they support. However, feedback from FFT, complaints and surveys tells us there is more work to be done in this area. Our aims for 2017/18 are: To develop the Trust s next three year Dementia Strategy and implement year one action plan To further develop training in line with the DH s Dementia Core Skills Education and Training Framework. Within this programme we aim to: Continue to provide dementia awareness training to all staff, achieving at least 80% compliance To develop and implement an e-learning package for dementia awareness update training To develop and deliver training tailored to the needs of staff key clinical areas prioritising A&E and Care of the Elderly settings. To deliver a more robust and consistent process for dementia screening to achieve 90% screening and assessment for patients over 75 admitted to the hospital To respond to findings of the National Audit of Dementia 2016 when data is available later in the year with a robust action plan to actively seek and respond to feedback from patients and carers regarding their experience at the Trust To consistently provide support for carers, in line with the Carers Strategy, due to be launched in June 2017 To develop a pathway of care for people with dementia when they are admitted to hospital, to support compassionate, person-centred care. Our success in screening older adult inpatients for dementia has been variable, this year we did not meet the target for 90% of patients over 75 years to be screened for potential dementia. 115

116 The Hillingdon Hospitals NHS Foundation Trust PRIORITY 4 Improving the discharge process Why is this one of our priorities? We consider safe and effective discharge to be of central importance in the pathway of care for our patients. We recognise that being discharged from hospital, which patients often feel is a place of safety, can be an anxious time. We also recognise that, once the decision has been made that discharge home can take place, it is an important element of a patient s experience that this takes place quickly and efficiently. Discharge planning starts on the patient s admission to hospital and there are protocols and procedures for our staff to follow to ensure this is a more streamlined and effective process. This is also a whole system issue with the interdependency on social and health care arrangements being available outside of hospital to ensure a safe discharge for patients. We plan to undertake a programme of work that will be designed to improve and streamline our discharge processes further, based on national best practice. A core component of the HHCP clinical pathway and models of care redesign is to support and improve the discharge system, process and patient/carer experience for frail and elderly patients. Work to address these areas is already well advanced, including: 1) Delivering the HHCP Service Delivery Model 2) Implementation of the SAFER patient flow bundle 1) The HHCP aims will be delivered: Via partnership working to provide appropriate support for patients in impending crisis in the community to avoid a) inappropriate admission to hospital b) extended length of stay c) readmission. Plus supporting seamless transition to other levels of support in their own residence Through partnership working, promoting and enabling self-care for exacerbations of chronic disease and maintaining independence despite increasing frailty. Providing appropriate responsive care for people with chronic disease or frailty when needed in the community or post-acute care By creating capacity for primary care through partnership working across health, social and voluntary sector services. Promoting and enabling self-care and a healthy lifestyle to maintain independence and well-being. Moving from reactionary to planned care. How are we doing so far? We aim to ensure each patient is treated as an individual and that there is continuity of care during transfer from one setting to another, whether this is back home or to another care facility. We discharge many thousands of patients a year and for the majority of people this process runs smoothly. We do however recognise that there is more work to be done to improve the discharge experience, especially for our older patients. In February 2017 a report by Healthwatch Hillingdon revealed varied expectations and satisfaction rate among the people they interviewed. Recommendations in the report fell within three themes: Communication and Information Processes and procedures Closer Integration and joined up working. 116

117 Annual Report and Accounts 2016/17 2) The SAFER patient flow bundle incorporates the following aspects: SSenior Review. All patients will have a senior review before midday by a clinician able to make management and discharge decisions. All patients will have an Expected A Discharge Date (EDD) and Clinical Criteria for Discharge (CCD), set by assuming ideal recovery and assuming no unnecessary waiting. Flow of patients to commence at the earliest F opportunity from assessment units to inpatient wards. Wards routinely receiving patients from assessment units will ensure the rst patient arrives on the ward by 10am. Early discharge. 33% of patients will be E discharged from base inpatient wards before midday. Review. A systematic multi-disciplinary team R (MDT) review of patients with extended lengths of stay (>7 days also known as stranded patients ) with a clear home rst mind set. S - Senior Review. All patients should have a senior review before midday. If we routinely undertake all the elements of the SAFER patient flow bundle we will improve the journey our patients experience when they are admitted to our hospital. We are rolling out an initiative called Red to Green across the Trust which will be a visual aid to patients and staff to demonstrate delays or progress in patient Pathways Our clinical design group across the whole system (social, community and Health) are currently working through the best model to provide an Integrated Discharge Team to better support patients and staff on the available options for care in the community from the beginning of the pathway. We are aware that we cannot look at discharge in isolation and that ensuring this works correctly is a whole system issue, requiring co-ordination between partners. Ensuring the availability of social workers, NHS community services and hospital therapists (particularly where they work across the hospital/community interface) and matching any increased focus within an acute trust on weekend discharges is essential. 117

118 The Hillingdon Hospitals NHS Foundation Trust Our aims for 2017/18 are: Our quality priorities will be monitored by clinical and management teams through their divisional performance reviews and via reports to the relevant sub-board Committee. The results will also be published in the 2017/18 Trust Annual Report. We will monitor the number of patients that are discharged on the day that we expected it to happen; we will also monitor the time of the day that patients are discharged. We will ask patients, via the in-patient survey, if they are happy with the preparation that has been made for their discharge. We will design and implement a system to capture feedback from patients and carers regarding their satisfaction with their discharge experience. We will triangulate this data with other sources of patient feedback to ensure that the changes we make are improving the quality for our patients. Our quality priorities will be monitored by clinical and management teams through their divisional performance reviews and via reports to the relevant sub-board Committee. The results will also be published in the 2017/18 Trust Annual Report. We will review our nursing processes and procedures for discharge planning to achieve uniformity in meeting agreed standards. This will include consistent use of the newly revised Working Together communication and information leaflet. We will work together with partner organisations and voluntary services to implement patient-centred discharge plans and models of care. Regarding HHCP, there are several initiatives either underway or about to be implemented to achieve the following:- Where patients have to be conveyed to hospital and be admitted, utilising improved whole system integrated services, they will only stay for the least amount of time as possible and will receive support and wrap around care to enable a safe and positive discharge from the acute trust. With supported MDT discharge services, care connection teams and geriatrician involvement the aim is also to be able to manage and keep patients at home for longer and avoid the need to be readmitted into the acute hospital. HHCP are ensuring that outcomes from patient and carer audits and feedback are included in clinical design and changes to pathways and service delivery. Our quality priorities will be monitored by clinical and management teams through their divisional performance reviews and via reports to the relevant sub-board Committee. The results will also be published in the 2016/17 Trust Annual Report. We will ensure patients and carers are actively involved in discharge planning and independent advocacy is arranged when required. We will review and develop the Discharge Lounge facilities. 118

119 Annual Report and Accounts 2016/ Formal Statements of assurance from the Board Information for our regulators Our regulators need to understand how we are working to improve quality so the following pages include specific messages they have asked us to provide: Provision of NHS Services During 2016/17 The Hillingdon Hospitals NHS Foundation Trust provided medicine, surgery, clinical support services and women s and children s NHS services. The Trust has reviewed all the data available to them on the quality of care in all of these relevant health services. The income generated by these relevant health services reviewed in 2016/17 represents 100% of the total income generated from the provision of the relevant health services by the Trust for 2016/17. National audits During 2016/17 36 national clinical audits and four national confidential enquiries covered relevant health services that The Hillingdon Hospitals NHS Foundation Trust provides. During that period the Trust participated in 83% national clinical audits and 100% of national confidential enquiries of the national clinical audits and confidential enquiries in which it was eligible to participate. The national clinical audits and national confidential enquiries that The Hillingdon Hospitals NHS Foundation Trust participated in, and for which data collection was completed during 2016/17, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry. Participation in clinical audit The Hillingdon Hospitals NHS Foundation Trust is committed to continually improving the healthcare we provide to service users and Clinical Audit is a crucial part of the Trust s strategy to improve the healthcare we provide. The Trust uses Clinical Audit to assess and monitor its compliance against national and local standards, and to review the healthcare outcomes of its service users. It provides healthcare professionals the opportunity to reflect on their individual practice and the wider practices across the clinical directorates and the Trust. The Hillingdon Hospitals NHS Foundation Trust actively encourages all clinical staff and those in training to be involved in Clinical Audit. The Trusts annual Clinical Audit Programme is formulated each year to ensure that the Trust meets all mandatory, regulatory and legislative requirements as laid out by the NHS governing bodies. It is specifically designed to include all applicable national clinical audits and Confidential Enquiries that the Trust is eligible to participate in, relevant published National Institute for Health and Care Excellence (NICE) guidance and NICE Quality Standards, and local governance and service level priority topics required to ensure compliance with statutory obligations. 119

120 The Hillingdon Hospitals NHS Foundation Trust Audit Participated Cases submitted Adult Critical Care Case Mix Programme Yes 100% National Emergency Laparotomy Audit Yes 66 cases submitted Bowel Cancer Audit Programme Yes 100% Endocrine and Thyroid National Audit Yes 100% Elective Surgery (National Patient Reported Outcome Measures (PROMs) Programme) Yes Hip 234 Knee 394 Yes 100% Hernia 19 Yes 100% Varicose Veins - 14 Yes 100% Falls and Fragility Fractures Audit Programme: National Hip Fracture Database Falls and Fragility Fractures Audit Programme: Fracture Liaison Service Database Yes 100% Yes 100% Major Trauma Audit Yes 100% National Joint Registry Yes Hillingdon 47% Mount Vernon 86% National Ophthalmology Audit Yes 100% National Prostate Cancer Audit Yes 100% BAUS Urology Audit Female Stress Incontinence Audit BAUS Urology Audit Percutaneous Nephrolithotomy (PCNL) No No Unable to participate due to resource issues in the Urology Department As above National Cardiac Arrest Audit Yes Confirming figure will be slightly less than 100% Rheumatoid and early inflammatory arthritis No Participation in this audit would not have benefited clinical care this was an organisational management assessment. Sentinel Stroke National Audit Programme Yes 100% Acute Myocardial Infarction Yes 100% National Heart Failure Audit Yes 100% National Chronic Obstructive Pulmonary Disease Audit Programme Yes Data submission has recently commenced British Thoracic Society Adult Asthma Yes 100% National Audit of Dementia Care Yes 100% National Adult Diabetes Audit : National Foot Ulcer audit Yes 44 cases submitted 120

121 Annual Report and Accounts 2016/17 Audit Participated Cases submitted National Adult Diabetes Audit : National Inpatient Diabetes Audit National Adult Diabetes Audit : National Pregnancy in Diabetes Audit Yes 100% Yes 100% National Core Diabetes Audit No Lead, for this audit, is working with IT to resolve issues to enable submission of data to the audit. National Diabetes Transition Audit No Trust could not be part of this audit, due to non-participation in the National Core Diabetes Audit National Lung Cancer Audit Yes 100% National Oesophago-gastric Cancer Audit Yes 100% National Audit of Moderate & Acute Severe Asthma (College of Emergency Medicine) National Audit of Severe Sepsis and Septic Shock (College of Emergency Medicine) National Comparative Audit of Blood Transfusion: Re-audit of red cell and platelet transfusion in adult haematology patients Yes 100% Yes 100% Yes 100% National Comparative Audit of Blood Transfusion: Re-audit of Patient Blood Management in Scheduled Surgery No The Trust participated in the first audit; decision was made not to participate in this re-audit as the Trust does not use significant levels of blood in surgery and not a risk area. National Intensive and Special Care (NNAP) Yes 100% British Thoracic Society Paediatric Pneumonia Audit Yes Audit ongoing Trust is participating National Paediatric Diabetes Audit (Royal College of Paediatric and Child Health) Maternal, New-born and Infant Clinical Outcome Review Programme (MBRRACE- UK) Yes 100% Yes 100% National Confidential Enquiries Child Health Clinical Outcome Review Programme: Chronic Neuro-disability and Young People s Mental Health Yes In progress, Trust is participating. National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Non-Invasive Ventilation Yes 100% NCEPOD Mental Health In General Hospitals Yes 100% NCEPOD Cancer in Children, Teens and Young Adults Yes In progress, Trust is participating. 121

122 The Hillingdon Hospitals NHS Foundation Trust The reports of the relevant national clinical audits were reviewed by the provider in 2016/17 and The Hillingdon Hospitals NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided. Audit Adult Critical Care Case Mix Programme Actions Overall we perform favourably against other similar units, for example, we have very few unplanned readmissions to ITU within 48 hours; patients that require an ITU bed are able to have one; during an ITU stay we perform well on not getting an ITU acquired infection in the blood. However, we have recognised that out of hours discharges and high risk admissions from the ward to ITU, again compared with other similar units, requires more work and areas for improvement to be identified. This will also be monitored via the Trust risk process. Falls and Fragility Fractures Audit Programme National Hip Fracture Database Trauma Audit & Research Network (TARN) National Bowel Cancer Audit National Emergency Laparotomy Audit National Audit of End of Life Care (EoLC): Dying in Hospital There is a continual drive to improve the standards and documentation to ensure quality and accuracy of data submission to the NHFD. One key area identified for improvement, from our results is the type of operation performed. A local audit of operation type will take place to review improvements needed. This audit will also confirm we are documenting the correct classification, as per the NHFD. A TARN administrator has been employed and we are now regularly submitting relevant cases to the audit, allowing us to get a clearer picture of how we manage this group of patients. We are now setting up a process to regularly review our results and make clinical care improvements if/where needed. To review reasons for longer length of stay, for these patients, the Colorectal Team is setting up a smaller working group to look at the Enhanced Recovery Programme and identify what improvements are required/can be made. An area for improvement identified was to make sure we submit all patients having a laparotomy to the audit. To do this the Anaesthetic Co-ordinator and Surgical Lead Nurse are reviewing when a laparotomy takes place and ensuring audit data is submitted. The results of this audit highlighted that the hospital needed to improve documentation of a patient s mortality risk before surgery, this will be done by promoting the use of a specific scoring system called P-POSSUM. To implement actions from this audit and improve EoLC across the trust, two sessions per week of Palliative Consultant time have been released to drive this work forward. This will be supported by the Lead Nurse for Palliative Care. The three main work streams are: improve care in the last days of life in inpatient setting. improve communication between primary and secondary care regarding patients thought to be in last phase of life, advance care planning and access and use of CMC across the Trust. development of a Trust wide EoLC strategy for sustained improvement. 122

123 Annual Report and Accounts 2016/17 Audit National Heart Failure Audit UK Parkinson s National Audit Actions The hospital has a newly identified Consultant lead for the Heart Failure audit, who will work alongside the Heart Failure Specialist Nurse on improvements for heart failure patients. As part of this we plan to undertake local review of our results on a more regular basis. To further improve care, a report has been set up to identify patients who regularly re-attend the hospital for heart failure. If a patient re-attends on three or more occasions this will be flagged to the consultant to review the case in more detail. Following increased communication between the Parkinson s Specialist Nurse and Consultant Neurologists, there has been an improvement in the overall referral process and referral to the Exercise programme Get up and Go. Consultant Neurologists are now referring to service more promptly and offering earlier intervention from the multi-disciplinary team. Information packs/leaflets have been issued to some of the relevant clinic areas and work continues to ensure these are available in all areas. National Audit of Pulmonary Rehabilitation National Inpatient Diabetes Audit National Cardiac Arrest Audit (NCAA) National Neonatal Audit Programme The service has implemented a respiratory education programme to improve awareness of pulmonary rehabilitation both within the hospital and community. As part of the new service, referrals to pulmonary rehabilitation from hospital services will be audited. A revised hypoglycaemia chart has been introduced and is in use in the hospital. A local audit on use of this chart will be taking place during 2017/18. The Trust continues to perform well against the standards within NCAA. Any identified areas of concern are investigated by the Resuscitation Officers and reported to the Resuscitation Committee. To improve data completeness and accuracy for this audit, discharge summaries are checked by Consultants. They ensure there is a documented record that: senior consultation took place within 24 hrs, contain results of babies with positive cultures and central line infections are included. A pilot neuro-developmental clinic has recently started and this will continue over coming months. Once a further new permanent consultant is appointed we will have a formal regular clinic slot sufficient to cover all babies born at less than 30 weeks. National Paediatric Asthma Audit National Audit of VTE risk in lower limb immobilisation (CEM) National Audit of Vital signs in children (CEM) Paediatric Respiratory Team hold regular training sessions for relevant staff groups, for example, Paediatric Doctors, A&E Paediatric Doctors and Nurses. Further sessions are planned as part of a rolling programme to maintain current good practice. A specific deep vein thrombosis guideline and risk assessment proforma has been agreed. All patients who require lower limb immobilisation and attend to Minor Injuries Unit or A&E are risk assessed and prescribed prophylaxis if required. A Patient Information Leaflet has been produced as part of this. A local clinical audit of practice will take place early 2017/18. As part of ongoing teaching for A&E nurses it is re-iterated that all children, with any abnormal vital sign need these to be repeated within 60 minutes. A local A&E audit newsletter, including this audit, was produced in December 2016 and issued to all ED staff to help raise awareness of improvements needed. 123

124 The Hillingdon Hospitals NHS Foundation Trust Audit National Audit of procedural sedation in adults (CEM) NCEPOD Treat the Cause Acute Pancreatitis Actions Procedural sedation proforma has been designed and will be trialled from April 2017 before final amendments and publication. A training session has taken place for middle grade doctors. The introduction of this proforma will also support change in practice identified from the local audit of clinical management of a dislocated shoulder. A local re-audit of procedural sedation, will take place from September The recommendations have been reviewed by lead General Surgeon and Gastroenterology Consultant and we perform well in a number of areas, for example, management of co-morbidity in patients with acute pancreatitis and patients managed by a multi-disciplinary team. We are looking further at the recommendations, relating to alcohol services, in line with a previous NCEPOD report to finalise action requirements. As part of current work to improve NEWS scoring within the hospital, separate guidance is being provided for A&E, which supports the recommendations within this NCEPOD report. 124

125 Annual Report and Accounts 2016/17 The reports of 84 local clinical audits were reviewed by the provider in 2016/17 and examples of The Hillingdon Hospitals NHS Foundation Trust actions to improve the quality of healthcare provided are as follows: Audit Clinical Record Keeping Standards Antenatal Screening Hepatitis B Screening in Maternity Safeguarding Children / Vulnerable Women Postnatally in Maternity Timely Identification and Treatment for Sepsis in A&E and Acute Inpatient Settings Actions The Trust continues to drive improvements in clinical record keeping standards. Stamps to document author name, designation and for doctors, GMC number, are more widely available and in use. There is a general drive for improvement where record keeping is highlighted at various meetings and from other audits, for example, the seven day services audit. Antenatal Screening training took place in Sept 2016 for existing staff, which included an update on overall screening requirements. Specific areas included in the training were to highlight the need for doctors and midwives to check blood results when seeing patients at 16 weeks and to document this, plus actions to be taken if results abnormal. Antenatal screening training is also given to doctors and new midwives on induction. For Hepatitis B screening we now have an enhanced process for recording that the woman is followed up appropriately and that the baby receives the vaccine and the necessary follow-up appointment. To support regular midwifery attendance at case review conferences. A parttime midwife post has been advertised and recruited to. The Trust Consultant Clinical Lead for Sepsis regularly audits, against local protocols, to ensure all appropriate patients are screened for sepsis and if needed antibiotics prescribed. As mentioned in the CQUIN section of this report, we are now consistently screening more than 90% of relevant A&E attendances and timely screening of patients on hospital wards has been improving throughout the year. In the majority of cases patients receive treatment within one hour. A new sepsis tool was introduced during 2016/17 and a priority for 2017/18 will be to increase use of this tool. Antimicrobial Resistance and Antimicrobial Stewardship Multi-disciplinary shift handover Upper Gastrointestinal Bleeds The Trust Antimicrobial Pharmacist audits antibiotic prescribing monthly. This is to determine whether prescriptions have been reviewed within 72 hours as per best practice. The National target, for review, is 90% and the Trust has exceeded this throughout the year. Junior doctors from Medicine, Surgery, Paediatrics, Obstetrics and Gynaecology have conducted the handover audits during 2016/17. The doctors observed day to night/night to day handover meetings and demonstrated an improvement in quality over the year. The Trust is now fully compliant with best practice guidelines for safe and effective shift handover and has fully developed plans for deployment of an electronic handover system. NICE recommend that a specific formal risk assessment score is performed for patients with acute upper gastrointestinal bleeding at first assessment. To improve documentation of this, a Blatchford score form has been introduced and is being used by the referring team, the Endoscopy nurses ensure this is completed. Upper gastrointestinal haemorrhage guidelines are going to be developed. 125

126 The Hillingdon Hospitals NHS Foundation Trust Audit Medical Assessment of Falls Actions This local audit was undertaken following publication of the National Inpatient Falls Audit. The audit aim was to improve the medical assessment and management of patients following an inpatient fall and to prevent further falls. The Trust has now introduced a new guideline Assessment and Management of Inpatient Falls; and an Inpatient Falls Review proforma. When a doctor or nurse is called to assess a patient, following an inpatient fall, the proforma is initiated. This proforma is used for an initial assessment and for the subsequent patient management plan. The proforma has been piloted on two target wards and is currently being re-audited to assess impact with a view to rolling it out trust wide. Nasogastric (NG) tube As a result of two Never Events that occurred within our Trust in 2015/16 concerning misplaced NG tubes, we are particularly conscious of providing our staff with information on the management of NG tubes, thereby reducing the harm to patients from an unidentified, misplaced tube. A new NG tube policy was published in line with the gap analysis work on the July 2016 Patient Safety Alert guidance and resource toolkit; this includes a revised NG Tube proforma. This supports the actions from the audit undertaken in Q3. Re-audit will take place in Q1 2017/18. NHS Medicines Protect Infection Control Audits A national audit tool has been implemented in the Trust to provide assurance in relation to safe and secure handling of medicines in clinical areas. Areas identified for improvement such as lockable storage facilities for intravenous fluids have been introduced. Rolling audits are being used to feed back to clinical staff on good areas of practice and other areas for improvement. There is an ongoing programme of clinical audit for infection control: Hand Hygiene, Below the Elbows, Documentation of Urinary Catheters and of Peripheral IV Devices and General Ward Infection Control/Environment audits are collated on a ward based dashboard data. To further drive improvement, an electronic sharing process is being introduced to enhance communication between the ward and infection control team. This enables sharing of good practice and where needed to drive improvement. Going forward the plan is for the wards to take greater ownership of their data, including analyse and devise a programme of improvement. 126

127 Annual Report and Accounts 2016/17 Commitment to research as a driver for improving the quality of care and patient experience The number of patients receiving relevant health services provided or sub-contracted by The Hillingdon Hospitals NHS Foundation Trust in 2016/17 that were recruited during that period to participate in research approved by a research ethics committee was 713. The Hillingdon Hospitals NHS Foundation Trust has a good research track record for a hospital of its size. Our main research activity is recruiting patients into high quality National Institute for Health Research (NIHR) portfolio adopted multicentre trials. We participate in commercial research funded by the pharmaceutical industry and noncommercial research which is funded from the DH via the NIHR NWL Clinical Research Network (CRN). In 2016/17 we received 382, from the NWL CRN for this work. The funding enables the Trust to employ research nurses and data managers to support the clinicians in this work. Our strategic aims for are: To expand the number of patients recruited into high quality clinical trials To expand the number of Specialties that are actively participating in clinical trials To adapt to the changing National and Regional organisation of clinical research and funding. This has enabled us to offer a greater number of patients, from different clinical areas, the opportunity to participate in research. In 2016/17 we became more research active in musculoskeletal disorders and diabetes. The Trust has an extensive research portfolio with a balance of observational and treatment trials across many clinical areas including cancer, stroke, haematology, ophthalmology, critical care, maternity and many of the general medicine and surgical specialities. We also support PhD and Masters Students from the local universities giving them access to our patients and staff for their projects. In 2016/17 we approved and supported two such university student projects. During 2016/17 we had approximately 65 NIHR Portfolio Studies open or in follow-up and we recruited 713 patients into 41 trials. When compared to other similar sized Trusts in London, our activity appears to be on par. All of our research activity is scrutinised for quality and compliance to the standards expected by the Research Governance Framework and the Health Research Authority. In addition we work to comply with the DH NIHR objectives. Furthermore, the Trust is in the early stages of Collaboration with Brunel University to form an Academic Centre for Health Sciences. Some of the priorities are: Deliver a sustainable Academic Centre for Health Sciences Increase research and education interactions (Joint conferences, research grants, sessional lecturing or participation, pump priming research) Create an environment of innovation. Participation in clinical research demonstrates The Hillingdon Hospitals NHS Foundation Trust s commitment to improving the quality of care we offer and to making our contribution to the nation s wider health improvement. This also allows clinical staff to stay abreast of the latest treatment possibilities giving patients access to new treatments that they otherwise would not have. 127

128 The Hillingdon Hospitals NHS Foundation Trust Lessons Learned from the Investigation of Serious Incidents During 2016/17, the Trust reported 47 Serious Incidents in accordance with the Serious Incident Framework and the categorisation of Serious Incident cases. This compares with 35 Serious Incidents in 2015/16. One Never Event, involving medication administered by the wrong route, was reported in August This investigation has been completed and reported to the Trust Board. The Board will monitor the action plan through to completion. Serious Incident cases reported during this period include unexpected admissions to neonatal care; grade 3 pressure ulcers and categories such as sub-optimal care of the deteriorating patient, delayed diagnosis, delayed treatment, drug incidents and information governance. 30 of these cases have been Non-Executive/Executive Director led panel investigations (these are usually formed for Never Events and unexpected death cases). There were two Grade 3 pressure ulcers incidents (these involve partial or full thickness skin loss and damage to the deepest layer of skin) reported during the period. Protecting patients from avoidable harm is something to which there is universal agreement and the Trust has clearly defined processes and procedures to follow to help to reduce the risk of these events occurring. However, where a serious incident does occur, lessons need to be learnt through a process of root cause analysis (RCA) investigation and actions taken to prevent reoccurrence. Some of the learning from these Serious Incidents during 2016/17 includes the following: Area Division Summary Maternity screening test Maternity appointment management Information security Maternity Maternity Maternity Ensure women who have had their first scan before 20 weeks gestation are offered the Down s screening blood test. Antenatal clinic appointments with the Obstetrician should be booked after the scan when a woman is a late booker. Community staff to transport minimum data required to support daily community visits and ensure it is secured at all times. Fall prevention Medicine Falls risk assessments must be reviewed after each patient fall as per hospital policy. Timely senior clinical review Medicine Ensure patients have a senior review in a timely manner despite hospital pressure from unplanned extra capacity. Records keeping Medicine A&E clerking booklet must be utilised and appropriately documented. NEWS compliance Medicine Review of the role of NEWS in A&E to update the Trust policy accordingly. Sepsis treatment management Medicine Intensive staff education and Trust-wide communication to be provided on the recognition and treatment of sepsis in its many different manifestations EoLC Medicine Information relating to a patient s Advanced Care Plan should be confirmed at the time of the patient s admission. Hospital internal transfer Medicine Appropriate hand over should happen when a patient is transferred to a different ward to ensure continuity of care 128

129 Annual Report and Accounts 2016/17 Area Division Summary Communication Maternity Communication between the community midwives and the hospital, between the staff and the different ward areas, and between the staff and our patients needs to be improved and given the highest priority. Review of diagnostic imaging Patient experience and communication Medicine Medicine Communication between radiologists and referring clinicians should be reinforced to enable earlier identification and action upon all tests results, particularly in the face of increased activity levels on each service. Patient s experience and communication should be enhanced to involve and empower patients in their treatment and care journey, and ultimately to improve patient s safety and experience. Electronic records Medicine The Gastroenterology department needs to ensure they accurately record all faxes received and work towards moving to an electronic system. Estates on-call response Diagnostic imaging reporting Maternity Medicine During a power outage it is vital a timely response is provided by the on-call team to ensure a prompt return of the power supply. A more robust radiology alert system is required to ensure that all significant findings are sent to the referrer and multidisciplinary team co-ordinator. Cancer Pathway Medicine It is important to consider the patient s past medical history of cancer when reviewing results from diagnostic tests and deciding on the next appropriate investigations. Biochemistry testing Following best practice and guidelines Pressure ulcer prevention Medicine Surgery and Anaesthetics Paediatrics The process for registering all relevant laboratory analysers with the EQA scheme needs to be more robust. The Trust needs to implement and adhere to guidance on urgent management of stone-forming patients who may be at risk of loss of renal function. Patients with learning / communication difficulties should have change of cast, when clinically safe to do so, to enable skin inspection. Records keeping Medicine When patients decline investigation there must be clear documented evidence in the medical notes of the discussion that reasonable alternatives have been explored in full. The documentation should include the patient refusal of other options explored. Medication Safety Medicine Student Nurse should have limited and appropriately supervised medication duties during their placement. Drug stock Medicine Appropriate stock of the correct oral syringes should be maintained within all departments in the hospital to enable good and safer practice. Patient discharge Medicine Patient should be promptly reviewed by senior and medical staff before being discharged home. Documentation of management plan Maternity All members of the neonatal team must document clearly the management plan, the response to therapy and the reasons for transfer to a tertiary centre. 129

130 The Hillingdon Hospitals NHS Foundation Trust Area Division Summary Cardiotocography (CTG) Monitoring London Ambulance Service (LAS) handover Fall assessment for high risk patients Anti-coagulation treatment management One-to-one supervision Communication within multidisciplinary team Musculoskeletal examination Maternity Medicine Medicine Medicine Medicine Medicine Medicine It is important to carry out a yearly CTG training to ensure staff are able to categorise, classify and escalate abnormal CTGs in a timely manner. The staff must be assured that they can care for a patient appropriately when receiving a handover from the LAS. All patients over 65 should be considered at a high level of risks of falls as per Trust policy. To reinforce the process of recognising and escalating high risk patients under anti-coagulation medication. If a patient has a one-to-one in place, when the patient is transferred to another ward, there should still be a one-to-one in place on each ward for the patient. Timely escalation and communication of vital clinical observations among members of the multi-disciplinary team should occur to ensure concerns on management are addressed without delay. The importance of an appropriate musculoskeletal screening upon relevant patients admissions is vital to avoid any missed diagnosis and delay in treatment. Serious incident and Never Event actions plans based on the learning from investigations are implemented and monitored via clinical divisional governance boards until fully completed. Directorled panel investigation reports and action plans are approved and reviewed by the Trust Board until fully completed. As part of our duty in being open and honest with patients and their families, the findings from serious incident investigations are shared with them and information is provided on the learning and the actions that the Trust is taking forward to prevent reoccurrence. Statutory Duty of Candour Key recommendation from the Francis Inquiry The Duty of Candour was passed by Parliament on 6 November 2014 and took effect on 27 November This places a requirement on providers of healthcare to be open with patients when things go wrong. Providers are required to establish the duty throughout their organisation ensuring honesty and transparency are the norm. What is the Statutory Duty of Candour? Where a notifiable safety incident has happened a health service organisation must as soon as reasonably practicable: Notify the patient, or their families that a safety incident has happened and apologise Provide an account of all the facts known about the incident Advise the patient what further enquiries into the incident are appropriate Provide reasonable support to the patient Follow up in writing confirming the information and results of further enquiries and an apology. What is a notifiable safety incident? Any unintended or unexpected incident that occurred in the organisation s care that resulted in or appears to have resulted in: Death directly related to the incident; or Severe harm, moderate harm or prolonged psychological harm (at least 28 days). 130

131 Annual Report and Accounts 2016/17 What does moderate harm mean? Moderate harm means: Harm that requires a moderate increase in treatment, and Significant, but not permanent harm. Moderate increase in treatment means: an unplanned return to surgery, an unplanned readmission, a prolonged episode of care, extra time in hospital or as an outpatient, cancelling treatment, or transfer to another treatment area (e.g. intensive care). How is the Trust implementing the Duty of Candour? The Trust has ensured that the Duty of Candour has been fully integrated into the Trust s Incident Reporting and Being Open policies. Processes and systems have been implemented to ensure the legal and contractual requirements of the Duty of Candour are met. Staff awareness on the Duty of Candour has been raised via training and discussions at divisional meetings. Moderate and above severity incidents and action plans are monitored at divisional governance meetings and learning is shared via divisional governance forums and through team discussions. The Trust has put in place a robust monitoring system managed by the governance department staff with performance reports to divisional governance boards and the Patient Safety Committee. 131

132 The Hillingdon Hospitals NHS Foundation Trust Commissioning for Quality and Innovation (CQUIN) targets The key aim of the CQUIN framework is to secure improvements in the quality of services and better outcomes for patients, whilst also maintaining strong financial management. In 2016/17 there were eight acute CQUIN schemes agreed, of which three were national and four were locally derived with Hillingdon Clinical Commissioning Group. One scheme focused on integration of IT systems; this scheme was applied across the whole of NW London with milestones being mirrored across NHS providers. In 2016/17, we have achieved 95% of our acute CQUIN target demonstrating a consistently excellent performance. In 2015/16 we achieved 83%. Having either fully or partially achieved all of our CQUINs for 2016/17 means that the quality of our services and the care that we deliver to our patients has continued to improve. CQUIN targets 2016/17 Achievement Commentary National Schemes Improving the health and wellbeing of NHS staff, visitors and patients 100% achievement This is the first year that the Trust has been working on this three year CQUIN with three key aims; to support the health and wellbeing of NHS staff members to provide healthy food options for patients, visitors and staff, and to promote uptake of the annual flu vaccination Improving identification and treatment of patients with suspected sepsis Reducing unnecessary use of antibiotics Partial (89%) achievement Partial (50%) achievement Progress has been very good to date and further improvement is anticipated over the next two years. The Trust is now consistently screening more than 90% of relevant A&E attendances for possible sepsis, and timely screening of patients on hospital wards has been improving throughout the year. In the majority of cases where possible sepsis is identified, patients receive treatment within one hour. The Trust is focusing on further improving the speed with which prescribed antibiotics are administered. The Trust has fully achieved all targets relating to timely review of antibiotic prescriptions. However, whilst the Trust did achieve a reduction in overall prescription of antibiotics, we did not achieve reductions in use of two specified drugs. The drugs for which they did not achieve a reduction are used as a first line treatment in cases of suspected sepsis. 132

133 Annual Report and Accounts 2016/17 CQUIN targets 2016/17 Achievement Commentary Regional Scheme Developing IT systems to support integrated care 100% achievement Local Schemes Evaluating current demand for hospital outpatient services and the implications on capacity requirements Providing specialist support, advice, and guidance to GPs, that will enable more patients to be cared for out of hospital where appropriate Providing evidence of best practice in safe and effective handover of patients (from day shift to night shift, and night shift to day shift) including at weekends 100% achievement 100% achievement 100% achievement Implementing an electronic handover system Improving services for patients approaching the end of their life, and supporting them to spend their last days in their preferred environment 100% achievement 2.5% of The Hillingdon Hospitals NHS Foundation Trust s income in 2016/17 was conditional on achieving quality improvement and innovation goals agreed between the 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. Total CQUIN income for 2016/17, is expected to be 3,343,366 (95%) for National, Regional, and Local schemes and 167,705 (100% of potential available income) for Specialised CQUIN schemes. In the previous year (2014/15) total income was 2,763,190 (83% of potential available income) for National, Regional, and Local schemes and 166,044 (100% of potential available income) for Specialised Commissioning. operation of controls over the Trust s procedures for achieving CQUIN targets. They looked in detail at processes employed and governance arrangements as well as the systems used to provide evidence of achievement. Their overall assessment was of substantial assurance. Further details of the agreed goals for 2017/18 and for the following 12-month period are available electronically at pubs/index.php Alternatively, please contact our PALS team on if you require a paper copy. In January 2015, an internal audit was conducted by TIAA to form an opinion on the design and 133

134 The Hillingdon Hospitals NHS Foundation Trust Care Quality Commission (CQC) registration The Hillingdon Hospitals NHS Foundation Trust is required to register with the CQC and its current registration status is that it is registered without conditions. The CQC has not taken enforcement action against the Trust during 2016/17. The Hillingdon Hospitals NHS Foundation Trust has not participated in any special reviews or investigations by the CQC during the reporting period. The Trust however, was inspected by the CQC in October 2014 as part of its planned and more detailed inspection regime. The final reports were published on 10 February The Trust was rated as Requires Improvement overall. The Trust received a good rating for the caring domain across all of its services; members of staff were observed to be kind and had a caring and compassionate manner. Most of the people that the inspection team spoke with said that care was given in a kind and respectful way. The Trust was issued with formal warning notices against: Regulation 10 Assessing and Monitoring the Quality of Service Provisions Regulation 12 Cleanliness and Infection Control. The Trust was also issued with five Compliance Notices against: Regulation 13 Management of Medicines Regulation 15 Safety and Suitability of Premises Regulation 16 Safety, Availability and Suitability of Equipment Regulation 20 Records Regulation 22 Staffing. The Board considered the overall rating ( Requires Improvement ) to be fair. All of the recommendations were accepted and the Board agreed a detailed action plan to make the necessary improvements. The findings provided a real impetus to ensure our assessment of the quality of our services fully encompassed review of systems and processes that our staff members follow, in addition to achieving key quality indicators and positive patient outcomes. The Trust has continued to sustain compliance rates for staff training for all statutory and mandatory training above the 80% or more compliance target, the majority of which are now achieving 90%. The Trust also adopted cleaning targets in line with the national specifications for cleanliness and has exceeded its targets during 2016/17. Recent infection prevention and control audits show improved compliance for hand hygiene and Bare below the elbows practice and our safeguarding children and adults arrangements have continued to be strengthened with excellent partnership working with local health and social care partners. We have made significant improvements on medicines management and security of medicines in our clinical areas. However, mock inspections show that the Trust is challenged with regard to adequate storage facilities to ensure clinical and pharmaceutical supplies are stored appropriately. Actions are being taken forward where further improvement is required. Following the CQC s re-inspection of the Trust on 5 and 7 May 2015: warning notices against regulations 10 and 12 were de-escalated the four red Inadequate ratings in the Safe domain against urgent and emergency care, medical care, surgery and services for children and young people were changed to Requires improvement An overall rating of Requires improvement was given for the Safe domain A requirement notice against Regulation 12: Safe Care and Treatment for Cleanliness and Infection Control was issued. The grid below provides an overview of our ratings based on re-inspection of the Trust on 5 and 7 May 2015; the report was published on 7 August The Trust has been working through a detailed improvement plan since the CQC published its report and this has been presented to the Trust s Quality and Safety Committee on a quarterly basis. 134

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136 The Hillingdon Hospitals NHS Foundation Trust KPMG recently undertook a review of the Trust s compliance against the CQC s Key Lines of Enquiry (KLOE), as part of the Trust s internal audit programme. The audit report acknowledges the overall quality improvements made by the Trust since its last inspection and outlines recommendations for further improvement to support compliance in some key areas of practice to support patient safety. The Trust s CQC action plan will be refreshed in line with the KPMG review recommendations and monitored by the Regulation and Compliance Committee with escalation to the Quality and Safety Committee. The Trust s ambition is to achieve an outstanding (with good as a minimum) CQC rating at future inspection. Moving forward, the Trust has agreed a programme of mock inspections using internal peer review and each core service will be benchmarked against the CQC inspection assessment frameworks to provide assurance on compliance and for key areas of improvement to be identified. The Trust s Board and management seek to take all reasonable steps and exercise appropriate due diligence to ensure the accuracy of the data reported in relation to the quality indicators outlined in the Quality Report, but recognises that it is nonetheless subject to the inherent limitations outlined within the statement from the Chief Executive Officer earlier in this report. Information Governance Toolkit The Hillingdon Hospitals NHS Foundation Trust s Information Governance Assessment Report overall score for 2016/17 was 82% and was graded green. This is termed as satisfactory with all requirements level 2 or above. Clinical coding error rate The Hillingdon Hospitals NHS Foundation Trust was not subject to the Payment by Results Clinical Coding Audit during 2016/17 by the Audit Commission. The Hillingdon Hospitals NHS Foundation Trust has not participated in any special reviews or investigations by the CQC during the reporting period. Data quality At the time of writing, The Hillingdon Hospitals NHS Foundation Trust are able to report on records submitted during April 2016 to December 2016 to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data: which included the patient s valid NHS number were: 99.0% for admitted patient care 99.8% for out-patient care and 96.5% for A&E care. which included the patient s valid General Medical Practice Code were: Action taken to improve data quality The Hillingdon Hospitals NHS Foundation Trust will be taking the following actions to improve data quality: Continue the comprehensive monitoring programme for data quality across the organisation through divisional based groups led by the Director of Operational Performance The quality of 18 week RTT incomplete pathway data and A&E performance data will continue to be reviewed monthly at the elective performance meetings, and also be the subject of internal data quality audits reported up to the Trust Audit and Risk Committee Trust Board Indicators assurance - regular review and local auditing Expanding the Data Quality Programme to include other key datasets used at key committees A continued focus on 18 week RTT training across the Trust for new and existing staff members % for admitted patient care; 100% for out-patient care; and 100% for A&E care.

137 Annual Report and Accounts 2016/17 137

138 The Hillingdon Hospitals NHS Foundation Trust 2.3 Performance against Core Quality Indicators 2016/17 In this part of the report the Trust is required to report against a core set of national quality indicators to provide an overview of performance in 2016/17. The following page provides information which has been obtained from the recommended sources and is presented in line with the detailed NHSI guidance. Data Inconsistencies A number of indicators are showing changes to 2016/17 data that was published in last year s Quality Report. There are several reasons for this as follows: 1 The statutory timescale within which the Quality Report is published is very tight. Not all of the latest data was available at the time of publication last year and so the Trust has taken the opportunity to update 2016/17 indicators with full year updates which are now available 2 National Indicators based on statistical methods by definition require re-basing. For example, standardised readmissions, HSMR and SHMI 3 Data quality or data completeness issues may have affected last year s indicators. If these have been identified then they have been rectified in this year s report. Indicator 1: Summary Hospital-level Morality Indicator (SHMI) Trusts are categorised into one of three bands: Where Trust s SHMI is higher than expected Band 1 Where the Trust s SHMI is as expected Band 2 Where the Trust s SHMI is lower than expected Band 3. The SHMI for the Trust, published in March 2017, was (benchmark period October 2015 to September 2016) Band 2 HES data. The Hillingdon Hospitals NHS Foundation Trust considers that this data is as described because it is issued to us by the Health and Social Care Information centre. Furthermore, the data is monitored at the monthly executive board meetings and triangulated with other data to understand meaning and highlight any issues. The Trust intends to improve this indicator, and so the quality of its services, by continuing to progress the implementation of the London Quality Standards and use our new Quality and Safety Improvement Strategy (2016 to 2021) to guide future actions which should be reflected in a sustained SHMI performance. Indicator 2: Palliative Care Coding Use of the palliative care codes has stabilised over the last few years and our coding rate (for deaths specifically) is marginally higher than last year and in line with the national average. The Hillingdon Hospitals NHS Foundation Trust considers that this data is as described because it is monitored on an ad hoc basis by clinical staff with support from our clinical coding team using the information that is available on the Trust s Information Management system. This provides daily refreshed information to proactively manage Trust performance through a framework of data integration and personalised reporting during patients care. The Trust intends to improve this indicator, and so the quality of its services, by further strengthening the data validation process via the implementation of monthly data validation. 138

139 Annual Report and Accounts 2016/ /16 Performance Target Performance London Trusts National Benchmark Source Benchmark Period Lowest Performing Trust Highest Performing Trust 1: Summary Hospital-Level Mortality (SHMI) (Band 3 Lower Than Expected) n/a (Band 2 Lower Than Expected) n/a n/a NHS Digital Oct-2015 to Sep-2016 WYE VALLEY NHS TRUST Band 1 (Higher Than Expected) THE WHITTINGTON HOSPITAL NHS TRUST Band 3 (Lower Than Expected) 2: the percentage of patient deaths with palliative care coded at diagnosis 28.8% n/a 28.3% n/a 29.6% NHS Digital Oct-2015 to Sep-2016 THE WHITTINGTON HOSPITAL NHS TRUST 0.4% GEORGE ELIOT HOSPITAL NHS TRUST 56.3% 3: Emergency readmissions to hospital within 28 days of discharge from hospital: children of ages 0-15 [Standardised] (Crude) 4: Emergency readmissions to hospital within 28 days of discharge from hospital: Adults of ages 16+ [Standardised] (Crude) The latest HSCIC publication was on Dec-2013 covering 2011/2012 data The next publication was due Aug-2016 but now the website states TBC see Section Compendium of population health indicators > Hospital Care > Outcomes > Readmissions Last Checked 13/04/2017 5: Clostridium difficile 12 Cases (7.9 Cases per 100,000 Beddays) 8 Cases (Lapes of Care Only) 12 Cases (6.8 Cases per 100,000 Beddays) 14.7 Cases per 100,000 Beddays 14.9 Cases per 100,000 Beddays PHE Apr-2015 to Mar THE ROYAL MARSDEN 38 Cases (66.0 Cases per 100,000 Beddays) MOORFIELDS EYE HOSPITAL (+3 other Trusts) 0 Cases (0 Cases per 100,000 Beddays) 6: Venous Thromboemolism (VTE) 94.6% 95% 96.2% 96.1% 95.6% NHS England Apr-2016 to Dec-2016 WESTON AREA HEALTH NHS TRUST (2016/2017 Q3 only) 76.48% SOUTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST (+4 other Trusts) (2016/2017 Q3 only) 100% 7: PROMS (Health Gain), Groin Hernia, EQ-5D Index/VAS / n/a / n/a / NHS Digital Apr-2015 to Mar-2016 (Provisional) THE WHITTINGTON HOSPITAL NHS TRUST NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST -10 SALISBURY NHS FOUNDATION TRUST CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION TRUST : PROMS (Health Gain), Hip Replacement, EQ-5D Index/VAS / n/a / n/a / NHS Digital Apr-2015 to Mar-2016 (Provisional) SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST ST GEORGE S UNIVERSITY HOSPITALS NHS FOUNDATION TRUST ST GEORGE S UNIVERSITY HOSPITALS NHS FOUNDATION TRUST BARNSLEY HOSPITAL NHS FOUNDATION TRUST : PROMS (Health Gain), Knee Replacement, EQ-5D Index/VAS / n/a / 4.25 n/a / NHS Digital Apr-2015 to Mar-2016 (Provisional) HOMERTON UNIVERSITY HOSPITAL NHS FOUNDATION TRUST EAST SUSSEX HEALTHCARE NHS TRUST NORTH TEES AND HARTLEPOOL NHS FOUNDATION TRUST ST GEORGE S UNIVERSITY HOSPITALS NHS FOUNDATION TRUST : PROMS (Health Gain), varicose vein (Primary), EQ-5D Index/VAS 0.03 / n/a 0.139/ -2.5 n/a / NHS Digital Apr-2015 to Mar-2016 (Provisional) UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION TRUST HAMPSHIRE HOSPITALS NHS FOUNDATION TRUST WRIGHTINGTON, WIGAN AND LEIGH NHS FOUNDATION TRUST : Percentage of staff employed by, or under contract to, the Trust during the reporting period who would recommend the Trust as a provider of care to their family of friends 66% n/a 64% n/a 70% NHS Staff Survey 2016 National NHS Staff Survey Report n/a n/a 12: Trust s responsiveness to personal needs of our patients 62.2% n/a Available June 2017 n/a n/a NHS Digital Aug Jan 2017 CROYDON HEALTH SERVICES NHS TRUST 54.4 THE ROYAL MARSDEN NHS FOUNDATION TRUST : [a] The number, and where available, rate of patient safety incidents reported within the period, and; [b] the number and percentage of such patient safety incidents that resulted in severe harm or death 5372 (35.16/1000 beddays) 22 (0.4%) n/a 5905 (40.01/1000 beddays) 28 (0.5%) 37.17/1000 beddays 0.5% 38.58/ 1000 beddays 0.4% NPSA NHSI Apr-2015 to Mar-2016 MEDWAY NHS FOUNDATION TRUST 14.77/1000 beddays THE WHITTINGTON HOSPITAL NHS TRUST 2.0% WYE VALLEY NHS TRUST 75.91/1000 beddays ROYAL DEVON AND EXETER NHS FOUNDATION TRUST 0% 14: Self certification against compliance with requirements regarding access to healthcare for people with a learning disability Fully Compliant Fully Compliant Fully compliant n/a n/a n/a n/a n/a n/a 139

140 The Hillingdon Hospitals NHS Foundation Trust Indicators 3 and 4: Emergency readmissions to hospital within 28 days of discharge The Hillingdon Hospitals NHS Foundation Trust considers that this data is as described for the following reasons: Emergency readmission to hospital shortly after a previous discharge can be an indicator of the quality of care provided by an organisation. Not all emergency readmissions are part of the original planned treatment and some may be potentially avoidable. Reducing the number of avoidable readmissions improves the overall patient experience of care and releases hospital beds for new admissions. However the reasons behind a readmission can be highly complex and a detailed analysis is required before it is clear whether a readmission was avoidable. For example, in some chronic conditions, the patient s care plan may include awareness of when his or her condition has deteriorated and for which hospital care is likely to be necessary. In such a case, a readmission may itself represent better quality of care. The Hillingdon Hospitals NHS Foundation Trust monitors the readmission rate using the national data sources and also through Dr Foster, an independent leading provider of healthcare intelligence. The Trust intends to improve this indicator, and so the quality of its services, by continuing to work collaboratively with our partners supporting the many schemes that are helping to reduce readmission rates and to ensure our patients are cared for in the most appropriate setting. Crude figures offer a number equal to the number of readmissions divided by discharge and is a standard that cannot be compared to other Trust s. Standardised figures on the other hand look at case mix and adjusts for population but unfortunately, such data is not available. This is the reason the Emergency readmissions to hospital within 28 days of discharge sections have been left blank in the Core Quality Indicators table. 1 The CQUIN for readmission finished in 2015/16 financial year 2 The automated alerts remain in place, but very few areas are undertaking the same intense system and process to understand the root cause 3 The overall readmission rate has continued to reduce there are several schemes via the Better Care Fund and the Accountable Care Partnership and the ambulatory clinics that continue to contribute towards this 4 All of the GPs in the borough continue to receive an automated at risk of readmission score (PAR) for all NEL patients which some of the practices are actively using as part of their risk stratification process; there are plans for Care Connection teams to be rolled out across the borough and this will help GPs to embed, looking at and using this score. 140

141 Annual Report and Accounts 2016/17 Indicator 5: Clostridium difficile (C. diff) The Hillingdon Hospitals NHS Foundation Trust considers that this data is as described because the Trust reported a total of 12 C. diff infections in 2016/17 with two lapses in care against a threshold of eight (lapses in care). This is an equal number of cases when compared with 2015/16: Chart 1: Trust attributed C. diff infections Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2015/ / Total

142 The Hillingdon Hospitals NHS Foundation Trust An RCA is undertaken for all cases of Trust attributed C. diff, with the Consultant in charge of care, Consultant Microbiologist, Deputy Director of Infection Prevention and Control, Infection Control Nurse, Ward Sister and responsible Matron forming a panel as part of this process. During 2016/17 all RCA investigation reports were presented to the CCG representative for review and scrutiny as to establish agreement regarding any lapses in care. Of the 12 cases presented to the CCG two were considered to have lapses in care and potentially avoidable as antibiotics were not prescribed in accordance with the Trust Antimicrobial Guidelines. The remaining 10 cases were predominantly elderly patients presenting as emergency admissions, acutely unwell with a history of clinically indicated antibiotic treatment in line with Trust Antimicrobial Guidelines. Antimicrobial Stewardship remains of paramount importance in the prevention of hospital acquired C. diff and there is now a full time Antimicrobial Pharmacist working in the Trust helping to increase awareness and knowledge of good prescribing practice and stewardship. The Trust intends to improve performance on this indicator and so the quality of its services, by progressing a refreshed annual infection control action plan with robust oversight by the Infection Control Committee during 2017/18. The CQUINs for 2017/18 which cover the assessment of clinical antibiotic review between 24 and 72 hours of patients with sepsis, who are still inpatients at 72 hours and the reduction in antibiotic consumption per 1,000 admissions, will assist in improving antimicrobial stewardship and patient safety further. The Trust intends to take the following actions to improve this indicator, and so the quality of its services: Continuing to undertake a full review of all C. diff Trust attributed cases by means of RCA investigations to allow any learning to occur Ensure actions and enforce where learning is found with regard to C. diff Continue to drive compliance to antimicrobial policy Maintain antimicrobial prescribing training at all IP&C updates Improve on a more strong and visible presence at ward level of the Infection Prevention and Control Team Continue to undertake joint audit work with the facilities staff to ensure that on-going standards of cleanliness are maintained. Indicator 6: Venous Thromboembolism (VTE) Venous thromboembolism or blood clots are a major cause of death in the UK. Some blood clots can be prevented by early assessment of the risk for an individual patient. The Hillingdon Hospitals NHS Foundation Trust considers that this data is as described for the following reasons; VTE risk assessment compliance for 2016/17 was 96.2% compared with 94.6% for 2015/16 and is monitored within the Trust clinical governance system. Furthermore, of 1,893 VTE examinations performed 52 were reported as VTE positive. On investigation, 11 of these patients were reviewed as being hospital acquired events. This compares to 2015, whereby 1,838 VTE examinations were performed and 39 scans were reported as VTE positive. On investigation, 12 of these patients were reviewed as being hospital acquired events. The Trust intends to take the following actions to improve this indicator, and so the quality of its services: staff education including junior doctors during their induction and nursing staff during education on documentation and drug administration documentation with checklists, which include VTE assessment, in medical notes involvement of ward pharmacists as part of the multi-disciplinary team to draw attention to any omissions on drug charts; modification of the drug chart to aid in ease of VTE risk assessment has been approved standard clinical practice that no patient is admitted to a clinical area without a VTE assessment completed. 142

143 Annual Report and Accounts 2016/17 The Trust has taken steps to understand the risk to patients and to share learning by RCA investigation of all identified cases of VTE during the past year found to be Hospital Acquired Thrombosis (HAT) - defined as a VTE which occurs during admission or within 90 days of discharge from hospital. We plan to respond and learn by: HAT RCA reports to be undertaken by the admitting team with the assistance of VTE experts via the VTE committee, to allow learning both at a local and organisational level. progressing the project to implement electronic prescribing which will contribute to improvements in the level of VTE risk assessment compliance and prophylaxis comparing year on year HAT to identify evidence of learning in addition to HAT divisional governance reporting and monitoring. Indicators 7, 8, 9 and 10: Patient Reported Outcome Measures (PROMs) The Hillingdon Hospitals NHS Foundation Trust considers that this data is as described for the following reasons; PROMs data is obtained through a pair of questionnaires completed by the patient, one before and one after surgery (at least three months after). Patients self-reported health status (sometimes referred to as health-related quality of life) is assessed through a mixture of generic and disease or condition-specific questions. For example, there are questions relating to mobility, self-care, such as washing and dressing, usual activities, such as work, study, house work, family or leisure activities, pain/ discomfort or anxiety/depression. For the purposes of the Annual Quality Report the PROMs data being reviewed is for the full year 2015/16. This is due to the fact that the data is available a year in arrears due to the lag in patients submitting questionnaires in the post-operative period. This is followed by a period of statistical validation and as such 2016/17 data is not expected until February to March In 2015/16 there was a decrease in the number of patients issued with pre-operative questionnaires. This was mainly attributed to the varicose veins and groin hernia patients. Our PROMs pre-operative issue rates for hip and knee replacements are higher than for groin hernia and varicose veins and this is due to the fact that questionnaires are given to patients at the pre-operative joint school. There is no such service provision for groin hernias and varicose veins because the services are set up in a different way. However there is commitment to improve our performance against this standard through the use technology to automate the process by which questionnaires are sent out to patients who are planned to undergo varicose vein and groin hernia procedures. In 2015/16 we achieved a participation rate of 68.6% (same as that of 2014/15) where of the 601 post-operative questionnaires sent out 412 were returned to the external company (Quality Health) that administers the post-operative PROMs data collection for the Trust. This compares to a 69.8% participation rate in England. The Trust intends to improve this indicator, and so the quality of its services, by continuing to increase its response rate for these four indicators to gain a more accurate picture of the impact our services. Furthermore, it plans to improve the scores received by identifying and sharing best practices with other Trust s and communicating more realism to patients concerning their expectations about the outcome of their planned treatment. Indicator 7: Groin hernia In 2015/16, the number of post-operative questionnaires returned was less than 30 and therefore could not be processed statistically. This means that the Trust was not allocated a score against this measure. Indicator 8: Hip replacement In 2015/16, patients continued to report a similar average improvement in health. When benchmarked against other providers in England, the hospital s results are lower than the national average in 2014/15. Indicator 9: Knee replacement In 2015/16, patients reported an average improvement in health. When benchmarked 143

144 The Hillingdon Hospitals NHS Foundation Trust against other providers, the hospital s results are similar to the England average, an improvement from that of 2014/15. The Trust intends to take the following actions to improve this indicator, and so the quality of its services, by identifying and sharing best practices with increasing the participation of patients to gain a more accurate picture of the impact our services have on patient reported health outcomes. Certain outcome measures report a patient s overall experience of surgery whereas other measures report more of an objective clinical measure. Whilst the results in this measure continue to be below national average there has been a marked improvement in the average improvement in health reported by patients compared to 2014/15. The Trust is just below the England average. The managerial and clinical teams intend to continue to make improvements against this measure with a view to it being in line with the England average by Indicator 10: Varicose Vein The Trust continues to perform well in this measure while recognising there is an opportunity for further improvement. Indicator 11: Staff Survey including Friends and Family Test question (SFFT) The Hillingdon Hospitals NHS Foundation Trust considers that this data is as described for the following reasons; The annual staff survey is used to understand staff experience and perceptions on a wide range of subject areas. The survey is undertaken by all NHS organisations enabling comparisons between similar Trusts and to compare the experiences of staff in a particular Trust with the national picture. The results below demonstrate the overall response to the SFFT questions within the 2016 Staff Survey: In response to the question: I would recommend my organisation as a place to work, 63% Agreed and Strongly agreed in 2016, compared to the total number of staff that responded. The average (median) for acute Trusts was 62% In 2015, the Trust achieved 65% In response to the question: If a friend or relative needed treatment, I would be happy with the standard of care provided by this organisation, 64% Agreed and Strongly agreed in 2016, compared to the total number of staff that responded. The average (median) for acute Trusts was 70% In 2015, the Trust achieved 66%. The Trust intends to improve this indicator, and so the quality of its services, by introducing pulse surveys to obtain regular snapshots of employee engagement and experience across the whole organisation or in specific areas, with certain staff groups in order to improve the response rate. It will also take the following actions to improve this indicator, and so the quality of its services, through a variety of programmes providing a sustained focus on improving staff experience. This includes extending the CARES ambassador programme to everyone in the Trust and working with our staff to build a brand as an employer of choice. Workforce Race Equality Standard (WRES) The scores presented below are split between White and Black and Minority Ethnic (BME) staff, as required for WRES. Our Trust in % Average (median) for acute Trusts 24% Our Trust in % Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months Percentage of staff believing that the organisation provides equal opportunities for career progression or promotion White BME 24% 87% 27% 88% 22% 90% White BME 77% 76% 73% 144

145 Annual Report and Accounts 2016/17 Indicator 12: Responsiveness to inpatients personal needs The Hillingdon Hospitals NHS Foundation Trust considers that this data is as described for the following reasons; This is a composite score from five questions taken from the CQC Inpatient Survey. Being involved in decisions about your care and treatment Finding someone to talk to about worries and concerns Being given enough privacy when discussing your condition and treatment Informing patients about medication side effects to watch out for after going home Knowing who to contact if worried about condition or treatment after leaving hospital. The Trust is currently awaiting the 2016/17 survey report which will be published in June 2017 with regard to being able to report the composite score of the above five questions. However, the Trust achieved 62.2% in 2015/16 compared with 63.3% in 2014/15. The Trust intends to improve this indicator, and so the quality of its services, by critically reviewing this data once it is received and formulating an improvement plan to improve performance on this indicator. Indicators 13a and 13b: The number, and where available, rate of patient safety incidents reported within the period, and; the number and percentage of such patient safety incidents that resulted in severe harm or death Trust is in the middle 50% of reporters for acute (non-specialist) organisations with a rate of incidents per 1,000 bed days (3,095 incidents). Organisations that report more incidents usually have a better and more effective safety culture and learning and improving as a result is more likely if the problems are recognised beforehand. Furthermore, 16 patient safety incidents resulted in severe harm or death compared to 19 such incidents between 1 October 2014 to 31 March This decrease is in line with the London and national figures. The Hillingdon Hospitals NHS Foundation Trust considers that this data is as described because prior to uploading to the NRLS, incident reports and all data therein they are reviewed by the Trust Patient Safety team, ensuring they are quality assured. The Datix system also alerts any errors during the exporting process which are corrected prior to the NRLS upload occurring. The Trust intends to take the following actions to improve this indicator, and so the quality of its services, by: Continuing to raise awareness of the importance of incident reporting and in particular near misses and no/low harm incidents (this will ensure learning to avoid the more harmful incidents from occurring) Ensuring there is more robust feedback on actions taken provided to reporters to ensure staff see the value of reporting patient safety incidents Continuing to ensure there is detailed root cause analysis investigation of all moderate/severe/ death reported incidents to support learning and changes in practice. Between 1 April 2015 and 31 March 2016, the Trust s rate of reporting patient safety incidents increased to per 1,000 bed days (5,905 incidents) compared with per 1,000 bed days (5,372 incidents) between 1 April 2014 and 31 March This is positive progress as part of an improved patient safety culture. Between 1 October 2015 and 31 March 2016, comparative data from the National Reporting and Learning System (NRLS) shows that the 145

146 The Hillingdon Hospitals NHS Foundation Trust Indicator 14: Access to healthcare for people with a learning disability The Trust ensures staff awareness with regard to the need to listen and make reasonable adjustments for those with learning disability. Clinical and nonclinical members of staff receive awareness training as part of their mandatory safeguarding training making them more aware of the needs of learning disability patients and their carers. The Trust s Good Practice Guidelines for staff working with people with learning disabilities remain in place. There are also care pathways for patients with learning disabilities in A&E, outpatients and the radiology department. Patients with a learning disability can provide feedback to the Trust on their experience by completing an easy-read survey. The Trust has remained fully compliant with this key indicator. The Trust intends to improve this indicator, and so the quality of its services, by continuing to raise awareness amongst its staff and ensure that its best practice guidance on caring for patients with a learning disability is followed so as to maintain performance on this indicator. From March 2017, the Trust is hosting one of the Learning Disability Nurses from the community team one day per week. They will work with the Head of Safeguarding Adults to support and enhance the care for patients with a learning disability. Improving services for people with a sensory disability The Trust has met the key requirements of AIS, namely: A working group of relevant Trust staff have met and contributed to the AIS solution Patient records at The Hillingdon Hospitals NHS Foundation Trust have been adapted to record the communication needs of patients with disability or sensory loss The responsibilities of AIS have been communicated to Trust staff Patients can register for AIS on the Trust web site, Patients/PatientLeaflets/AccessibilityA5Leaflet4. pdf. Otherwise, AIS leaflets with an application form will be placed in Outpatient areas and A&E at the end of October Hearing loops have also been installed in public areas across the Trust which not only improves communication for these patients but also ensures their privacy, dignity and well-being. Signage has been improved across both sites to ensure easier way-finding for patients and visitors. In addition the Trust has a contract with One Stop Language Services for the provision of BSL for patients using our services. Definitions of the two mandated indicators for substantive sample testing by the Trust s auditors are: weeks RTT for patients on incomplete pathway 2. A&E department four-hour target. Independent auditors are engaged by the council of governors of The Hillingdon Hospitals NHS Foundation Trust to perform an independent assurance engagement in respect of The Hillingdon Hospitals NHS Foundation Trust s quality report for the year ended 31 March 2017 and certain performance indicators contained therein. As a result of the audit, the following steps have been undertaken to improve data quality for these two indicators: 1. The Trust is rolling out a new online training package and will be ensuring all staff that record 18 week RTT pathway information have undertaken the training 2. The Trust will reinforce with all staff in the A&E department the process around data entry to monitor adherence to the fourhour target. In addition, the Trust will look to remove duplication of data entry and increase the automation of the process while investigating any anomalies. 146

147 Annual Report and Accounts 2016/17 Inpatient falls Older people and those who are frail are at risk of life changing harm and increased mortality if they sustain a fracture or a head injury as a result of the fall. We therefore remain committed to ensuring we minimise this risk to patient safety through the programme of work being taken forward via the Trust-wide Falls Group under the Sign up to Safety campaign. The 2016/17 year-end rate was 4.6 falls per 1,000 bed days compared to the 2015/16 year-end rate of 4.3 falls per 1,000 bed days. This means the challenging Trust target of 3.9 falls per 1,000 bed days was not met although it must be noted these results are well within published national averages. The Trust will be participating in the next stage of the National Falls audit this year, which will provide the opportunity to re-evaluate our prevention strategies against current recommendations. In summary: The Therapy team are progressing an initiative to increase use of walking aids among relevant patients, following positive evaluation of a similar project implemented elsewhere in the country. This will be piloted in elderly care wards in May 2017 A Trust wide group has focused on methods to reduce the harm suffered from patient falls including ensuring risk assessments for each patient who may be susceptible to falling are undertaken on admission and if having to transfer to another ward. Implementing improved care plans to provide increased supervision for as many patients at high risk of falling as possible and implementing an arm s length initiative to ensure that patients have their call bell within reach to call for assistance to mobilise The Trust will continue to work hard over the next year to reduce this level of harm even further and achieve the required reduction by March

148 The Hillingdon Hospitals NHS Foundation Trust Part 3 Other key quality information and improvements we have made in 2016/17 In this part of the Report we have included the Quality of Care and Operational Performance metrics as outlined in the Single Oversight Framework against which the Trust will be monitored by NHSI. This section does not include some of the key quality indicators that were provided in last year s Report. The reader should access the Integrated Quality and Performance dashboards that are submitted to the Trust Board on a monthly basis for this other information. Indicator 1: Staff sickness The Trust is reviewing the Trust s Sickness Absence Policy as a means to further reduce sickness rates and improve sickness absence management. Indicator 2: Staff turnover The Trust is reviewing the staff skills mix in areas with high turnover, along with targeted recruitment campaigns to address work life balance as the most cited leaving reason. That is, night-only nurse recruitments. Indicator 3: Executive team turnover None of the Trust s Executive Team left during 2016/17 and as a result the turnover rate is well within the 2016/17 performance figure. Indicator 5: Proportion of temporary staff There is an ongoing effort by the Trust to reduce reliance on agency and bank staff by improving the Trust s time to recruit permanent staff. There is also greater use and uptake of the e-roster system to effectively plan and anticipate possible shifts needing to be filled by temporary staff. Indicator 6: Aggressive cost reduction plans Cost reduction plans have been identified and pursued by all Divisions across the Trust, as part of the NHS wide Quality Innovation Prevention Productivity QIPP programme. QIPP and cost reduction programmes have to be ambitious while striking a balance that does not adversely impact patient care. All cost reduction initiatives are subjected to a Quality Impact Assessment evaluation with high risk schemes assessed by a specialist panel, of the savings identified 11,256k were non-recurrent. That is, a reduction in costs which are unlikely to occur again. Successful cost reduction schemes have been effective across diverse areas of the Trust including electricity tariff renegotiation, water leakage detection, reduced agency staff spend and increased use of digital dictation and more effective use of internal facilities services. Indicator 7: Percentage of complaints responded to within agreed timescales Although often uncomfortable to hear, complaints provide us with the opportunity to learn from our patients and their families and improve the services and care we provide. When reviewing a complaint, an action plan is drawn up to address the failings identified. Examples of specific improvement actions implemented as a result of complaints include: Issue identified A patient suffered delay in receiving their followup appointment following an urodynamic test. 148

149 Annual Report and Accounts 2016/ /16 Performance 2016/17 Target 2016/17 Performance London Trusts National Benchmark Source Benchmark Period 1. Staff Sickness 3.53% 3% 3.22% 3.34% 4.30% NHS Digital Apr-2016 to Mar Staff Turnover 16% 13% 15.96% n/a n/a n/a Apr-2016 to Mar Executive Team Turnover N/A 0.00% n/a n/a n/a Apr-2016 to Mar NHS Staff Survey 2016 National 3.86 N/A 3.85 n/a 3.81 NHS Staff Survey Sep-2016 to Dec-2016 Report n/a n/a n/a n/a 5. Proportion of Temporary Staff As at Mar-16, 63.88% of shifts requiring filling were filled with bank employees and 19.97% were filled with agency employees 6. Aggressive Cost Reduction Plans 8,014K Actual 9,500K Plan 1,486K variance n/a As at Mar-17, 64.04%of shifts requiring filling were filled with bank employees and 24.55% were filled with agency employees 9,038K 15,664,252 3% to 4% of income 3% to 4% of income n/a Apr-2016 to Mar Written Complaints - rate 70.7% 90.0% 67.7% n/a n/a n/a n/a 8. Staff FFT % Recommended Care 66% n/a 64 n/a 70% nhsstaffsurveys. Apr-16 to Sep-16 com 9. Occurance of any Never Event n/a n/a n /a NHS Improvement 10. NHSE/NHSI Patient Safety Alerts outstanding 100.0% 100.0% 85.7% n/a n/a Local Apr-16 to Mar Mixed Sex Accomodation Breaches NHS England Apr-16 to Feb Inpatient Scores from FFT - % positive 95.3% 94% 96.9% 94.7% 95.4% NHS England Apr-16 to Feb A&E Scores from FFT - % positive 93.4% 94% 94.2% 85.2% 86.2% NHS England Apr-16 to Feb Emergency C-Section Rate 18.6% 16% 17.80% n/a n/a n/a n/a 15. CQC Inpatient Survey (Responsiveness to inpatients personal needs) 62.2% Awaiting data n/a n/a Picker Institute Jul-16 Europe 16. Maternity Scores from FFT - % positive 92.1% 94% 96.1% 93.6% 95.6% NHS England Apr-2016 to Feb VTE Risk Assessment Already on Core Quality Indicators List 18. C difficile - variance from Plan (Lapses in care) n/a n/a Local Apr-16 to Mar

150 The Hillingdon Hospitals NHS Foundation Trust 19. C difficile - infection Rate Already on Core Quality Indicators List 2015/16 Performance 20.MRSA bacteraemias 0.7 cases per 100,00 bed days 21. HSMR ( ) 22. HSMR - Weekend ( ) 23. SHMI Already on Core Quality Indicators List 24. Potential Under-reporting of patient safety incidents Already on Core Quality Indicators List 2016/17 Target 2016/17 Performance London Trusts case per 100,000 bed days < ( ) < ( ) 1.1 case per 100,000 bed days 83.6 ( ) 86.7 ( ) National Benchmark Source 1.8 cases per 100,000 bed days Benchmark Period PHE Apr-15 to Mar Dr Foster Apr-16 to Nov Dr Foster Apr-16 to Nov Emergency Readmissions within 30 days 7.6% Local Target 7.0% n/a n/a n/a n/a 26. A&E 4 hour Target 92.0% 95% 84.0% 90.1% 89.6% NHS England Apr-16 to Dec RTT - Patients on Incomplete Pathway 96.1% 92% 92.4% 89.6% 90.9% NHS England Apr-16 to Dec Cancer 62 Day Urgent GP Referral / NHS Screening Service 91.3% / 98.6% 85% / 90% 88.4% / 95.0% n/a 82.3% / NHS England Apr-16 to Dec % 29. Maximum 6-week wait for diagnostic procedures 0.01% 1% 0.02% 1.40% 1.50% NHS England Apr-16 to Dec-16 Definitions for the indicators are included in NHSI s Single Oversight Framework (available on 150

151 Annual Report and Accounts 2016/17 What we have done about it: A formal pathway has been developed by the gynaecology service to ensure all patients receive a follow-up appointment within six weeks of an urodynamic study. Issue identified A patient did not receive adequate pain relief after an operation. What we have done about it: New pain relief administration pumps have been purchased Staff have received additional training on pain relief and the use of the new pumps. In 2016/17 the Trust received 374 complaints, of which 93.0% were acknowledged within three working days. As the investigation period is typically 30 working days, the number of complaints on which responses were due during the financial year differs because of investigation time overlap at the beginning and end of the year. There were 353 complaint responses due during 2016/17, of which 67.7% (239) were completed within the timescale agreed with the complainant. Disappointingly, this is lower than achieved last year. Underlying reasons include staffing challenges due to sickness absence in the Complaints Management Unit and competing priorities within clinical divisions impacting on ability to respond to complaints in a timely manner. To ensure a similar situation does not happen in the future, and to build on the service improvement already implemented to improve the timeliness and quality of responses to complainants, the following actions are underway: Complaints management process is being strengthened to ensure quality-focused timedriven investigatory reports Up-skilling of individual staff within the complaints team and closer working between the PALS and Complaints teams to create a flexible, multi-skilled workforce Activity monitoring to identify surges in activity at an early stage to ensure appropriate allocation of resources Divisional teams taking a proactive role in resolving concerns at an early stage, with increased personal contact with complainant Provision of complaints investigation training for divisional and clinical teams. Indicator 9: Occurrence of any Never Event The Trust aims to continually reduce the number of Never Events that occur and encourage a transparent culture where mistakes are reported and learning is shared to improve patient safety. Patients who have suffered harm because of any medical error should rightly expect that what happened to them has been the subject of a thorough investigation to determine what happened, why and what lessons have to be learned. In August 2016, in our Medicine division, one Never Event was reported that related to wrong route administration of medication. Fortunately, the patient did not suffer any adverse effects from the incorrect administration but the findings and learnings from the investigation were shared within the Trust and with the NHS Commissioning Board and Brent, Harrow and Hillingdon CCG, to identify opportunities for learning outside the organisation. Indicator 10: NHS England / NHSI Patient Safety Alerts completed within deadline The Trust recognises and accepts its duty to distribute and action safety alert notices received via the Central Alerting System. The Trust ensures that all alerts are communicated promptly to all relevant members of staff and that action to comply with alerts is taken within DH timescales in order to safeguard patients, visitors and staff from harm. There was one delayed response to a Patient Safety Alert from the Trust to NHSI in 2016/17, which was due to a miscommunication between teams. However, the detailed action plan had already been developed and implemented. No Patient Safety Alerts are currently overdue from 2016/

152 The Hillingdon Hospitals NHS Foundation Trust Indicator 11: Mixed sex accommodation breaches The Hillingdon Hospitals NHS Foundation Trust is pleased to confirm that it continues to be compliant with the Government s requirement to eliminate mixed-sex accommodation, except when it is in the patient s overall best interest, or reflects their personal choice. We have the necessary facilities, resources and culture to ensure that patients who are admitted to our hospitals will only share the room where they sleep with members of the same sex, and same-sex toilets and bathrooms will be close to their bed area. Sharing with members of the opposite sex will only happen when clinically necessary for example where patients are clinically unwell and need high clinical input such as in the Intensive Treatment Unit. If our care should fall short of the required standard, we will undertake an RCA investigation and report it. Indicators 12, 13 and 16: FFT Since April 2013, patients have been asked whether they would recommend hospital wards and A&E departments to their friends and family if they needed similar care or treatment. This means every patient in these wards and departments is able to give feedback on the quality of the care they receive, giving hospitals a better understanding of the needs of their patients and enabling improvements. During 2016/17, the Trust received feedback from 28,201 patients who had either attended the A&E department, an outpatient department or had been an inpatient or maternity patient during 2016/17. Our results for this period are set out below. How do our FFT results compare with others? The graphs opposite show the FFT results and response rate for A&E and inpatients for 2017 (the most recently published data February 2017). Any breaches of mixed accommodation will be reported to the Trust Board through the Board quality exception reports, and audit results will be discussed with the Commissioners at the contract review meetings. Positive Responses Inpatient 95% Negative Responses Inpatient 2% Maternity 96% Maternity 1% A&E 89% A&E 5% 152

153 Annual Report and Accounts 2016/17 Chart 2: Friends and Family Test: A&E 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 87.4% 12.7% 6.7% England 85% 13.9% 7.6% London 94.1% 8.5% 1.4% THHFT Data: Feb 2017 Response Rate Percentage Recommended Percentage Not Recommended Response rate and percentage of positive and negative results for A&E The chart above shows that the response rate for A&E in February is lower than the England and London rate. We do significantly better however than England and London in relation to the percentage of people who recommend the service and positively lower the percentage for those who do not recommend. Response rate and percentage of positive and negative results for Inpatients The percentage of people who would recommend is more than the England and London score. We have a lower percentage of patients who would not recommend in relation to London and England. However, the response rate for Inpatients in February was slightly lower than the London and England rates and this is indicated in the chart below. Chart 3: Friends and Family Test: Inpatients 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Data: Feb % 94.6% 97.1% 25.4% 24.3% 21.9% 1.6% 1.8% 1.2% England London THHFT Response Rate Percentage Recommended Percentage Not Recommended 153

154 The Hillingdon Hospitals NHS Foundation Trust What patients have told us is good about their experience Inpatient ward I thoroughly enjoyed my experience in Kennedy Ward. I have been looked after extremely well. Food is good and nurses although very busy were very caring. Accident & Emergency Staff was rushed off their feet with trollies backed up. But they still had time to keep an eye and make sure you were not in pain and were very friendly. Maternity The midwives were very helpful and friendly and offered a lot of help and advice. Midwife (named) taught me how to properly breast feed my baby which has made all the difference. What patients have told us could be improved Extended waits in A&E due to lack of capacity Action Reviewing patients on an hourly basis, working with wider economy to reduce extended waiting times. Could improve communication between departments, teams and with patients Action Reintroduced customer care training to give staff the tools they need to continually develop their working relationships and the service that their departments offer. Need to provide more information and improve communication with patients and carers with regard to discharge planning Action The Trust developed a Working Together leaflet involving stakeholders and services users. Continuing to work with our partners on improving communication pathways. 154

155 Annual Report and Accounts 2016/17 Indicator 14: Emergency Caesarean Sections We continue to review all emergency caesarean sections to ensure best practice and learn from any identified findings. This remains a continuous challenge due to the complex nature of our current demographic. We have seen continuous improvement in our elective work, including a Consultant Midwife led vaginal birth after caesarean clinic. As part of the Northwest London Maternity System we now have a sector wide maternity dashboard which enables us to compare practice and share learning. Indicator 15: CQC Inpatient Survey The Hillingdon Hospitals NHS Foundation Trust commissioned The Picker Institute Europe to undertake the survey for 2016/17. The CQC will use these results when publishing the national survey of inpatients on 31 May The results of our 2015/16 survey are based on responses from 420 patients who completed the survey, giving a response rate of 34%; the average response rate of all Trusts in the Picker survey results was 41%. This survey has highlighted the many positive aspects of the patient experience: Care: always enough privacy when being examined or treated - 89% Care: answered the call button within 5 minutes - 81% Surgery: anaesthetist/other staff member fully explained how the patient would be put to sleep or control pain - 81% Hospital: room or ward was very/fairly clean - 93% Hospital: toilets and bathrooms were very/fairly clean - 93% Overall: 79% rated care 7+ out of 10 Overall: treated with respect and dignity - 79%. The Trust scored significantly lower than its 2014/15 score in three questions: A&E Department: not enough/too much information about condition or treatment Discharge: not told who to contact if worried Discharge: staff did not discuss need for further health or social care services. The adult inpatient survey provides a helpful annual check of our inpatients experience and enables the Trust to compare our performance with that of other trusts. Overall the 2015/16 results provided by Picker show that there are a number of areas where patients have reported a worse experience compared with the previous year. There are a number of transformational and quality improvement programmes underway that have links to the areas for an improved experience for patients; these include improving communication and provision of information, strengthening the patient pathway through the hospital to discharge home, improving recruitment and retention to ensure continuity and a high standard of care is delivered, and driving forward our ambition for strong professional standards and clinical leadership. Indicator 18: C difficile, variance from plan C. diff cases will inevitably occur as patients need to be treated with appropriate antibiotics. A lapse in care is defined as an element/s or care that could have been done better and that the case could have been avoided. However, all the lapses in care that have occurred at the Trust during 2016/17 have been due to inappropriate or prolonged antibiotic prescribing. Learning from these cases are to be presented by appropriate clinical teams at governance meetings. Also, local learning has been shared via Matrons, Link nurses (nurses that share information and provide formal, two-way communication between specialist teams and nurses in the clinical area) and Senior Sisters meetings. In the 2015/16 survey, the Trust scored significantly better than the Picker average (83 Trusts) for the following questions: Hospital: patients using bath or shower area who shared it with opposite sex Hospital: felt threatened by other patients or visitors. 155

156 The Hillingdon Hospitals NHS Foundation Trust Indicators 21 and 22: HSMR The HMSR for the Trust for year 2016/17 to date is ( ) data from Dr Foster April to December 2016 and is below the national benchmark of 100 but is above the London average of ( ). The Trust weekday HSMR 2016/17 year to date is ( ) and weekend HSMR 2016/17 YTD is ( ) and has been in the expected range April to December The Trust is tracking the HSMR monthly and has a robust Mortality Review Process in place reviewing all deaths occurring in hospital overseen by the Mortality Surveillance Group. Recent guidance will guide us as to how best to progress our identification, screening and investigation, where appropriate, and learning from deaths in our Trust. The Trust will review and adapt its Mortality Review Process in line with the NHS England Framework on Learning from Deaths published March In the meantime the Trust will continue its current process until the new review process is established. The Mortality Surveillance Group will draw up a policy which will clarify and document the roles and responsibilities, governance arrangements and reporting requirements of the new process. Indicator 26: A&E four-hour target (mandated indicator for external assurance testing) The year-end performance for patients attending the A&E department was 83.9%; with the Trust facing significant challenges over the past year as a result of an unprecedented increase in overall activity. Activity for patients with high levels of acuity and dependency, increased by 10% compared to 2015/16; with similar paediatric activity increasing by 16% following the closure of paediatric services at Ealing Hospital. London Ambulance Service attendances of A&E also increased, with blue light activity up by 25% when compared with 2015/16. Exit block, whereby patients are unable to go from A&E into a hospital inpatient bed, continues to remain a significant factor for the increased time patients spend in the A&E department. In recognition of the challenges being faced, the Trust and CCG jointly commissioned the NHSI Emergency Care Improvement Programme Team together with an external consultant to facilitate the diagnosis, review and improvement of patient flow across the Trust and Health Economy. A formal governance board was established to oversee the implementation and delivery of recommendations provided by the team. The programme focuses on four key areas: Reducing inappropriate attendances Achieving the four-hour standard and reducing admissions Safely and effectively discharging patients Sustainability in workforce and workforce management. Key initiatives that have been prioritised, aim to reduce attendances from the community, divert patients to ambulatory care pathways, improve flows through A&E and expedite discharge from the base wards, to reduce the amount of time each patient spends in A&E. Good progress has been observed by NHSI and the Trust to date. Average attendances of greater than 160 patients per day presents an ongoing challenge for the clinical team working in a confined physical space. The Trust is currently seeking support to expand the A&E Department footprint, to future-proof the capacity of its services and accommodate for current and future service demand. Quality reporting and data integrity remain a key priority for the A&E department and the Trust. The A&E four-hour standard quality indicator was reviewed by our external auditor as a mandated indicator for testing as stipulated by NHSI. Preliminary feedback identified conflicting information between supporting documentation and the Trust data; this means that there are several sources of data with regard to electronic data capture as well as times recorded on hard copy casualty cards; some of this data was conflicting in the sample tested. Following this sample collection, the Trust has implemented a new policy and data recording process that will improve compliance to national reporting standards. 156

157 Annual Report and Accounts 2016/17 Indicator 27: RTT waiting times (mandated indicator for external assurance testing) The Trust continues to focus on providing patients definitive treatment within 18 weeks of referral. The performance indicator we are monitored against in relation to this standard is an incomplete pathway performance. We perform well against the standard and compared with other Trusts we are a high performer. This year has been more challenging in achieving the standard due to cancellations for the junior doctors strikes, our essential theatre refurbishment and the emergency pressures we faced this winter. We have monitored this closely through our waiting list meetings and have recovery plans in place to continue to drive up performance. Incomplete pathways remain under continuous scrutiny and on-going validation by Trust management. There is an on-going training programme led by the Director of Operational Performance, for all staff associated with recording and delivering the RTT pathway. The RTT standard quality indicator was reviewed by our external auditor as a mandated indicator for testing as stipulated by NHSI. The outputs of the audit will be factored into the training programme which will be more extensive for the coming year. An on-line tool will also be made available and all new starters to the Trust will have detailed training. Indicator 28: Cancer 62 Day Urgent GP Referral / NHS Screening Service Cancer performance is being maintained for all the national waiting times standards. The quality of services is monitored annually via the national peer review programme. Tumour specific work programmes also reflect areas for service development. Indicator 29: Maximum 6-week wait for diagnostic procedures To sustain this we have participated in detailed capacity and demand modelling in diagnostic areas. Improving Patient Safety During 2016/17, The Hillingdon Hospitals NHS Foundation Trust has continued to be a member of the Imperial College Health Partners (ICHP) Patient Safety Collaborative (PSC). This is one of 15 PSCs set up to help improve the safety of patients and ensure continual learning sits at the heart of healthcare in England. As the Academic Health Science Network for North West London, ICHP works with its partner organisations and service users to focus on specific areas of local clinical need. Its vision is to support its partners to embed safety in every aspect of their work. This means that: Patient and carer views are obtained and heard at all levels as a critical indicator of safety There is a strong ethic of team working and shared responsibility for patient safety Effective safety measurement and monitoring systems are in place in all clinical settings Clinical processes, practices, equipment and environment are standardised and simplified A hub for Quality Improvement is being developed with involvement of safety champions from all clinical areas. Our PSC continues to make progress with a number of initiatives already underway. The Trust is involved in some of these key patient safety programmes of work and these include membership at the Foundations of Safety best practice forum, developing the role of both staff and public patient safety champions, supporting a prescribed improvement model and working to ensure effective medicines optimisation. The PSC programme of work is aligned with and supports the national Sign up to Safety campaign which the Trust signed up to in the latter part of 2014 and is outlined earlier in this report. High levels of demand also brought challenges for achievement of the maximum six week wait for a diagnostic test. However, this was achieved. 157

158 The Hillingdon Hospitals NHS Foundation Trust Infection Prevention and Control Meticillin Resistant Staphylococcus aureus (MRSA) Blood stream Infections (BSI) The chart below shows there were two cases of MRSA BSI attributed to the Trust in 2016/17 and both cases had a Post Infection Review undertaken. With respect to the first case it was found that although the sample was shown to have an MRSA bacteraemia the patient was not symptomatic of this and not treated as such. Therefore, the specimen was deemed a contaminate. That is, prolonged periods of storage at ambient temperature and delay in transport of specimens to the laboratory may increase the incidence of contaminants. The second MRSA BSI attributed to the Trust was post 48 hours. A Post Infection Review was undertaken and although unclear of exact source, the case was linked to a nephrostomy and learning has been addressed by the creation of both a nephrostomy tube patient leaflet and a guideline to support care given. MRSA screening criteria changed significantly in the last quarter of 2016/17 due to revised national guidance being applied to Trust policy. This will reflect in a substantial reduction in the number of MRSA screens undertaken but will continue to focus on more high risk areas opposed to the previous blanket approach of screening all. Due to the changes in screening monthly and annual compliance measured against the MRSA screening policy for elective and emergency cases is not available. Informatics will be working with Infection Prevention and Control to create a new reporting benchmark. Meticillin Sensitive Staphylococcus aureus (MSSA) The chart below shows that in 2016/17 there were three cases of MSSA attributed to the Trust, a 57% reduction when compared with seven MSSA cases in 2015/16. There continues to be no mandated threshold for MSSA. Chart 4: Trust attributed MRSA bloodstream infections Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2015/ / Total

159 Annual Report and Accounts 2016/17 Chart 5: Trust attributed MSSA bloodstream infections Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2015/ / Total 7 3 Escherichia coli (E. coli) bloodstream infections The Trust has been collating data on E. coli BSIs since 2012/13 onto the public health national mandatory surveillance site. Since then it has been recognised that the number of E. coli BSI are continuing to increase year on year. In 2015/16 there were 40,000 reported cases of E. coli BSIs in England; this is an increase of 20% in the past five years. As a result, in November 2016, The Health Minister addressed the need to reduce gram negative bacteraemia and has highlighted E. coli as a primary focus to reduce these numbers significantly, starting with a 10% reduction in 2017/18 and expanding to an overall reduction of 50% by 2020/21. The Trust will aim to reduce nosocomial E. coli BSIs linked to catheters and urinary tract infections by giving a heightened focus within these two areas over the coming year. The Infection Prevention and Control team will be working collaboratively with the Continence leads to improve care and reduce usage and duration of urinary catheters as well as improving communications within acute and community care settings. The chart below shows that in 2016/17 the Trust reported 31 cases of post 48 hours E.coli BSI that was eight more than that in 2015/16 when 23 were reported. A much higher number of E.coli cases, where seen pre-48 hours, was therefore attributed to the CCG who had 149 cases in 2015/16 with an increase of 30 cases in 2016/17 totalling

160 The Hillingdon Hospitals NHS Foundation Trust Chart 6: Trust attributed E. coli bloodstream infections Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2015/ / Total Lastly, Gram-negative bacteria are a specific type of bacteria with unique characteristics. Like most bacteria, they can cause infections throughout the body. In 2017/18, surveillance of infections caused by this type of bacteria has been expanded to incorporate Pseudomonas and Klebsiella as well as E. coli. Sepsis Once sepsis is diagnosed, quick action by medical staff can help save lives. The Trust is committed to enhancing staff awareness and has agreed an improvement target with Hillingdon CCG. This aims to improve the Trust s sepsis screening of patients using a range of screening tools as well as ensuring the Sepsis Six care bundle is initiated by the medical team within an hour of diagnosis. Sepsis Six prompts staff to give antibiotics, give fluids intravenously, give oxygen if levels are low, take blood cultures to identify the type of bacteria causing sepsis, take a blood sample to assess the severity of sepsis and monitoring the patients urine output to assess severity and kidney function We have also nominated a Consultant Anaesthetist as the Trust s medical lead for sepsis. He has been spearheading internal awarenessraising activities, improving training for all relevant staff and monitoring the organisation s effectiveness at addressing cases of sepsis when they are confirmed. Work has been undertaken with Trust staff to increase staff awareness and responsiveness when sepsis is suspected. The Trust is now consistently screening more than 90% of relevant A&E attendances for possible sepsis, and timely screening of patients on hospital wards has been improving throughout the year. In the majority of cases where possible sepsis is identified, patients receive Sepsis Six within one hour. The Trust is focusing on further improving the speed with which prescribed antibiotics are administered. 160

161 Annual Report and Accounts 2016/17 Annex 1: Statements from our stakeholders THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST Consultation on the Trust s Quality Account /2017 Response on behalf of the External Services Scrutiny Committee at the London Borough of Hillingdon The External Services Scrutiny Committee welcomes the opportunity to comment on the Trust s 2016/2017 Quality Report and acknowledges the Trust s commitment to attend its meetings when requested. Following the CQC inspection in 2014 where THH was rated as requires improvement, the Trust has been working through a detailed improvement plan which has resulted in: compliance rates for staff training for all statutory and mandatory training continuing to exceed the target; the National Specification for Cleaning targets being exceeded during 2016/2017; improved compliance in relation to hand hygiene and bare below the elbow practice; and significant improvements in relation to medicines management in clinical areas. However, Members are aware that the Trust still faces challenges with regard to adequate storage facilities for clinical and pharmaceutical supplies and are interested to see what effect interventions will have. Although THH has not achieved the 90% target for National Early Warning System (NEWS) compliance to support early escalation of the deteriorating patient, there have been improvements in performance during 2016/2017. Furthermore, it is recognised that there are still instances where non-compliance is as a result of documents not being completed properly rather than the patient not being assessed. To this end, the revised policy is being re-launched and Members look forward to receiving an update on the impact that this action has on achieving the target. During 2016/2017, THH had aimed to reduce the number of complaints related to key themes (including communication and staff attitude) by 5%. The Trust should be commended as the improvements that have been put in place have resulted in a reduction of 47% in communication related complaints and a 56% reduction for staff attitude. Although Members are aware that there has been a reduction in the overall number of complaints, this information has not yet been triangulated and detailed information has not been included in the report to support this improvement. Furthermore, the Trust has only managed to respond to 67.7% of complaints within the specified time against a target of 90%. Whilst the Committee appreciates that there are reasons for this, effort will need to be made to improve response times. Although THH A&E achieved 8.7% against a target of 20% FFT response rate (the national average is 14%), the Committee is aware that the Trust has been under pressure with regard to an increasing number of A&E presentations. London Ambulance Service (LAS) attendances at A&E have also increased, with blue light activity up by 25% when compared with 2015/16. Action taken to alleviate this includes the improved monitoring of LAS queues and LAS handover times, facilitating overall emergency care flows and providing clearer coordination and leadership in the department. The LAS has confirmed that this action has also had a positive impact on its performance. Furthermore, exit block, whereby patients are unable to go from A&E into a hospital inpatient bed, continues to remain a significant factor for the increased time patients spend in the A&E department and Members would like an update on action that will be taken. Easing the carer and patient journey has played a key role in the improvements made by THH this year with the implementation of national initiatives such as John s Campaign. Members 161

162 The Hillingdon Hospitals NHS Foundation Trust are encouraged that THH has signed up to John s Campaign where carers are able to support their loved ones outside of visiting times in accordance with their wishes and can provide a significantly improved patient experience. As feedback from the FFT, complaints and surveys have indicated that there is more work to be done in this area, Members look forward to receiving updates on the action that is taken. The Committee notes the development of internal strategies for people at end of life and supporting carers and is keen that these reflect an interrelationship with Borough-wide strategies. Recruitment and retention appears to be an issue for the NHS and THH has been no exception. The turnover rate in Hillingdon was 16% in 2016/2017 against a target of 13%. Members are aware that recruitment has been undertaken in the Philippines with 11 new staff due to start in August 2017 but that there have been issues in relation to candidates passing the English language test. Although the Trust also recruits students from Buckinghamshire New University, Members are concerned that the withdrawal of bursaries will reduce the number of students wanting to train as nurses which will make recruitment even more challenging for THH. Members are supportive of the identified priorities for 2017/2018 and note with particular interest the new priority of improving hospital discharge. This is an area that exemplifies the need for partnership working to support the Hospital in minimising unnecessary length of stay. The Committee would not only wish to see how partners are supporting the Hospital but also how the Trust creates a culture that enables it to be supported. Looking forward, there are areas where the Trust continues to demonstrate that progress and improvements have been made but the Committee notes that there are a number of areas where further improvements are still required. We look forward to being updated on the progress of the implementation of priorities outlined in the Quality Report over the course of 2017/

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168 168 The Hillingdon Hospitals NHS Foundation Trust

169 Annual Report and Accounts 2016/17 The Hillingdon Hospitals NHS Foundation Trust s response to its key stakeholders The Hillingdon Hospitals NHS Foundation Trust thanks all its stakeholders for their comments about the 2016/17 Quality Report. The Trust is pleased that its key stakeholders recognise the Trust s commitment to improve the quality of the care and services that we provide and to work closely with them in achieving further improvement. The Trust enjoys a good working relationship with both Healthwatch Hillingdon and with the Hillingdon Clinical Commissioning Group and it looks forward to further collaborative working to help shape the quality agenda and delivery of safe, high quality care. The Trust is pleased that its key stakeholders are in agreement with its quality priorities for 2017/18, recognising where we have made good progress in quality improvement across a range of quality indicators and also where further work needs to be driven forward to realise the expected outcomes. The Trust has taken comments on board as part of the consultation for the Quality Report and as such these are aligned with our partners views on where we need to focus our efforts. Information on the ACP and our aims for working with our partners on this key initiative has been included in the Report as requested by our commissioners. Our stakeholders have recognised and commended our performance on some of the key quality indicators and it has also been acknowledged that the Trust has progressed extensive work following the Care Quality Commission inspection to further improve the quality of its services. Areas of underperformance have been acknowledged and the Trust would like to reassure its stakeholders that these areas will continue to be a key priority for the Trust and a focus in the forthcoming year. This includes A&E performance against the 4-hour target, response rates for FFT in the A&E department and complaints response rates. The Trust is pleased that the ESSC recognises the amount of work that has been undertaken by the Trust over the last year in achieving its quality priority targets. The Trust also welcomes the acknowledgement by the ESSC of the activity that we have seen through our A&E department and the work that is being taken forward to improve in this area. We will continue to keep our key stakeholders updated on our progress as requested. Our stakeholders have recognised that we have presented an honest and robust summary of the overview of quality of care at the Trust, acknowledging, alongside our achievements, that some targets have not been met fully with regard to the quality priorities set for 2016/17, such as the seven day working priorities and NEWS compliance. Comments from our local Healthwatch on achievement of our priorities have been taken on board and the final draft of the report has included more clarity on degree of compliance against our targets. It has also been recognised that the Trust has been committed to continuing to improve the quality of its services and impact positively on the patients experience of care despite the unprecedented activity that the Trust has seen in the last year. It has been acknowledged that a high majority of patients who responded to the Friends and Family Test said they would recommend the Trust. Healthwatch Hillingdon has noted however that their review of discharge and maternity services show a number of areas of communication that require improvement and acknowledges that as a Trust we recognise this and we continue to focus upon these areas. We look forward to continuing our very positive working relationships with our key stakeholders to support the delivery of improved quality of care and patient experience. 169

170 The Hillingdon Hospitals NHS Foundation Trust Independent auditor s report to the council of governors of The Hillingdon Hospitals NHS Foundation Trust on the quality report We have been engaged by the council of governors of The Hillingdon Hospitals NHS Foundation Trust to perform an independent assurance engagement in respect of The Hillingdon Hospitals NHS Foundation Trust s quality report for the year ended 31 March 2017 (the Quality Report ) and certain performance indicators contained therein. This report, including the conclusion, has been prepared solely for the council of governors of The Hillingdon Hospitals NHS Foundation Trust as a body, to assist the council of governors in reporting The Hillingdon Hospitals NHS Foundation Trust s quality agenda, performance and activities. We permit the disclosure of this report within the Annual Report for the year ended 31 March 2017, to enable the council of governors to demonstrate they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicators. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Council of Governors as a body and The Hillingdon Hospitals NHS Foundation Trust for our work or this report, except where terms are expressly agreed and with our prior consent in writing. Scope and subject matter The indicators for the year ended 31 March 2017 subject to limited assurance consist of the national priority indicators as mandated by NHS Improvement: Respective responsibilities of the directors and auditors The directors are responsible for the content and the preparation of the quality report in accordance with the criteria set out in the NHS foundation trust annual reporting manual issued by NHS Improvement. Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that: the quality report is not prepared in all material respects in line with the criteria set out in the NHS foundation trust annual reporting manual and supporting guidance; the quality report is not consistent in all material respects with the sources specified in section 2.1 of the NHS Improvement 2016/17 Detailed requirements for external assurance for quality reports; and the indicators in the quality report identified as having been the subject of limited assurance in the quality report are not reasonably stated in all material respects in accordance with the NHS foundation trust annual reporting manual and supporting guidance and the six dimensions of data quality set out in the Detailed guidance for external assurance on quality reports. We read the quality report and consider whether it addresses the content requirements of the NHS foundation trust annual reporting manual and supporting guidance, and consider the implications for our report if we become aware of any material omissions. percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the reporting period; and percentage of patients with a total time in A&E of four hours or less from arrival to admission, transfer or discharge. We refer to these national priority indicators collectively as the indicators. 170

171 Annual Report and Accounts 2016/17 We read the other information contained in the quality report and consider whether it is materially inconsistent with: board minutes for the period April 2016 to March 2017; papers relating to quality reported to the board over the period April 2016 to 31 March 2017; feedback from the Commissioners dated 19/05/2017; feedback from the governors dated 09/05/2017; feedback from Overview and Scrutiny Committee, dated 18/05/2017; the trust s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated 22/05/2017; the latest national patient survey dated 31/05/2017 (this is awaited); the latest national staff survey dated 07/03/2017; Care Quality Commission inspection dated 07/08/2015; the Head of Internal Audit s annual opinion over the trust s control environment dated 25/05/2017; and any other information included in our review. We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with those documents (collectively the documents ). Our responsibilities do not extend to any other information. Assurance work performed We conducted this limited assurance engagement in accordance with International Standard on Assurance Engagements 3000 (Revised) Assurance Engagements other than Audits or Reviews of Historical Financial Information issued by the International Auditing and Assurance Standards Board ( ISAE 3000 ). Our limited assurance procedures included: evaluating the design and implementation of the key processes and controls for managing and reporting the indicators; making enquiries of management; testing key management controls; limited testing, on a selective basis, of the data used to calculate the indicator back to supporting documentation; comparing the content requirements of the NHS foundation trust annual reporting manual and supporting guidance to the categories reported in the quality report; and reading the documents. A limited assurance engagement is smaller in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement. We are in compliance with the applicable independence and competency requirements of the Institute of Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our team comprised assurance practitioners and relevant subject matter experts. 171

172 The Hillingdon Hospitals NHS Foundation Trust Limitations Non-financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information. The absence of a significant body of established practice on which to draw allows for the selection of different, but acceptable measurement techniques which can result in materially different measurements and can affect comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and methods used to determine such information, as well as the measurement criteria and the precision of these criteria, may change over time. It is important to read the quality report in the context of the criteria set out in the NHS foundation trust annual reporting manual and supporting guidance. The scope of our assurance work has not included testing of indicators other than the two selected mandated indicators, or consideration of quality governance. Basis for qualified conclusion Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the reporting period The indicator for the percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the reporting period requires the Trust to accurately record the start and end dates of each patient s treatment pathway, in accordance with the detailed requirements set out in national guidance. Our procedures included testing a risk based sample and so the error rates identified from that sample should not be directly extrapolated to the population as a whole. We found that from our sample of 21 records tested: for 19% of items in our sample of patients records tested, the pathway start date was not accurately recorded; for 5% of items in our sample of patients records tested, the pathway end date was not accurately recorded; for 10% of items in our sample, the pathway appeared to have been opened incorrectly, affecting the calculation of the published indicator; and for 19% of items in our sample of patients records tested, we were unable to obtain sufficient supporting evidence to confirm the details necessary to test the calculation of the indicator. As a result of the issues identified, we have concluded that there are errors in the calculation of the percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the reporting period indicator for the year ended 31 March We are unable to quantify the effect of these errors on the reported indicator. 172

173 Annual Report and Accounts 2016/17 Annex 2: Statement of Directors responsibilities in respect of the Quality Report 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. NHSI 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. the [latest] CQC Inpatient Survey 31/05/2017 (this is awaited) the [latest] national staff survey 07/03/2017 the Head of Internal Audit s annual opinion of the trust s control environment dated 25/05/2017 CQC inspection report dated 07/08/2015 the Quality Report presents a balanced picture of the NHS foundation trust s performance over the period covered 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 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 [the date of this statement] papers relating to quality reported to the board over the period April 2016 to [the date of this statement] feedback from commissioners dated 19/05/2017 feedback from governors dated 09/05/2017 feedback from local Healthwatch organisations dated 22/05/2017 feedback from Overview and Scrutiny Committee dated 18/05/2017 the trust s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated 22/05/2017 (draft copy) 173

174 The Hillingdon Hospitals NHS Foundation Trust 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 [this point is only required where the foundation trust is not reporting performance against an indicator that otherwise would have been subject to assurance] as the trust is currently not reporting performance against the indicator [xxx] due to [xxx], the directors have a plan in place to remedy this and return to full reporting by [xxx] 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 Shane DeGaris Chief Executive The Hillingdon Hospitals NHS Foundation Trust 30th May 2017 Richard Sumray Chair The Hillingdon Hospitals NHS Foundation Trust 30th May

175 Annual Report and Accounts 2016/17 Glossary A Accessible Information Standard (AIS) Accountable Care Partnership (ACP) Accident and Emergency (A&E) department Acute Medical Unit (AMU) Acute Myocardial Infarction Allied health professionals (AHPs) Ambulatory care pathway The standard makes sure that people who have a disability, impairment or sensory loss get information that they can access and understand, and any communication support that they need. A new organisational form which integrates care around patients. It is a partnership between primary, acute, community, social care and third sector providers who have agreed to take responsibility for providing all care for a given population for a defined (and long) period of time. Most importantly, the partnership is held to account for achieving a set of pre-agreed quality outcomes within a given budget. The A&E department is for patients who are acutely ill, or are experiencing a lifethreatening or limb-threatening problem that have either self-referred (come in themselves) or been brought in by ambulance. The first point of entry for patients referred to hospital as emergencies by their GP and those requiring admission from A&E. Acute myocardial infarction is the medical name for a heart attack. Heart attacks occur when the flow of blood to the heart becomes blocked. They can cause tissue damage and can even be life-threatening. These are health care professions distinct from nursing, medicine, and pharmacy. AHPs include everything from podiatrist, dietitian, and physiotherapist, diagnostic radiographer to Occupational Therapist, Orthoptist and Speech and Language Therapist. Allows patients who are safe to go home to be managed promptly as outpatients, without the need for admission to hospital, following an agreed plan of care for certain conditions. B Berwick Review Better Care Fund Blended therapy assessment model British Sign Language British Thoracic Society Commissioned following the Mid Staffordshire Hospitals enquiry and publication of the Francis Report. The review includes recommendations to ensure a robust nationwide system for patient safety. This is a programme spanning both the NHS and local government. It has been created to improve the lives of some of the most vulnerable people in our society, placing them at the centre of their care and support, and providing them with wraparound fully integrated health and social care, resulting in an improved experience and better quality of life. Blending of the assessments usually undertaken by the physiotherapist and the occupational therapist whereby either therapist may assess for both so the patient can be seen by one person able to assess a broader range of functional ability and ascertain how identified needs may be met and resolve these issues by advice, therapeutic input, provision of equipment. The sign language used in the United Kingdom (UK), and is the first or preferred language of some deaf people in the UK. Exists to improve standards of care for people who have respiratory diseases and to support and develop those who provide that care. 175

176 The Hillingdon Hospitals NHS Foundation Trust C Care Pathway Care Quality Commission (CQC) Central Alerting System Clinical audit Clostridium Difficile infection (C. diff) Commissioners Commissioning for Quality and Innovation (CQUIN) CQC Inpatient Survey Anticipated care placed in an appropriate time frame which is written and agreed by a multi-disciplinary team. The independent regulator of health and social care in England. A web-based cascading system for issuing patient safety alerts, important public health messages and other safety critical information and guidance to the NHS and others, including independent providers of health and social care. A quality improvement process that seeks to improve patient care and outcomes by measuring the quality of care and services against agreed standards and making improvements where necessary. A type of infection that occurs in the bowel that can be fatal. There is a national indicator to measure the number of C. Diff infections that occur in hospital. Responsible for ensuring adequate services are available for their local population by assessing needs and purchasing services. A payment framework enabling commissioners to reward quality by linking a proportion of the Trust s income to the achievement of local quality improvement goals. An annual, national survey of the experiences of patients who have stayed in hospital. All NHS Trusts are required to participate. The Picker Institute Europe, co-ordinates the survey programme on behalf of the CQC. D Department of Health (DH) Dr Foster The government department that provides strategic leadership to the NHS and social care organisations in England. An organisation that provides healthcare information enabling healthcare organisations to benchmark and monitor performance against key indicators of quality and efficiency. E Escherichia coli (E. coli) A bacterial infection that can cause severe stomach pain, bloody diarrhoea and kidney failure. F Five Year Forward View Foundation Trust (FT) Four-hour A&E target Fragility Fracture Document first published in October 2014, developed by partner organisations that deliver and oversee health and care services with advice provided by patient groups, clinicians and independent experts to create a collective view of how the health service needs to change over the next five years if it is to close the widening gaps in the health of the population, quality of care and the funding of services. NHS foundation Trusts were created to devolve decision making from central government to local organisations and communities. They still provide and develop health care according to core NHS principles - free care, based on need and not ability to pay. The NHS Constitution sets out that a minimum of 95 per cent of patients attending an A&E department in England must be seen, treated and then admitted or discharged in under four hours. Healthy bones should be able to withstand a fall from standing height; a bone that breaks in these circumstances is known as a fragility fracture. 176

177 Annual Report and Accounts 2016/17 Francis Report Freedom to Speak Friends and Family Test (FFT) Following failures in care at the Mid Staffordshire NHS Foundation Trust, Sir Robert Francis QC was selected to chair an independent public inquiry into those failings. The report from that enquiry on 6 February 2013 made a number of wide ranging recommendations for change which affected a number of organisations. The Freedom to Speak Up Review was a review into whistleblowing in the NHS in England and it was chaired by Sir Robert Francis. An opportunity for patients to provide feedback on the care and treatment they receive. Introduced in 2013 the survey asks patients whether they would recommend hospital wards, A&E departments and maternity services to their friends and family if they needed similar care or treatment. G Governors The Hillingdon Hospitals NHS Foundation Trust has a Council of Governors. Governors are central to the local accountability of our foundation Trust and helps ensure the Trust board takes account of members and stakeholders views when making important decisions. H Health and Social Care Information Centre Healthcare Assistant Healthwatch HomeSafe An Executive Non Departmental Public Body set up in April It collects, analyses and presents national health and social care data helping health and care organisations to assess their performance compared to other organisations. Under the supervision and direction of qualified nursing staff, healthcare assistants carry out a wide range of duties to care for, support, and provide information to patients and their families. The national consumer champion in health and care. They have significant statutory powers to ensure the voice of the consumer is strengthened and heard by those who commission, deliver and regulate health and care services. All elderly patients (those over 65) admitted to Hillingdon Hospital are screened to identify whether or not they require a comprehensive geriatric assessment. The assessment team, led by a consultant geriatrician, identifies the level of support patients will need at home in order to successfully recover, without the need to stay in hospital. Upon discharge from hospital Age UK, social services and Central North West London Foundation Trust provide a range of services from short-term rehabilitation to longer term care support. Hospital Episode Statistics (HES) Hospital Standardised Mortality Ratio (HSMR) The national statistical data warehouse for the NHS in England. HES is the data source for a wide range of healthcare analysis for the NHS, government and many other organisations. A national indicator that compares the actual number of deaths against the expected number of deaths in each hospital and then compares Trusts against a national average. 177

178 The Hillingdon Hospitals NHS Foundation Trust I Indicator Information Governance Inpatient A measure that determines whether the goal or an element of the goal has been achieved. The way by which the NHS handles all organisational information in particular the personal and sensitive information of patients and employees. It allows organisations and individuals to ensure that personal information is dealt with legally, securely, efficiently and effectively, in order to deliver the best possible care. A patient who is admitted to a ward and staying in the hospital. J John s Campaign Launched in November 2014 after the death of Dr John Gerrard. The aim of the campaign is to give the carers of those living with dementia the right to stay with them in hospital, in the same way that parents stay with their sick children. K Keogh Review A review of the quality of care and treatment provided by those NHS Trusts and NHS Foundation Trusts that were persistent outliers on mortality indicators. A total of 14 hospital Trusts were investigated as part of this review. L Laparotomy (Emergency) Local Clinical Audit London Quality Standards (LQS) A surgical operation that is used for people with severe abdominal pain to find the cause of the problem and in many cases to treat it. A general anaesthetic is given and the surgeon makes an incision (cut) to open the abdomen (stomach area). Often the damaged part of an organ is removed and the abdomen washed out to limit any infection. A type of quality improvement project involving individual healthcare professionals evaluating aspects of care that they themselves have selected as being important to them and/or their team. Professional consensus standards designed to address the unacceptable variations found in the provision of unscheduled care. They mandate timely clinical review by junior, consultant and multi-disciplinary staff; timely access to key diagnostic, interventional and other allied clinical services; robust monitoring of patients with appropriate responses to clinical deterioration; and patterns of extended working seven days per week. M Magnetic resonance imaging (MRI) Major Trauma Mandatory Meticillin-resistant staphylococcus aureus (MRSA) A type of scan that uses strong magnetic fields and radio waves to produce detailed images of the inside of the body. The results of an MRI scan can be used to help diagnose conditions, plan treatments and assess how effective previous treatment has been Major trauma is any injury that has the potential to cause prolonged disability or death; this includes head injuries, life-threatening wounds and multiple fractures. Mandatory means must as outlined by an organisation for the role of the staff member. A type of infection that can be fatal. There is a national indicator to measure the number of MRSA infections that occur in hospitals. 178

179 Annual Report and Accounts 2016/17 Meticillin-sensitive Staphylococcus aureus (MSSA) Mortality rate Multi-disciplinary team meeting MSSA can cause serious infections, however unlike MRSA MSSA is more sensitive to antibiotics. The number of deaths in a given area or period, or from a particular cause. A meeting involving healthcare professionals with different areas of expertise to discuss and plan the care and treatment of specific patients. N National Clinical Audit A clinical audit that engages healthcare professionals across England and Wales in the systematic evaluation of their clinical practice against standards and to support and encourage improvement and deliver better outcomes in the quality of treatment and care. The priorities for national clinical audits are set centrally by the DH and all NHS Trusts are expected to participate in the national audit programme. National Confidential Enquiry into Patient Outcome and Death (NCEPOD) National Early Warning Scoring system (NEWS) National Joint Registry (NJR) National Reporting and Learning System (NRLS) Never Events NHS Improvement (NHSI) NHS number NCEPOD s purpose is to assist in maintaining and improving standards of care for adults and children for the benefit of the public by reviewing the management of patients, by undertaking confidential surveys and research, by maintaining and improving the quality of patient care and by publishing and generally making available the results of such activities. An early warning scoring system used to track patient deterioration and to trigger escalations in clinical monitoring and rapid response by the critical care outreach team. The scoring system used to trigger escalation is based on routine observations of respiratory rate, oxygen saturation levels, blood pressure, temperature, pulse rate and level of consciousness combined to give weighted scores that in turn trigger graded clinical responses. The NJR collects information on all hip, knee, ankle, elbow and shoulder replacement operations, to monitor the performance of joint replacement implants and the effectiveness of different types of surgery, improving clinical standards and benefiting patients, clinicians and the orthopaedic sector as a whole. A central database of patient safety incident reports submitted from health care organisations. Since the NRLS was set up in 2003, over four million incident reports have been submitted. All information submitted is analysed to identify hazards, risks and opportunities to continuously improve the safety of patient care. Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. Never Events include incidents such as wrong site surgery, retained instrument post operation and wrong route administration of chemotherapy. Trusts are required to report nationally if a Never Event occurs. Responsible for overseeing foundation trusts and NHS trusts, as well as independent providers that provide NHS-funded care. A 12 digit number that is unique to an individual, and can be used to track NHS patients between organisations and different areas of the country. Use of the NHS number should ensure continuity of care. 179

180 The Hillingdon Hospitals NHS Foundation Trust O Oesophago-gastric Ophthalmology Outpatient Overview and Scrutiny Committee (OSC) Refers to the oesophagus (tube that food passes through when we swallow) and to the stomach. The branch of medicine that deals with the anatomy, physiology and diseases of the eye. A patient who goes to a hospital and is seen by a doctor or nurse in a clinic, but is not admitted to a ward and is not staying in this hospital. Looks at the work of NHS Trusts and acts as a critical friend by suggesting ways that health-related services might be improved. It also looks at the way the health service interacts with social care services, the voluntary sector, independent providers and other Council services to jointly provide better health services to meet the diverse needs of the area. P Palliative care coding Patient Safety Incident Pressure ulcers Priorities for improvement Patient Reported Outcome Measures (PROMs) Summary Hospital-level Mortality Indicator makes no adjustments for palliative care. As a result, The Health and Social Care Information Centre currently publish two contextual indicators on palliative care to support the interpretation of the SHMI. One of these is the Percentage of deaths with palliative care coding, which provides a basic indication of percentage rates of deaths that are coded with palliative care either in diagnosis or treatment specialty fields. Any unintended or unexpected incident which could have or did lead to harm for one or more patients receiving NHS care. Sores that develop from sustained pressure on a particular point of the body. Pressure ulcers are more common in patients than in people who are fit and well, as patients are often not able to move about as normal. There is a national requirement for Trusts to select three to five priorities for quality improvement each year. This must reflect the three key areas of patient safety, patient experience and patient outcomes. PROMs collect information on the effectiveness of care delivered to NHS patients as perceived by the patients themselves. Hospitals providing four key elective surgeries invite patients to complete questionnaires before and after their surgery. The PROMs programme covers four common elective surgical procedures: groin hernia operations, hip replacements, knee replacements and varicose vein operations. R Readmission Referral to treatment (RTT) Requirement notice A national indicator that assesses the number of patients who have to go back to hospital within 30 days of discharge from hospital. In England, under the NHS Constitution, patients have the right to access certain services commissioned by NHS bodies within maximum waiting times, or for the NHS to take all reasonable steps to offer a range of suitable alternative providers if this is not possible. The NHS Constitution sets out that patients should wait no longer than 18 weeks from GP referral to treatment. Used by the CQC when a registered provider is in breach of a regulation or has poor ability to maintain compliance with regulations, but people using the service are not at immediate risk of harm. This is only the case when assessments state the provider is able to improve its standards and in cases when the service provider has no prior history of poor performance. Once issued, the provider is required to deliver a report showing how they will comply with their legal obligations along with an explanation of the action they propose to implement. 180

181 Annual Report and Accounts 2016/17 Root Cause Analysis (RCA) A method of problem solving that looks deeper into problems to identify the root causes and find out why they re happening. S Safety Huddle SAFER patient flow bundle Sentinel Stroke National Audit Programme Sepsis Serious Incident Shaping a Healthier Future Shared competency framework Statutory Summary Hospitallevel Mortality Indicator (SHMI) Sustainability and Transformation Plan (STP) Short multi-disciplinary briefings designed to give healthcare staff, clinical and non-clinical and opportunities understand what is going on with each patient and anticipate future risks to improve patient safety and care. A standardised way of managing patient flow through hospitals. If consistently followed (with minimal variation) the bundle will help improve patient flow. This aims to improve the quality of stroke care by auditing stroke services against evidence-based standards, and national and local benchmarks. A potentially fatal whole-body inflammation (a systemic inflammatory response syndrome) caused by severe infection. An incident requiring investigation that results in one of the following: Unexpected or avoidable death Serious harm Prevents an organisation s ability to continue to deliver healthcare services Allegations of abuse Adverse media coverage or public concern Never Events A programme to improve NHS services for people who live in North West London bringing as much care as possible nearer to patients. It includes centralising specialist hospital care onto specific sites so that more expertise is available more of the time; and incorporating this into one co-ordinated system of care so that all the organisations and facilities involved in caring for patients can deliver highquality care and an excellent experience. Amalgamation of the core skills routinely thought of as performed by a Physiotherapist with the core skills routinely thought of as performed by an Occupational Therapist, and taught to both roles. This enables either therapist to assess a patient both from an occupational therapy and physiotherapy perspective, and to provide certain interventions from either or both professions to make best use of time and for the benefit of the patient, usually to enable discharge. Statutory means decided or controlled by law. An indicator which reports on mortality at Trust level across the NHS in England. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the Trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there. Five year plans for the future of health and care services in local areas. NHS organisations have come together with local authorities and other partners to develop the plans in 44 areas of the country. 181

182 The Hillingdon Hospitals NHS Foundation Trust V Venous thromboembolism (VTE) An umbrella term to describe venous thrombus and pulmonary embolism. Venous thrombus is a blood clot in a vein (often leg or pelvis) and a pulmonary embolism is a blood clot in the lung. There is a national indicator to monitor the number of patients admitted to hospital who have had an assessment made of the risk of them developing a VTE. W Warning notice Whole Systems Integrated Care The CQC is able to serve warning notices regarding past and continuing failures to meet legal requirements. They include a timescale, which if not met generates further enforcement action. Aims to improve the quality and experience of care for patients and service users, save money across the local health and social care system, and enhance professional experience by helping people in health and social care, work more effectively together. Languages/ Alternative Formats Please call the Patient Advice and Liaison Service (PALS) if you require this information in other languages, large print or audio format on:

183 Annual Report and Accounts 2016/17 4 Annual Accounts 2016/17 183

184 The Hillingdon Hospitals NHS Foundation Trust 5 Statement of Directors Responsibilities in Respect of the Accounts 184

185 Annual Report and Accounts 2016/17 Statement of Directors Responsibilities in Respect of the Accounts The Directors are required under the National Health Services Act 2006 to prepare accounts for each financial year. Monitor, with the approval of the Secretary of State, directs that these accounts give a true and fair view of the state of affairs of the Trust and of the Statements of Comprehensive Income, Financial Position, Tax Payers Equity, Cash Flow and all disclosure notes in the Annual Accounts. In preparing these accounts, Directors are required to: Apply on a consistent basis accounting policies according to the NHS Foundation Trust Annual Reporting Manual 2016/17 with the approval of the Secretary of State Make judgements and estimates which are reasonable and prudent State where applicable accounting standards have been followed, subject to any material departures disclosed and explained in the accounts; Comply with International Financial Reporting Standards. The Directors are responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the Trust and to enable them to ensure that the accounts comply with requirements outlined in the above mentioned direction of the Secretary of State. They are 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. The Directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the accounts. 185

186 The Hillingdon Hospitals NHS Foundation Trust 6 Independent Auditor s Report 186

187 Annual Report and Accounts 2016/17 INDEPENDENT AUDITOR S REPORT TO THE BOARD OF GOVERNORS AND BOARD OF DIRECTORS OF THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST Opinion on financial statements of The Hillingdon Hospitals NHS Foundation Trust In our opinion the financial statements: give a true and fair view of the state of the Trust s affairs as at 31 March 2017 and of its income and expenditure for the year then ended; have been properly prepared in accordance with the accounting policies directed by NHS Improvement Independent Regulator of NHS Foundation Trusts; and have been prepared in accordance with the requirements of the National Health Service Act The financial statements that we have audited comprise: the Statement of Comprehensive Income; the Statement of Financial Position; the Statement of Changes in Taxpayers Equity; the Statement of Cash Flows; and the related notes 1 to 31. The financial reporting framework that has been applied in their preparation is applicable law and the accounting policies directed by NHS Improvement Independent Regulator of NHS Foundation Trusts. Going concern Emphasis of Matter We have reviewed the Statement of the Chief Executive s Responsibilities as the Accounting Officer contained in the Annual Governance Statement and the disclosure made that the Trust is a going concern. In response to this, we: reviewed the Trust s financial performance in 2016/17 including its achievement of planned cost improvements in the year; made enquiries regarding management s expectation around further funding requirements; reviewed the Trust s cash flow forecasts and the Trust s financial plan submitted to NHS Improvement including CIP plans; and held discussions with management to understand the current status of contract negotiations with its commissioners. Whilst we have concluded that the Accounting Officer s use of the going concern basis of accounting in the preparation of the financial statements is appropriate based on the continuation of clinical services, these conditions indicate the existence of a material uncertainty which may give rise to significant doubt over the Trust s ability to continue as a going concern. The financial statements do not include the adjustments that would result if the Trust was unable to continue as a going concern. Our opinion is not modified in respect of this matter. Certificate We certify that we have completed the audit of the accounts in accordance with the requirements of Chapter 5 of Part 2 of the National Health Service Act 2006 and the Code of Audit Practice. Despite reporting a surplus for 2016/17, the recurrent underlying performance of the Trust is a deficit. The Operational Plan for 2017/18 & 2018/19, approved in December 2016, shows the Trust delivering deficits of 15.3m in each year. As a consequence, the Trust is deemed to be in distress and will require interim cash support. 187

188 The Hillingdon Hospitals NHS Foundation Trust Summary of our audit approach Key risks Materiality Scoping Significant changes Significant changes in our approach in our approach The key risks that we identified in the current year were: NHS Revenue and Provisions Accounting for Property Valuations Management override of controls Going Concern (see emphasis of matter paragraph above) The materiality that we used in the current year was 5.1m which was determined on the basis of 2% of Revenue. Our audit was scoped by obtaining an understanding of the entity and its environment, including internal control. The Trust does not have any subsidiaries and is structured as a single reporting unit and so the whole Trust was subject to a full audit scope. There have been no significant changes in our approach. Independence We are required to comply with the Code of Audit Practice and Financial Reporting Council s Ethical Standards for Auditors, and confirm that we are independent of the Trust and we have fulfilled our other ethical responsibilities in accordance with those standards. We confirm that we are independent of the Trust and we have fulfilled our other ethical responsibilities in accordance with those standards. We also confirm we have not provided any of the prohibited non-audit services referred to in those standards. 188

189 Annual Report and Accounts 2016/17 Our assessment of risks of material misstatement The assessed risks of material misstatement described below are those that had the greatest effect on our audit strategy, the allocation of resources in the audit and directing the efforts of the engagement team. NHS revenue and provisions Risk description As described in Notes 1.4, Accounting Convention, and 1.7, Income Recognition, there are significant judgements in recognition of revenue from care of NHS patients and in provisioning for disputes with commissioners due to: the complexity of the Payment by Results regime, in particular in determining the level of overperformance revenue to recognise; the judgemental nature of provisions for disputes with commissioners and other counterparties; and the risk of revenue not being recognised at fair value due to adjustments agreed in settling current year disputes and agreement of future year contracts. Details of the Trust s income, including 209.9m of Commissioner Requested Services, are shown in note 3 to the financial statements. NHS debtors are shown in note 15 to the financial statements. The Trust earns revenue from a range of commissioners, increasing the complexity of agreeing a final year-end position. The settlement of income with commissioners continues to present challenges, leading to disputes and delays in the agreement of year end positions. How the scope of our audit responded to the risk We evaluated the design and implementation of controls over recognition of Payment by Results income and the debt provisioning process. We have agreed baseline contract income to underlying contracts and checked settlement agreements to third party confirmation. We have agreed final negotiated positions to third party confirmations and, where possible, cash receipt. By extension, our review of variances in the Agreement of balances (AoB) exercise also gives some comfort in this area. We have tested the year-end calculations for accrued revenue in relation to partially completed patient spells at year end. We challenged key judgements around specific areas of dispute and actual or potential challenge from commissioners and the rationale for the accounting treatments adopted. In doing so, we considered the historical accuracy of provisions for disputes and reviewed correspondence with commissioners. Key observations The evidence we obtained from our audit procedures supported the revenue, receivables and provisions balance held by the Trust and the appropriateness of the assumptions used in its provisioning calculation. 189

190 The Hillingdon Hospitals NHS Foundation Trust Accounting for Property Valuations Risk description The Trust holds property assets within Property, Plant and Equipment at a modern equivalent use valuation of 126.2m (2015/16: 118.4m) and investment properties at valuation of 32.4m (2015/ m). The valuations are by nature significant estimates which are based on specialist and management assumptions (including the floor areas for a Modern Equivalent Asset, the basis for calculating build costs, the level of allowances for professional fees and contingency, and the remaining life of the assets) and which can be subject to material changes in value. The net valuation movement on the Trust s estate, shown in note 12.1, is a net upward revaluation of 4.1m. The net valuation movement on investment properties, shown in note 14, is an upward revaluation of 11.3m. How the scope of our audit responded to the risk We evaluated the design and implementation of controls over property valuations, and tested the accuracy and completeness of data provided by the Trust to the valuer. We used Deloitte internal valuation specialists to review and challenge the appropriateness of the key assumptions used in the valuation of the Trust s properties using benchmarking and knowledge of local real estate economy. We have reviewed the disclosures in note 1.12 and evaluated whether these provide sufficient explanation of the basis of the valuation and the judgements made in preparing the valuation. We assessed whether the valuation and the accounting treatment of the impairment were compliant with the relevant accounting standards, and in particular whether impairments should be recognised in the Income Statement or in Other Comprehensive Income. Key observations The evidence we obtained from our audit procedures supported the valuation of the property assets held by the Group and the appropriateness of the assumptions used in its calculation. Management override of controls Risk description We consider that in the current year there is a heightened risk across the NHS that management may override controls to fraudulently manipulate the financial statements or accounting judgements or estimates. This is due to the increasingly tight financial circumstances of the NHS and close scrutiny of the reported financial performance of individual organisations. The Trust has been allocated 7.5m of the Sustainability and Transformation Fund, contingent on achieving financial and operational targets each year, equivalent to a control total for the year of a surplus of 5.1m. NHS Improvement has allocated funding for a bonus to organisations that exceed their control total, including offering trusts 1 of additional funding for each 1 above the control total. This creates an incentive for reporting financial results that exceed the control total. The Trust s reported results show a surplus of 5.1m, equivalent to 0.08m above the control total. All NHS Trusts and Foundation Trusts were requested by NHS Improvement in 2016 to consider a series of technical accounting areas and assess both whether their current accounting approach meets the requirements of International Financial Reporting Standards, and to remove excess prudence to support the overall NHS reported financial position. The areas of accounting estimate highlighted included accruals, deferred income, injury cost recovery debtors, partially completed patient spells, bad debt provisions, property valuations, and useful economic lives of assets. Details of critical accounting judgements and key sources of estimation uncertainty are included in note

191 Annual Report and Accounts 2016/17 How the scope of our audit responded to the risk Manipulation of accounting estimates Our work on accounting estimates included considering each of the areas of judgement identified by NHS Improvement. We have considered both the individual judgements and their impact individually and in aggregate upon the financial statements. In testing each of the relevant accounting estimates, engagement team members were directed to consider their findings in the context of the identified fraud risk. Where relevant, the recognition and valuation criteria used were compared to the specific requirements of IFRS. We tested accounting estimates (including in respect of NHS revenue and provisions and property valuations discussed above), focusing on the areas of greatest judgement and value. Our procedures included comparing amounts recorded or inputs to estimates to relevant supporting information from third party sources. We evaluated the rationale for recognising or not recognising balances in the financial statements and the estimation techniques used in calculations, and considered whether these were in accordance with accounting requirements and were appropriate in the circumstances of the Group. Manipulation of journal entries We used data analytic techniques to select journals for testing with characteristics indicative of potential manipulation of reporting, focusing in particular upon manual journals. We traced the journals to supporting documentation, considered whether they had been appropriately approved, and evaluated the accounting rationale for the posting. We evaluated individually and in aggregate whether the journals tested were indicative of fraud or bias. We tested the year-end adjustments made outside of the accounting system between the general ledger and the financial statements. Accounting for significant or unusual transactions We considered whether any transactions identified in the year required specific consideration and, other than additional procedures performed to address the increased risk in the higher debtors balance (see Revenue risk), we did not identify any requiring additional procedures to address this risk. Key observations We did not identify concerns involving management override of control or the use of overly aggressive or conservative accounting estimates. These matters were addressed in the context of our audit of the financial statements as a whole, and in forming our opinion thereon, and we do not provide a separate opinion on these matters. 191

192 The Hillingdon Hospitals NHS Foundation Trust Our application of materiality We define materiality as the magnitude of misstatement in the financial statements that makes it probable that the economic decisions of a reasonably knowledgeable person would be changed or influenced. We use materiality both in planning the scope of our audit work and in evaluating the results of our work. Based on our professional judgement, we determined materiality for the financial statements as a whole as follows: Materiality Basis for determining materiality Rationale for the benchmark applied 5.0m (2015/16: 4.8m) 2% of revenue (2015/16: 2% of revenue) Revenue was chosen as a benchmark as the Trust is a non-profit organisation, and revenue is a key measure of financial performance for users of the financial statements. We agreed with the Audit and Risk Committee that we would report to the Committee all audit differences in excess of 250k (2015/6: 239k), as well as differences below that threshold that, in our view, warranted reporting on qualitative grounds. We also report to the Audit and Rick Committee on disclosure matters that we identified when assessing the overall presentation of the financial statements. An overview of the scope of our audit Our audit was scoped by obtaining an understanding of the Trust and its environment, including internal controls, and assessing the risks of material misstatement at the Trust level. Audit work was performed at the Trust s head offices in Hillingdon directly by the audit engagement team, led by the audit partner. The audit team included integrated Deloitte specialists bringing specific skills and experience in property valuations and information technology systems. Opinion on other matters prescribed by the National Health Service Act 2006 In our opinion: the parts of the Directors Remuneration Report and Staff Report to be audited have been properly prepared in accordance with the National Health Service Act 2006 the information given in the Performance Report and the Accountability Report for the financial year for which the financial statements are prepared is consistent with the financial statements. 192

193 Annual Report and Accounts 2016/17 Matters on which we are required to report by exception Use of resources We report to you if we are not satisfied that the foundation trust has put in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources. Basis for qualified conclusion The Trust has described in its Annual Governance Statement concerns related to financial sustainability. The foundation trust s outturn position for 2016/17 was an underlying deficit and the Trust s 2017/18 plan submission in November 2016 showed a further deficit forecast of 15.3 million for 2017/18. These issues, which are not wholly within the control of the Trust, are evidence of weaknesses in proper arrangements for planning finances effectively to support the sustainable delivery of strategic priorities and maintain statutory functions. Qualified conclusion On the basis of our work, with the exception of the matters reported in the basis for qualified conclusion paragraph above, we are satisfied that, in all significant respects, The Hillingdon Hospitals NHS foundation Trust put in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources for the year ended 31 March Annual Governance Statement and compilation of financial statements Under the Code of Audit Practice, we are required to report to you if, in our opinion: the Annual Governance Statement does not meet the disclosure requirements set out in the NHS Foundation Trust Annual Reporting Manual, is misleading, or is inconsistent with information of which we are aware from our audit; or proper practices have not been observed in the compilation of the financial statements. We are not required to consider, nor have we considered, whether the Annual Governance Statement addresses all risks and controls or that risks are satisfactorily addressed by internal controls. We have nothing to report in respect of these matters. Reports in the public interest or to the regulator Under the Code of Audit Practice, we are also required to report to you if: any matters have been reported in the public interest under Schedule 10(3) of the National Health Service Act 2006 in the course of, or at the end of the audit; or any reports to the regulator have been made under Schedule 10(6) of the National Health Service Act 2006 because we have reason to believe that the Trust, or a director or officer of the Trust, is about to make, or has made, a decision involving unlawful expenditure, or is about to take, or has taken, unlawful action likely to cause a loss or deficiency. We have nothing to report in respect of these matters. 193

194 The Hillingdon Hospitals NHS Foundation Trust Our duty to read other information in the Annual Report Under International Standards on Auditing (UK and Ireland), we are required to report to you if, in our opinion, information in the annual report is: materially inconsistent with the information in the audited financial statements; or apparently materially incorrect based on, or materially inconsistent with, our knowledge of the Trust acquired in the course of performing our audit; or otherwise misleading. In particular, we are required to consider whether we have identified any inconsistencies between our knowledge acquired during the audit and the directors statement that they consider the annual report is fair, balanced and understandable and whether the annual report appropriately discloses those matters that we communicated to the audit committee which we consider should have been disclosed. We confirm that we have not identified any such inconsistencies or misleading statements. Respective responsibilities of Accounting Officer and auditor As explained more fully in the Accounting Officer s Responsibilities Statement, the Accounting Officer is responsible for the preparation of the financial statements and for being satisfied that they give a true and fair view. Our responsibility is to audit and express an opinion on the financial statements in accordance with applicable law, the Code of Audit Practice and International Standards on Auditing (UK and Ireland). We also comply with International Standard on Quality Control 1 (UK and Ireland). Our audit methodology and tools aim to ensure that our quality control procedures are effective, understood and applied. Our quality controls and systems include our dedicated professional standards review team and independent partner reviews. This report is made solely to the Board of Governors and Board of Directors ( the Boards ) of The Hillingdon Hospitals NHS Foundation Trust, as a body, in accordance with paragraph 4 of Schedule 10 of the National Health Service Act Our audit work has been undertaken so that we might state to the Boards those matters we are required to state to them in an auditor s report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Trust and the Boards as a body, for our audit work, for this report, or for the opinions we have formed. 194

195 Annual Report and Accounts 2016/17 Scope of the audit of the financial statements An audit involves obtaining evidence about the amounts and disclosures in the financial statements sufficient to give reasonable assurance that the financial statements are free from material misstatement, whether caused by fraud or error. This includes an assessment of: whether the accounting policies are appropriate to the Trust s circumstances and have been consistently applied and adequately disclosed; the reasonableness of significant accounting estimates made by the Accounting Officer; and the overall presentation of the financial statements. In addition, we read all the financial and non-financial information in the annual report to identify material inconsistencies with the audited financial statements and to identify any information that is apparently materially incorrect based on, or materially inconsistent with, the knowledge acquired by us in the course of performing the audit. If we become aware of any apparent material misstatements or inconsistencies we consider the implications for our report. Craig Wisdom ACA (Senior statutory auditor) for and on behalf of Deloitte LLP Chartered Accountants and Statutory Auditor St Albans 30 May

196 The Hillingdon Hospitals NHS Foundation Trust 7 Foreword to the accounts 196