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Annual Report and Accounts 2014/15 King's College Hospital NHS Foundation Trust Annual Report and Accounts 2014/15 Presented to Parliament pursuant to Schedule 7, paragraph 25(4) (a) of the National Health Service Act 2006 CONTENTS Introduction ....................................................................................... 15 Who we are 15 A year of challenges 15 Chair’s Statement 17 Chief Executive’s Statement 18 Strategic Report ................................................................................ 23 How King’s is Regulated 23 Key operational and performance highlights 25 Ensuring Financial Sustainability 28 Planning for the Future 32 King’s Health Partners Academic Health Sciences Centre 33 King’s Workforce and Values 35 Workforce statistics 35 Caring for the Environment 37 Directors’ Report ............................................................................... 49 King’s People 49 Respecting and Protecting Patient Information 57 Code of Governance 60 Board of Directors 62 Remuneration Report 73 Council of Governors 74 Patient and Public Focus: Listening and Responding .................. 85 Improving Patient Care 85 A Representative Membership 94 IN FOCUS: ALWAYS AIMING HIGHER 97 Quality Account 2013/14 ................................................................. 105 Part 1: Statement on quality from the chief executive of the NHS Foundation Trust 107 Part 2: Priorities for improvement and statements of assurance from the Board 110 Part 3. An Overview of performance in 2013/14 against mandated national key standards 172 Annual Accounts 2014/15 ............................................................... 193 Glossary ACRONYM/WORD A&E ACC AHP AHSC ANS BCIS BHRS BME BREEAM BSCN BSI BSS CCG CCS CCTD CCUTB C-difficile CDU CEM CHD CHR – UK CLAHRC CLINIWEB CLL CLRN CNS COPD COPD COSD COSHH CPPD CQC CQRG CQUIN CRF CRISP CT MEANING Accident & Emergency Accredited Clinical Coder Allied Health Professionals i.e. Physiotherapists, Occupational Therapists, Speech & Language Therapists etc. Academic Health Science Centre Association of Neurophysiological Scientists Standards Bone Cement Implantation Syndrome British Heart Rhythm Society Black and Minority Ethnic Building Research Establishment Environmental Assessment Method British Society for Clinical Neurophysiology The British Standards Institution Breathlessness Support Service Clinical Commissioning Groups (previously Primary Care Trusts) Crown Commercial Service Critical Care and Trauma Department Critical Care Unit over Theatre Block Colistridium Difficile Clinical Decisions Unit Royal College of Emergency Medicine Congenital Heart Disease Child Health Clinical Outcome Review Programme (UK) Collaboration for Leadership in Applied Research and Care The Trust's internal web-based information resource for sharing clinical guidelines and statements. Chronic Lymphocytic Leukemia Comprehensive Local Research Network Clinical Nurse Specialist Chronic Obstructive Pulmonary Disease Chronic Obstructive Pulmonary Disease Cancer Outcomes and Services Dataset Control of Substances Hazardous to Health Continuing Professional and Personal Development Care Quality Commission Clinical Quality Review Group (organised by local commissioners) Commissioning for Quality and Innovation Clinical Research Facility Community for Research Involvement and Support for People with Parkinson’s Computerised Tomography 7 DAHNO DH/KCH DH DNAR DoH DTOC ED EDS EMS EPC EPMA EPR ERR ESCO EUROPAR EWS FFT FY GCS GP GSTS Pathology GSTT H&S HASU HAT HAU HCAI HCAs HESL HF HIV HNA HQIP HRWD HSCIC HSE HTA IAPT IBD ICAEW ICNARC ICO 8 National Head & Neck Cancer Audit Denmark Hill. The Trust acute hospital based at Denmark Hill Do Not Attempt Cardiopulmonary Resuscitation Department of Health Delayed Transfer of Care Emergency Department Equality Delivery System Environmental Management System Energy Performance Contract Electron Probe Micro-Analysis Electronic Patient Record Enhanced Rapid Response Energy Service Company European Network for Parkinson’s Disease Research Organization Early Warning Score Staff Friends & Family Test Financial Year Glasgow Coma Scale General Practitioner Venture between King’s, Guy’s and St Thomas’ and Serco plc Guy's St Thomas' NHS Foundation Trust Health & Safety Hyper Acute Stroke Unit Hospital Acquired Thrombosis Health and Aging Units Healthcare Acquired Infections Health Care Assistants Health Education South London Heart Failure Human Immunodeficiency Virus Holistic Needs Assessment Healthcare Quality Improvement Partnership ‘How are we doing?’ King’s Patient/User Survey Health and Social Care Information Centre Health and Safety Executive Human Tissue Authority Improving Access to Psychological Therapies Inflammatory Bowel Disease Institute of Chartered Accountants in England and Wales Code of Ethics Intensive Care National Audit & Research Centre Information Commissioner’s Office ICT ICU IG Toolkit IGSG IGT IHDT iMOBILE IPC ISO ISS JCC KAD KCH, KING's, TRUST KCL KHP KHP Online KPIs KPMG LLP KPP KWIKI LCA LCN LIPs LITU LUCR MACCE MBRRACE-UK MDMs MDS MDTs MEOWS MHRA MINAP MRI MRSA MTC NAC NADIA NAOGC Information and Communications Technology Intensive Care Unit Information Governance Toolkit Information Governance Steering Group Information Governance Toolkit Integrated Hospital Discharge Team Specialist critical care outreach team Integrated Personal Commissioning International Organization for Standardization Injury Severity Score Joint Consultation Committee King’s Appraisal & Development System King's College Hospital NHS Foundation Trust King’s College London – King’s University Partner King's Health Partners King’s Health Partners Online Key Performance Indicators King’s Internal Auditor King’s Performance and Potential The Trust's internal web-based information resource. Used for sharing trustwide polices, guidance and information. Accessible by all staff and authorised users. London Cancer Alliance Local Care Networks Local Incentive Premiums Liver Intensive Therapy Unit Local Unified Care Record Major Adverse Cardiac and Cerebrovascular Event Maternal, Newborn and Infant Clinical Outcome Review Programme Multidisciplinary Meeting Myelodysplastic Syndromes Multidisciplinary Team Modified Early Obstetric Warning Score Medicine Health Regulatory Authority The Myocardial Ischaemia National Audit Project Magnetic Resonance Imaging Methicillin-resistant staphylococcus aureus Major Trauma Services N-acetylcysteine National Diabetes Inpatient Audit National Audit of Oesophageal & Gastric Cancers 9 NASH NBOCAP NCEPOD NCISH NCPES NDA NEDs NEST NEWS NHFD NHS NHS Safety Thermometer NHSBT NICE NICU NIHR NJR NNAP NPDA NPID NPSA NRAD NRLS NSCLC OH/ORPINGTON HOSPITAL OSC PALS PbR PICANet PiMS PLACE POMH POTTS PROMS PRUH/KCH PRUH PUCAI PwC 10 National Audit of Seizure Management National Bowel Cancer Audit Programme National Confidential Enquiry into Patient Outcome & Death Studies National Confidential Inquiry into Suicide & Homicide for People with Mental Illness National Cancer Patient Experience Survey National Diabetes Audit Non-Executive Directors National Employment Savings Trust National Early Warning System National Hip Fracture Database National Health Service A NHS local system for measuring, monitoring, & analysing patient harms and ‘harm-free’ care NHS Blood and Transplant National Institute for Health & Excellence Neonatal Intensive Care Unit National Institute for Health Research National Joint Registry National Neonatal Audit Programme National Paediatric Diabetes Audit Pregnancy Care in Women with Diabetes National Patient Safety Agency National Review of Asthma Deaths National Reporting and Learning Service Non-Small Lung Cancer The Trust acquired services at this hospital site on 01 October 2013 King’s Organizational Safety Committee Patient Advocacy & Liaison Service Payment by Results Paediatric Intensive Care Audit Network Patient Administration System Patient Led Assessments of the Care Environment Prescribing Observatory for Mental Health Physiological Observation Track & Trigger System Patient Reported Outcome Measures Princess Royal University Hospital. The Trust acquired this acute hospital site on 01 October 2013 Pediatric Ulcerative Colitis Activity Index PricewaterhouseCoopers QMH RCPCH RIDDOR ROP RRT RTT SBAR SCG SEL SEQOHS SHMI SIRO SLAM SLHT SLIC SSC SSIG SSNAP SUS SW TARN TTAs TUPE UAE UNE VTE WHO WTE Queen Mary’s Hospital Royal College of Paediatric and Child Health Reporting of Injuries, Dangerous Diseases and Dangerous Occurrences Regulations Retinopathy of Prematurity Renal Replacement Therapy Referral to Treatment Situation, Background, Assessment & Recognition factors for prompt & effective communication amongst staff Specialist Commissioning Group (NHS England) South East London Safe Effective Quality Occupational Health Service Standardised Hospital Mortality Index. This measures all deaths of patients admitted to hospital and those that occur up to 30 days after discharge from hospital. Senior Information Risk Owner South London & Maudsley NHS Foundation Trust South London Health Care Trust. SLHT dissolved on 01 October 2013 having being entered into the administration process in July 2012. Southwark & Lambeth Integrated Care Programme Surgical Safety Checklist Surgical safety Improvement Group Sentinel Stroke National Audit Programme Secondary Uses Service Social Worker Trauma Audit & Research Network Tablets to take away Transfer of Undertakings (Protection of Employment) Regulations United Arab Emirates Ulnar Neuropathy at Elbow Venous-Thromboembolism World Health Organisation Whole Time Equivalent 11 Introduction Introduction Queen Mary’s Hospital (Sidcup) and Beckenham Beacon. Who we are King’s College Hospital NHS Foundation Trust has a reputation for providing excellent local healthcare in the boroughs of Lambeth and Southwark and, more recently, in Bromley and Lewisham. It also provides a range of specialist services for patients across south east England and beyond. King’s has been recognised nationally and internationally for its work in the fields of liver disease and transplantation, neuro-sciences, diabetes, cardiac services, haemato-oncology and fetal medicine. Designated a Major Trauma Centre and host to two of eight hyper-acute stroke units in London, King’s also plays a key role in the education and training of the next generation of medical, nursing and dental students. King’s is also part of the Academic Health Sciences Centre known as King’s Health Partners (KHP). Together with academic partners King’s College London and fellow foundation trusts Guy’s and St Thomas’ and South London and Maudsley, KHP brings together an unrivalled range of physical and mental health clinical and research expertise. The combined strengths of this collaboration benefits patients through breakthroughs in research and improvements in patient care. A year of challenges This year, King’s has been adapting to its new status as an enlarged organisation, and the various challenges and opportunities this has brought with it. In October 2013, the Trust took over the Princess Royal University Hospital (PRUH), following the dissolution of South London Healthcare NHS Trust (SLHT). It also took over Orpington Hospital, plus services at Since October 2013, the Trust has made great progress on a number of fronts, not least in patient satisfaction at the PRUH, which has gone up, at the same time as the number of complaints has come down. The PRUH stroke unit has moved from unaccredited status to one of the top 20 units in the country. The Trust has also revived Orpington Hospital, and turned it into one of the largest orthopaedic centres in London, with outstanding patient outcomes, a Friends and Family score of 100% and a five star rating on NHS Choices. However, the historic financial and quality issues at the PRUH were materially worse than anticipated during the due diligence process, and the Trust needed to make investments quickly to ensure patient safety on the PRUH site, including increasing the nurse to patient ratio on the wards. The King’s Board took a deliberate decision, in consultation with local stakeholders, to prioritise the quality and safety of patient care over financial performance. For example, the necessary use of agency staff - at an increased cost - to fill vacant nursing positions while permanent staff were recruited. This was a major contributory factor to the challenged financial position the Trust now faces. Following an investigation by Monitor, King’s has committed to the delivery of one and two year financial recovery plans and a five year strategic plan for the future. King’s has also undertaken to work closely with Monitor and other stakeholders to address the financial and capacity challenges in the wider South East London health economy. This report tells the story of how King’s has performed during the period 01 April 2014 – 31 15 March 2015 and how the challenges have been tackled by the people who work here. It reflects on this year’s performance and next year’s priorities for providing quality, patient-centred care whilst addressing significant financial challenges. 16 Chair’s Statement I write this statement with mixed feelings. On 1 April, I will retire as Chair of King’s, a role I have always felt honoured to hold. Of course, I am excited about what the future may hold, but I am also sad to end my formal association with the Trust as Chair, a position I have held since 2010. My last year as Chair has been a busy one. I have been working closely with the Trust Executive and our other Non-Executive Directors to get to grips with our status as an enlarged organisation, and what this means for our patients. As Chair, I know how important it is for us to properly integrate services and bring together the hospitals we run. This has been a major challenge since October 2013, when we took over the Princess Royal University Hospital (PRUH), Orpington Hospital, and services at other sites. Our mantra from the outset has always been ‘one hospital, across multiplesites’, and we are making progress towards this becoming a reality. Of course, I am also a doctor, and understand the importance of making sure we continue to get the basics right - that is, providing first-rate care to the patients we treat, every day of the week. To achieve this – whilst running and integrating three hospitals, plus services at other sites – was never going to be easy, and so this has proved to be. As Tim says overleaf, the services we provide continue to be in high demand, which reflects well on our staff. However, it does mean operational performance has been challenged, although we are taking steps to address this. We’ve continued to engage with those stakeholders who are local to the hospitals we run. Many organisations are involved in delivering healthcare locally, so we have made a concerted effort to engage with them, to ensure we work together to improve care for patients - both in and outside the hospital. This year, we welcomed a new Council of Governors, with 74 staff and members of the public standing for election to 19 posts. The new ‘intake’ of Governors reflects the varied and diverse nature of the communities we serve and they will play a key role in the future direction of the Trust. The past year has also reminded us of our strong links with the local community, plus those from further afield. In August, the Trust organised a week of commemorative events to mark 100 years since the beginning of the First World War. We took this opportunity to remember those who died or who were injured, and our staff who tried to heal them. The events included a re-dedication of the Memorial Garden at Orpington Hospital, which served as a military hospital for Canadian and British troops during the war. We were delighted to welcome Deputy High Commissioner for Canada, Alan H Kessel, and the representative for Ontario, Aaron Rosland, who paid us a special visit. Finally, I believe King’s will always be a special place to work and be treated, and I would like to wish everyone all the best for the future, not least my successor, Lord Bob Kerslake. Professor Sir George Alberti Former Chair 17 Chief Executive’s Statement Last year’s report covered our acquisition of the Princess Royal University Hospital (PRUH) in October 2013 following the dissolution of South London Healthcare NHS Trust (SLHT). As well as the PRUH, we also took over Orpington Hospital, as well as patient services at Queen Mary’s Hospital (Sidcup) and Beckenham Beacon. The historic financial and quality issues at the PRUH were materially worse than identified in the due diligence process, and we needed to make investments quickly to ensure patient safety on the PRUH site. The King’s Board took a deliberate decision, in consultation with local stakeholders, to prioritise the quality and safety of patient care over financial performance. For example, the necessary use of agency staff - at an increased cost - to fill vacant nursing positions while permanent staff were recruited. This was a major contributory factor to the challenged financial position the Trust now faces. Operationally, the key issues for us centred around demand for services locally. Both our Emergency Departments (ED) have seen high levels of attendance and admission and this has led to extended ED waits for our local patient population. Planned operations have also been affected by the influx of emergency patients, leading to a lack of beds, the need to cancel operations and longer waiting lists. Throughout the year, we have been working closely with Monitor, the health regulator, discussing our operational performance and our finances, and at the end of the year Monitor launched a formal investigation with the aim of finding a solution to these long-standing 18 problems at the Princess Royal University Hospital. We have been tasked with preparing one and two year recovery plans and a 5 year strategy. To help us meet the challenging financial recovery targets we appointed a transformation and turnaround director in March who will be driving cost savings across the organisation to reduce our deficit. We are also pleased that Monitor recognised the need for a system wide solution. This is a key part of delivering improvements in patient care, as well as addressing the financial and capacity challenges in South East London. We will be working closely with Monitor and other stakeholders to address the financial and capacity challenges both in the Trust and in the wider health economy. We shouldn’t lost sight of the real achievements we have made over the last year, despite the financial and operational challenges. We have increased staffing levels at the PRUH, and improved the physical environment people are treated in. Patient satisfaction has increased, and the number of complaints is down. The PRUH stroke unit has moved from unaccredited status to one of the top twenty units in the country, and we have revived Orpington Hospital and turned it into one of the largest orthopaedic centres in London, with outstanding patient outcomes, a Friends and Family score of 100% and a five star rating on NHS Choices. The pace of change across the organisation shows no signs of slowing down. At Denmark Hill, we are also treating more patients than ever before. Two key projects – a new critical care facility, and a helipad for the Ruskin Wing – are now well underway. Both projects are of strategic importance to the Trust, and are very visible signs to our patients and staff of our plans to modernise the site, and provide truly world-class patient services. However, our most important asset will always be our staff. The past year has been rewarding for me because, despite the challenges outlined above, staff have really stepped up to the plate, and continued to do everything within their powers to deliver high-quality patient care. We have all welcomed new staff and different ways of working, and I believe we are a better organisation as a result. Finally, I would like to thank Professor George Alberti, our Chair, for the enormous contribution he has made to the Trust since taking on the role in 2010. George retired on 1 April 2015, and I wish him all the best for the future. His predecessor, Lord Kerslake, has already started with us, and we all look forward to working with him. I hope you enjoy this report, and find it useful. *Tim Smart Chief Executive *Tim Smart retired as Chief Executive in April 2015, and Roland Sinker, Chief Executive Officer becoming Acting Chief Executive 19 Strategic Report distribution which might reasonably be expected to be declared or paid for the period of 12 months However it drew Monitors attention to the following factors which may cast doubt on the ability of King’s to provide Commissioner Requested Services: commissioner funding regime; the availability of central funding at the right time; The ability to agree timely repatriation of patients to their local hospitals; and resolution of any issues related to claims for the acquisition of former SLHT sites and services. Strategic Report How King’s is Regulated King’s has been a foundation trust since December 2006. As such its regulated by Monitor and required to make periodic submissions pertaining to its strategic plans, and its audits financial and operational performance. These plans and submissions provide the framework for decision-making and performance tracking. As part of King’s annual reporting to Monitor, the Board of Directors had to assess and forecast how the organisation would perform operationally and financially. The Board also had to self-certify against three statements: 1. General condition systems for compliance with License Conditions. 2. Continuity of services condition 7 – availability of resources. 3. How it will perform in relation to the corporate governance statements outlined in the licence On completing a review of its performance against licence conditions, schedule of assurance against corporate governance statements, board assurance framework and the risk registers, the Board identified and selfcertified that there were risks to achievement of the following targets for 2014/15: RTT 18 Week Admitted; A&E 4 hour Waiting Time; Cancer waiting times; C.Difficile; and That a reasonable expectation, was that King’s would have the required resources available to it after taking into account in particular (but without limitation) any These challenges did not dissipate during the period and the King’s decided to prioritise patient care and delivering a high standard of service by investing in its services in particular at the PRUH site. Accordingly, King’s welcomed the regulator, Monitor’s, investigation in March 2015. Although Monitor recognised that King’s had made progress in improving services at the PRUH, this has not been sufficient, as it had become clear the challenge was greater than initially anticipated. Following the investigation, Monitor agreed with King’s that it will: develop and implement an effective shortterm financial recovery plan to deliver the required improvements at the PRUH that King’s planned to make when it took over the hospital; and develop and implement a longer-term plan by working closely with other national and local health care organisations (including NHS England and local commissioners) to ensure patient services are improved, and also provided in a sustainable way for the future. 23 Table 1: Financial & Governance Performance 2013/14 and 2014/15 2013/14 2014/15 Continuity of Risk Rating Governance Risk Rating Continuity of Risk Rating Governance Risk Rating Quarter 1 n/a n/a 3 Under Review Quarter 2 n/a Green 3 Under Review 3 Considering investigation 2 Under Review Investigation 3 Considering investigation 2 Red - Under Enforcement Action Quarter 3 Quarter 4 24 Key operational and performance highlights During 2014/15 King’s continued to see high numbers of patients coming into its Emergency Department (ED) and requiring emergency admission,following the unprecedented increase in activity levels in 2013/14. Consequently, King’s bed occupancy has remained high at 95% throughout the year on both acute sites at Denmark Hill and the Princess Royal University Hospital (PRUH). This has put considerable pressure on delivering King’s key performance targets such as getting patients into hospital quickly enough and managing infection control trajectories across the enlarged organisation. King’s is not alone in these challenges as these pressures are mirrored across South East London. Emergency department ‘4-hour wait’ performance During the period, King’s faced significant challenges in meeting its 4-hour waiting time target but has made significant investment on both its acute sites in the form of additional staff and extra capacity to ensure optimal performance in light of the increasing demand. Medical and surgical assessment units have been setup during the year to better manage the flow of emergency patients into the hospital. Denmark Hill ‘4-hour wait’ performance Increased numbers of mental health patients attending the Denmark Hill site ED and the high numbers of repatriation patients remaining in beds have restricted patient flow in ED and in acute beds. Performance improvements against trajectory helped be achievement of the 4-hour wait target in October and November. However continued failure in each quarter resulted in an overall failure of the 4-hour target at the Denmark Hill site during 2014/15. PRUH ‘4-hour wait’ performance This failure was also mirrored at the PRUH site where the 4-hour target was not met during 2014/15. There were significant performance improvements at the site in the first six months of the year but performance worsened going into Q4 with breaches due to bed availability being a significant factor. Drivers for this position included the fact that more acutely ill patients were attending the hospital, a majority of whom required treatment in the resuscitation area of the ED, which was constantly running at full capacity during the period. A further driver was the insufficient staff establishment numbers in ED. Unfilled shifts resulted in cubicle closure in the ED. King’s has prioritised treating patients quickly and safely. However, in the short-term, this led to is a high degree of reliance on agency staff which impacted on the financial position. King’s has prioritised nursing recruitment to reduce the use of agency staff. King’s continues to manage emergency performance at a senior executive level on a daily basis with the Board and its regulators, through work with local commissioners and NHS England to address key issues such as tertiary and rehabilitation repatriation delays. The number of patients attending the ED also increased in December by a further 2% with 1,000 more patients seen compared to December in the previous year. 25 Patient Access targets Throughout the year, high levels of emergency admissions have heavily impacted on the achievement of 18-week referral to treatment targets for admitted patients across King’s. The non-admitted completed pathway and incomplete pathway targets were achieved during the period. However, the admitted completed pathway target was not achieved during any quarter in 2014/15. This was anticipated and declared in the forward plan submitted to Monitor. A strong focus was maintained on improving performance in this area with actions to increase on-site and off-site working using private providers. Cancer waiting time targets were achieved with the exception of the 2-week wait from referral to date seen target which was not met in quarter 1. The 62-day wait for first treatment target was not achieved in quarter 2 or quarter 4. This was consistent with the risk assessment submitted to Monitor at the beginning of the period. Denmark Hill access target highlights: During the period, King’s worked hard to reduce the backlog of 2000 patients waiting over 18weeks to have their elective procedures carried out at the Denmark Hill site. The original plan was to get this down to 1200 by September but unfortunately, this was not achieved until the end of November. Factors which impacted on King’s clearing this backlog included increased bed pressures and the lack of external private patient capacity which was lower than forecast. National waiting time targets for cancer patients were achieved which ensured that cancer and suspected cancer patients were treated in a timely manner throughout the year. It is however unlikely that King’s will achieve the 62day wait for first treatment target for Q4. 26 PRUH access target highlights King’s planned to reduce the backlog of admitted patients waiting over 18-weeks to 450 patients. However, this target was not met due to the high number of emergency patients occupying beds at PRUH and the fact that the levels of private hospital capacity available to outsource these patients was lower than planned. A number of equipment failures in the Day Surgery Unit have also impacted on the number of patients the Trust could treat. The 18-week admitted completed target has not been achieved and the non-admitted completed target was only achieved in quarter 1. The incomplete pathway target was achieved in quarters 2 and 3. Due, in part, to delays in a number of services being moved to Beckenham Beacon hospital to create additional capacity, the 2-week wait from referral to date seen target was not achieved in the reporting period. Bed pressures have also impacted on achievement of the 62 day wait for the first cancer treatment target. This target was only met in quarter 1 of the reporting period. Infection prevention and control There were 77 C-difficile cases that were attributed to the Trust in 2014/15, an increase compared to the 69 cases that were reported during 2013/14. This is also higher than the stretch target of 58 cases set by the Department of Health for the Trust. All of these cases are subjected to a thorough review to identify any cases due to “Lapse in Care” and to put mitigating actions in place. A “Lapse in Care” is defined in National Guidance as “a case where evidence exists that policies and protocols consistent with national guidelines and standards weren’t followed”. Seven cases were considered to be Lapses in Care. These lapses related to antibiotic use, either an inappropriate type of antibiotic chosen or a concern with the duration of treatment. Denmark Hill infection control highlights The number of cases of C-difficile increased during 2014/15 with a total of 57 cases which was above the site quota of 42 cases, and higher than the 49 cases in 2013/14. Although no longer a reporting requirement, there were six cases of Methicillin-resistant Staphylococcus aureus (MRSA) attributed to King’s during the year. No evidence of cross transmission was seen on ribotyping tests. There were four cases declared as lapses in care relating to antibiotic use. PRUH infection control highlights There were 20 cases of C-difficile attributed to the PRUH during 2014/15, consistent with the previous year, but higher than the quota of 16 cases. There were no cases of MRSA attributed to PRUH during the year. Three cases were declared to be lapses in care relating to antibiotic use. King’s continues to monitors other instances of healthcare acquired infections (HCAI) and this remains a priority area. Mortality indicators In line with guidance from the Department of Health, King’s has continued to review mortality based on the Summary Hospital-level Mortality Indicator (SHMI). The SHMI for 2014/15 is 91, an improvement on the SHMI of 94 for 2013/14, and better than the expected index of 100. This indicates that outcomes continue to be better than expected. Stroke Unit King’s specialist stroke units at the Denmark Hill and PRUH sites have scored highly in the Sentinel Stroke National Audit Programme (SSNAP) for 2014/15 which scores all stroke units across the country so that they can monitor their progress against national standards. The unit at Denmark Hill has achieved the highest overall score of all of the units in London and joint-highest nationally, while the unit at the PRUH was scored highly for the high standard of its thrombolysis care, and the efficiency of its scanning. Patient Data and System Integration A key priority for the King’s was to work on integrating all patient activity data collection into one patient administration (PiMS) system. During 2014/15, the Trust has migrated data from the patient administration systems historically used on the Sidcup and PRUH sites to the PiMS system that is being used on the Denmark Hill site. All patient activity is therefore now recorded on a single system across the Trust. 27 Ensuring Financial Sustainability 2014/15 was the first full financial year since the acquisition of the services and assets of part of the former South London Healthcare NHS Trust (SLHT). On 01 October 2013, King’s received all services provided at PRUH, excluding the services provided within Green Parks House. King’s also received all SLHT services provided at Orpington Hospital; all SLHT services provided at Beckenham Beacon for a period of three years, except where otherwise requested by Bromley Clinical Commissioning Group at an alternative site once the King’s lease expires; and all SLHT services provided at the Sevenoaks site. King’s also received a range of services provided at Queen Mary’s Hospital (QMH) in Sidcup, including all dental services, community midwifery services and ophthalmology (for an interim period of 22 months). Inpatient elective surgery, endoscopy and Programmed Investigation Unit/Day Assessment Unit services provided on the QMH site for PRUH patients were also received by King’s, with a view to them being repatriated to King’s sites as soon as possible. Over the last 18 months, following the acquisition of the Princess Royal University Hospital (PRUH) and services on other sites in South East London, the Board of King’s College Hospital NHS Foundation Trust has taken a series of decisions using good information that prioritised patient safety, quality and access over financial performance. The historic financial and quality issues at the PRUH were materially worse than identified in the due diligence process, and the Trust needed to make investments quickly to ensure patient safety on the PRUH site, including increasing the nurse to patient ratio on the wards. The necessary use of agency staff at an increased cost to fill these positions while 28 permanent staff were recruited is a major contributory factor to the challenged financial position the Trust now faces. The financial implications of these decisions resulted in a year end operating deficit of £15.9 million. After financing costs and asset value impairments, the total deficit from continuing operations was £52 million. In addition to the investments made at the PRUH a number of other factors added to the cost pressures facing the Trust: A general shortage of capacity, exacerbated by high levels of emergency demand and the difficulty in discharging patients fit-fordischarge either back into the community or to their referring hospital. This led to a significant proportion of elective procedures being undertaken offsite in the private sector or out of hours. Both of these alternatives cost more than in-house treatment during normal working hours. A difficulty in recruiting sufficient numbers of suitably qualified permanent staff. This led to a significant increase in expenditure on temporary staff in order to maintain safe staffing levels. A shortfall in the delivery of cost improvement plans, particularly the delivery of benefits outlined in the Full Business Case arising from the new enlarged organisation. In order to address these issues the Trust formulated a series of plans to restrict activity and designed to reduce expenditure which Monitor and Commissioners did not feel able to support. In order to produce a sustainable recovery plan, the Trust appointed PwC to assist in identifying savings and productivity opportunities. This was supplemented by the appointment of a Transformation and Turnaround Director in March 2015. Monitor launched an investigation in February 2015 due to ‘longstanding issues at the PRUH’. The Trust welcomed the outcome of the investigation and that there was a recognition that a system wide solution was required. As a result of the investigation, the Board of Directors undertook to produce a series of recovery plans covering one, two and five years during 2015. Liquidity and capital As a result of the size of the deficit the Trust has also needed to address liquidity concerns. Cash flow planning has, with the assistance of PwC, been enhanced and an interim support facility of £59m agreed with Monitor and the Department of Health. More long term support will be agreed once the five year strategic plan has been submitted in October 2015. The cash impact of the deficit incurred in 2014/15 has affected the ability of the Trust to comply with the better payment practice code – 79% of invoices by value being paid within the 30 day period (53% by volume). The Trust paid £4,000 in the financial year as a result of penalties assessed under the Late Payment of Commercial Debts (Interest) Act 1998. Total capital expenditure in 2014/15 was £49m – the major schemes being the start of a new project to expand critical care capacity and the completion of a new MRI and Cardiac facility. For future years, the capital programme has been reviewed to include only schemes that are already in progress, are essential for health and safety reasons or directly contribute to the financial recovery plans. Going Concern Due to the materiality of the financial issues, the Board has carefully considered whether the accounts should be prepared on the basis of being a ‘Going Concern’. The Board considered the advice in the Government Reporting Manual that “The anticipated continuation of the provision of a service in the future, as evidenced by inclusion of financial provision for that service in published documents, is normally sufficient evidence of going concern.” After making enquiries, the directors have concluded that there is sufficient evidence that services will be continue to be provided and that there is financial provision within the forward plans of commissioners. This provision will also be dependent on both acceptance and delivery of the financial recovery plans and continuation of support from the Department of Health. The Directors have a reasonable expectation that this will be the case. More information on going concern can be found on pages 226-227 in the Annual Accounts. Value for money and improved efficiency Divisions and corporate departments delivered £29.9m of cost improvement schemes representing 56.4% of the planned schemes during 2014/15, a reduction in the delivery success compared to previous years. This was predominantly due to the high levels of emergency demand adversely affecting plans for improved productivity in the areas of nursing, medical staff and theatre utilization. In order to improve the delivery rate as well as providing a system to identify, track and manage the larger portfolio of schemes required to achieve the recovery plan, the Trust has established a Programme Management Office, which, in the first instance, will be operated by PwC. All savings schemes pass through a process of identification, verification 29 and quality impact assessment before being added to the programme. The Quality Impact Assessment is undertaken by the Medical Director and Director of Nursing to ensure that schemes are not proceeded with if there is a risk to patient safety. The identification of schemes is being led by the new Turnaround and Transformation Director. The first year recovery plan calls for the identification of £86m worth of savings in order to begin to address the underlying deficit and further cost pressures facing the acute sector. Pending the development of the five year strategic plan later in 2015, it is currently anticipated that the Trust will regain financial balance in 2017/18. During the year, the Trust supplemented its available capacity, by expanding the activities of the King’s Orthopaedic Centre at Orpington. This facility enables patients requiring elective joint surgery to be seen in a purpose built facility with dedicated support facilities and minimises the risk of cancellations due to emergency pressures. Non-clinical activities KCH Commercial Services Limited, the company established to oversee commercial operations, continues to diversify income by expanding commercial activities both in the UK and overseas. It has now been in operation for seven years. During that time, the first of the operating companies, Agnentis Limited, successfully established itself as a market leader in patient costing and benchmarking solutions before divesting the associated products in 2012. KCH Management Limited continues to develop a hospital management and consultancy business both in the UK and overseas, predominantly in the Middle East and Africa. King’s first non-UK operation opened in Abu Dhabi, UAE in October 2014. KCH Management owns 49% of the company, the 30 maximum allowable under local statutes, operating the Clinic. The company also operates a successful international recruitment business both for Kings and other healthcare organisations. GSTS Pathology, a venture between King’s, Guy’s and St Thomas’ and Serco plc, rebranded to become known as Viapath LLP. Its performance has continued to improve and the venture delivered a surplus attributable to Kings in the year of £1.4m. The company divided its activities between services and operations during the financial year and, following a consultation exercise, the Trust transferred its formerly seconded staff to the company under the TUPE regulations. King’s is a public benefit corporation and its principal purpose is the provision of goods and services for the purposes of the health service in England. During the reporting period, income from the provision of goods and services for the purposes of the health service in England was greater than from the provision of goods and services for any other purpose. Income received from non-NHS services is directly invested in the provision of NHS services and do not impact the services provided to NHS patients. For the financial year 2014/15, it is estimated that the surplus reinvested was approximately £5m. Changes to accounting policies There were no significant changes to accounting policies during the year. Cost allocation requirements King’s has complied with the cost allocation and charging requirements set out in HM Treasury and Office of Public Sector Information guidance. Table 2: Key Financial Implications Full Year (£’000) Operating income and costs Operating income from continuing operations Operating expenses from continuing operations Operating surplus Net finance costs Share of profit of Associate/Joint Ventures accounted for using equity method Gain from transfer by absorption Corporate tax expense (Deficit)/surplus from continuing operations External audit services Deloitte LLP is King’s external auditor having been appointed by the Council of Governors in May 2011 for a period of three years following a competitive tendering exercise. King’s incurred £128,000 in audit services fees in relation to the statutory audit for the year to 31 March 2015 and £27,000 in respect of audit-related assurance services. So far, as King’s directors are aware, there is no relevant audit information of which the auditors are unaware. King’s directors have taken all of the steps that they ought to have taken as directors in order to make themselves aware of any audit information and to establish that the auditors are aware of that information. Borrowing and capital plans Due to the adoption of International Financial Reporting Standards, the majority of the Trust’s reported borrowing represents past expenditure on the private finance initiative schemes for the Golden Jubilee Wing and Ruskin Wing at Denmark Hill and the Princess Royal University Hospital. Further borrowing has been undertaken to finance the construction of the new Critical Care 2014-15 2013-14 1,083,782 892,054 (1,099,712) (871,875) (15,930) 20,179 (36,642) (27,250) the 757 1,278 (250) (52,065) 65,542 59,749 Facility. At 31 March 2015, loans outstanding to the Foundation Trust Financing Facility totaled £70m. Because of the continuing service provider relationship that the Foundation Trust has with NHS England and clinical commissioning groups, and the way those commissioners are financed, the Foundation Trust is not exposed to the degree of financial risk faced by business entities. The Foundation Trust has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the Foundation Trust in undertaking its activities. King’s has low exposure to interest rate risk and credit risk material for the assessment of the assets, liabilities, financial position and results of the entity. Due to the Trust’s 49% holding in King's College Hospital Clinics LLC (KCHC), operating in the United Arab Emirates, the Trust is exposed to limited currency risk in the form of currency rate fluctuations on interest and capital repayments of the loan denominated in Emirati Dirhams (AED). The foundation trust is currently exposed to liquidity risk due to its requirement for working 31 capital support. The Trust has secured £59.7m of Interim Revolving Working Capital Support Funding from Monitor/DoH but agreement is required from Monitor regarding the amount that may be drawn down on a monthly basis. Further information about these risks can be found in the financial statements on pages 191257. The policy of maintaining King’s asset base by committing capital expenditure on existing assets at a level broadly consistent with their rate of depreciation will continue subject to the criteria regarding capital programme schemes outlined above. Full details of financial performance in 2014/15, the responsibilities of the Accounting Officer and a statement from the auditors can be found in the Annual Accounts 2014/15 on pages 191257. The accounts have been prepared under a direction issued by Monitor under the National Health Service Act 2006. Planning for the Future The King’s vision is to deliver a health system built around patient need, offering all our patients the highest quality of care for mind and body – and true to the King’s Values. The Trust aims to be three hospitals in one – a network rather than a set of buildings: A multi-site local hospital providing acute urgent care and consolidated, rapid access local outpatient and elective care. 32 A major regional emergency centre for South East London, Kent and Sussex. A leading national specialist hospital at the heart of an Academic Health Sciences Centre with high impact academic research and teaching. As such, King’s provides services to local residents of Lambeth, Southwark, Bromley, Bexley and Lewisham. For people across south east London and Kent, King’s is the designated major trauma centre, a heart attack centre and a regional hyper-acute stroke centre. King’s is recognised across the UK and internationally for its work in liver disease and transplantation, neurosciences, diabetes, cardiac services, haematology and foetal medicine. The local health system faces a tremendous challenge - to transform care models to meet the needs of an ailing and ageing population and improve quality at a time when finances are very strained. The south east London health economy faces a net financial deficit, both in financial year (FY) 2015/16 and over the next five years - approximately £1 billion. Performance for referral to treatment (RTT), clinical outcomes for key services, and discharge times need to improve while there is demographic growth and increasing demand for services. King’s 2-year recovery plan aims to ensure King’s rectifies its budget position, and to ensure King’s is efficient, highly productive and fosters innovation in all areas. In addition to a robust programme of cost improvement, four transformative strategic options will be pursued during 2015/16. These will support the financial recovery and also improve the quality of services offered and address some of the pressing needs of the local health system. However, if King’s is to achieve long-term sustainability more ambitious changes at King’s and more joined-up system redesign across the health economy are required. It is likely that significant service changes which will need either increased funding or for significant strategic choices with impact across the whole health system to be made and implemented. King’s is therefore developing a refreshed 5year Strategic Plan which will be submitted to Monitor by the end October 2015. This detailed work will consider; demographic trends; demand for services; local health system issues; funding and demand management; competitor effects; clinical policy and regulatory changes; workforce changes and challenges; and technology, education and research developments. The 5-year strategy will address the continued development of King’s academic partnership with King’s College London (KCL) and fellow foundation trusts Guy’s and St Thomas’ (GSTT) and South London and Maudsley (SLaM) - the Academic Health Sciences Centre known as King’s Health Partners (KHP). This exists to create a centre where world-class research, education and clinical practice are brought together for the benefit of patients, so that the lessons from research are used more swiftly, effectively and systematically to improve patient care. Work is underway to work up detailed proposals to develop a suite of academic “Institutes” across the KHP partners and will form an important part of the future identity of King’s. The development of this detailed strategic plan has already started. Because of its complexity and wide-ranging impact on people and organisations, King’s is committed to involve and engage staff, governors and local commissioners and stakeholders. Quality priorities King’s Quality Account, on pages 103-190, sets out the priority areas for improving quality in the coming year, as well as evaluating performance against last year’s priorities. King’s Health Partners Academic Health Sciences Centre King’s Health Partners (KHP) Academic Health Sciences Centre was set up in 2009. It brings together a world-leading research led university (King’s College London) and three successful NHS foundation trusts (Guy’s and St Thomas’, King’s College Hospital and South London and Maudsley). KHP launched its five year plan in summer 2014, aimed at transforming health and wellbeing, locally and globally. Combining its focus on key underpinning themes of excellence in education, research translation and clinical practice, public health, integrated care, mind and body and value based healthcare KHP also aims to achieve internationally competitive standards of practice in a number of key specialties. A key part of the KHP’s vision for excellence is the way in which it continues to align itself with partners right across the south east London health care economy. Colleagues from across KHP have been closely involved in the development of the ‘Our Healthier South East London’ strategy and KHP is committed to supporting and enabling its successful delivery. Local services KHP is aware that successful delivery of the six borough strategy in SE London requires the ongoing delivery of high quality services right across the three foundation trusts and wider partners. To this end, KHP is committed to seeking continuous improvement of its services, working closely with partners across the sector to deliver joined up and effective care for local people. Provision of excellent local services remains the highest priority and KHP is taking significant strides towards the integration of care: 33 working with local colleagues to develop and deliver Local Care Networks and GP federated structures which KHP fully support as an important step towards better integrated care. building on close partnership working through the Southwark & Lambeth Integrated Care programme (SLIC) and the detailed programmes within each of its providers. the advent of locality based integrated care models will be a major contributor. Specialised Services People in south east London should have access to the very best specialist care, as benchmarked against the best in the world. KHP believe that a new type of clinical academic model for south east London (and stretching across the south of England), working across sites and campuses, bringing together the combined strength of the partners, would provide improved outcomes and experience for patients and service users whilst ensuring the delivery of its science and translational research ambitions. KHP is currently scoping the feasibility of making further improvements to its services across KHP and in doing so is considering the following points: the nature of differing specialties now and in the future will require bespoke and carefully calibrated models of delivery, particularly with regard to clinical pathways across out of hospital and in hospital care environments. 34 some specialties may require highly specialised tertiary diagnostic and treatment facilities in one place to enable translational practice. For others the model of care may require a new focus on localities, communities and acute hospital pathways. improved informatics and data sharing will be crucial – the development of KHP Online and its planned evolution into the Local Unified Care Record (LUCR) is a major step in the right direction. the collective strength in KiHP’s partner organisations and leveraging the expertise of clinical services, research and education into a more joined up offer. improved access to the very best specialist care with the best outcomes for patient and family experience. provide networks of care across south east London/south east England that support acute, community and primary care. As set out in the five year plan, KHP is focusing on achieving internationally competitive excellence in the seven key specialties of cancer, cardiovascular, child health, dental, diabetes, mental health & neurosciences and regenerative & transplantation medicine through the establishment of institutes that bring together clinical service, teaching and research. Research KHP is working hard to speed up the flow of research into translation to clinical care, from basic science through to novel therapeutics, drug discovery, clinical trials and applied research so that the local population reap the benefits more quickly. Education and training KHP will continue to develop its educational and training programmes to support the emerging models of care recognising the increasing need for healthcare workers that can work across traditional boundaries and apply their skills in a range of settings. Central to everything KHP does will be a focus on improving outcomes, experience and public health for patients, service users and local population. CCG, local government, stakeholder, locality and patient perspectives will drive KHP’s thinking. To this end KHP look forward to hearing views and reflections from CCG colleagues and wider stakeholders about how it moves forward and make the changes needed for patients and service users. KHP is committed to working with local partners over the coming months to shape and design the collective vision for excellence. King’s Workforce and Values The five King’s Values were developed by staff and patients of King’s in 2009 and are now firmly established as the guiding principles which underpin how King’s work with patients, relatives, carers, local communities and our own colleagues. Understanding you Working together More information about how King’s works with its members and governors to ensure that hospital services meet the needs of its diverse community can be found on pages 94-96. Ensuring that the human rights of patients are protected is an important part of King’s practice. King’s policies uphold protocols of the European Convention on Human Rights, and recognise the importance of human rights such as privacy, dignity, liberty and right to life. Workforce statistics King’s is a significant employer in the local area and is committed to the training and development of its staff. Always aiming higher Making a difference in our community provides examples of the My Promise standards as they relate to each value. Implicit in King’s Values and significant factors in King’s strategic thinking are social, community and human rights issues. Tackling the health inequalities prevalent amongst sections of the local population is an area of focus for both King’s and KHP. Inspiring confidence in our care Figure 1: King's Values Each value is underpinned by four or five defining statements that set out King’s approach. King’s has taken its values to the next step by introducing ‘My Promise’. ‘My Promise’ has been developed in response to feedback from staff, who told King’s they wanted to promote positive behaviours and performance. ‘My Promise’ supports and develops the King’s Values placing the emphasis on individual responsibility and In the table on the next page there is a breakdown of staff according to age, ethnicity, gender, recorded disability, sexual orientation and religion covering the past three years. During the period the Board of Directors consisted of ten male directors and 5 female directors. More information about King’s workforce and in particular its approach to equality and diversity can be found in the directors’ report on pages 49-57. 35 Table 3: Breakdown of staff Age 0-16 17-21 22+ Ethnicity White Mixed Asian or Asian British Black or Black British Other Unknown Gender (all staff) Male Female Gender (senior managers)* Male Female Gender (directors)* Male Female Recorded Disability Yes No Not Declared Unknown Sexual Orientation Bisexual Gay Heterosexual Lesbian I do not wish to disclose Unknown Religion Atheism Buddhism Christianity Hinduism Islam Jainism Judaism Sikhism Other I do not wish to disclose Unknown Total Staff Numbers 36 2011/2012 Headcount % 2012/2013 Headcount % 2013/2014 Headcount % 0 50 7177 0% 1% 99% 0 69 7845 0% 1% 99% 0 117 10984 3736 225 1246 1742 137 141 52% 3% 17% 24% 2% 2% 4119 242 1366 1838 154 195 52% 3% 17% 23% 2% 2% 1879 5348 26% 74% 1986 5928 - - - 2014/15 Headcount % 1% 99% 1 109 11658 0% 1% 99% 6148 314 1861 2214 208 356 55% 3% 16% 20% 2% 3% 6356 329 2155 2299 249 380 54% 3% 18% 20% 2% 3% 25% 75% 2641 8460 24% 76% 2771 8997 24% 76% - - 10 18 36% 64% 12 11 52% 48% - - - 11 5 69% 31% 10 7 59% 41% 216 6064 215 732 3% 84% 3% 10% 223 6771 216 704 3% 86% 3% 9% 291 9103 888 819 3% 82% 8% 7% 280 9949 839 700 2% 85% 7% 6% 54 74 4449 31 1445 1174 1% 1% 62% 0% 20% 16% 56 97 5141 33 1366 1221 1% 1% 65% 0% 17% 15% 77 123 7596 41 1941 1323 1% 1% 68% 0% 17% 12% 74 161 8830 50 1866 787 1% 1% 75% 0% 16% 7% 444 42 3289 225 258 14 17 29 366 1373 1170 7227 6% 1% 46% 3% 4% 0% 0% 0% 5% 19% 16% 601 52 3705 249 293 12 19 35 397 1334 1217 7914 8% 1% 47% 3% 4% 0% 0% 0% 5% 17% 15% 913 79 5193 336 375 11 24 53 549 2258 1310 11101 8% 1% 47% 3% 3% 0% 0% 0% 5% 20% 12% 1117 139 5925 389 461 14 27 98 619 2201 778 11768 9% 1% 50% 3% 4% 0% 0% 1% 5% 19% 7% Caring for the Environment King’s undertakes sustainability reporting in line with the HM Treasury 2013/14 guidance Public Sector Annual Reports: Sustainability Reporting in the Public Sector. Sustainability reporting is an important element of King’s performance and the need to minimise impact on the environment and to operate as a sustainable and efficient organisation is recognised. On 1 October 2013, King's took over responsibility for the Princess Royal University Hospital (PRUH) in Bromley, as well as Orpington Hospital and other satellite buildings such as the Havens, Beckenham Beacon, Queen Mary’s Sidcup, etc. This dramatic increase in the size of King’s estate has naturally resulted in an increase in Gas, electricity, water and waste costs and volumes. Summary of performance As a result of the increased estate the King’s total energy consumption increased by 9%, carbon emissions by 25% and water consumption by 51%. The total waste generated increased by 1,149 in 2014 -2015. Summary of future strategy King’s Environmental Strategy details objectives and targets for the following environmental themes: Improving the patient experience; Designing and maintaining the built environment; Waste management and minimisation; Pollution prevention; Energy and CO2 management; Water; Sustainable procurement; Low carbon transport and travel; Staff engagement and ownership; Working with our stakeholders; and Governance and finance. A copy of King’s Environmental Strategy document can be obtained from: [email protected]. Greenhouse gas emissions King’s has increased its carbon emissions this year by 25% due to the acquisition of the PRUH and Orpington hospitals and increased activity on all sites. Table 4: Summary of energy performance Area Performance 2014 – 15 Greenhouse Gas Emissions (Scope 1, 2, 3 Business Travel (excluding air and rail travel) Emissions (000, tonnes) 33.6 Consumption (kWh) 174,587,056 Expenditure (£) £6,153,786 Amount (tonnes) 5,357 Expenditure (£) £1,798,537 Consumption (m3) 307,118 Expenditure (£) £575,046 Estate Energy Estate Waste Estate Water 37 It is increasingly challenging to reduce energy consumption on site because King’s is a successful and growing trust which will increase its energy consumption as it increases in size and activity increases. Work is well underway on the design and build of a critical care unit and helicopter pad at the Denmark Hill site. Further new buildings will be added to King’s estate in 2015/16, all of which will be heated and powered from energy generated sustainably from King’s Energy Centre. All new buildings and refurbishments are being designed by the projects team with energy efficiency and sustainability as a priority. As forecast last year the annual energy costs and consumption increased substantially this year by 9% and 11% respectively as a result of the PRUH and Orpington Hospital acquisitions. Waste management Overall the total waste generated by King’s has increased by 1,149 tonnes in 2014 – 2015 compared to 2013 – 2014. ‘Sharpsmart Services’ The Sharpsmart’s sharps containment system are reusable sharp bins that improve the safety of healthcare workers when disposing of sharps and lessens the environmental impact of waste disposal. The service was installed at King’s in September 2010 and rolled out fully in July 2011. This service is currently in operation at the Denmark Hill site only but it is intended to extend the system to all Kings Sites. The benefits of the Sharpsmart reusable bin service include: Prevention of disposable sharps containers being sent for disposal which has reduced 38 King’s sharps waste output by 242 tonnes since installation. An estimated £169,734.15 reduction on disposal costs resulting for the reduction of sharps waste sent for incineration during this period. 1,370 tonnes reduction in CO2 output by using the Sharpsmart system. Safe use and reduction in needle stick injuries overall compared to previous single use sharp containers in view of its robust component. General non-hazardous waste and furniture items continue to be diverted to materials recycling facilities and this has continued improving the recovery of materials for recycling with high yield recovery percentages There are currently ongoing schemes to increase the recycling and recoverable materials at the satellite sites which will be reported separately in future reports. The provision of waste management services is a fixed annual cost to King’s. Any increases in costs associated with waste quantities, HM taxes or gate fees, are at risk with the contractor. The total cost of waste disposed was £1,798,537 in 2014 - 2015. Environmental management system King’s has successfully operated an Environmental Management system that complies with the requirements of ISO 14001 since October 2012. This covers the activities and responsibilities of the Capital, Estates and Facilities Department on the Denmark site. The EMS has been very effective in providing the architecture to enable effective environmental risk management by our staff and contractors and drives continual improvement. Continued commitment to the maintenance of this accreditation provides a system of assurance that the department is compliant with all waste and environmental legislation. The Orpington and Princess Royal University Hospitals are currently outside of the scope of the EMS. It is the intention to bring these sites within the remit of the EMS by 2017 and 2019 respectively. King’s has undergone a number of successful BSI surveillance audits which raised no non conformities and showed the trust was making continual improvement. A recertification Audit will take place in October 2015 towards the end of the 3 year certification period which, on successful completion, will reaccredit King’s for a further three years. All the main partners of King’s are accredited to an EMS, which shows they take their environmental responsibility seriously. These include Medirest (Compass Group), Veolia, Norland and Sodexo Ltd. Energy and CO2 management King’s Environmental Strategy has superseded the Carbon Management Plan. King’s, for the time being, continues to work towards a target to reduce CO2 emissions by 25% by 2015. With the acquisition of the PRUH and Orpington hospitals, however, the historic absolute targets are no longer appropriate to the larger hospital estate. It will be necessary for King’s to move away from absolute carbon reduction targets to relative targets. The new target should be in place for the new reporting year. In the interim King’s plans to reduce its carbon emissions by a further 1% in 2015-2016 compared to this year. Energy cost inflation Gas and Electricity is procured by the trust through Crown Commercial Service (CCS) Framework agreements. CCS is an executive agency and trading fund of the Cabinet Office of the UK Government. It is the largest buyer of gas and electricity in the UK which aims to deliver savings on costs through significant aggregation. Since October 2014, there has been a volatile but generally downward trend in gas and electricity prices assisted by milder weather than in previous years. Concern has been raised about a reduction in large scale gas storage capacity within the UK and the impact this may have on gas prices over next year’s heating season. It is hoped that as CCS has purchased a large % of gas and electricity in advance this will lock in some of the cost reduction benefits over the 2015-2016 financial year. The increasing size of the trust estate continues to have a negative effect on budgets. Total energy costs have risen to £6,153,786 further increasing the need for energy efficiency measures. Water minimisation Working closely with Thames Water, a water reduction strategy is being developed. The first stage has been to install water meter data loggers across the Denmark Hill site. This was completed in March 2015 and now all water consumption data is available on the fusion automatic monitoring and targeting system. This will provide the detailed water consumption data required to carry out leak detection analysis later in the project. King’s is also working with Thames Water to develop an emergency response plan in the event of a failure of the mains water supply to the Denmark Hill site. This will be delivered in 4 stages the first of which, to create an onsite and surrounding hydraulic model, stared this year. Water process are set to rise significantly over the coming years with the building of the 39 Thames Tideway Tunnel resulting in increases of approximately 25% for all Londoners and London based businesses. 4. BMS Upgrade Works in order to upgrade out of date systems and improve control over heating and cooling systems. King’s increased water consumption on the 2014/15 figure by 57% as a result of the acquisition of the PRUH and Orpington hospitals. Summary of Benefits: Reduce Energy Consumption by 6% Reduce Carbon Emissions By 1,892 tonnes Reduces Corporate Risk Reactive Maintenance reduced Payback Period - 11 Years Energy performance contract In March 2013, the Trust signed an Energy Performance Contract (EPC) to deliver £7.8 million of energy efficiency and heating infrastructure improvements to the Denmark Hill site. King’s applied to the Department of Health for a grant in order to deliver the EPC and were successfully awarded £3m. The EPC was planned to be delivered over 20 months and involved upgrading the heating infrastructure, reducing risk, energy consumption and carbon emissions at Denmark Hill. The Energy Performance Contract is an innovative approach to energy reduction whereby the ESCO guarantees a reduction in the Trust’s energy consumption. The Energy Performance Contract consists of 4 main engineering projects: 1. A District LTHW Heating Scheme. This uses the free heat from the CHP jackets in order to supply 5 plant rooms and displace the use of costly steam. 2. Plate Heat Exchanger Installations. A large number of Plate Heat Exchangers (PHXs) were installed across the site and replaced old, inefficient shell and tube calorifiers. 3. Thermal Insulation Works were carried out on extensive areas of steam and hot water pipework. The benefits of the works include; reducing heat loss, saving energy and improving the patient staff environment by reducing overheating. 40 Improving the patient experience through behavioural change. King’s has engaged Global Action Plan to deliver Operation TLC on 20 wards of the Denmark Hill Campus. Operation TLC is behavioural change programme focussed on creating better environments for patients and delivering financial and carbon savings. The programme will engage staff at all levels of the organisation including nurses, doctors, facilities, security and cleaning staff in order to deliver financial savings and environmental improvements. This project will start in March 2015 and will focus on the following 3 actions: turning off equipment when not in use, switching off lights where possible and closing doors and windows. Designing and maintaining the built environment King’s has targets in place to attain ‘Excellent’ under the Building Research Establishment Environmental Assessment method (BREEAM) on all new build projects and ‘Very Good’ on all major refurbishments. The key sustainability measures in both the Centenary Wing and the Critical Care Unit over the existing Theatre Block (CCUTB) project are: 25% improvement in water consumption compared with the notional building. 5 credits under Ene01 with 25% improvements of BER over TER. Best Practice construction site management. Best practice construction site waste management. Measures are specified to minimise Noise and light pollutions. Resource efficiency and use of materials with low environmental impacts over the lifecycle of the building. Some of these projects are outlined overleaf: 41 20092010 20102011 20112012 20122013 20132014 20142015 Non-Financial Indicators (1,000 tCO2e) Total Gross Emissions 24.4 25.3 25.3 26 31 36.7 Total Net Emissions 24 21.1 20.7 22 26.8 33.6 Gross Emissions (Scope 1 direct) Gross Emissions (Scope 2 and 3 - indirect) 8.9 19.7 19.7 18.6 21.7 23 15.6 5.6 5.6 7.4 9.3 13.6 (£s Financial Related Energy million) Indicators Consumption (million kWh) Table 5: Greenhouse gas emissions Electricity (non-renewable) 28.5 10.2 10.1 12.2 9.7 49.9 Electricity (renewable) n/a n/a n/a n/a n/a Gas 48 107 106 116 114 LPG 0 0 0 0 0 Other 0 0 0 0 0 3.5 3.2 3.8 4.1 4.6 Expenditure on energy Expenditure Accredited Offsets 42 n/a n/a n/a n/a n/a 124.6 6.2 n/a Greenhouse Gas Emissions (1,000 tCO2e) 2008- 2009- 2010- 2011- 2012- 2013- 2014- 2009 2010 2011 2012 2013 2014 2015 2516 2592 3198 2995 3205 3941 5090 Total 1238 1192 1459 1335 1327 1603 2596 Landfill 909 1032 1158 1070 736 99 100 Reused/ Recycled 369 368 581 590 859 1273 779 Composted 0 0 0 0 0 0 0 Incinerated with energy recovery 0 0 0 0 283 967 1616 Incinerated without energy recovery 0 0 0 0 0 0 0 904,309 950,338 978,164 1,268,596 1,798,537 Financial Indicators (£s) Non - Financial Indicators (tonnes) Total Waste Hazardous Waste Non Hazardous Waste Total Waste (£s) N/A N/A In 2009/10 revised PFI contract to include total waste management. This is for all waste streams including hazardous chemical waste. Table 6: Waste 43 Centenary Wing Construction of the Centenary Wing was completed in December 2013. It utilises a modular system of construction whereby individual modules are assembled at an off-site factory location with many of the internal services already installed. There are several advantages associated with the modular construction system: Energy efficiency due to high levels of efficient insulating materials integrated into the modular system assemble in a controlled off-site factory environment; Reduced disruption and noise on site for patient and staff; Reduction in construction and building related waste; and Reduced vehicle movements involved in the actual construction process including construction materials and waste removal; and Energy for space heating, domestic hot water are provided by connecting to the combined heat and power plant heating network. Critical Care Unit over Theatre Block The new Critical Care Unit over the existing Theatre Block (CCUTB) has been designed to support world class care and to achieve BREEAM Excellent rating in support of the trust’s aspirations for an environmentally friendly campus. It has been designed to achieve optimum energy performance by designing a high performance building fabric, low air leakage rates, high efficiency lighting solutions and energy efficient building services. Energy for space heating, domestic hot water and cooling will be provided by connecting to the combined heat and power plant heating and cooling network. 44 The south facing aspect of the CCUTB building has been designed to maximise the use of natural daylight. A fully glazed curtain wall is proposed for the south facing rooms which will maximise natural daylight in these spaces. A good level of natural daylight reduces the demand for electric lighting, Saving carbon and energy but also creates and enhances the environment for patients, visitors and staff. Construction of the CCUTB commenced in 2013. Helipad Helicopter ambulances have for many years landed in the local Ruskin Park which is a Civil Aviation Authority recognised landing site in order to take emergency patients to King’s emergency department for treatment. This involves disruption to the park and requires the presence of the police to secure the site. The London Ambulance Service also provides the ambulances to transfer the patients to the operating theatre. King’s has started the construction of a helipad on top of the Ruskin Wing. This will provide a safer, more patient-centred approach that would have the added advantage of reducing the secondary effects on the police and London Ambulance Service and the inconvenience to the public inherent with the aircraft landing in the park. The helipad will facilitate landings of helicopters transferring patients to King’s by shortening transfer times from the existing landing zone in Ruskin Park, to the benefit of all patients, and by removing the existing disruption to the use of the park and noise and disturbance, to the benefit of neighbouring residents. The Helipad is due for completion in December 2015. Low carbon transport and travel Work has continued to promote activity and wellbeing to staff. A staff bicycle user group remains established and continues to support and promote cycling to work as an alternative low carbon means of transport. In November 2012, King’s was fully registered for the Transport for London Cycle Superhighway Workplace Offering and was awarded credits to exchange for cycle parking, training or cycle safety checks. King’s has purchased a tracking system for the internal transport staff vehicles. This allows us to monitor driving techniques in relation to fuel use, hours worked or whether further training would be required. This may be extended to all King’s lease cars in order that departments can monitor fuel and driving behavior. King’s is also looking at replacing the transport fleet and has had trials of Toyota hybrid cars for GP collections. The hybrid Toyota is still the vehicle of choice with any remaining vans that we lease being EURO 5/6 to reduce emissions and save on fuel with stop start technology. Southwark Council has now formally responded to Transport for London’s (TfL) consultation into the route options for the Bakerloo line extension. The council strongly supports the development and delivery of a tube extension via the Old Kent Road and via Camberwell and Peckham. This would produce opportunities for a shift to public transport away from car travel across staff, patients, visitors and students. conditions from 9 GP surgeries across Lambeth in growing their own crops, encouraging both healthy eating and the physical exercise gained from gardening. The crops will be grown on King's land and at local GP surgeries. 10 Large planters for growing vegetables, containing 2 tons of soil each, have been located in the garden of Jennie Lee House at King’s. These will be tended by groups of patients led by experienced group leaders. The Lambeth GP Food Co-op is a co-operative of patients, doctors, nurses, and Lambeth residents. It was recognised by NHS Sustainability Unit and Public Health England as 'Best sustainable food initiative in the NHS' 2013. The Lambeth Food Co-op work is supported by NHS Lambeth Clinical Commissioning Group and Lambeth Council. The project at King’s was launched as part of NHS Sustainability Day – which is a national day to challenge NHS organisations to think about how they can better use energy, resources and their land. Governance King’s Environmental Strategy places an emphasis on the improvement of staff engagement and ownership, working with our stakeholders and governance systems to ensure that King’s continues to evolve to become a more sustainable and efficient organisation. The Board of Directors receives reports on sustainability twice a year. The strategic report was approved by the Board of Directors on 26 May 2015 and signed on its behalf by: Climate change adaption and mitigation King’s has a target in place to assess how climate change may impact the site and to devise an action plan outlining adaption measures. Biodiversity and the natural environment King’s has a target in place to assess how the implementation of promoting biodiversity on site can assist the healing process. This year King's have been working with the Lambeth GP Food Co-op to roll out a patient-led gardening project. It seeks to involve patients with chronic Roland Sinker Acting Chief Executive Date: 26 May 2015 45 Directors Report Directors’ Report Statement of directors’ responsibility The strategic report, financial statements and annual report taken as a whole are fair, balanced and understandable. Together they describe the development and performance of King’s throughout the year and the principal risks and uncertainties ahead. They provide the information necessary for patients, members, regulators and other stakeholders to assess King’s performance, business model and strategy during the year 2014/15. King’s People 2014/15 was a year of integrating new sites, services and people as part of King’s workforce growth and organisational change initiatives. The aspiration was to ensure that King’s embarked on an organisational development journey which looked to embed the five King’s Values. Key organisational development themes included: Leadership and talent management; Performance assessment and development; Continuing professional and personal development; and Staff engagement. Already recognised for its culture of continuous improvement and consistently high levels of support for staff development, on 07 March 2014 King’s demonstrated that it continued to meet the requirements of the Investors in People National Standard at Gold level and now has ‘Champion’ status as well. King’s has been a ‘Gold’ standard ‘Investor in People’ since 2010. Leadership and talent King’s programmes are designed to be multi professional, to embrace leaders at all levels, be available across the enlarged Trust. Where appropriate the programmes are open to King’s Health Partners delegates, or they are run in partnership. Examples include: Front-line leaders: an established programme at ward manager and service manager level; First-time leaders: developing the leaders self-awareness aimed at new leaders/managers; A year long Band 6 development programme for nurses across the PRUH, Beckenham Beacon, Orpington and Queen Mary’s; Action learning groups for clinical Therapy staff at Denmark Hill; Aspiring ward managers: newly designed and commissioned for the enlarged King’s, this programme is aimed at Band 6 nurses and midwives. It first ran in 2014 and is running again in 2015 Coaching for performance aimed at all managers; A robust Preceptorship Programme for all newly qualified nurses; Strategic and operational leaders; Action learning sets for matrons run over 2014 and early 2015; Combined leadership development programme for matrons and ward managers in Trauma, Emergency and Medicine developed specifically for staff based at the PRUH ended early 2015; King’s department of Postgraduate Medical and Dental Education offers multidisciplinary leadership development for senior clinicians; Leadership for foundation trainees; Training Tomorrow’s Trainers: for senior registrars preparing for their first consultant appointment; 49 50 Coaching and mentoring focused on unlocking potential and maximising performance; Staff successes also include Institute of Leadership and Management; and specialist post-graduate qualifications, including MBA’s and the NHS Leadership Academy programmes; Medical or Dental workforces on any Agenda for Change pay banding. Apprenticeship programmes have been delivered within the Trust using the national apprenticeship frameworks in business administration, customer service and health & social care at level 2 since 2011 and more recently through a partnership arrangement with Lambeth Further Education College. Apprentices can acquire key / functional skills, a work based qualification (qualification credit framework / national vocational qualification), technical certificate and employee rights and responsibilities. To address the widening participation agenda the Trust and Lambeth College deliver an innovative “Sector Work Based Academy” over a four week period. Diploma vocational qualifications for support staff are provided and there are active learners across all sites. Staff successes include Institute of Leadership and Management; and specialist post-graduate qualifications, such as MBAs and NHS Leadership Academy programmes; Development sessions for governors have had positive uptake. Staff gaining first or second professional qualifications through secondment, include healthcare assistants training as nurses and adult nurses training as midwives. Performance assessment & development A newly designed Kings Appraisal & Development system (KAD) for non-medical staff was rolled out Trust-wide from 1st April 2014; KAD links individual objectives to King’s objectives and values, as well as supporting performance review in line with incremental progression; Since July 2014, we have been developing a talent management approach with a difference called King’s Performance and Potential (KPP) to ensure that all individuals are fulfilling their potential at work; KPP does this by identifying talents and aspirations, then facilitating a range of stretch learning opportunities; it has been designed to complement KAD and will be rolled out Trust-wide during 2015; A separate appraisal and revalidation system for medical and dental staff uses colleague and patient feedback to support successful revalidation. Continuing professional and personal development (CPPD) Education commissioning for the 2014/15 academic year has ensured equal access for non-medical staff across all King’s sites. Health Education South London (HESL) funding for 2014/15 provided development funding for Nursing, Midwifery, Allied Health Professionals, Managerial, Administrative, Scientific and Informatics and all other non- Staff health and wellbeing Under the Public Health Responsibility Deal, King’s pledges to actively support staff to lead healthier lives. King’s has secured accreditation against a set of nationally approved standards known as a Safe Effective Quality Occupational Health Service (SEQOHS). King’s annual wellbeing event is a popular opportunity for staff to check out their lifestyle choices against health indicators. Muscular skeletal and mental health issues continue to be the highest causes of staff absence. The rate of sickness for financial year 2014/15 was 3.47%. King’s benchmarks well within the NHS as evidenced by October 2014 data, in which South London overall reported the lowest regional rate in England at 3.68% with the highest national region reporting 5.19%. Health and Safety Activity In 2014/15 much Health and Safety activity continued on major consolidations. Further integration of South London Hospital facilities and safety management on several new sites with three main exercises: integration of all health and safety policies, procedures, incident reporting and recording systems. cross site working arrangements for committee. a new H&S information system was launched in September 2014 underpinning risk assessment, monitoring, audit, frontline department support and document management with training being rolled out to all department managers. an audit of new occupancies was prepared for action in 2015/16 to assure fire, first aid, manager training and coordination with contractors. a wide range of H&S policies and procedures have been upgraded for the integrated trust in 2014/15. new procedures for hazardous substances have been prepared in 2014/15 for roll out in 2015/16. Incidents Headline Incident figures are now available comparing 2014/15 for the integrated Trust with previous years, based on recorded incidents per 100 staff. The rate of violence reports on the main database was up 81% for financial year 2014 compared to in financial year 2013. This is an artefact - a new source of data was added to the reports database in April 2014. A digest comparing cohorts is in preparation to analyse underlying trends. Other reported Health and Safety incidents per 100 Staff were up 4% for the year. The main contributors to all H&S incidents were violence (44% of all) workplace incidents (19%), Blood borne viruses (11%). Significant Incidents A routine HSE inspection of a small refurbished microbiology facility at PRUH revealed some missing safety documents for pathology autoclaves. In November 2014 an immediate prohibition notice was served, the autoclaves withdrawn from service and alternative waste service used temporarily. Urgent inspection and certification works resulted in the lifting of enforcement action in January 2015. A wide ranging trust-wide review of autoclaves and similar pressure plant was put in hand reporting to senior risk committees for completion in 2015. Notifiable incidents – (RIDDORs*) are down from a recorded 40 in 2013/14 to a projected 32 for 2014/15. (*incidents notifiable under the Reporting of Incidents Diseases and Dangerous Occurrence Regulations 2013) Accident Investigations The Operations (Safety) Department conducted two separate Accident Investigations over the last 12 months: one connected with a Slips’ 51 Incident in Orpington Car Park where a visitor slipped on ice, resulting in treatment at the PRUH A&E and the latter, a Slips’ Incident at Queen Mary’s, Sidcup (investigation still undergoing). Training The H&S team monitor against the Trust target of 80%. Overall compliance with H&S training stood at 80.2 % at the end of Q4 2014. Efforts have been implemented to increase the Trust’s Statutory Safety compliance to a target of 85% by introducing an additional training day in Orpington, as well as extra Mandatory Sessions in the PRUH. These steps all supplement the current sessions already in practice in the Trust. A new course “Managing Health, Safety & Risk”, designed for those with supervisory responsibilities in the Trust, is currently being constructed for use in the latter part of 2015, as another method to supplement the promotion of the safety culture in the Trust. This will be a combination of the following topics: Incident Reporting & Investigations Violence and Aggression/Stress Health Monitoring COSHH Online DATIX Workplace Risk Assessment The Online Datix Workplace Risk Assessment, implemented in Sep 14, was designed to assist the plethora of management within the Trust to efficiently and effectually conduct valid Workplace Risk Assessments. The instruction process is time consuming in that for effective coverage, the Operations Safety Team must conduct one-to-one instruction. This time consuming but necessary training has resulted in approximately 12% of all staff being instructed. The overall strategic training objective for total coverage of the Trust is anticipated to conclude by mid-2016. 52 Summary The report highlights the significant amount of work that has been undertaken during 20142015 to improve the management of H&S in the Trust. The Operations Safety Department continues to make progress with revised inspection and assessment programmes, streamlined training and the use of Online Datix Workplace Risk Assessments being implemented with the sole aim of improving compliance with statutory requirements and making H&S management more accessible, convenient and uncomplicated to staff. In order to improve the visibility of H&S within the Trust, the team is undertaking to provide further bespoke training sessions to all departments requesting support, so that staff have access to the most up to date safety information. The KPIs highlighted throughout this report have been identified as pivotal to the achievement of more robust H&S management going forward and progress will be reported to the Board via the quarterly OSC reports. Reward and recognition King’s Commendation: recognises outstanding contributions to patient care or hospital services by an individual or team. 24 King’s Commendation Awards were awarded to teams and individuals in 2014/2015 King’s Long Service awards ceremony in April 2015 recognised 100 staff who had attained 25 or 40 years with King’s in the last three years; Michael Parker Inclusion Award: Gold and silver awards were presented to staff exemplars of inclusion at the 2014 AGM; Annual awards ceremonies recognise achievers in education and development across all disciplines; Actions taken in the financial year to provide employees systematically with information on matters of concern to them as employees: At induction, new staff are introduced to the Kingsweb intranet and provided with the necessary tools and training to access regular corporate communications. King’s Daily Bulletin, Kingsdocs, Kwiki and the Chief Executive’s monthly bulletin are examples of important information sources and communication. King’s intranet also provides easy links and access to information about King’s Health Partners. King’s management/ committee structure and culture of regular team meetings ensure that key issues are cascaded throughout the organisation. Bi-monthly Joint Consultation Committee (JCC) involves and informs staff representatives on matters of significance. The JCC nominates a staff side representative to serve as a stakeholder governor on the Council of Governors. Actions taken in the financial year to encourage the involvement of employees in King’s performance: The 2014 national NHS staff survey reported King’s ‘above average’ nationally for good communication between staff and senior managers and for staff feeling able to contribute towards improvements at work. Challenges and success are regularly communicated by the Chief Executive in his monthly brief to staff. Despite the managerial challenges of 2014/15, 57% of staff with 12 months or more service received performance appraisals. Actions taken in the financial year to achieve a common awareness on the part of all employees of the financial and economic factors affecting the performance of King’s: The Chief Executive maintained a strong focus on King’s financial position throughout the year, keeping staff informed through his monthly brief. Emphasis was placed on the importance of achieving significant cost reductions and the role of individual staff. The JCC received regular updates on the financial position. 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: Throughout 2014/15, the JCC was regularly well attended by representatives of recognised trade unions and staff associations and senior management. The British Medical Association has a seat at the JCC table but, in practice, specific matters relating to medical and dental staff are discussed at the Local Negotiating Committee. The activity of staff-led diversity groups included invitations to senior King’s staff to discuss issues of specific interest. Kings in Conversation repeated February – May 2015. Staff culture survey repeated February / March 2015. Staff Friends and Family test run quarterly. A Diverse Workforce King’s Denmark Hill site is located in one of the most diverse areas in London. The sites acquired in 2013 have further added to the diverse composition of staff and patients. 53 Equality, diversity and inclusion are more important than ever and must remain front-ofmind as King’s works towards its goal of ‘effortless inclusion’. Three staff-led diversity groups are active in taking forward King’s work on the national Equality Delivery System – the Trust is now equality objective setting using EDS2. They are the Cultural Diversity Network, Disability Inclusivity Network and the Lesbian, Gay, Bisexual and transgender Forum. Individually and collectively these groups provide support and networking opportunities for their members, whilst at the same time hold King’s to account on its equality and diversity commitments. King’s has worked closely with external partners such as Stonewall. Over 1,300 staff have been trained on Stonewall’s Train the Trainer scheme. King’s commitment King’s is committed to employing a workforce that reflects the diverse communities it serves and delivers great care. King’s reviewed the way equality & diversity is managed with a view to ensuring this is mainstreamed in day-to-day business for both staff and patients. The Chief Executive provides the Trust Board with a 6 monthly Inclusion Report and local equality objective setting is completed with relevant stakeholders and monitored via three Board level Trust committees in line with EDS2 goals and outcomes. In 2014/15, the Education and Workforce Development Committee considered the Annual Equality and Diversity Workforce Report, which details information regarding the demographics of staff. 43% of King’s staff are from BME 54 background and 54% are white (2014/15 Annual E&D Report). Reviewing and changing policies to reflect commitment to equality All existing and planned policies are reviewed against equality and diversity indicators on a three year cycle, thereby ensuring that King’s considers the impact on staff and patients from different backgrounds. Policies are equality impact assessed and the assessments are available via King’s Equality and Diversity webpage: www.kch.nhs.uk/about/corporate/equality-anddiversity Staff have 24/7 access to two support services: Dignity at Work Helpline, which supports staff in relation to bullying and harassment; and Workplace Options, which offers telephone, online and web-based advice on a range of matters including legal matters, financial management, and general counselling. Kingsflex, King’s flexible working scheme, helps staff balance family and work commitments. National initiatives In addition to the EDS, relevant equality information is published to ensure compliance with the Public Sector Equality Duties as set out in the Equality Act (2010). We are ‘positively diverse’ King’s is accredited as a nationally recognised Positive About Disabled People ‘Two-Ticks’ employer and is reassessed on a regular basis. Equality and diversity training is mandatory for all new staff and a majority of all staff have been appropriately trained. This helps ensure staff have the skills and knowledge to provide patients with consistently high standards of care. Positive about disabled people King’s has a Disability Charter which sets out its ethos and a firm commitment to disability equality. King’s also has a Disability and Deaf Guide which outlines the responsibilities and behaviours expected of staff and managers. King’s recruitment, training and equal opportunities policies are designed to support those who declare a disability. Policies apply from the pre-employment stage, when applying for vacancies, to supporting those who become disabled during the course of their employment and ensure that all staff have equal access to promotion and development opportunities. To help improve the experience of those working at King’s with a disability, staff are signposted to relevant support provided through the Occupational Health & Wellbeing service and Disability Inclusivity Network. Training is also provided for staff working with people who may have learning disabilities, and there are elearning programmes available which relate to a range of diversity issues, plus an introductory British Sign Language e-learning programme. Listening to Staff A listening organisation Each year King’s takes part in the national survey of NHS staff. In 2014 the annual survey was complemented by the introduction of the Staff Friends & Family Test. Staff Friends & Family Test Staff FFT was introduced nationally from 1st April 2014 and is run on a quarterly basis. Staff are asked their opinion on two broad areas; would staff recommend the Trust as a place to receive treatment and would they recommend the Trust as a place to work. In each survey quarter, the response from King’s staff has been well above the national average for both of these. In Q3 the Trust was in the top 20% nationally for both as recorded in the National Staff Survey. National Staff Survey The 2014 response rate to King’s participation in the national NHS staff survey was down to 30%, which was attributed to the introduction of Staff FFT which affected response rates nationally. Response rates at the PRUH have also been low in previous years. King’s scored well for overall staff engagement. A score of 3.78 placed King’s ‘better than average’ nationally. Of the 29 national key findings, King’s ranked in the top 20% for 7; and in the worst 20% for 10. See the figure 2 on page 56 and table 7 and on page 57. 55 Most Favourable Comparisons with Other Trusts King’s recorded the following as the most favourable Key Findings compared to other Trusts: Staff agreeing their role makes a difference to patients. Staff reporting errors, near misses or incidents in the last month. Staff experiencing physical violence by other staff in the last 12 months. Staff recommending the Trust as a place to work / receive treatment. Agreeing feedback from patients / service users is used to make informed decisions in their directorate/department. action plans developed. These action plans with associated enabling works were taken forwards under one umbrella workstream called ‘All Together Better’. ‘All Together Better’ is King’s transformation programme. The three areas of focus: Doctors, nurses and managers working effectively together. Empowering staff to take confident decisions. Promoting positive behaviours and performance. This cultural survey has been repeated in February / March 2015 and the results are currently being analysed. Action plans to address the findings of the national Staff Survey will be devised in line with the findings of the Trust’s Culture Survey and implemented throughout 2015. Staff engagement King’s has initiated a number of key activities designed to improve understanding of what matters to staff. King’s in Conversation was launched as part of King’s response to the Francis Report and its recommendations. The project engaged in dialogue with 1,420 staff and patients across all sites in 2013/14 and this work is being repeated between February – May 2015. An anonymous staff cultural survey was rolled out across all sites towards the end of 2013 with the aim of assessing King’s cultural ‘baseline’ post acquisition, using an academic behavioural engineering model. Action plan for 2014/15 The feedback obtained as part of King’s in Conversation and the cultural survey was analysed and clear priority areas emerged and 56 Figure 2: National Staff Survey Response Rates Table 7: National Staff Survey Rankings 2013 / 14 King’s Staff experiencing discrimination at work Having well-structured appraisals Appraised in last 12 months Witnessing harmful errors, near misses or incidents in last month Feeling pressure in last 3 months to attend work when unwell Agreeing that their role makes a difference to patients Recommending King’s as a place to work or receive treatment Reporting errors, near misses or incidents witnessed in the last month Experiencing physical violence from staff in last 12 months Agreeing feedback from patient’s / service users is used to make informed decisions in their directorate / departments 2014 /15 King’s 17% 40% 78% 35% Nat. Average 11% 38% 84% 33% 24% 20% 28% 65% 40% Nat. Average 11% 38% 85% 34% Improvement/ Deterioration 3% deterioration 12% deterioration 13% deterioration 5% deterioration 28% 36% 26% 8% deterioration 92% 91% 92% 91% No Change 4.08% 3.68% 3.88% 3.60% 0.2 deterioration 88% 90% 99% 90% 2% improvement 2% 2% 1% 3% 1% improvement N/A N/A 66% 56% N/A Respecting and Protecting Patient Information The Information Governance Steering Group (IGSG) is responsible for reviewing the effectiveness of King’s information governance systems and processes. It reports directly to the Quality and Governance Committee and receives reports from the Patient Records Committee and the Data Quality Steering Group. The IGSG is chaired by King’s Senior Information Risk Owner (SIRO) and members include the Caldicott Guardian, Director of ICT, Information Security Manager, Freedom of Information Lead/Deputy SIRO, Information Governance & Records Manager and Patient Records Service Managers. The IGSG agenda is driven by Information Governance Toolkit requirements. It works to ensure the highest practical standards and systems for the confidential handling of patient information and personal data within King’s. During the year 2014/15 there were five serious incidents related to a confidentiality breach, the details of which and the actions taken are summarised in figure 3 overleaf. 57 Incident 1 required. Description: On 11 August 2014 a computer was discovered to be missing presumed stolen from the Day Surgery Unit, Denmark Hill campus. Computer was password protected and policy in place that data not saved to local drive. Potential risk that data was saved onto local drive, not known how many individuals might be affected, possibly < 500. Incident 4 Action taken by the Trust: reported to ICO. Recommendation made to bring forward a project to prevent data being saved on local computer drives and for local management to improve security measures including Kensington locks, locks on office doors and swipe card restrictions. Further action required by ICO: o/s Incident 2 Description: Three sets of interview notes (1 fully identifiable, 2 partially identifiable) have been lost from the KCH site of a joint KCH/KCL research project. 3 people affected. Action taken by Trust: Full investigation and search carried out, it is considered that the lost information is likely to have been put in the confidential waste. Study protocols have been reviewed. Sensitive information is no longer stored on site; now taken to the study main office at end of each day. All of the study’s staff have taken HSCIC training modules: Introduction to Information Governance and Information Governance: The Beginner's Guide. They have also taken HSCIC’s module on Secure Handling of Confidential Information. th Description: On 14 September 2014 five desktop computers were stolen from a paediatric research area at Denmark Hill campus. Number of people affected not known, but possibly <100. Action taken by Trust: The incident was reported to the police and to the ICO. Physical security measures were reinforced and the project to prevent data being saved on local computer drives commenced, with priority given to areas where incidents have occurred previously. Further action required by ICO: No further action required Incident 3 th Description: On 26 September 2014 patient handover sheets were left in a public area at the Princess Royal Hospital, Bromley, found and handed in promptly by member of the public. Repeat of type incident within 12 month period. <30 people affected. Action taken by Trust: Reported to the ICO. Caldecott Guardian identified the locum responsible and spoke to his agency regarding refreshing his IG training. He then followed up with Trust-wide Communications and specific discussion in the Junior Doctor Forums. Further action required by ICO: No further action 58 Further action required by ICO: o/s Incident 5 Description: Near miss; blood test results for 120 patients faxed in error to another hospital via NHS mail’s secure faxing service. Error immediately identified by other hospital and originator informed. Fax went to secure area at receiver Trust and was immediately contained, reported and securely destroyed thus preventing any disclosure of confidential information. Action taken by Trust: Review of protocols and guidance about the use of fax. Corporate risk register entry review. Further action required by ICO: o/s Note: An incident was identified in year and reported to the ICO as a level 2 incident. This involved the posting of code to an external website. However, after a risk analysis it was concluded that the incident should be downgraded and this was communicated to the ICO. The ICO required no further action. Figure 3: Serious incidents involving information loss or confidentiality breach Information Governance Toolkit attainment levels King’s College Hospital NHS Foundation Trust’s score for 2014-2015 for Information Quality and Records Management, assessed using the Information Governance Toolkit was 73%, which equals satisfactory compliance. 80% of the toolkit requirements were level 2, the remaining 20% were all level 3. 59 Code of Governance Statutory framework King’s College Hospital NHS Foundation Trust received foundation trust status on 01 December 2006. The Trust is a public benefit corporation and its principal purpose is the provision of goods and services for the purposes of the health service in England. Governance framework King’s College NHS Foundation Trust has applied the principles of the NHS Foundation Trust Code of Governance on a comply or explain basis. The NHS Foundation Trust Code of Governance, most recently revised in July 2014, is based on the principles of the UK Corporate Governance Code issued in 2012. King’s meets all the main principles of the code especially those relating to the development and management of patient services, information provision and accountability for the use of public resources. The Trust has agreed to take steps to reduce waiting times for patients and improve its financial position, following an investigation by Monitor. The regulator carried out an investigation at King’s in March 2015 after the trust was unable to resolve long-standing problems at the Princess Royal University Hospital (PRUH), which it took over in October 2013. Although Monitor recognises that King’s has made progress in improving services at the PRUH, this has not been sufficient; as it has become clear the challenge is greater than initially anticipated. Following the investigation, Monitor has agreed with King’s that the trust will: develop and implement an effective shortterm recovery plan to deliver the required improvements at the PRUH that King’s planned to make when it took over the hospital; and 60 develop and implement a longer-term plan by working closely with other national and local health care organisations (including NHS England and local commissioners) to ensure patient services are improved, and also provided in a sustainable way for the future. King’s governance framework comprises its membership body, the Council of Governors and the Board of Directors. The Trust’s membership is drawn from patients, staff and individuals from the local constituencies it serves. More information about recruiting and involving members in the life of King’s can be found on pages 94-96. The Council of Governors is elected by the membership or appointed by various organisations in accordance with the Trust Constitution and the ‘fit and proper’ persons test described in the provider licence. The Council of Governors is responsible for representing the interests of members and stakeholders in the governance of the King’s. The Council of Governors exercises statutory powers, such as the appointment or removal of non-executive directors, appointing the external auditor, approving mergers, acquisitions and significant transactions, holding the nonexecutive directors individually and collectively to account and representing the interests of members and the public. The Council of Governors meets formally four times per year to discharge its duties. The matters specifically reserved for the Council’s decision are set out in the Trust’s Constitution. More information about the Council of Governors, including its composition and terms of office, can be found on pages 77-82. Led by the Chair, the Board of Directors sets King’s strategy, determines objectives, monitors performance and ensures that adequate systems are maintained to measure and monitor effectiveness, efficiency and economy. It decides on matters of risk and assurance and is responsible for delivering high quality and safe services. It provides leadership and effective oversight of King’s operations to ensure it is operating in the best interests of patients within a framework of prudent and effective controls that enables risk to be assessed and managed. Further information about King’s internal controls and approach to clinical and quality governance can be found in the Annual Governance Statement on pages 193-195. The Board of Directors comprising the Chair non-executive directors and executive directors are collectively responsible for the success of King’s. All directors meet the ‘fit and proper’ persons test. The terms of office and voting rights of each director is recorded in table 8 on page 63-70. The Board considers that all of its nonexecutive directors (NEDs) are independent in character and judgement, including Professor Ghulam Mufti, who was the representative from the Medical School at King’s College London throughout the reporting period. NEDs bring a breadth of expertise to the Board and provide objective and balanced opinions on matters relating to King’s business. The independence of NEDs are tested at interview and at their annual performance review. The Board meets regularly and has a formal schedule of matters specifically reserved for its decision. The Board delegates other matters to the executive directors and other senior managers. The Board of Directors and the Council of Governors meet together periodically to discuss topical and strategic matters. The Trust’s Constitution sets out the roles and responsibilities of the membership body, Council and the Board. It also details the resolution procedures for resolving any disputes between the Council of Governors and the Board of Directors. To develop an understanding of the views of members and governors, Board members attend meetings of the Council of Governors and its sub-committees, the Annual Members Meeting and community events. Management framework The Board of Directors is responsible for the management and governance of King’s. It is responsible for ensuring compliance with the Trust’s provider license, constitution, mandatory guidance issued by the independent regulator, Monitor, and with relevant statutory requirements and contractual obligations. Commercial opportunities and activities are subject to scrutiny by the Board of Directors and the minutes of commercial companies Board of Directors meetings, to ensure that benefits derived from non-NHS income are channeled into supporting King’s core NHS activities without incurring significant financial or reputational risk. Information about King’s services outside the UK can be found in the strategic report on page 30. Information, development and evaluation Directors and governors are supplied with information in a timely manner in an appropriate form and quality to enable them to discharge their duties. The information needs of the Board of Directors and Council of Governors are subject to periodic review. The performance of the Board of Directors, its committees and individual directors are subject to regular review, as outlined on page 70. Company directorships and other significant interests and commitments King’s maintains a register of interests for its directors and governors. Arrangements to view the register can be made by contacting the Foundation Trust Office on [email protected] Board members and governors are asked to declare any interests and to self-certify that he/she meets the eligibility criteria set out in the Trust’s Constitution. In addition, governors and directors are subject to a disclosure and barring 61 service investigation (formerly the criminal records bureau). auditors are aware of that information. Accountability and audit The Council of Governors reappointed Deloitte LLP as King’s external auditor on 11 December 2011 for a further two years. In addition, the Board of Directors maintains a sound system for evaluating and continually improving effectiveness of its risk management and internal control processes. King’s re-appointed KPMG to undertake a comprehensive internal audit, the plan for which is discussed with executive directors, non-executive directors and the Audit Committee. Board of Directors The Board of Directors ensures effective scrutiny of financial and operational matters through its designated committees and regular reporting to the Board by presenting a balanced and understandable assessment of King’s position and forward plans. Information about King’s financial, quality and operational objectives and performance, including clinical outcome data, is published to allow members and governors to evaluate its performance. Within this annual report, information about King’s future plans and likely future developments, for example, the development of King’s Health Partners is recorded in the ‘Planning for the Future’ section of the strategic report. Information about the financial risk management policies, use of financial instruments and plans for capital projects can also be found in the strategic report in the section entitled ‘Ensuring Financial Sustainability’. Information about greenhouse gas emissions can be found in the ‘Caring for the Environment’ section. So far as King’s directors are aware, there is no relevant audit information of which the auditors are unaware. King’s directors have taken all of the steps that they ought to have taken as directors in order to make themselves aware of any audit information and to establish that the 62 Executive directors are full time King’s employees. Non-executive directors are appointed by the Council of Governors on a four year fixed term contract. The Council of Governors also has the power to remove nonexecutive directors. Executive directors manage the day-to-day running of King’s whilst the Chair and the non-executive directors provide strategic and board level guidance, support and challenge. The members of the Board boast a wide range of skills and bring experience gained from NHS organisations, other public bodies and private sector organisations. The skills portfolio of the directors, both executive and non-executive, is wide-ranging and includes accountancy, audit, education, management consultancy, law, engineering and medicine. This broad coverage of knowledge and skills strengthens the effectiveness of the Board of Directors giving assurance that the Board of Directors is balanced, complete and appropriate to supporting King’s in meeting its objectives. There have been changes to the Board in the period which are illustrated in table 8 on overleaf. These changes include Professor Sir George Alberti retiring as Trust Chair in March, Marc Meryon resigned from his post has nonexecutive director. The Trust also said goodbye to Tim Smart who retired from his role as Chief Executive. The Trust was delighted to welcome Lord Kerslake who took on the role of chair in April 2015 and the recruitment process to find a new NED and Chief Executive is currently underway. The current Board members can be found on page 65. 12 7 Remunerations & Appointments Committee 2 11 Quality & Governance Committee Strategy Committee Board Integration Committee 5 Finance & Performance Committee 11 Education & Workforce Committee Number of meetings held Audit Committee Board of Directors Term of Office Table 8: Board of Directors - Meetings, Attendance, Committee Memberships 4 1 Membership/Attendance Attendee Chair (1) (10) (5) (1) 2011-2015 (10) (4) Chair (1) Marc Meryon Non-Executive Director 2014-2015 (09) (5) Chair (1) Professor Ghulam Mufti Non-Executive Director 2012-2016 (10) Chair (1) Sue Slipman Non-Executive Director 2012-2016 (09) Chair (0) Christopher Stooke Non-Executive Director 2011-2015 (11) Chair (5) Chair (1) Tim Smart Chief Executive Retired 2015 (09) Attendee Professor Sir George Alberti Chair Retired 2015 Chair (10) Lord Kerslake* Chair (voting) 01/04/2015 1 Faith Boardman Non-Executive Director 2012-2016 Graham Meek Non-Executive Director 63 Board Integration Committee Education & Workforce Committee Finance & Performance Committee Quality & Governance Committee Strategy Committee (10) Mr Michael Marrinan Medical Director Currently (10) Roland Sinker** Acting Chief Executive Simon Taylor Chief Financial Officer Dr Geraldine Walters Director of Nursing & Midwifery Jane Walters (non-voting) Director of Corporate Affairs & Trust Secretary Pedro Castro (non-voting)*** Interim Director of Strategy Trudi Kemp (non-voting) Director of Strategic Development Ahmad Toumadj (non-voting) Interim Director of Capital & Estates Steve Leivers Director of Transformation & Turnaround Jeremy Tozer Interim Chief Operating Officer Current (10) Current (11) Current (10) Current (11) Resigned (3/3) 10/2014 (5/5) 02.2015 (1/1) N/A 02/2015 (0/0) N/A 04/2015 (0/0) N/A Attendee Attendee Remunerations & Appointments Committee Board of Directors Current Audit Committee Term of Office Angela Huxham Director of Workforce & Development *During the period Sir Bob Kerslake attended meetings of the Board at Committees as part of induction process. ** Roland Sinker was the Chief Operating Officer who took over the role of Acting Chief Executive due to the absence of the Chief Executive ***Until September 2014 the Substantive Director of Strategy Jacob West was on secondment. See Remuneration Report on pages 73-74 for more information. 64 65 Directors’ biographies Non-Executive directors Professor Sir George Alberti (Chair) Internationally renowned for his work in the field of diabetes, George has also been instrumental in shaping recent healthcare policy towards the management of urgent care and major emergencies. He served as a non-executive director of the Trust before being appointed as Trust Chair in December 2011. George was knighted in 2000 for services to diabetic medicine, and is a member of the World Health Organisation’s expert advisory panel on diabetes. He is a past Dean of Medicine at the University of Newcastle upon Tyne and a former President of the Royal College of Physicians. He was the Government’s National Clinical Director for Emergency Access from 2002 to 2009, and was the author of the influential Emergency Access – Clinical Case for Change. George’s retired as Chair and his term ended 31 March 2015. Faith Boardman Faith lives in Lambeth, and brings 40 years of public service at both the local and the national level. She has a proven track record of delivering service improvements in large public sector organisations that are dealing with substantial change, and significant financial, performance and customer challenges. She has been Chief Executive of the Child Support Agency (1997-2000) and more recently of Lambeth Council (2000-05). She is Chair of Trustees for Vauxhall City Farm, and also works with the Metropolitan Police in a non-executive capacity, as an independent adviser to the Mayor's Office for Policing and Crime. Faith also took on the role of Trustee on the Trust’s Charity in April 2014. 66 Faith joined the Trust Board in March 2012. Her term currently will end in March 2016. Graham Meek (Vice Chair) Graham is a trustee of the British Cardiovascular Society and a non-executive director of Filtronic plc and Capital Gearing Trust plc. He was previously chairman of two other listed companies, ICM Computer Group plc and SPI Lasers plc. During his career as an investment banker with Wood Mackenzie, Smith New Court and Merrill Lynch, he advised a broad range of UK companies on capital raising, mergers and acquisitions and corporate strategy. Graham joined the Trust Board in December 2011 and his current term of office will end in November 2015. Marc Meryon Marc Meryon is a partner and Head of Industrial Relations of international law firm Eversheds LLP. Marc specialises in employment law and is recognised in the legal directories as an expert in industrial relations. He frequently comments on this area in both broadcast and print media. Marc acts for a large number of household names in a wide range of sectors including manufacturing, transport/logistics and healthcare, advising on effective organisational change in a unionised environment, as well as managing and resolving industrial disputes. In the healthcare sector he has advised Trusts on equal opportunities law, the application of the working time directive and pay protection for junior doctors. Marc was a non-executive director of the Trust from August 2010 until his resignation with effect from 31 March 2015. Professor Ghulam J Mufti Professor Mufti has worked at King’s since 1985 when he was appointed as a senior lecturer/consultant haematologist. His current appointment is Professor of Haemato-oncology, Clinical Director of Pathology and Head of the Department of Haematology, one of the largest in Europe. Ghulam is internationally renowned for research and treatment of myelodysplastic syndromes (MDS) and other pre-leukaemic diseases, and has published over 400 original papers in medical journals. He is founding member of the International MDS foundation Board, Chair of the UK MDS Forum and Member of GSTS Members Board. He was formerly a member of the scientific committee of Leukaemia & Lymphoma Research. He has been a non-executive director of the Trust since December 2012; his term will end in December 2016. the role of Director of Corporate Responsibility before becoming Director of Communications. She has been Chair of the Financial Ombudsman Service, has held a number of non-executive positions in the private and public sectors, including Thames Water and was most recently a trustee of NEST Corporation, the pension scheme set up by government to support auto-enrolment. Christopher M Stooke Christopher graduated in economics from Durham University and started his accountancy career at PwC. He was made partner in 1990 and was responsible for the audit of a number of blue chip companies in the UK and Europe, mainly in the financial services sector. From 2003 to 2009 he was Chief Financial Officer of Catlin Group, the FTSE 350 insurer. He is now a non-executive chairman of two companies, a non executive director at a third company and one charity, in addition to King's. He has lived in south London almost all his life and is now based in Dulwich. Chris joined the Trust Board in November 2011 and his current term of office will end in October 2015. Before joining the NHS, Tim had a 30-year career in the commercial sector, first with Shell and latterly with BT. He brings with him a wealth of experience in customer service and satisfaction, developing commercial partnerships, and team and people development. Sue Slipman Sue was the founding Chief Executive of the Foundation Trust Network, the national trade association for authorised and aspirant foundation trusts in the NHS. She was also director of the campaigning charity, The National Council for One Parent Families and ran the Gas Consumer Council. She was an executive director at Camelot where she held Executive directors Timothy Smart (Chief Executive) Since 2008, when he joined the Trust, Tim has brought a renewed focus on improvements in patient experience, service quality, and partner and stakeholder relationships. He has worked in the Middle East, the Netherlands and the US. He also has experience as a non-executive director of a USlisted financial services company and as a Trustee of two national charities. He is an elected member of the Foundation Trust Network Board. Tim is also on the KHP Partners' Board, and the members' boards of GSTS and the London Cancer Alliance. Tim has a passion for equality and inclusiveness. He is proud of the fact that the Trust is now a safer hospital and that it is increasingly reflective of and integrated with the local communities it serves. He is also proud that the focus on closing the local health inequality gap and involvement in King’s Health Partners, is attracting more talent to the area, and has also resulted in the growth of employment and 67 career opportunities for the local population, not least through the innovative volunteers’ programme. Tim retired as Chief Executive Officer on 30 April 2015. Angela Huxham (Director of Workforce Development) Angela’s career in people management began in manufacturing during a period of industrial unrest. Experience in insurance, retail and local government were followed by a move to health in 2002 as HR Director of a leading teaching hospital. She joined the King’s Board in her current role in 2009. Within the NHS she has engaged nationally in various reforms of national terms, conditions and pensions, latterly chairing the 2014 negotiations to design a new contract for doctors in training. Angela is a Chartered Fellow of her professional institute and holds an MSc in Human Resource Leadership Mr Michael Marrinan (Medical Director) Michael graduated in business studies before commencing his medical degree. He then trained as a Cardiothoracic Surgeon, primarily in London and the US. He was appointed as trust Medical Director in February 2010 having been Deputy Medical Director since 2008. Michael has been a Consultant at King’s for over 20 years, and has been heavily involved in clinical, educational and managerial improvements through the Trust. His overriding responsibility, with others, is to ensure that the quality of care for our patients is of the highest order. In keeping with this he is chair of the Patient Safety Committee, chair of the Serious Incident Committee and vice-chair of the Patient Outcomes Committee and a member of the Patient Experience Committee. In addition he is the Trust lead for research and is heavily involved in ungraduated and post graduate education and training. He is a 68 member of the KCL committee supervising development of the new medical undergraduate curriculum. He is currently a leader in the integration of the Princess Royal University Hospital within King’s College Hospital and the development of a 21st century system of highquality networked care. Roland Sinker (Chief Operating Officer) Roland joined the Trust in 2005 as Director of Strategy for King’s and worked latterly as Joint Director of Strategy for King’s and Guy’s and St Thomas’. He was appointed Director of Operations in July 2009 and Chief Operating Officer in April 2012. Prior to joining the NHS, Roland worked as a lawyer and management consultant. Roland is a Director and Company Secretary of KCH Commercial Services and is on the Board of GSTS, the pathology joint venture. Simon Taylor (Chief Financial Officer) Simon has worked at King’s for over 20 years holding positions as Financial Controller and Director of Finance before becoming Chief Financial Officer in 2002. He is also responsible for Information Services, Capital Estates & Facilities and overseeing King’s commercial developments. Simon is a director of KCH Commercial Services and its subsidiaries, Agnentis Ltd and KCH Management Ltd. Jeremy Tozer (Interim Chief Operating Officer) Jeremy (Jez) is a qualified pharmacist. After becoming a Chief Pharmacist early on in his career, moved into various areas of general management before taking first Board Position 9 years ago. Since then he has been part of several Trust Boards up and down the country in the position of Chief Operating Officer and has a specific focus on delivering sustainable operational performance and introducing systems of performance management. Dr Geraldine Walters (Director of Nursing and Midwifery and Director of Infection Prevention and Control) A cardiac nurse by background, Geraldine has held a number of executive nurse director posts in acute NHS Trusts in London. Geraldine is Visiting Professor at both Buckinghamshire New University and the Florence Nightingale School at King’s College London. Geraldine is an advisor to the Florence Nightingale Foundation, a member of the National Advisory Group on Clinical Audit and Enquiries and a trustee of Trinity Hospice. She served as a member on the Morecambe Bay Inquiry Panel. Geraldine worked in a variety of hospitals in her early career, including King’s, and subsequently gained a PhD and an MBA. Jane Walters (Director of Corporate Affairs and Trust Secretary) Jane has worked at the Trust since 1992, holding positions as Business Manager and Head of Corporate Services before being appointed as Director of Corporate Affairs and Trust Secretary in 2004. Her earlier career was in local government, where she worked in a variety of senior roles in the fields of corporate governance, communications and quality assurance. Jane holds a Masters in Social Policy from the University of Cranfield, and leads King’s Patient Experience and Volunteering Programmes. She is also responsible for corporate and clinical governance and communications and marketing. She is a director of KCH Management Ltd. Outside of the Trust, she is Vice Chairman of St Christopher’s Hospice, Sydenham. Trudi Kemp (Director of Strategic Development) Trudi joined King’s in October 2014. Prior to her appointment she was Director of Strategic Development at St George’s Healthcare NHS Trust, having joined as a consultant in Public Health Medicine in 2002. Qualifying in Medicine in 1986, she holds masters degrees in Medical Law and Ethics and in Public Health. She is a Fellow of the Faculty of Public Health and an educational supervisor for specialist trainees in public health. Trudi is responsible for developing and implementing the Trust's strategy, ensuring our service developments meet the needs of the populations we serve. Ahmad Toumadj (Interim Director of Capital, Estates and Facilities) Ahmad was born in Iran and educated in the UK. He holds a master’s degree in Architecture from University College London and is a Fellow of The Chartered Institute of Building. After working in the construction industry he joined the NHS in 1979, where he has worked as a Technical Officer and Director of Capital, Estates and Facilities in a number of organisations. During his 34 years in the NHS he has been responsible for the commissioning of the Chelsea and Westminster Hospital and the master planning of St George’s Hospital in south west London. Ahmad has been employed by King’s since 1997. He has overseen its modernisation and the commissioning of its flagship Golden Jubilee building. Ahmad remains integral to King’s, where he currently works as Director of Business Development with a special remit for projects in the Gulf States. In March 2015 he was invited to join the Executive Team again as Interim Director of Capital, Estates and 69 Facilities, until a permanent appointment is made. Steve Leivers (Director of Transformation and Turnaround) Steve Leivers is a highly skilled director of transformation and turnaround with a successful track record of delivering sustainable financial balance in challenging situations. Over the last decade he has led a number of major NHS cost reduction programmes, QIPP initiatives, clinical transformation projects and turnaround programmes. Steve has a strong clinical background as a chief nurse and has had a successful career in operations management in the NHS and the commercial sector. Over the last ten years Steve has personally developed and implemented initiatives which have delivered savings in a variety of NHS Trusts including acute, mental health and community. These programmes have all been developed using a protocol which requires a comprehensive assessment of clinical risk to ensure that patient care cannot be compromised in favour of CIP delivery. This ensures that executive directors are able to assure trust boards that services remain robust and fit for purpose as well as delivering good value for money. Pedro Castro (Interim Director of Strategy) Pedro is the Interim Director of Strategy at King’s. He has a background in Strategy and Healthcare consultancy and he has worked extensively over the last 10 years across all health sub-sectors internationally. In the UK, he has worked with a large number of NHS organisations including providers, commissioners and regulators. Pedro’s contract came to an end in July 2014. 70 Evaluation and development of the Board Executive directors hold a weekly meeting to monitor and respond to current issues, particularly in relation to quality, performance and finance. The Chair and non-executive directors hold informal meetings on a regular basis to discuss matters relating to the running of King’s without the executive directors present. Collectively the Board holds development sessions periodically throughout the year to allow for deeper discussion and investigation of key topics. In addition, The Board used the evaluation of the Board conducted by the internal auditors, KPMG, to inform a Board Development Programme which included a 3600 appraisals, 1:1 interviews and a facilitated development day. The programme was delivered by Personal Best International Ltd. Personal Best has no former connection with the Trust. Board members also undertake personal development on an on-going basis. All executive and non-executive directors have an annual performance appraisal and personal development plan, which forms the basis of their individual development. The performance of executive directors is reviewed by the Chief Executive and considered by the Remuneration and Appointments Committee. Annual performance appraisals were completed in June 2014 and are next due in June 2015. The process for evaluating the performance of the Chair and non-executive directors has been agreed in consultation with the Council of Governors. Board meetings and committees The Board of Directors met regularly throughout the year. The Board also has seven Committees which also meet regularly and are each chaired by a non-executive director. The Board of Directors approve the terms of reference which detail the remit and the delegated authority of each committee. Each committee completes an annual review and self-assessment which is then presented to the Board of Directors. In addition to regularly reporting to the Board of Directors, committee minutes are a standing item on each Board agenda. Table 8 on pages 63-64 records the membership of each Board committee. Audit Committee The Audit Committee is responsible for monitoring the externally reported performance of King’s and for providing independent assurance to the Board of Directors in a range of areas including internal control, risk management, external assurance of risk management processes, internal and external audit and financial reporting. King’s also has a zero-tolerance policy towards fraud and bribery and this committee is responsible for overseeing the work of the counter fraud team. It continues to closely monitor the effectiveness of internal control and audit processes on behalf of the Board of Directors. The committee is chaired by Christopher Stooke who brings a wealth of financial expertise to the Committee. The internal and external auditors regularly attend committee meetings in addition to the Chief Financial Officer, Chief Executive and the Director of Corporate Affairs, although they are not members of the committee. The Trust Chair and other members of the executive team attend meetings of the committee by invitation. The broad knowledge and skills of the members and attendees strengthens the effectiveness of the committee. King’s is satisfied that the committee is sufficiently independent. During the reporting period the committee considered reports from internal and external auditors around significant issues including data quality, assurance and security, divisional risk management, data migration and integration, medical appraisals and revalidation, nursing staff levels, procurement, core financial systems and reporting, CIPS, bank and agency staffing and effectiveness of divisional meetings. It also received reports on counter fraud investigations and recommendations. In May 2014 the committee fulfilled its oversight responsibilities with regard to monitoring the integrity of the financial statements, the annual accounts and the annual governance statement (formally known as the statement of internal control), before submission to the Board. The Audit Committee met with the external auditors and considered the significant risks they identified in both their audit plan and subsequent conversations. The Committee ware in agreement that these represent the significant risks to the Trust. Further details of these risks and the External Audit findings and conclusions can be found as part of the External Auditor’s Opinion on the Accounts on page 204-208. Independence of the external auditor King’s external auditors, Deloitte, have communicated the following matters to the Audit Committee: The principal threats, if any, to objectivity and independence identified by the auditor, 71 including consideration of all relationships between King’s, directors and the auditor; Any safeguards adopted and the reasons why they are considered to be effective; Any independent partner review; The overall assessment of threats and safeguards; Information about the general policies and processes for maintaining objectivity and safeguarding independence when undertaking non-audit work. Deloitte is not aware of any relationships that may affect the independence and objectivity of the team, and which are required to be disclosed under auditing and ethical standards. Board Integration Committee The Board Integration Committee was established to support the work around the acquisition of sites and services from the former South London Healthcare Trust and to oversee the integration process. This committee was disbanded in March 2015 so that the Board could give focus to the key elements in its forward plan to tackle the financial challenges facing the Trust. Education and Workforce Development Committee This Committee is responsible for providing assurance to the board on the Trust’s strategy and plans for its entire workforce focusing on education learning and organisational development, workforce information, planning, resourcing and deployment and staff engagement, reward, recognition, health and wellbeing. Finance and Performance Committee This committee is responsible for reviewing and monitoring King’s operational and financial performance against core targets and indicators 72 and for ensuring that King’s remains compliant with Monitor’s financial and governance risk ratings. Quality and Governance Committee This committee is responsible for overseeing the three key dimensions of quality: patient safety, patient experience and patient outcomes as well as organisational safety, risk management and compliance and information governance. Patient complaints and/or video stories are a regular item on the agenda. Strategy Committee This committee is responsible for overseeing the development of King’s strategy and vision. It also reviews progress against King’s strategic objectives, discusses major strategic issues and monitors external political, economic and social factors which influence the hospital’s business. Remuneration and Appointments Committee On behalf of the Board of Directors, this committee agrees executive directors’ remuneration and terms of service. Together with the Chief Executive, committee members form a panel for the appointment of executive directors. More information can be found in the remuneration report on pages 73-74. Remuneration Report The remuneration and terms of service of the Chair and non-executive directors (NEDs) are determined by the Council of Governors, taking account of market and survey data from relevant benchmark sources which can include the Foundation Trust Network and the Trust’s NHS peer group. More information about this process and the role of the Council of Governors’ Nominations Committee can be found on page 76. Remuneration for the King’s most senior managers (directors accountable to the Chief Executive) is determined by the Remuneration and Appointments Committee, which comprises the Chair and the non-executive directors. See table 8 on pages 63-64 for committee membership and meeting attendance. The work of the Remuneration and Appointments Committee is informed by relevant benchmark data, periodic assessments conducted by independent remuneration consultants and by salary awards and terms and conditions applying to other NHS staff groups. The work of the committee is supported by the Director of Workforce Development who is not a member of the committee. Prior to King’s acquisition of sites and services from the former SLHT on 01 October 2013, the Remuneration and Appointments Committee had reviewed the directors’ pay and reward framework involving recognised job evaluation tools, external comparators and independent advice. Post acquisition, executive pay was reassessed in the light of organisational expansion and the consequent changes in the scale and complexity of director responsibilities. The Committee agreed to reflect the significant challenges faced by the enlarged organisation and to adjust director salaries in two stages. The first stage was effective from the date of acquisition and the second from 1 April 2014. King’s strategy and annual planning processes set key business objectives which, in turn, inform individual and collective objectives for senior managers. Individual performance and that of King’s as a whole is closely monitored, discussed throughout the year and forms part of the annual appraisal as outlined on page 70. Details of senior employees’ remuneration can be found on pages 236-237 of the annual accounts. Note 4.7 on page 238 sets out accounting policies for pensions and other retirement benefits. The only non-cash element of the most senior managers’ remuneration packages is pension related benefits accrued during membership of the NHS Pension Scheme. Contributions into the scheme are made by both the employer and employee in accordance with the statutory regulations The Medical Director is a medical consultant within the Trust, whose role is undertaken on a fixed term, three-year contract, renewable by agreement. The contract was reviewed in February 2013 and extended for a further three years. Additional paid programmed activities are provided in the Medical Director’s job plan to enable the performance of these additional responsibilities. As an executive Board member the Medical Director also receives a pay supplement. All other directors are substantive employees of the Trust employed on openended employment contracts which can be terminated by the Trust with contractual notice. Until September 2014, the substantive Director of Strategy was, with the agreement of the Board, seconded into a regional role until 73 leaving King’s to take up a Harkness Fellowship. An interim Director of Strategy was in post throughout quarter one. A new substantive Director of Strategy joined the Board on 1 October 2014. Compensation in the event of early termination for substantive directors would be in accordance with contractual entitlements as set out in the Agenda for Change national terms and conditions of service. Signed: Roland Sinker Acting Chief Executive Date: 26 May 2015 Council of Governors Following the acquisition of new sites and services in outer south east London from the now dissolved South London Healthcare Trust the Council of Governors had a transitional composition. The transitional arrangements were in place during the period until the new Council commenced its term on 01 December 2014. The council of governors is made up of elected and appointed stakeholders. Elected governors make up the majority of the council and appointed stakeholder governors include representatives from clinical commissioning groups and local councils, which play an important part of stakeholder relations. Governors are elected by the members of the Trust. The membership constituencies include patients, staff and residents from Bromley, Lambeth, Lewisham and Southwark. 74 The composition of the Council, names of individual governors and their terms can be found in the tables on pages 78-82. Governor elections During the period the Trust held elections in the patient, staff, Lambeth and Southwark constituencies. 17 candidates stood for governor in the Patient constituency, 19 in the staff constituencies and 17 in the Lambeth constituency and 21 stood in the Southwark constituency. Further information can be provided on the elections by contacting the Foundation Trust Office at [email protected] Function and meetings of the Council of Governors The Council of Governors met four times during the reporting period. The attendance of individual governors at these meetings, which were held in public, is detailed in tables on pages 78-82. All directors are invited to attend Council meetings. Individual directors, executive and non-executive, regularly present items at Council meetings, in accordance with the planned agenda. Each governor sub-committee has an appointed executive lead and one or two affiliated non-executive directors. The Council of Governors has two key functions, which are to hold non-executive directors to account for the performance of the Board and to represent the interests of members and the public. The Council of Governors also has specific responsibilities, which include the appointment, remuneration and removal of the Chair and other non-executive directors. The term of office for governors is four years. During the reporting period, the Council of Governors: Received and considered the Trust Annual Report and Accounts and the auditor’s report on the accounts; Received regular updates on King’s business planning process and provided comments which were duly incorporated into King’s forward plan and submitted to Monitor in May 2014; Approved changes to the Trust Constitution; Received regular information on and discussed the financial and performance challenges facing the Trust in particular the Monitor investigations and results; and Appointed the new chair. Governors receive regular reports on the Trust’s finances and performance. Governors in the community Governors are active within the community, helping to facilitate communication between King’s, members and the local community. Governors are pivotal to sharing King’s vision and performance with key stakeholders. As guardians of the community interest, the Council of Governors ensures that the needs of members are considered in the planning of future services. Further information about governor engagement can be found on pages 85-96. Governor sub-committees The Council of Governors has sub-committees which provide the opportunity for governors to delve deeper into issues that are of interest to members, patients and the local community. All governors are eligible to sit on governor sub- committees, with the exception of the Nominations Committee for which governors stand and are elected. Membership and Community Engagement Committee This committee monitors membership recruitment and reviews the engagement and experience strategy ensuring that membership continues to be representative as well as identifying ways in which the membership can be more actively involved. Committee members are encouraged to provide feedback about the engagement activity they have been personally involved with, both within and outside King’s, and opportunities for facilitating communication between governors and the membership are explored. More information about these opportunities can be found on pages 85-96. Patient Experience and Safety Committee This committee acts as a reference group for King’s planned activity around patient experience and safety. This year a particular focus has been King’s response to the Francis Report and recommendations. Committee members are involved with a range of initiatives to improve patient experience and safety and to monitor progress against King’s quality priorities. Strategy Committee This committee reviews King’s strategy and annual forward plan, and feeds back to the Council of Governors. It considers external factors and the climate in which King’s operates, such as revised commissioning structures. 75 Nominations Committee This committee is responsible for determining and administering the selection process for the appointment and remuneration of the Chair and non-executive directors, and recommending the preferred candidates to the Council of Governors for appointment. This includes consideration of the structure, size and composition of the Board. It also monitors the performance of non-executive directors and makes recommendations to the Council of Governors for the reappointment or removal of individual non-executive directors. The members of the committee are detailed in table 11 on page 82. The committee met three times during the reporting period. It also makes recommendations to the Council on the remuneration and terms and conditions of nonexecutive directors. Governor development and engagement King’s is committed to providing on-going support and training for governors and opportunities to engage with staff, directors, member and one another. Governors were invited to participate in workshops at which topical issues selected by governors themselves were presented by directors and other senior members of staff. Three governor development days were organised in-year, one of which was delivered to governors from all three foundation trusts within King’s Health Partners by the Foundation Trust Network. Governors have also received presentations from external speakers invited to sub-committee meetings and workshops in order to give different perspectives on relevant issues. 76 The process to develop a full business case for the acquisition of sites and services from South London Healthcare Trust was a key feature of discussions throughout the reporting period. A number of opportunities were organised for governors to hear more about the developing plans, regulatory requirements and implications for King’s. Governors, members and directors came together to share ideas about King’s vision and future plans at community events and the Annual Members Meeting. There was also an annual joint meeting of the Board of Directors and Council of Governors and all governors are invited to attend Board of Directors meetings. Governors also participated in ward-based initiatives such as collecting patient stories and the King’s in Conversation project. More information about these involvement activities can be found on pages 85-96. Governors are provided with a secure remote resources centre through which they can access information relevant to their role. Some governors attended external events hosted by the Foundation Trust Governors’ Association and the Foundation Trust Network during the reporting period. Company directorships and other significant interests and commitments King’s maintains a register of interests for its governors, which is open to the public. Arrangements to view the register can be made by contacting the Foundation Trust Office on [email protected] 77 Table 9: Council of Governors and Attendance at Meetings 01 April - 30 November 2015 Term CONSTITUENCY 78 MEETINGS 1 2 Derek Cookson 01/12/2011 - 30/11/2014 Patient Patient x x Thomas Duffy 01/12/2011 - 30/11/2014 Patient Patient x Patti Kachidza 01/12/2011 - 30/11/2014 Patient Patient Pida Ripley 01/12/2011 - 30/11/2014 Patient Patient David Sullivan 01/12/2011 - 30/11/2014 Patient Patient x x Jan Thomas 01/12/2011 - 30/11/2014 Patient Patient Eniko Benfield 01/12/2011 - 30/11/2014 Public Bromley x Paul Corben 01/12/2011 - 30/11/2014 Public Bromley Penny Dale 01/12/2011 - 30/11/2014 Public Bromley Anoushka 01/12/2011 - 30/11/2014 Public Bromley Michael de AlmeidaCarragher Robinson 01/12/2011 - 30/11/2014 Public Lambeth Central x Godwin Ubiaro 01/12/2011 - 30/11/2014 Public Lambeth Central x Fiona Clark 01/12/2011 - 30/11/2014 Public Lambeth North Christopher North 01/12/2011 - 30/11/2014 Public Lambeth North x Nandakumar Ratnavel 01/12/2011 - 30/11/2014 Public Lambeth South Alan Hall 01/12/2011 - 30/11/2014 Public Lewisham Pam Cohen 01/12/2011 - 30/11/2014 Public Southwark Central NOTE Term CONSTITUENCY MEETINGS NOTE Barbara Pattinson 01/12/2011 - 30/11/2014 Public Southwark Central Barrie Hargrove 01/12/2011 - 30/11/2014 Public Southwark Council N/A Resigned Catherine McDonald 01/12/2011 - 30/11/2014 Public Southwark Council N/A Resigned Andrew McCall 01/12/2011 - 30/11/2014 Public Southwark North Joe Onabaworin 01/12/2011 - 30/11/2014 Public Southwark North Stuart Owen 01/12/2011 - 30/11/2014 Public Southwark South Michelle Pearce 01/12/2011 - 30/11/2014 Public Southwark South Michael Pedro 01/12/2011 - 30/11/2014 Staff Administration and Clerical x Phyllis Barnett 01/12/2011 - 30/11/2014 Staff Allied Health Professionals Rachel Burman 01/12/2011 - 30/11/2014 Staff Medical and Dentistry CV Praveen 01/12/2011 - 30/11/2014 Staff Medical and Dentistry Carolyn Campbell-Cole 01/12/2011 - 30/11/2014 Staff Nurses and Midwives x x Nicky Hayes 01/12/2011 - 30/11/2014 Staff Nurses and Midwives Helen Mencia 01/12/2011 - 30/11/2014 Staff Nurses and Midwives x x Ahmad Toumadj 01/12/2011 - 30/11/2014 Staff Support Staff x Robert Evans 16/12/2013 - 15/12/2016 Stakeholder Bromley Council x Jim Gunner 05/03/2014 - 05/03/2017 Stakeholder Bromley CCG Diane Summers 06/10/2013 - 05/10/2016 Stakeholder Guy's & St Thomas' Hospital NHS Foundation Trust Constituency no longer exists 79 Term CONSTITUENCY MEETINGS Phidelma Lisowska 01/09/2013 - 30/08/2016 Stakeholder Joint Staff Committee Chris Mottershead 01/07/2012 - 30/06/2015 Stakeholder King's College London x Sue Gallagher 01/01/2013 - 31/12/2015 Stakeholder Lambeth CCG Warren Turner 29/01/2013 - 28/01/2016 Stakeholder London South Bank University Jim Dickson 01/03/2012 - 28/02/2015 Stakeholder Lambeth Council Richard Gibbs 09/05/2011 - 08/05/2015 Stakeholder Southwark CCG x NOTE Constituency no longer exists Table 10: Council of Governors & Meeting Attendance - 01 December - 31 March 2015 CONSTITUENCY 80 MEETINGS ATTENDED Anoushka de AlmeidaCarragher 30/01/2014 - 30/01/2017 Public Bromley Eniko Benfield 30/01/2014 - 30/01/2017 Public Bromley Paul Corben 30/01/2014 - 30/01/2017 Public Bromley Penny Dale 30/01/2014 - 30/01/2017 Public Bromley Alan Hall 30/01/2014 - 30/01/2017 Public Lewisham Fiona Clark 01/01/2015 - 30/11/2018 Public Lambeth Christopher North 01/01/2015 - 30/11/2018 Public Lambeth NOTES CONSTITUENCY MEETINGS ATTENDED Nandakumar Ratnavel 01/01/2015 - 30/11/2018 Public Lambeth Grace Okoli 01/01/2015 - 30/11/2018 Public Lambeth Barbara Pattinson 01/01/2015 - 30/11/2018 Public Southwark Pam Cohen 01/01/2015 - 30/11/2018 Public Southwark Andrew McCall 01/01/2015 - 30/11/2018 Public Southwark x Victoria Silvester 01/01/2015 - 30/11/2018 Public Southwark Jo Millett (nee Artus) 01/01/2015 - 30/11/2018 Staff Nurses and Midwives Nicky Hayes 01/01/2015 - 30/11/2018 Staff Nurses and Midwives CV Praveen 01/01/2015 - 30/11/2018 Staff Medical and Dentistry Cornelius Lewis 01/01/2015 - 30/11/2018 Staff Allied Health Professionals Roger Engwell 01/01/2015 - 30/11/2018 Staff Administration and Clerical Helen Ahmet 01/01/2015 - 30/11/2018 Patient Patient Derek St Clair Cattrall 01/01/2015 - 30/11/2018 Patient Patient Thomas Duffy 01/01/2015 - 30/11/2018 Patient Patient Catriona Ogilvy 01/01/2015 - 30/11/2018 Patient Patient x Pida Ripley 01/01/2015 - 30/11/2018 Patient Patient Jan Thomas 01/01/2015 - 30/11/2018 Patient Patient x NOTES 81 MEETINGS ATTENDED CONSTITUENCY Gunner 16/12/2013 - 15/12/2016 Stakeholder Bromley Clinical Commissioning Group Robert Evans 05/03/2014 - 05/03/2017 Stakeholder Bromley Council Diane Summers 06/10/2013 - 05/10/2016 Stakeholder Guy's & St Thomas' Hospital NHS Foundation Trust Phidelma Lisowska 01/09/2013 - 30/08/2016 Stakeholder Joint Staff Committee x Chris Mottershead 01/07/2012 - 30/06/2015 Stakeholder King's College London Sue Gallagher 01/01/2013 - 31/12/2015 Stakeholder Richard Gibbs 09/05/2011 - 08/05/2015 Stakeholder Jim Dickson 01/03/2015 - 30/04/2018 Stakeholder Lambeth Council Kieron Williams Stakeholder Southwark Council N/A Roger Pafford Stakeholder South London and Maudsley NHS FT N/A Lambeth Clinical Commissioning Group Southwark Clinical Commissioning Group Table 11: Membership of the Nominations Committee Members Term 82 Jim 02/01/2015 - 01/01/2018 NOTES Constituency Prof Sir George Alberti, Committee Chair Member during 01 April 14 – 31 March 2015 (Retired) Lord Kerslake, Committee Chair Member from April 2015 (Current) Nanda Ratnavel , Vice Chair Member during 01 April 14 – 31 March 2015 (Current) Public Governor Fiona Clark Member during 01 April 14 – 31 March 2015 (Current) Public Governor Thomas Duffy Member during 01 April 14 – 31 March 2015 (Current) Patient Governor Rachel Burman Member during 01 April 14 – 31 March 2015 (No longer Governor) Staff Governor Pam Cohen Member from January 2015 (Current) Public Andrew McCall Member from January 2015 (Current) Public Reappointed Joined on 02/01/2015 Patient & Public Focus Patient and Public Focus: Listening and Responding Improving Patient Care King’s is committed to addressing healthcare inequalities and responding to the needs of the local population. This is one reason why the majority of foundation trust members and the governors who are elected to represent them are drawn from the London boroughs of Lambeth, Southwark, Lewisham and Bromley. Other members have an association with King’s because they are patients, staff or affiliated to partner organisations. More information about membership constituencies can be found on pages 94-96. This year, we welcomed new Governors to the Council of Governors as well as new members from across our patient, public and staff constituencies. During the year 2014/15, members and governors have continued to play an active role in helping to improve services and ensuring that they meet the health needs of the diverse community served by the hospital. Council of Governors: representing the patient voice As outlined on pages 74-75, the key functions of the Council of Governors are to hold non-executive directors to account for the performance of the Board and to represent the interests of members and the public. In order to meet these responsibilities governors ensure that the patient voice remains at the forefront of King’s work by providing lay representation and an external perspective on a range of committees and working groups. These include: End of Life Care Group; Older People's Committee; Maternity Services Liaison; Nutrition Support Steering Group Patient Experience Committee. Governors also have their own committees, which focus on strategy, patient experience and safety, membership and community engagement. More information about governors and their sub-committees can be found on 75-76. Patient experience Both governors and members continue to volunteer to help with a range of projects aiming to improve the experience of patients. Some of these projects are outlined below. PLACE assessments Governors and members have joined multidisciplinary teams to take part in our annual Patient Led Assessments of the Care Environment (PLACE). Teams of assessors go into all our hospitals to assess how the environment supports patients’ privacy and dignity, food, cleanliness and general building maintenance. The focus is entirely on the care environment, not clinical care provision or staff competency. Improving Patient Food Service Governors and Members have continued to take part in patient food service audits on our wards to help to improve the quality of patient food. These audits include interviews with patients about different aspects of patient food. 85 King's in Conversation This year, the trust has run another series of King’s in Conversation events to gather feedback from patients, visitors and staff about their views of King’s. Governors have again played a crucial role in gathering views through formal group discussions or via 'pop up conversations' held in corridors, offices and the canteen. Annual Members Meeting On 25 September 2014 governors and members gathered for the Annual Members Meeting. The event was well attended and members were offered the chance to have routine health checks such as blood pressure and blood sugar. There were also information focussing on fundraising for our helipad, volunteering, King’s one year on from joining forces with the PRUH and, a stand on King’s and World War 1. A review of the past year was presented by the Chief Executive, Timothy Smart; Chief Financial Officer, Simon Taylor presented a financial review; and Tom Duffy, reported to members on the activities of the Council of Governors during the year and how they have discharged their responsibilities. The formal part of the meeting was followed by break-out sessions on three of King’s key services: Dental services, orthopaedics and ophthalmology. Service improvements following staff or patient surveys or comments and Care Quality Commission reports Care Quality Commission (CQC) During the reporting period Chief Inspector of Hospitals, Professor Sir Mike Richards, identified 18 trusts that would be among the first to be inspected by the end of 2013 under the new inspection regime. 86 The now dissolved South London Healthcare Trust appeared on the list as ‘high risk’. On 02 December a team of inspectors arrived at the PRUH. They were provided with information about the acquisition process and as part of their inspection spoke with members of staff, patients and carers and individual directors. King’s was invited to participate in a Quality Summit to discuss the outcome of the inspection and the draft report, then on 06 February 2014 the final report was published highlighting areas of good practice and areas requiring improvement. King’s was asked to respond outlining the actions that would be undertaken to meet these essential standards. National patient surveys This year, results were published for the annual CQC inpatient survey and a national A&E survey. The Department of Health also commissioned a national cancer patient experience survey. Inpatient survey Results for the 2014 National Inpatient Survey were not published by the time the Annual Review went to press National A&E survey The results of the national A&E survey were published in December 2014. This is the first time that both acute sites based at Denmark Hill and PRUH were included in a national survey. King’s was rated amber – the same as expected for all sections apart from ‘environment and facilities’ which was rated red – worse than expected. In summary, there was a small drop in overall score from 2012 but improvements in some areas including questions about waiting times. The lowest performing section was about patient’s perceptions of their ‘Care and Treatment’ with DH site scoring 6% higher than the PRUH. Based on comparable questions. DH has increased by 1 point from 7.4 to 7.5 between 2012 and 2014. PRUH scores have decreased by 1 point between 2012 and 2014 from 6.9 to 6.8. Performance fell compared to London Peers. Response rate of 30% compared to 34% nationally Department of Health national cancer survey 2013/2014 This survey seeks the views of patients aged 16 and above with a primary diagnosis of cancer admitted as an inpatient or daycase patient and discharged discharged between 01/9/12 and 30/11/13. 1,204 King’s patients from both Denmark Hill and PRUH were sent a survey and 632 completed surveys were returned - a response rate of 56% compared to 64% nationally National results published on Friday 26th September 2014. Although there was good improvement in some areas of patient experience, the results remain disappointing. Ten out of sixteen sections show improvement in scores with good improvement in patient experience of: • Finding out what was wrong with you • Deciding the best treatment • operations • Information before discharge • Hospital care as outpatient /day case Performance in four sections deteriorated including patient experience of cancer research where there was a drop nationally. There has been significant work to improve the experience of patients with cancer and, following the survey results, further work is planned over the coming year, focussing on: • • • • • • • Trust-wide focus on cancer patient experience with improving cancer patient experience as one of the Trust’s two patient experience quality priorities included in our Quality Account Continued formal monitoring of the MDTs progress re improving patient experience – via peer review Work in partnership with Macmillan for service improvement related to the patient Quality improvement programme for Clinical Nurse Specialists Information hubs to be developed at the PRUH Chartwell outpatient unit and around the hospital A rolling programme of HOPE courses (‘moving forwards’ course) Introduction of complementary therapy service Patient Experience Surveys ‘How are we doing?’ patient surveys The ‘How are we doing?’ (HRWD) patient feedback programme, incorporating the Friends and Family Test, continues to be used to drive improvement in the quality of patient experience. HRWD inpatient Survey This is the first year where we have had a full set of results for both the Denmark Hill (including Orpington) and Princess Royal sites. At Denmark Hill, the year started well with an overall satisfaction score of 87, one above our target. Performance dipped from 87 May to December but recovered at the end in the last quarter of the year to 87. Orpington wards have achieved excellent patient satisfaction ratings, with Bodington Ward exceeding the target score over the whole year. Overall the PRUH has performed slightly below the Denmark Hill site reaching one below target for three months of the year. How are we doing? outpatient survey On the Denmark Hill site, performance has been good with the overall target score met or exceeded in seven months of the year. King’s was an early implementer site for the Friends and Family Test for outpatients and day case. A How are we doing outpatient survey, incorporating FFT, was launched at the Princess Royal and other Bromley sites on 1st October 2014. The Friends and Family Test The NHS-wide Friends and Family Test (FFT) is an important opportunity for patients to provide feedback on the care and treatment that they have received in order to improve services. Introduced nationally for inpatient and emergency patients on 01 April 2013 and for maternity patients on 01 October 2014, the FFT asks patients whether they would recommend hospital wards, emergency departments and maternity services 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. King’s was an ‘early implementer’ site for Friends and Family for outpatients and day case patients and launched on 1st October 2014 across all our sites and satellite units. 88 From April 1st 2015, the Friends and Family Test will be extended to all services including patient transport services. Following a review of the Friends and Family Test during 2014, the scoring for FFT was changed in October 2014. The ‘nett promoter’ score was replaced with a score based on the percentage of patients who would recommend a service against the percentage of patients who would not recommend a service. New guidance to support the Friends and Family Test was published in July 2014. FFT: inpatients Overall, King’s wards have performed well over the year with the Friends and Family score for the trust reaching a high in January of 96% of inpatients recommending King’s as a place to be treated. This placed Wards across all of King’s sites above both the London and national average scores. This performance continued into February with the Trust exceeding the London average and equalling the national average score of 95%. There have been some very good results amongst wards across King’s. For example, at Orpington Hospital, Bodington Ward has achieved 100% satisfaction for seven of the last twelve months. In February, 99% of our neurosciences inpatients at the Denmark Hill site said that they would recommend King’s and, at the PRUH, 100% of our paediatric inpatients said they would recommend the PRUH. Over the year, the number of survey responses at the PRUH has been growing and across the trust, we have met our response rate targets linked to CQUIN funding (Commissioning for Quality and Innovation). FFT: emergency departments FFT performance in the emergency setting is more variable against a background of unprecedented activity and pressure on emergency departments nationally. At the Denmark Hill, scores have dropped slightly over the year but remain two to three percentage points below the national average. At the PRUH, the year started well with improving scores and reaching parity with the DH site in July 2014 with a score of 85% of patients who would recommend the department. However, scores deteriorated with a higher number of patients than average who would not choose to recommend emergency services at the PRUH. The trust remains on track to meet CQUIN targets linked to FFT response rates. FFT: maternity services The maternity FFT is structured so that women are given the opportunity to provide feedback on care received at different points along their maternity journey. It is continuing to prove challenging to achieve robust response rates, particularly for the antenatal and community midwifery stages. We have introduced new delivery methods for obtaining feedback including volunteer support and the use of iPads. Overall, results are positive with King’s performing well compared to other London hospitals. The PRUH Oasis birthing unit, in particular, has had very positive results over the last year. FFT: Outpatients Friends and Family was launched in outpatients as part of the overall trust How are we doing? Outpatient survey. At the DH site, the outpatient survey has been in place for a number of years and the PRUH and other Bromley sites went live on 1st October 2014. The remainder of trusts nationally launched FFT for outpatients and day case patients on 1st April 2015 and results will be published for all trusts later in the year. A key challenge for us will be to gather good numbers of surveys so that we can be confident that the feedback we receive represents the views of our outpatients. Service improvements Below are some examples of improvements that have been introduced as a result of feedback from our patients: Our Child Health wards have started a Health: ‘Shh noise at night campaign’ on children’s wards to reduce noise on the wards Medical 4 ward at the PRUH has introduced self-closing bins to reduce noise disturbance for patients. Surgical Wards 1 and 2 at the PRUH now use King’s Volunteers to help patients complete their ‘this is me’ document. At the DH site, Coptcoat Ward have introduced a staff rota for cleaning checks and on Matthew Whiting, nurses now have a presence on ward rounds. At our Musculoskeletal Service based at Queen Mary’s Sidcup, the team have improved wait times in clinic by almost 15%. They have also introduced whiteboards to display any delays in Clinic so that patients know how long they may have to wait if there are delays. As part of our work to improve discharge for patients, we’ve put a number of actions in place on some of our wards including, post 89 discharge phone calls to patients and a new ‘Home for Lunch’ leaflet. Patient experience priorities Detailed information about the work undertaken this year around patient experience quality priorities can be found in the Quality Account on pages 103-190. Patient experience reports continue to provide integrated monthly data on complaints, contacts with the Patient Advice and Liaison Service (PALS) and the Friends and Family Test survey. King’s Volunteers Our in–house hospital volunteering scheme has gone from strength to strength this year. The number of volunteers at our Bromley sites has more than doubled since October 2013, and we now have a grand total of just over 1,700 volunteers across all of our hospital sites. Our Hospital 2 Home scheme, which involves volunteers meeting patients on the ward, assisting them through the discharge process, and providing short term befriending visits once they are at home, has also continued to thrive. To date, this scheme has performed 167 community visits and over 350 telephone calls to vulnerable and elderly patients. “The volunteer is a lovely young lady and so helpful. It’s nice to know I haven’t been forgotten after being sent home. I think all hospitals should have this service. It really makes my day” Patient discharged from Annie Zunz Ward. The volunteering service has launched several new initiatives this year. Our Home Hamper scheme, which began in November 2013 and has already received nearly 50 referrals, offers patients in need a small food parcel to take home with them upon 90 discharge. Our hampers are predominantly targeted at those who have been long-term inpatients and may not have much in their cupboards upon return home, those who are being discharged to a new home environment, and those who face other hardships. To provide additional support to patients whilst in hospital, we have also launched a volunteer-led day club on Saturdays . Social clubs seeks to provide stimulation and alleviate boredom for inpatients who are medically well enough to leave the wards. The range of activities which patients have the opportunity to participate in goes from film afternoons to bingo sessions, to arts and crafts and reminiscence activities. Following a successful pilot at our Denmark Hill site, our Home Hamper and social club initiatives will be rolled out to the Princess Royal Hospital over the course of the next year. Our volunteers have continued to have a highly positive impact on patient experience. Those who had access to a volunteer between January 2013 and August 2014 scored the Trust on average 3.63 points more highly on our Friends and Family Test comparative to patients who did not. Additionally, those with access to a volunteer were 2% more ‘extremely likely’ to recommend the Trust to friends and family. concerns and problems, which last year handled 8,363 enquiries, an activity increase of 35% from 2013/14. Responding to complaints King’s received 586 complaints during 2014/15 concerning the Denmark Hill site which is a 23% reduction on the number of complaints received in 2013/14 (758). A total of 399 complaints were made during the reporting period concerning the Princess Royal University Hospital and other sites in Bromley for which King’s is now responsible. This is an 8% reduction in complaints from the previous year. As an enlarged organisation, overall we recorded 985 for the year, a 17% reduction compared to 2013/14. Within year we made some changes to the way we handle complaints from the point at which they are received and this has impacted on our activity levels particularly in the second half of the year. We increased our focus on dealing with complaints from a service user perspective and wherever possible found immediate support in remedying problems and ensuring dialogue is established between the complainant and the service/clinical staff. This approach has been positively received both by our patients and staff, and complements the established role of PALS in resolving The profile of complaints has broadly remained the same as in past years, in that half of all our complaints relate to some aspect of clinical treatment. Alongside these, are concerns relating to outpatient appointment arrangements, discharge decisions, staff attitude and our communication about care plans and treatment. The organisational pressures on inpatient beds due to emergency and trauma care, impacted on the number of complaints we received that concerned a cancelled admission for elective surgery. Just over 50% of complaints responded to were upheld. We invite complainants to tell us about their experience in making a complaint and review the results from this survey through the Serious Complaints Committee, chaired by a non-executive director, to continuously assess our complaint handling and to measure the impact of changes we have made. Just over 100 members of staff have attended training this year to support their writing skills when responding to a complaint. As an organisation we welcome complaints as a means of improving performance and learning from complaints is ongoing and is often linked with outcomes following clinical incident investigations. Complainants and patients have participated in meetings with staff and also in listening events, patient video stories, and contributed to a number of general improvements across the organisation. 91 Stakeholder relations The Board of Directors recognises the importance of effective communication, dialogue and engagement with a wide range of stakeholders across a broad geographical area which includes six local authorities who scrutinise our services via Health Overview and Scrutiny Committees to which we report when consulting on quality priorities or when potential changes to the provision of services are proposed. The Trust attends and engages with the Health and Wellbeing Boards in order to assist with informing commissioning priorities and defining the strategic direction of local health and social care services. Throughout the year, the Trust holds a series of stakeholder events to share emerging thinking in relation to our strategic development and options with Trust membership and to ensure that the views of governors and members are communicated to the Board and are reflected in our work going forward. Through the year, King’s engages with local Healthwatch in a number of ways. Healthwatch take part in our annual Quality Account Stakeholder events which bring together key stakeholders to help us develop and agree our quality priorities for the coming year. In the last year, Lambeth Healthwatch hosted a joint meeting for the Healthwatch for Southwark, Lambeth and Bromley with patients and members of the public to discuss service reconfiguration linked to King’s acquisition of the PRUH, specifically elective orthopaedic surgery at Orpington Hospital and elective gynaecology services at the PRUH. These meetings are part of our regular programme of quarterly meetings with Healthwatch. Healthwatch also attend our annual 92 Stakeholder events held for both the Denmark Hill and Bromley sites. The Annual Members Meeting is a key event in the King’s calendar and an opportunity to communicate with members, in addition to regular written communication and events for members. A series of community meetings are held annually to enable members to feed into King’s annual strategic planning process and to ensure that the views of governors and members are clearly communicated to the Board. Southwark and Lambeth Integrated Care King’s is committed to working with partners across local boroughs to integrate services at a local level to improve patient care. One example of an on-going project which involves working alongside key stakeholders is Southwark and Lambeth Integrated Care (SLIC). King’s is a founder member of SLIC, along with South London and Maudsley and Guy’s and St Thomas’. SLIC is a movement for change that aims to genuinely shift how care services are delivered so that they are coordinated around the needs of people, treating mental health, physical health and social care needs holistically. SLIC is governed by a federation of the leading commissioning and provider organisations across Southwark and Lambeth. This includes the two local authorities, the two local clinical commissioning groups, representation from local medical committees, three foundation trusts (encompassing acute and community services and physical and mental health), as well as the King’s Health Partners and Guy’s and St Thomas’ Charity. In practice SLIC has fulfilled two main functions: it provides a neutral space where partners come together to work through the difficult practical challenges associated with leading system transformation; and it supports the rapid testing and implementation of specific interventions aimed at improving the value of care received by the frail and elderly. Work to date has built an ever deepening shared understanding of the issues, a commitment to action, and an understanding of the options to reduce avoidable emergency admissions, speed up delays in discharge, improve mental and physical health liaison, and reduce admissions to residential care. To make fundamental changes in the care system, King’s will need to work closely with commissioners and partners to transform how care is commissioned, paid for and provided. This work will: Identify if and how health and social care budgets are brought together to fund services for specified segments of the population; Recommend different financial mechanisms and incentives to help providers focus on preventing avoidable activity and providing care in the right place at the right time; and Establish ways in which the various providers can come together across the full value-chain, either in formal or virtual organisations and networks, to manage contracts and sub-contracts for the provision of coordinated care. This type of transformation is well aligned with the Call to Action endorsed by NHS England, Monitor and the CQC. However, it is widely recognised that such a transformation will require a fundamental change in the way that resources, including people, buildings and infrastructure, are utilised within the whole health economy. Patient information Brochures All King’s patient information, produced to support consent, follows a set template to ensure that all necessary information is included and that it is written in jargon-free English. Braille versions are available on request, as are translations for those patients whose first language is not English. Brochures are available in printed formats, on the hospital intranet for use by staff and on the external website for download by patients and carers. Following the integration of Princess Royal University Hospital (PRUH) in Oct 2013, we began the process of replacing the online patient information system at PRUH, Orpington Hospital, Beckenham Beacon and Queen Mary’s Hospital with that of King’s. Working with staff at the sites we have been able to update a significant quantity of the brochures and will look to complete this task by the end of 2015. Key achievements During the year we developed the Maternity Records and Maternity Care Books to be given our ladies expecting babies at King’s. Maternity Records would combine all documentation acquired during the stages of pregnancy into one publication. This would avoid loose sheets, different titled booklets and scraps of paper and allow notes to be written and added when required. It would be light, robust and durable as it needs to be carried by mums and act as a reference to their journey to the birth of their baby. The Maternity Care Book aims to help 93 Expectant mums make the right choices before, during and after their pregnancy – for them and their baby. Both books are widely used and have been very well received. They replace and enhance Department of Health booklets which had been phased out. Websites King’s is committed to providing online information that is accessible to the widest possible audience, regardless of technology or ability, including disabled people, people with visual impairments and those with motor and cognitive disabilities. The King’s website conforms to the World Wide Web Consortium (W3C) Web Content Accessibility Guidelines 2.0 at the AA standard, making it more user friendly for everyone. Enhanced quality governance reporting The Quality Account on pages 103-190 outlines King’s quality priorities and processes for monitoring progress in achieving them. In addition King’s Board of Directors has regard for Monitor’s Quality Governance Framework, principally through the work of the Quality and Governance Committee and its reporting committees which focus on the three dimensions of quality: patient outcomes, patient safety and patient experience. The reporting structures and processes for the governance of quality are well embedded across the Trust. These processes operate across the organisation to ensure that patient outcomes, patient and organisational safety and patient experience King’s is integrated within an existing and established quality governance monitoring framework and robust performance management infrastructure. 94 The Board of Directors continues to receive a monthly performance report and performance scorecard which provides up to date information on key quality indicators and highlighting current quality and safety issues and action being taken. A suite of other reports are received on a quarterly basis including a comprehensive integrated quality and governance report. This report includes updates on quality priorities and driving improvement across the quality dimension. The Quality & Governance Committee reviews the adequacy of and progress against action plans. More information about the Quality and Governance Committee can be found on page 72. Further detail about King’s quality governance processes can be found in the Annual Governance Statement within the annual accounts on pages 195-203. A Representative Membership A strategy for membership development is incorporated within King’s Engagement and Experience Strategy. It outlines the approach to ensuring that it has a membership reflective of local communities, how the membership is involved in the work of King’s and how King’s can make a difference in the local community. King’s membership is split into three constituencies: public, patient and staff. Public membership - anyone who is 16 years old or over and lives within the London Boroughs of Lambeth, Southwark, Bromley or Lewisham is entitled to become a public member. Patient membership - anyone who is 16 years old or over and lives outside the four boroughs but has been a patient of King’s in the last six years, or has been the carer of a patient of King’s in the last six years, is entitled to become a patient member. Staff membership - All staff that have employment contracts lasting more than 12 months are automatically opted into membership. They have the option to opt out should they wish to. King’s Volunteers and full time employees of King’s contractors are also eligible to become members, though they have to opt in to become a member. In 2013/2014, in accordance with the revised membership development strategy, a target of maintaining a patient and public membership of between 9,800 and 11,100 members was set. King’s currently has 11,065 Patient and Public Members and 10,966 staff members. This totals as 22,031 Members across King’s. King’s continues to work hard to ensure that its membership is representative of the local community, and takes steps to ensure that membership is accessible to all who are eligible, irrespective of age, gender, race or social background. Demographics of the membership are monitored using the King’s membership database and any gaps can be addressed with targeted recruitment. King’s has focused on building Membership engagement during the period. An involved membership A number of initiatives were undertaken to involve members with activities at King’s. Regular publication of @King's magazine to update members on news and events, as well as opportunities to get more involved, along with notification of all Council of Governor activities; Programme of Member Health talks on public health and how services are structured and delivered across both acute sites at the DH and PRUH; Member’s E-Bulletin is sent once a month. This contains information about upcoming Health Talks, involvement events and opportunities and information from HealthWatch partners. A Members Survey was conducted over the summer, 89% of respondents were satisfied with their level of involvement with King’s; The Trust held two community events for members to share the Trust’s strategic plans for the future with the membership and to give them an opportunity to share their views with King’s. One was held at Denmark Hill and one in Bromley. 158 members attended the two events. The Annual Public Meeting again proved popular with over 140 members and around 50 members of staff and the public attending. The evening began with health checks including Blood Pressure, Glucose and BMI and an opportunity to look at information stands. After the formal part Members were invited to attend 3 different health information seminars on the topics of Ophthalmology, Dentistry and Orthopaedics. Members have continued to play a role in improving the patient food service. For the last four years members have taken part in daily food service audits on our wards at Denmark Hill and talked to 95 96 patients about all aspects of the food service. Patient Led Assessments of the Care Environment (PLACE). PLACE is a collaboration between staff and patient/member assessors, with patients/members making make up at least 50 per cent of the assessment team. Governors, Members and Healthwatch stakeholders were also involved in this year’s PLACE assessments both at the PRUH, Denmark Hill and Orpington Hospitals. Goldfish Bowl Events are an opportunity for patients or carers to feedback to staff members that have been involved in their care about aspects that worked well or could have been improved. King’s is working with both Bromley and Lambeth Colleges to engage with younger members and the wider community. Students have also attended several of the Member health talks Members and Governors have attended Dementia training to help them gather important patient feedback on the elderly care/ dementia wards. Members and Governors have continued to help on the wards at both Denmark Hill and the PRUH helping patients, especially on the elderly wards complete feedback surveys about their experiences. King’s held its Open Day for the first time on the Princess Royal University Hospital site on Sunday 6 July 2014. Governors engaged with the public talking to them about the King’s, Membership and the role of the Governors. They also took short videos stories about people’s experiences and helped to sign up new Member’s. Over 1,500 Members, patients and members of the public attended the event. A digest of the Trust Annual Report, called the Annual Review, published in the summer; and Members’ section on the website with useful up-to-date information, news and more information on how they can get involved. Contacting the membership team If you have any queries regarding membership, please contact the membership team: Membership Office King’s College Hospital FREEPOST NAT 7343 London SE5 9BR Email: [email protected] Telephone: 020 3299 8785 IN FOCUS: ALWAYS AIMING HIGHER We have seen considerable strengthening of research and development activity at King’s College Hospital in the past year, in line with the National Institute for Health Research (NIHR) strategy and with best practice. Our goal is to contribute fully to the NIHR mission to support and conduct leading-edge research focused on the needs of patients, their families and the public. Through our research we strive to improve the quality of the patient and family experience in our services, offer opportunities to receive the latest therapies being tested in the NHS, if patients and their families wish, and improve the effectiveness and costeffectiveness of treatments we provide. Progress in offering patients the opportunity to be involved in research In the financial year 2014/15 Kings College Hospital NHS Foundation Trust recruited 12,489 patients to NIHR portfolio studies (both commercial and academic). This is a 57% increase in raw recruitment to NIHR portfolio studies during the last year. There were 232 academic portfolio studies that recruited at least one patient. Kings College Hospital NHS Foundation Trust was ranked in the top 10 performing Trusts in England for raw recruitment numbers to NIHR portfolio studies within the 2014/15 Financial Year. This improvement in performance builds on earlier progress. Kings College Hospital NHS Foundation Trust have steadily increased recruitment to NIHR Portfolio studies in the last five years – see figure – with a 290% increase in annual recruitment from 2010/11 baseline to the current 14/15 recruitment level. These studies provide excellent opportunities for our patients to be offered the best in research. Being included in the NIHR portfolio is a quality mark of research studies, as it shows they have had sound external peer review and are important to the NHS. This is also good for our staff, as it provides networks and links to the best centres in the country. The studies boost training, as trainee doctors and nurses, are exposed, first hand, to the potential therapies of tomorrow. Working with commercial partners to discover and test ways to improve care for patients and families, Kings College Hospital NHS Foundation Trust opened 75 commercial studies during 2014/15. 64 of these studies were NIHR portfolio badged. We increased our recruitment into NIHR commercial portfolio studies a total of 481 patients were recruited in 2014/15 financial year. The graph below highlights this excellent commercial recruitment performance, and the particular improvement seen in 2014/15. 97 Kings College Hospital NHS Foundation Trust also participated in 59 academic non portfolio studies (not student) and 63 student projects in the last financial year. However, a key challenge for Kings College Hospital NHS Foundation Trust for the future is to offer our patients and families the opportunity to take part in more intervention studies. These are the studies that test new treatments, such as medicines or models of care. This is critical for advancing health care. Our strategy going forward is to prioritise and strengthen our support for the NIHR portfolio intervention studies (noncommercial and commercial), and widen the opportunities for patients and families to take part, if they wish. Meeting our targets A vital component of delivering research is to ensure that studies are opened and conducted efficiently and safely. The Research Office plays a major role in 98 helping this process, advising staff and the requirements of research and helping to monitor studies. The NIHR sets targets on how quickly the Research Office has to process studies, and also how quickly investigators have to recruit the first patient. We have considerably improved how we meet NIHR targets in the last year and are now proud to be among the upper quartile of performing large trusts in England. In the latest 70 day report (Q3) Kings had improved performance from the previous quarter by 19%. Kings College Hospital has a 4 day median for obtaining NHS permissions - a regional top three performance. Progress with Patient and Public Engagement Patient and public engagement is a core part of how we wish to plan and conduct research. We would like to highlight here one of our exemplar projects – CRISP. CRISP is a Community for Research Involvement and Support for People with Parkinson’s (CRISP). It is a patient and public involvement group in line with INVOLVE, an NIHR government initiative to empower patients and the public to involve their views in research and actively take part in translating current research into treatment. Hosted at King’s College Hospital and led by Professor Ray Chaudhuri, CRISP, reviews, advises and enables “real life” research in Parkinson’s (see picture). Research Highlights The most important aspect of research is how it discovers new treatments, tests ways to improve care for patients and their families, or increases our understanding of the conditions. It is impossible to include all the aspects of our achievements in this – but below we provide some highlights. Future Developments In a time of economic constraint, research and development become even more important. If the NHS is to meet the challenges of the ageing population, the growth in chronic disease – all good challenges brought about by advances in treatment, care and health – it must improve the effectiveness and cost effectiveness of care. Only research can do this properly. Therefore, at King’s we will play our role in this, working with our partners, especially colleagues within our Academic Health Science Centre, King’s Health Partners, with local hospitals, and across King’s College London, to discover and provide the very best innovation and research to improve the health, care and wellbeing of our local population. prioritise the high quality NIHR portfolio adopted commercial and noncommercial studies, to ensure that we can provide the very best. We will foster the development of our clinical investigators and the many research nurses and support staff who contribute to these programmes. We will increase patient and public involvement in our studies, to improve the quality. We will also ensure that we have a financial model to deliver high quality research through support, grants and money awarded from the NIHR, research councils, charities, our commercial partners, the university and its partners, as well as the individual donors and philanthropists, who all do so much to improve patients and family care. PARKINSONS DISEASE King’s led the multicentre European Collaborative study (EuroInf), which was successfully completed and published. It was the first study of its kind to compare Apomorphine and Duodopa treatments for advanced Parkinson’s and their effect on non-motor symptoms of Parkinson’s. Using the same European collaboration network (EUROPAR), a study assessing prevalence and characteristics of Early Morning Offs (EMO) in Parkinson’s was completed and published, including 320 patients and 9 international centres. Clinically the team have seen their status as an International Centre of Excellence being renewed, and are now part of the Parkinson’s UK Excellence Network owing to their innovative care delivery. We will ensure that the research office, that supports our investigators and studies, provides the very best service, efficiently and effectively. We will 99 INNOVATING @KINGS – from bench to bedside REPRODUCTIVE HEALTH AND CHILDBIRTH Kings College Hospital NHS Foundation Trust is the top recruiting Trust in England in the NIHR Reproductive Health and Childbirth Specialty Group. This is predominantly due to the First Trimester cfDNA Testing Study (Clinical Implementation of Cell Free DNA Testing in Maternal Blood in the First-trimester of Pregnancy) led by Professor Kypros Nicolaides which has recruited a total of 6,265 patients in the 2014/215 financial year. MALIGNANT HAEMATOLOGY The King’s haematology research unit has played a major part in the evaluation of new treatments for chronic lymphocytic leukaemia (CLL), the commonest blood cancer in the western world. Over the last 3 years a total of 28 patients have been recruited to these studies with impressive results (e.g.: N Engl J Med. 2014;371:213–223). Many of the patients entered into these studies had failed multiple lines of treatment and would otherwise have had a very poor prognosis. Kings were recently the first site outside of the US to recruit to a phase 2 study of ACP 196, a novel Bruton’s tyrosine kinase inhibitor and are currently the highest recruiters in Europe to this trial. CLINICAL RESEARCH FACILITY Our fully functional Clinical Research Facility (CRF) provides considerable improvements in how we offer treatment related studies to patients and perform investigations. The Clinical Research Facility supports over 100 studies. It has highly specialised equipment and projects range from mental health disorders to diabetes. 100 WORLD FIRST PROJECTS We have opened several world first projects. For example our new trial OPTCARE Neuro. This NIHR funded trial is a unique collaboration between neurology and palliative care services, to test the early palliative care integrated with neurology for patients. The Cicely Saunders Institute of King’s College London and King’s College Hospital is leading this 5 centre study involving King’s, Nottingham, Cardiff, Liverpool, Brighton. INNOVATING @KINGS – from bench to bedside BETTER QUALITY OF LIFE, EVEN IN THE FACE OF RESPIRATORY DISEASE King’s College Hospital NHS Foundation Trust pioneered a new Breathlessness Support Service (BSS). Refractory breathlessness is found in many conditions, such as respiratory disease, heart failure and cancer, is very distressing and often causes hospital admission. The service was developed collaborating between palliative care, respiratory medicine, physiotherapy and occupational therapy. It aimed to give patients with severe refractory breathlessness a single point of contact where their breathlessness could be assessed and supported. The BSS was evaluated in a randomised controlled trial recruiting 105 local patients, with funding won from NIHR, and published in The Lancet Respiratory Medicine (2014;2(12):97987). The BSS significantly improved quality of life, in particular mastery of breathlessness, and significantly improved survival for those who received it, compared to best standard care. Importantly, the research also found that the BSS did not increase overall costs to the NHS, social services or patients and families. Expansion of a unique research team working across many acute specialties – critical care, anaesthetics, injuries and accidents and trauma. The research team are currently supporting an increased portfolio of 34 studies - both academic and commercial. Extended research staff cover (from 8am8pm) has resulted in increased recruitment, particularly to complex, time critical studies. Since July 2014, 42% of recruitment to Crash 3 and Halt It studies has come through extended research cover to 8pm. King’s is In an ideal position to take advantage of the current £60million investment in critical care which will result in Kings having the most ICU beds in the UK 101 INNOVATING @KINGS – from bench to bedside INVESTIGATING THE BEST WAY TO MAKE TRIED AND TESTED TREATMENTS AND SERVICES ROUTINELY AVAILABLE The NIHR supports the South London Collaboration for Leadership in Applied Research and Care (CLAHRC), for which we are the host lead Trust. The CLAHRC aids many clinical areas, as it aims to help translate and implement the best research findings into practice. The new Professor of Implementation Science, Professor Nick Sevdalis, has now joined us and the CLAHRC has established a centre for implementation science. Many projects are underway across South London including: diabetes care, stroke, palliative care, infection, maternal and women’s health, alcohol and public health (http://www.clahrcsouthlondon.nihr.ac.uk/). The CLAHRC is holding open meetings so that local people can influence the research, as well as working with commissioners of services. 102 DIABETES Diabetes Research at King’s College Hospital was honoured this year by being awarded 3 of the named lectureships at the annual Diabetes UK conference – the Mary McKinnon Lecture was given by Carol Gayle and Khalida Ismail representing 3 Dimensions of Care for Diabetes (3DFD), an innovative programme harnessing medical, mental health and social support to improve diabetes outcomes. The Arnold Bloom lecture was given by Mike Edmonds, talking about new treatments for diabetic foot disease and the Dorothy Hogdkin Lecture was given by Peter Jones, a collaborator of our human islet transplantation for intractable hypoglycaemia programme. The year also saw the conclusion of the NIHR Programme Grant “Non-pharmacological interventions to improve diabetes outcomes”, including the highly successful piloting of a new intervention to reduce severe hypoglycaemia risk in the most vulnerable patients; completion of a detailed metabolic phenotyping of recently diagnosed type 2 diabetes in the Black West African population of South London, and the start of a new collaboration around both islet transplantation and diabesity with Dresden and Rome. The group published over 20 papers in 2014 from established work in hypoglycaemia avoidance, to use of technologies in glucose sensing and insulin delivery, diabetic foot disease and the new work in metabolic surgery. Quality Account King’s College Hospital NHS Foundation Trust Quality Account 2013/14 Presented as part of the “Annual Report and Accounts 2014-2015” to Parliament pursuant to the Health Act 2009 and supporting regulations, e.g. the National Health Service (Quality Accounts) Regulations 2010 and Amendments Regulations 2011, 2012 and 2013. Part 1: Statement on quality from the chief executive of the NHS Foundation Trust King’s continues to put quality and safety at the forefront of everything that we do. Our values are deeply embedded in our culture and we will ensure they remain so. Over the last 18 months, we have asked staff at all our sites, through various surveys and listening events, what they think about working at King’s. One of the things staff told us was that they want to see us promote positive behaviours and performance. So now, we are taking the next step by introducing ‘My Promise’: aspirational examples of how we want everyone at King’s to genuinely live our values. My Promise is linked to the King's Values, and guides us when we have to consider the feelings of others and use our judgement to make difficult decisions. As an organisation which continues to develop and grow we do not underestimate the ongoing pressure on our staff and aiming for high staff engagement and compassionate leadership as everyday business will be an integral part of our Trust strategy We do not under-estimate the continued challenges associated with our acquisition of parts of the former South London Healthcare Trust and the financial status of our organisation. Acquisition and integration work continues and we have demonstrable success stories. In April this year, we had our planned CQC inspection and the organisation rose to the challenge and initial comments from inspectors praised our warmth and welcome. The next year will be challenging but if we continue to work together as well as we have done over the last 12 months, I am confident that we will achieve the necessary changes and continue to improve the quality of care across the boroughs we serve. Quality Priorities Our stakeholder engagement around the setting of quality priorities this year has been carried out across two patient catchment areas; we have had discussions with key stakeholders representing Bromley in addition to Lambeth and Southwark, to reflect our presence at the PRUH and other new sites. In 2013/14 we chose 6 very ambitious quality priorities. Decreasing our number of inpatient falls was achieved and whilst we have seen improvements in the remaining 5 areas, 12 months has not been long enough to see the amount of improvement we would like so we will be continuing with 5 of last year’s priorities Our quality priorities for 2015/16, as devised and agreed with local stakeholder groups include: Maximising King’s contribution towards preventing disease e.g. smoking and alcohol Improving the care of patients with hip fracture Improving experience and coordination of discharge Improving the experience of cancer patients Medication Safety Safer Surgery There are a number of inherent limitations in the preparation of Quality Accounts which may affect 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 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 have 107 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. We further recognise that there are limitations around our data sets around referral to treatment targets and diagnostic waits and these were highlighted as part of the external audit findings but also in an earlier review we commissioned or internal auditors to carry out. There were some stark revelations about our data tracking and the evidence we maintain and the we now have plans to redress these. The Trust was recently granted a reporting holiday so it can address its data issues and the accuracy of the information in its systems. Our governors also chose 6-week diagnostics waits as the Trust was an outlier to be tested as part of the external audit review. It has since become evident that there are some ongoing training requirements to address what are very simple clerical errors which impact the validity our data keeping. The Trust and its Board 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 with the exception of the matters identified in respect of the 18-week referral to treatment incomplete pathway. 108 Structure of this report The following report summarises our performance and improvements against the quality priorities and objectives we set ourselves for 2014-2015. It also outlines those we have agreed for the coming year (20152016). The Trust acquired the new sites and services on 01 October 2013 and we are not able to fully consolidate all data due to ongoing Information technology developments therefore PRUH and Denmark Hill site data are included separately where appropriate. We have outlined our quality priorities and objectives for 2015-2016 under the same headings: patient safety, clinical effectiveness and patient experience. We have detailed how we decided upon the priorities and objectives and how we will achieve and measure our performance against them. The regulated Statements of Assurance are included in this part of the report. We have also provided other information to review our overall quality performance against key national priorities and national key standards. This includes the 2014/15 requirement to report against a core set of indicators relevant to the services we provide; using a standardised statement set out in the NHS (Quality Accounts) Amendment Regulations 2013. We have also published the Statements from Clinical Commissioning Groups, NHS England, Health Overview and Scrutiny Committees, and Healthwatch that outline their response to this Quality Account. Having had due regard for the contents of this statement to the best of my knowledge, the information contained in the following Quality Account is accurate. To the best of my knowledge, the information contained in the following Quality Account is accurate. Signed: Roland Sinker Acting Chief Executive Date: 26 May 2015 109 Part 2: Priorities for improvement and statements of assurance from the Board Our 2014/15 Quality Priorities and Objectives Patient Experience Clinical Effectiveness The table below summaries the six priorities for quality improvements the Trust focused on in 2014/15. These priorities were ratified by the Board of Directors in February 2014 our Board of Directors reflecting on the comments and feedback we had from our governors, stakeholders and employees. 110 Priority Key Objectives (Outline) Measure 1. Working to reduce preventable ill-health Increase assessment of patients to identify whether they want help with reducing the likelihood of harm caused through smoking and alcohol. Increase the number of staff trained to provide brief interventions for smoking and alcohol. Increase the number of referrals for specialist smoking and alcohol support. Increase the number of smoking ‘quitters’. Identify opportunities to promote exercise and healthy eating. Outcome/ Process 2. Improve outcomes of patients following hip fracture Improve pain relief. Reduce time before surgery. Increase physiotherapy to help people recover sooner. Reduce length of stay in hospital. Increase the number of patients who are discharged to their own home. Increase the % of patients who have a bone health and falls assessment, and thereby reduce the likelihood that patients will fall and incur further injury in the future. Outcome/ Process 3. Improving experience and coordination of discharge: elderly, renal and surgery Reduction in ‘unsafe’ discharges as reported by primary care, community and social work colleagues. Improvement on 2013-14 discharge audit results (elderly care, surgery and renal). Positive qualitative feedback from stakeholders and users. Increase of 5 points in ‘How are we doing?’ survey combined scores for questions relating to discharge and reduction in comments about the discharge process. Better experience for elderly and vulnerable patients with timely discharges and more seamless transfers and cross agency working. Outcome/ Process RAG Priority Key Objectives (Outline) Patients and their families receiving better information and explanations in regard, to the discharge process, medications and any ongoing concerns they may have. Process/ Outcome Increase the number of clinicians who have undertaken the National Advanced Communication Course across the organisation. Ensure patient have a Holistic Needs Assessment (HNA) undertaken. Patients are receiving appropriate information at the right time. More patients having improved access to the trust e.g. Cancer Helpline. Provide education for ward nurses to improve their understanding of cancer patients’ needs. 5. Improving the identification and management of patients at risk of falling in hospital Reduction in falls with moderate and major to <3 per month. Reduction in falls by age band. Appropriately assessed pre fall. Process/ Outcome 6. Safer surgery Zero never events. Effective use of surgical checklist. Completion & situational awareness. Process/ Outcome 4. Improving the experience of cancer patients Patient Safety Measure 14/15 PRIORITY 1: RAG Working to reduce preventable ill-health What we aimed to do Increase assessment of patients to identify whether they want help with reducing the likelihood of harm caused through smoking and alcohol What we achieved Over 80% of patients are screened for smoking and harmful alcohol use, and then given evidence-based brief advice and interventions, in the acute surgical and medical units plus other key wards at Denmark Hill (DH) and the Princess Royal University Hospital (PRUH), and this is being rolled out to our maternity services. Increase the number of staff trained to provide brief interventions for smoking and alcohol. Over 230 clinical and support staff have been trained in how to offer very brief advice and onward referral to smoking cessation and referrals for smoking cessation have tripled in the first 3 quarters of this year compared to 2013/14. Increase the number of referrals for specialist smoking and alcohol support. The Denmark Hill site went 100% smoke-free on 12 January with PRUH set to follow suit shortly. 111 Increase the number of smoking ‘quitters’. Identify opportunities to promote exercise and health eating. 14/15 PRIORITY 2: improve outcomes of patients following hip fracture What we aimed to do Improve pain relief. 112 We have worked with the providers of the hospitals’ food to ensure that menus are healthy and they have explained to us how they are reducing salt, have eradicated the use of trans fats and are providing improved information to support patients and staff in making healthier choices. Reduce time before surgery. Increase physiotherapy to help people recover sooner. Reduce the length of stay in hospital. Increase the number of patients who are discharged to their own home. Increase the proportion of patients who have a bone health and falls assessment, and thereby reduce the likelihood that patients will fall and incur further injury in the future. What we achieved The key improvement actions for 2014-15 have been on the Denmark Hill site, and: More people are having their surgery within 36 hours of arriving at hospital. Post-operative pain relief has improved. Average time to discharge home from the orthopaedic ward is 3 days shorter. All our patients get a falls assessment. 96% of people are getting geriatric assessments within 72 hours. Denmark Hill’s performance in achieving all 9 nationally-identified criteria of best practice has improved significantly in the past year: Q1: 28.3% Q2: 40.63% Q3: 45.65% Areas in which there is still work to do include: Physiotherapy support. Further improve time to surgery. Improve along the entire care pathway at both of our acute hospital sites, DH and PRUH. 14/15 PRIORITY 3: Improving experience and coordination of discharge: All elderly care wards, renal inpatient wards and surgical wards What we aimed to do Increase of 5 points for ‘How are we doing?’ combined scores for questions relating to discharge and reduction in negative comments about the discharge process. What we achieved DENMARK HILL SITE How are we doing evaluation: 113 To support further improvement in patient experience we also: Piloted a day after discharge telephone call The scripts for the first 6 months have now been analysed and the data will be used to feedback to staff and action plan for further improvements. The following questions are asked: How are you feeling since you left hospital yesterday? Did we give you any medication to take home with you? Are you experiencing any problems at all? Is there anything I can explain about your medication? Do you have a follow-up appointment with us in outpatients? Are you happy that you know when the appointment is? If you have any further questions over the next few days do you know who to contact? Is there anything else you would like to ask me at all? 114 Did you find this conversation useful? Was it helpful being called after you were discharged home? Thematic analysis demonstrated that the majority of patient’s had a good experience in hospital and appreciated the phone calls. An example of one ward, Mathew Whiting (orthopaedics), results are below: Safer and better experience for elderly and vulnerable patients with timely discharges and more seamless transfers and cross-agency working measured by decrease in quality alerts/adverse incidents. Responses and queries contribute to overarching themes providing the ward managers areas to develop and improve with staff when planning discharge and providing information to patients: Use of supporting agencies Hospital to Home volunteer service: This is a new service launched over the last year over specific wards initially but service is expanding as more volunteers are recruited and trained. The Hospital to Home service has now performed; 115 140 community visits to patients post-discharge Assisted 51 unique patients Made over 250 phone calls to patients post-discharge Whilst the Hospital to Home scheme is predominantly a befriending service, our volunteers have helped patients do the following with many other things. For example, helping with rent arrears, arranging appointments with other services in addition to onward referrals to other agencies such as SAIL and stroke care The Home Hamper Scheme is a volunteer-led initiative to provide small food parcels to patients discharged from hospital. This service will receive referrals for any patient identified as having a need by ward staff, particularly targeting those who are vulnerable either due to age, social isolation or homelessness. All food has been charitably donated and this service is cost-neutral to the Trust. Medihome Increasing usage with associated increase in saved bed days and good engagement from our quality account wards 116 Homeless team A Multi-Disciplinary team based across KCH and GSTT, with a SLaM service launching in January 2015. At KCH, a needs assessment was completed in December 2013 and the service was launched in January 2014. We have had just over 500 referrals in one year, with 183 of these referrals coming from A&E/CDU. Discharge coordination for this group of patients is often complex but the team have helped to manage this and avoid unnecessary readmission. Many had extremely complex immigration status. The team have helped to register patients with GPs, engage with primary care (including nursing clinics) and held a number of network meetings around frequent attenders at A&E, as well as assisting with housing interventions and linking people with social care, legal aid and the voluntary sector. A new transfer of care programme has been established on the Denmark Hill site to enhance the discharge process and patient experience in relation to hospital discharges. Part of the programme is building better 117 communications and relationships with community partners- in this respect a Safer Faster Compassionate Discharge event was held in November which was very well attended by hospital staff and community partners. In addition work progressing to enhance the information provided to staff about discharge partners and processes which includes updating Kings web and ward based resource folders. Governance Community services are based within our partner trust Guys and St. Thomas’s and historically there was no robust governance system to ensure incident reports around discharge were being investigated and learnt from effectively KCH and GSTT partners have now agreed: GSTT to develop a clear way for identifying and collating all discharge adverse incidents (AIs) supported by the GSTT governance team. These AIs will then be passed to a central point at KCH who will put these onto the KCH AI system (as appropriate). These AIs will then be processed through the normal governance channels for investigation. On a monthly basis a report will be supplied examining lessons learned, themes and actions which can be shared with GSTT. The same report will also be used to highlight and action themes at the Out of Hospital meeting. Patients and their families receiving better information and explanations about the discharge process, medications and any ongoing concerns they may have. Discharge coordinators and the MDT ensuring that they are entering discharge planning information on to the discharge summary for complex patients. This provides valuable information to GP’s patients, their carers and families. Launch of the ‘Leaving Hospital’ discharge leaflet in January 2015 which is mandatory to be provided for all patients being discharged. The leaflet provides valuable information about who to contact if they have any issues or concerns including: their estimated date of discharge, how to prepare for leaving the hospital, information about their medications, equipment and social services contacts. Launch of Medicines Information for Patients service: This is a web-based subscription service which provides bespoke information leaflets on medicines in easily-understandable language. It is available to all staff. 118 Improvements in discharge audit results. For 2014/15, we will use the same tool to be able to see improvement but will plan to improve the audit tool to give more detail going forward. Initial audits were conducted between February and May of 2014- targeting elderly care, renal and surgery. These audits demonstrated the need to improve compliance with use of the discharge checklist, providing information to patients and GP’s about their discharge plans, and ensuring the community received the right referrals. Wards have action plans and have had support to improve the quality of discharge planning for patients, under 5 key headings: Discharge checklist, discharge summaries, Leaflets/written information, transfer letters/referral letters, verbal/written communication. Repeat audits demonstrate improvements: SURGERY: Significant improvement in the issuing of patient leaflets with regard to their conditions and treatment. Significant improvement in the staff educating patients and providing written information regarding their medications. Improvement in the use of the discharge checklist- but this will require further action plans . *Of note many patients in the data set did not require a district nurse or use of the wound care plan 119 Significant improvement in the utilization of the discharge checklist- * note none of the patients audited required the complex discharge checklist to be completed Significant improvement in the issuing of patient leaflets with regard to their conditions and treatment Significant improvement in the staff educating patients and providing written information regarding their medications RENAL In addition to this work there has been continued effort to make day after discharge phone calls to patients which although not recognized in this audit tool- further enhances the discharge experience for patients leaving your wards 120 HEALTHCARE OF THE AGING UNITS (DENMARK HILL) Improvement in the evidence that patients were being given leaflets with regards to their treatment and conditions. Improvement in the evidence that there was a discussion and/or written information given to patients regarding their medications. Needs to be further action planning regarding the use of the discharge checklist as usage has declined rather than improved. 121 PRINCESS ROYAL UNIVERSITY HOSPITAL SITE Discharge improvements remain a high priority at the PRUH. there are many work streams associated with improvements. Early audit information carried out via the Commit 2 Care programme has highlighted that the majority of wards are flagging as RED. The approach to this audit is to look at written evidence from the Nursing and Medical Notes, also set patient questions around their involvement with planning discharge and behind involved in the decision to discharge. The introduction of Medihome in December has had little impact on the wards due to capacity of the team and the criteria of patients’ needs further work. The number of discharge co-ordinators within the PRUH site has now increased and currently in a transition phase in which a clear role definition is being worked up. 122 14/15 PRIORITY 4: Improving the experience of cancer patients What we aimed to do Patients continue to highlight a number of areas where we need to make improvements including: How we communicate; Lack of access to key staff such as the Clinical Nurse Specialist and Doctors; The information that we provide regarding any proposed clinical care and the support available; Involving patients in decisions about their care and ensuring that they understand their care plan; and Lack of confidence and trust in ward nursing staff. What we achieved 30 clinical staff (Consultants, AHPs and CNSs) undertook the National advanced communication skills training. A Full time welfare advice service solely for cancer patients commenced across both sites in November. The Macmillan Information centre attained the maximum excellent quality rating in the Macmillan Quality Environment inspection in January. The number of patients supported via the Macmillan Information Centre continued to increase ( increase of 78% since 2012 with 575 attendances in Nov 2014). The Trust’s cancer helpline (9-5 Mon – Fri service) was used more extensively and roll out to the PRUH site commenced following the introduction of PIMs at the PRUH. >30 % increase in the number of HNAs undertaken by the CNS teams, with designated HNA clinics undertaken weekly at the Macmillan Information Centre. A series of semi-structured interviews were undertaken as part of a listening in action exercise. Further areas for improvement were identified and actions implemented. Patient information leaflets were revamped. An annual programme of internal peer review for each MDT was commenced with MDTs being held to account for the patient experience. A review and improvement of the oral chemotherapy patient pathway was undertaken with all patients now having chemo nurse review and support. 123 14/15 PRIORITY 5: Reducing the number of falls in hospital for patients What we aimed to do Reduce the number of inpatient falls Review the falls risk assessment documentation to ensure it is fit for purpose and that the same approach to falls risk is consistent across sites Make falls prevention training mandatory for all nursing staff. Progress in recruitment process of a pool of staff who will be available to provide immediate 1:1 care to patients who are deemed at high risk of falls. Develop falls metrics (such as injurious patient falls per 1000 bed days by age range, patient falls by ward by month) to enable tracking of performance at Trust, Divisional and ward level. Review the root causes of moderate and serious patient falls at the Safer Care Forum to identify common themes and develop safety improvements. What we achieved Rate of falls per 1000 bed days has reduced at DH & PRUH from 5.3 and 6.7 (Oct-Dec 13) to 4.8 and 5.7 (Oct-Dec 14) respectively. Patient falls with moderate harm (or above) reduced from 36 to 25 (DH) and increased from 35 to 40 (PRUH). The reduction in falls cross-site occurred against an increase in activity and patient acuity. In 2014, there were 289 fewer patient falls at DH and 160 fewer patient falls at PRUH compared to 2013. “Specials” team to assist with 1:1 nursing at DH - phase 2 recruitment underway (phase 3 to be completed by April 15). “Specials” risk assessment developed and currently being piloted. RN nursing levels reviewed & increased cross-site. Safer Care Forum is used effectively to triangulate safety data and identify areas where improvement work can be done, for example, medical wards have a multi-disciplinary working group to look at fundamentals of dignified care to decrease falls and toileting related harms – impact not available until mid-2015. Training: Improved falls prevention training rates amongst nursing staff through continued face-to-face training by Falls Team, promotion of e-learning training and development of an e-learning “app”. Falls training is ,mandatory and percentage of staff trained has gone from March 2014 – 78% to March 2015 – 86%. Improving Documentation: Reviewed and updated inpatient nursing documentation and now have consistent use of falls risk assessments. Leadership & Engagement: Extending Executive Nursing leadership & engagement to additional wards in 2015/16. Improve patient engagement through rollout of Falls Passport across sites. Benchmark Performance: Benchmarked KCH performance against comparable Trusts according to Shelford methodology. Rollout of ward accreditation scheme (Commit to Care) at DH 124 14/15 PRIORITY 6: Safer Surgery What we aimed to do Increase assessment of patients to identify and develop a standard operating procedure for SSC use at King’s. Develop an audit tool and audit programme to assess the quality of SSC use across all surgical environments. Audit effectiveness of policy revisions from 13/14 and compliance. Ensure all relevant policies and procedures are in date or reviewed. What we achieved Draft policy currently being discussed by the Safer Surgery Improvement Group (SSIG) with a view to publication in April 2015. Annual full site audit was completed July – Sept 2014. A request has been submitted for funding for 4 KCL students to undertake the audit again in Summer 2015. A Theatre Audit Nurse has also been appointed by CCTD and she is undertaking regular audit. The anonymous survey has is also being re-done across all sites including all interventional areas. The SSIG meeting has now been expanded to include the PRUH, Orpington and QMS sites. A PRUH Surgical Safety Lead has been identified. Both the surgical count and surgical site marking policy have been reviewed and revised in response to incidents via the Safer Surgery Improvement Group. Audits have covered both the quantitative (completion of checklist) and qualitative (quality of checks) components of the use of the SSC. Improve the standard of completion of SSC. Empower staff need to challenge SSC noncompliance. Implement learning from Root Cause Analysis of never events in 13/14 Video indicating support from Medical Director and Chief Nurse shown at theatre mornings and Mortality meetings. Surgical Safety Screen saver and Poster Campaign. Memo from the Medical Director and Director of Nursing to all staff. Training re: Never Events and reporting incidents occurs regularly at theatre audit mornings. Conduct monthly audits of SSC compliance (as per audit tool and programme above) and publish results on monthly divisional scorecards. Action plans from the Never Events continue to be reviewed on a monthly basis at the SSIG. Where Trust wide pre-emptive action in other areas/specialties is identified, the group oversees actions in relation to this. This learning was also shared with KHP colleagues at a Safety Connections Conference. Extend audit tool for evaluation of pre-operative process (which has been successfully trialed in vascular surgery) to other surgical specialties. It has not been possible to include the qualitative compliance audit data in the divisional scorecards yet. Resources to undertake monthly surveillance of each interventional area to be identified. Develop a surgical safety website on Kwiki. A pre-assessment working group has been set up, led by Divisional Manager for CCTD to standardise and improve our pre-operative assessment processes. 125 Continue to monitor surgical specialty compliance with SSC via presentation at the Safer Surgery Improvement Group. Develop an electronic SSC on the theatre system (Galaxy) ready for pilot by the March 2015. Surgical Safety Website has been established. It includes links to relevant policies and learning from local never events. There is a monthly schedule for specialty feedback. This has been re-prioritised based on findings from the 2014 SSC Audit. There has been no further progress on the development of an electronic SSC. Work on standardising the approach to SSC on all sites has been prioritised. Once standardised across multi-site specialties, then electronic options will be re-visited. 126 Our 2015/16 Quality Priorities and Objectives This section of the Quality Report summarises our patient safety, clinical effectiveness and patient experience objectives for 2015/16, how these were developed, and how these will be achieved and measured. The six priorities for quality improvements the Trust will take forward in 2015/16 are outlined below. These priorities were ratified by the Board of Directors in February 2015. The Trust takes a holistic approach to developing its quality priorities and accordingly the Board ensures it reflects on the comments and feedback our governors, stakeholders and employees. In a busy acute hospital like King’s, there are always several quality improvements going on at any given time. The wider range of improvements to patient care happening across King’s will not stop or slow down, but we have honed a clear set of priority objectives. These act like a set of promises that everyone at King’s commits to meet or exceed this year. From our various consultations, we know they are clear and meaningful to you as our key stakeholders. We would like you to support our agenda for continuously improving our high quality patient care and to hold us to account. The process for developing priorities involved collaborating and communicating with our stakeholders in the following ways. A long-list of priorities were identified with the executive chairs and leads of each of the committees which focus on the three dimensions of quality, namely Patient Safety, Patient Outcomes and Patient Experience. External stakeholders’ perspectives were collected in prioritising the long list of potential areas for improving patient safety, clinical effectiveness and patient experience at the two stakeholder events. Each stakeholder was given the opportunity to comment on the draft report. We also attended the parallel discussions at our Academic Health Science Centre partners, GSTT. This has involved discussions with the patients and public who highlighted and helped select the Trust’s priorities. Frontline teams/subject matter experts were consulted about the work planned to meet these quality improvements, to shape feasible improvement objectives. The Performance Directorate was closely involved to ensure alignment with the emergent CQUIN framework. Learning from the past We have also learnt that organisation-wide quality improvements may warrant the profile and attention over a period longer than 12 months. We have therefore reflected on how we build on our success to sustain and continue improving. The diagram below summarises our quality objectives and priorities over the last four years. Reflected on our progress with the current year’s quality priorities. We reviewed this at the Board Quality and Governance Committee, as well as the Stakeholder Engagement Events in January 2015 for Lambeth, Southwark and Bromley stakeholders. 127 Patient Safety 2011/12 2012/13 2013/14 2014/15 Reduced hospital acquired infection Improve identification and escalation of acutely ill patients Management of the cutely unwell patient Reduction in falls Minimise harm acquired in the hospital Surgical Safety Checklist Surgical Safety Improve end of life care Improve outpatient experience Reducing mortality associated with alcohol and smoking Improve diabetes care Improve patient experience of discharge Improve outcomes of patients with hip fracture Improve responsiveness to inpatients personal need Dementia Improve experience of cancer patients Chronic obstructive pulmonary disease Improve experience of discharge for patients Reduce avoidable death, disability and chronic ill health from venous thromboembolism (VTE) Patient Experience Patient Outcomes Improve medication safety 128 Improve end of life care Improve diabetes care Improve the consistency of positive inpatient experience Improve cleanliness of the hospital environment Clinical Effectiveness 2015/16 Quality Priorities Priority Key Objectives (Outline) 1. Maximising King’s contribution towards preventing disease e.g. smoking and alcohol Develop KCH and PRUH as ‘health promoting hospitals’, continuing the culture change that started in 2014/15 to make health promotion mainstream. Increase assessment of patients to identify whether they want help with reducing the likelihood of harm caused through smoking and alcohol. Increase the number of staff trained to provide brief interventions for smoking and alcohol. Increase the number of referrals for specialist smoking and alcohol support. Increase the number of smoking ‘quitters’. Identify opportunities to promote exercise and healthy eating. Improve pain relief. Reduce time before surgery. Increase physiotherapy to help people recover sooner. Reduce length of stay in hospital. Increase the number of patients who are discharged to their own home. Increase the % of patients who have a bone health and falls assessment, and thereby reduce the likelihood that patients will fall and incur further injury in the future. Across all sites: Improvement on 2013-14 discharge audit results (elderly care, surgery and renal). Positive qualitative feedback from stakeholders and users. Better experience for elderly and vulnerable patients with timely discharges and more seamless transfers and cross agency working. Patients and their families receiving better information and explanations in regard to the discharge process, medications and any ongoing concerns they may have. Increase the number of clinicians who have undertaken the National Advanced Communication Course across the organisation. Ensure patient have a Holistic Needs Assessment (HNA) undertaken. Patients are receiving appropriate information at the right time. More patients having improved access to the trust e.g. Cancer Helpline. Provide education for ward nurses to improve their understanding of cancer patients’ needs. Increase reporting rate of mediation errors Reduce medication errors with high risk medications Reduce errors of wrong drug/wrong patient Ensure nursing staff are competent in medication associated calculations 2. Improving the care of patients with hip fracture Patient Experience 3. Improving experience and coordination of discharge 4. Improving the experience of cancer patients Patient Safety 5. Medication Safety 6. Safer surgery Zero never events. 100% compliance with completion of safer surgical checklist >75% compliance with quality checks performed CQ* Y N N N N N *CQ=Part of our CQUIN framework of national and locally agreed targets 129 15/16 PRIORITY 1: Working to reduce preventable ill health Preventing ill health is a key priority for the NHS and King’s made excellent progress in 2014-15 with our quality priority in this area. There is much to be done, however, and along with our stakeholders we have decided that the focus on preventing ill health should remain for a further year. We will Develop KCH and PRUH as ‘health promoting hospitals’, continuing the culture change that started in 2014/15 to make health promotion mainstream. Increase the number of staff trained to support patients in reducing smoking and harmful alcohol use; Objectives/Measures Local Incentive Premium will be agreed to support the development of KCH and the PRHU as Health Promoting Hospital The identification of patients who smoke and/or are using alcohol in a harmful way; The provision of advice to these patients; Referrals made into specialist smoking services; and The roll-out of training to staff. Increase provision of advice and brief interventions relating to smoking and harmful alcohol use; At the end of 2015-16 a greater number of our patients will have received: Advice on smoking and harmful alcohol use; and Increase referrals into smoking cessation and alcohol services; Referrals into specialist services, where this is requested. Work with the providers of hospital food, both on the wards and in our cafes, to promote and deliver healthier food; A greater number of our staff will have received the training that they need to offer evidence-based advice and brief interventions relating to smoking and harmful alcohol use. Review ways in which we can increase promotion of exercise to improve health; Continue work to implement NICE public health guidance. 130 15/16 PRIORITY 2: Improving outcomes for patients following hip fracture Hip fracture was a quality priority for 2014-15 with effort primarily focused on our Denmark Hill site. We have made significant improvements over the year but there is much that can still be achieved and, along with our stakeholders, we agreed that hip fracture should remain a quality priority for a further year. We will Increase the proportion of patients getting the surgery they need to repair their hips in under 36 hours. Objectives/Measures of success The National Hip Fracture Database collects key data from all hospitals in relation to hip fractures and will provide King’s with data that will enable us to compare our results over time, and with other hospitals. Key outcomes that we will measure include: Length of stay in hospital; Proportion of patients who are discharged to their own home; Time before surgery; Provision of physiotherapy and mobilisation; Proportion of patients who have a bone health and falls assessment; and Assessment of patients’ mental status before and after surgery. At the end of 2015-16 our patients will: Receive the specialist care that they need in hospital, including support from careof-the-elderly doctors and a faster time to surgery; Ensure that all patients receive the physiotherapy they need. Ensure effective shared care between orthopaedics and geriatrics. Increase the proportion of patients who have a geriatric assessment within 72 hours. Ensure all patients are tested for delirium before and after surgery. Ensure all patients have a falls assessment and a bone health review. Increase the proportion of our patients who have an admission anaesthetic review prior to surgery, to ensure that our patients are in the best health for surgery. Our work in 2015-16 will focus on the care pathway for hip fracture patients on both of our acute hospital sites, Denmark Hill and the PRUH. Be fitter so that they can be discharged from hospital earlier and are more likely to be going to their own home; Receive preventative advice and treatment so that they are less likely to fall in the future, or if they do fall, they are less likely to incur a serious injury. 131 15/16 PRIORITY 3: Improving experience and coordination of discharge Increased demand on our capacity urges us to ensure that our discharge coordination provides a safe and positive experience for our patients and stakeholders. Our aim would be for a more person-centred quality priority in this area, linking to the development of integrated care. We will Objectives/Measures of success Denmark Hill Optimise integrated Care a. Southwark and Lambeth Integrated Care (SLIC): Achieve integrated working in the hospital environment building better communications between all parties (internal & external) to facilitate safer patient discharge. b. SLIC: Increase and embed Care home interface meetings- group including hospital and care home managers to enable effective admission and discharge communications. c. Potential reduction in the number of bed day delays attributable to our local social services authorities reported via the Delayed Transfer of Care to the Department of Health. Improvement in the quality of discharge planning information in the discharge notification. Improvement in the utilization of the Trust discharge checklist as per policyenhancing the quality of the discharge. Choice policy and IHDT working - consistent process for managing and explaining the process of care home placement to patients and relatives- measured by reduction in the number of 'family choice' delays on the DTOC report. All discharged patients to have ‘Leaving Hospital’ leaflet to ensure improved communication with patients and their carers regarding the process for discharge and setting an expected date of discharge. Integration of LA social workers- Improved flow of information regarding previous community services for clients plus LA SW carrying case load on ward- promoting efficient working practices- measured by SLIC data- potential reduction in section 2/5 process and LOS. Potential reduction in the number of bed day delays attributable to our local social Continue to increase usage and profile of Homeless team. d. Increased usage of @Home service across all specialties. 132 We will Objectives/Measures of success services authorities reported via the Delayed Transfer of Care to the Department of Health. Positive feedback from our care home colleagues. Demonstrable progress of an effective pathway between identified healthcare and aging units (HAUs) and specified care homes. Positive feedback from our care home colleagues regarding transfer of care between inpatients, the Emergency Department (including CDU) and care homes. Demonstrable progress of an effective pathway between identified HAU wards and specified care homes – evidence that effective documentation including clinical advice, advance care planning and DNAR information is sent to and from care homes to hospital. Evidence of increased uptake of advance care plan documents including the local PEACE document in care homes and evidence that this is associated with reduction in admissions of people who are on a palliative trajectory/ end of life. Reduced number of missed referrals in ED. Shared expertise and improved information sharing to assist with complex discharge – evidenced by case studies. Providing a seamless service for homeless patients from acute to community setting for rough sleepers and hostel dwellers. A reduction in the number of bed days attributable to medically fit for discharge. Increase in the numbers of patients being referred and accepted to @Home service- to capacity of 80 (overall per week)- measured by @Home data 133 We will @Home service used to capacity and challenged during winter periods- ensuring that’s medically stable patients have early discharge- measured by @Home data LAS pilot- ensure that this is considered as a business case and long term service provision for @Home- ensuring admission avoidance where possible- measured by GSTT community services Report monthly numbers of Medicines Information for Patients leaflets offered to patients. b. Commit to Care ward accreditation system discharge indicators to be green across the organisation. Develop and conduct quarterly surveys of patients’ experiences with their medicines while in hospital. c. Telephone follow up calls to embedded and routine in all appropriate in patient wards areas (50% in first 6/12 up to 85% by year end). Evidence of improvements initiatives based on themes arising from calls. Evidence through audit of care home discharge bundle that care homes are receiving follow up calls and key issues identified and addressed as appropriate. Improvements in Patient Experience surveys re discharge. 95% generated and sent as evidenced by EPR audit. Improve safety and experience for our patients a. Improve timeliness and quality of information around medications for patients and carers. d. Ensure all in patient wards have individual actions plans to improve discharge, share good practice and innovative ideas. e. Ensure all patients who have received care from a therapist has a detailed discharge summary sent to GP. Increase the number of discharges before 11:00 Ensure a robust referral system to external agencies, Bromley Health and Medihome Implement criteria led discharge throughout medicine and surgery 134 Objectives/Measures of success PRUH All inpatient wards with the exception of specialist areas will have a daily target of 2 patients before 10.00 monitoring of this will take place within the bed meeting. Results will be feedback to ward areas at the end of the month. A measure of success might lead to increased capacity in the AM of a shift rather than currently after 17.00. This will be reviewed after 6 months with the aim of monthly targets set on differing wards. A reduction in number of bed days attributable to medically fit for discharge patients. Increased awareness of external services to help discharge the patient safely shifting the care back to the community. Criteria led discharge will be implemented to ensure discharge number s of the We will Commit to Care ward accreditation system discharge indicators to be green across the organisation Telephone follow up calls to embedded and routine in all appropriate in patient wards areas(50% in first 6/12 up to 85% by year end) 15/16 PRIORITY 4: Objectives/Measures of success weekend improve. Initially it will focus on medical specialities. Patients will be able to be discharged by either a nurse, doctor or therapist if they achieve their set parameters over the weekend. Rather than waiting for the consulting team to review on a Monday. The admitting team for a nominated individual to review will set parameters. As stated. However the indicator criteria will be reviewed mid-year to ensure that we are monitoring the essential criteria or any new pilots such as telephone follow ups or criteria led discharge. Evidence of improvement initiatives based on themes arising from calls. Ward need to keep a log of telephone calls made. Improving the experience of cancer patients Since 2010, Kings has consistently featured in the bottom 10 of Trusts in England for the cancer patient experience. More recently, there has been some improvement, but it is clear that we still have a long way to go in order to align the patient experience with our excellent clinical care and outcomes for cancer patients. Patients continue to highlight a number of areas where we need to make improvements including: How we communicate Lack of access to key staff such as the Clinical Nurse Specialist and Doctors The information that we provide regarding any proposed clinical care and the support available Involving patients in decisions about their care and ensuring that they understand their care plan; Lack of confidence and trust in ward nursing staff We will Ensure that all the core MDT members (doctors and CNSs) are trained in national advanced communication skills training Objectives/Measures of success KPIs will be developed for the CNS teams, and progress against these and the quality metrics below will be assessed at bi-monthly meetings with the CNS teams and their DHons/HoNs. 135 We will Ensure that all patients are seen by the CNS/support worker at diagnosis Increase the number of holistic needs assessments undertaken within 31 days of diagnosis and within 6 weeks of completion of treatment Ensure all patients receive a FU call from the CNS teams within 48 hours of diagnosis, and within 24 hours of discharge from hospital following treatment Ensure that the CNS teams to review in-patients at least once during their in-patient stay in order to provide further information and support Ensure patients and GPs are provided with an end of treatment summary / care plan Establish health and well-being events for patients (for example HOPE courses) Undertake specialist training for nurses and HCAs on the in-patient wards Work with Macmillan to develop the band 4 support worker role in each MDT – an innovative role aimed at helping patients to navigate through their pathways and to provide ‘one to one support’ Introduce designated nurse led pre-assessment clinics for patients commencing chemotherapy treatment Continue with the rolling annual internal peer review of each MDT – holding teams to account for progress being made against their patient experience action plans 136 Objectives/Measures of success MDTs will be held to account for progress being made against their patient experience action plans and in the achievement of the metrics below at the bimonthly Trust cancer patient experience steering group and Trust cancer committee meetings MDTs will be held to account at the Trust’s annual internal peer review meetings Analysis of the NCPES results for 2015 & 2016 (due to the time lag of the survey process, demonstrable improvements are unlikely to be realised until 2016). Analysis of the LCA commissioning metrics & COSD datasets by the Trust cancer management team At the end of 2015-16 there will be: Improvement in the 2016 National Cancer Patient Experience Survey. 100% of all core MDT Doctors and CNSs to be trained in Advanced Communication Skills 100% patients to have a CNS present at / immediately after diagnosis 100% patients to receive a phone call FU within 48 hours of their cancer diagnosis 50% increase in the number of Holistic needs assessments being undertaken within 31 days of diagnosis and within 6 weeks of completion of treatment 100% patients commencing chemotherapy to receive a designated nurse led preassessment and ‘new patient talk’ 100% patients to receive FU phone support within 24 hours post discharge from surgery /in-patient admission (related to their cancer) 70% patients to be reviewed at least once by a CNS during an in-patient stay 50% of patients to receive an end of treatment care plan 30% of patients to attend health & well-being support events upon completion of treatment Designated cancer information “hub” to be established at the PRUH Chartwell Unit, and Macmillan Information pods to be placed around the PRUH hospital CNS teams to undertake bi-monthly teaching on the relevant in-patient wards Psycho-social support for cancer patients to be formalised at the PRUH – Palliative Care Social Worker to undertake weekly sessions at the PRUH, and introduce IAPT services We will Objectives/Measures of success Develop a designated cancer information hub in the PRUH Chartwell unit and work with Macmillan to ensure that information pods are available in key areas throughout the PRUH Successful partnership working with Macmillan with investment to pursue 3 key themes of work – cancer patient experience, survivorship and care closer to home. Improvements in all 3 of these areas is key to improving the overall patient experience. Establish a Trust cancer patient experience steering group Develop KPIs for the CNS teams which aid to hold the teams to account for quality improvements 137 15/16 PRIORITY 5: Surgical Safety Culture This is one of our priorities for this year and, although good progress has been made we would like to continue to have as strong focus in this key safety area with the aim of building this year's work to achieve the following: We will To develop and implement a strategy to ensure the Surgical Safety Checklist (SSC) is integrated into the working practices of all theatre/interventional teams. 15/16 PRIORITY 6: Objectives/Measures of success Zero Surgical Never Events 100% compliance with completion of safer surgical checklist >75% compliance with quality of checks performed. 20% improvement in Surgical Safety Culture rating Medication Safety The Trust does not seem to have any significant concerns with medication safety however there have been some ‘no harm’ errors, particularly in paediatrics, involving calculation and strength of drugs. In view of this and ongoing high operational demand and patent acuity we would like to ensure that we work to prevent medication adverse incidents. We will Objectives/Measures of success Proposed implementation of the ‘rule of one’ on Paediatric wards Reduction in incidents involving 10-fold errors as a barrier to erroneous tenfold administration. Reduction in incidents involving administration of drugs to patients with known Incorporation of observational patient identification audit into allergies audit tools to monitor positive patient identification and target areas of non-compliance. Increase in % of nursing staff passing the drug calculation competency assessment at 100% Continue rollout of EPMA to ED and implement e-systems in Critical Care to reduce chance of drug administration to patients Reduction in the number of medication errors involving the wrong patient. with documented allergies. Review drug calculation competency testing regime for nurses. 138 Statements of assurance from the Board cases required by the terms of that audit or enquiry. Information on the review of services During the reporting period 2014/15 the King’s provided and/or sub-contracted 9 relevant health services. The NCEPOD studies the Trust participated in are detailed on page 146. King’s has reviewed all the data available to them on the quality of care in all these relevant health services. The reports of 42 national clinical audit were reviewed by the provider in 2014/15 and King’s intends to take actions to improve the quality of healthcare provided in the actions detailed on pages 147-165. The income generated by the relevant health services reviewed in the reporting period 2014/15 represents 100% of the total income generated from the provision of relevant health services by the Trust for the reporting period 2014/15. In addition, an extensive programme of local audits were reviewed by the provider in 2014/15 and King’s intends to take the following actions to improve the quality of healthcare provided in the descriptions detailed on pages166-168. Participation in Clinical Audits and National Confidential Enquiries During the reporting period 2014/15, 46 national clinical audits and 4 national confidential enquires covered relevant health services that the King’s provides. Information on participation in clinical research The number of patients receiving relevant health services provided or sub-contracted by Kings in 2014/15 that were recruited during that period to participate in research approved by a research ethic committee was 12,489. During that period King’s participated in 100% national clinical audits and 100% national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in. More information on King’s research activity can be found in the Annual Report on pages 97-102. The national clinical audits and national confidential enquiries that King’s was eligible to participate in during 2014/15 are listed on pages 142-146. The national clinical audits and national confidential enquires that King’s participated (with data collection completed) during 2014/15 can be found on pages 142-146 The national clinical audits and national confidential enquires that King’s participated in and for which data collection was completed during 2014/1 are listed on pages 142-146 alongside the number of registered Goals Agreed with Commissioners: The Commissioning for Quality and Innovation (CQUIN) framework A proportion (2.4%) of King’s income in 2014/15 was was conditional on achieving quality improvement and innovation goals agreed between King’s and both NHS South London Commissioning leads & NHS England as part of the Commissioning for Quality and Innovation (CQUIN) payment framework. This equated to a total of £17.5m in 2014/15. Please see the tables on pages 165-166 for the detailed report of performance as measured for our CQUIN indicators in 2014/15 for King’s. King’s has delivered significant quality improvements under the 139 CQUIN schemes as shown on pages 168171. Quality Account and Local Incentive Premiums (LIPs) Providers and commissioners come together to agree the detail of local priorities and how they will be achieved and measured. A series of milestones and targets are agreed in advance and each provider is required to submit evidence to commissioners at regular intervals in order to secure the funding associated with them For 2015/16 King’s had the option to either select the ‘Enhanced Tariff Option’ under the proposed 2015/16 National Tariff payment system; or to select the ‘Default Tariff Rollover’ which is a continuation of the arrangements for 14/15. King’s selected the Default Tariff and as a consequence CQUIN schemes are no longer applicable. Therefore, King’s has agreed with its Commissioners the implementation of four Local Incentive Premium initiatives for the 2015/16 in place of local CQUIN schemes and are listed below: • Local Incentive Premium Scheme 1 Medicines Optimisation (DH) • Local Incentive Premium Scheme 2 - Care Planning (DH) • Local Incentive Premium Scheme 3 – Prevention - Every Contact Counts (DH and PRUH) • Local Incentive Premium Scheme 4 – Emergency Care (PRUH). Statements from the Care Quality Commission (CQC) King’s is required to register with the Care Quality Commission (CQC) and its registration status as at 31 March 2015 is without any condition for all locations. The CQC has not taken enforcement action against King’s during the period 01 April 2014 – 31 March 2015. 140 The Trust has not participated in any special reviews or investigations by the CQC during the reporting period. The Trust continues to make improvements to availability of medical records and the Emergency Department and emergency medical pathway at the PRUH to improve quality of care in line with compliance actions issued following the CQC inspection at the PRUH in December 2013. The CQC carried out a planned Trust-wide inspection from 13 to 17 April 2015. Initial high-level feedback highlighted an open and transparent culture across the organisation as well as areas of excellence. The CQC also fed back on areas for improvement which were all known to the Trust. Actions are currently being taken to address these issues. A formal report will be published twelve weeks after the inspection. Clinical coding error rate King’s was subject to the annual mandatory Coding Audit for Information Governance Standards during the 2014/15 financial year. There were 12 specialty audits completed during this period, both by external and internal accredited coding auditors across all sites and a total of 511 episodes were audited across 12 specialties. In the last year, King’s has continued the established external audit programme focusing on specific areas. There is also a regular process of validation of abstracted data for coding between clinical staff and coder. During 2014/15 the overall Information Governance Audit coding inaccuracy rate was 5.7% and is lower than the national 7.0% average error rate, as identified in the Payment by Results Assurance Framework 2011/12 (the last year at which accuracy of inpatient coding was tested at all NHS Acute Trusts) The Trust maintains a robust audit and training cycle allowing early identification of error and subsequent revision of the coded clinical data prior to final submission to the Secondary Uses Service (SUS). Information Governance Toolkit attainment levels King’s Information Governance Assessment Report overall score for 2014/15 was 73% and was graded green (satisfactory). This is higher than the previous year. There are twelve areas where our scores have either improved to either level 2 or 3 on their previous score. Information Governance awareness and mandatory training procedures are in place and all staff are appropriately trained. A formal information security risk assessment and management programme for key Information Assets has been documented implemented and reviewed. Business continuity plans are up to date and tested for all critical information assets (data processing facilities, communications services and data) and service - specific measures are in place. All information assets that hold, or are, personal data are protected by appropriate organisational and technical measures. Procedures are in place for monitoring the availability of paper health/care records and tracing missing records. The Trust has achieved a satisfactory score in all areas (80% level 2, 20% level 3 – the highest possible level). Twelve areas improved on last year’s scores and there was one additional area. This demonstrates our commitment to developing a high quality and robust approach to Information Governance. As a result of having responsibility for the IG Toolkit sitting with a single permanent IG Manager, the process of completion has been even more rigorous than in previous years. In summary all areas achieved a satisfactory score: 80% of areas were level two 20% of areas were level three Improvement in 12 areas plus reporting on one new area Payment by Results (PbR) King’s was not identified as necessary for a Payment by Results (PbR) clinical coding audit in 2014/15, however for Trusts that were subjected to PbR audit in 2014/15, the national average coding error rate identified in the Data Assurance Framework was 8% for inpatients. From the above statements, assurance can be offered to the public that the Trust has in 2014/15: Performed to essential standards (e.g. meeting CQC registration), as well as excelling beyond these to provide high quality care; Measured clinical processes and performance to inform and monitor continuous quality improvement; Participated in national cross-cutting project and initiatives for quality improvement e.g. strong and growing recruitment to clinical trials. These statements are included in accordance with both Monitor’s NHS Foundation Trust Annual Reporting Manual (December 2013) for the quality report, as well as the Department of Health’s Quality Accounts Regulations (2013, 2012, 2011, 2010). 141 Statements of Assurance Evidence Participation in Clinical Audits and National Confidential Enquiries The following list is based on that produced by the Department of Health and Healthcare Quality Improvement Partnership (HQIP). NB: Data for the PRUH is not available for several audits during this period, as it was still part of the South London Healthcare Trust at the time of the data collection. 142 Audit Title Reporting period Participation DH PRUH Acute Yes Yes Adult Community Acquired Pneumonia 01/12/14 31/01/15 ICNARC Case Mix Programme - General Intensive Care Unit ICNARC Case Mix Programme - Liver Intensive Therapy Unit (LITU) National Emergency Laparotomy Audit – Clinical Audit 01/04/14 – 31/03/15 Yes Yes 01/04/14 – 31/03/15 Yes N/A DH = 100%. PRUH - service not provided. 07/01/14 – 30/11/14 Yes Yes National Joint Registry 01/04/14 31/03/15 Yes Yes Pleural Procedures 01/06/14 – 31/07/14 Yes Yes Not available at time of report participation rate included in annual report, due to be published Jul-15. Not available at time of report data collection closes 31 March 2015. DH = 20 patients and PRUH = 11 patients. Trauma Audit and Research Network, TARN 01/01/14 – 31/12/14 Yes Yes Audit of Transfusion Practice in Children and Adults with Sickle Cell Disease 01/01/14 – 30/06/14 Bowel Cancer 01/04/13 – 31/03/14 Head and Neck Oncology N/A Blood and Transplant Yes N/A Cancer Yes Yes N/A N/A % of cases submitted Not available at time of report data collection closes 31 May 2015. DH and PRUH = 100%. DH = 94.2%. PRUH - data collection started 1 January 2015. Not available at time of report data collection closes 31 March 2015. PRUH - not eligible to participate due to small patient numbers. Not available at time of report data collection closes 27 March 2015. King’s - service not provided. Service centralised at Guy's and Audit Title Reporting period Participation DH PRUH Lung Cancer 01/01/14 – 31/12/14 Yes Yes Oesophago-gastric Cancer 01/04/13 – 31/03/14 Yes Yes Prostate Cancer - Clinical Audit 01/04/14 – 31/07/14 Yes Yes Prostate Cancer Organisational Audit 31/10/13 – 29/11/13 Yes Yes Acute Coronary Syndrome or Acute Myocardial Infarction (MINAP) Cardiac Rhythm Management 01/04/14 – 31/03/15 Heart Yes Yes 01/04/14 – 31/03/15 Yes Yes Congenital Heart Disease 01/04/14 – 31/03/15 Yes N/A ICNARC National Cardiac Arrest Audit National Adult Cardiac Surgery Audit 01/04/14 – 31/03/15 01/04/14 – 31/03/15 Yes Yes Yes N/A National Audit of Percutaneous Coronary Interventional Procedures 01/01/14 – 31/12/14 Yes N/A National Heart Failure Audit 01/04/14 – 31/03/15 Yes Yes National Vascular Registry – abdominal aortic aneurysm repairs 01/01/10 – 31/12/14 Yes N/A National Vascular Registry – Carotid Endarterectomy 01/01/12 – 31/12/14 Yes N/A Pulmonary Hypertension Audit N/A N/A N/A Chronic Kidney Disease in Primary Care N/A Long-term Conditions N/A NA % of cases submitted St Thomas' NHS Foundation Trust. (GSTT). Not available at time of report data collection closes 30 June 2015. Not available at time of report data collection closes 27 March 2015. Not available at time of report data collection closes 6 March 2015. King’s = 100%. Not available at time of report data collection closes 31 May 2015. Not available at time of report data collection closes 30 June 2015. Not available at time of report data collection closes 4 May 2015. PRUH - service not provided. DH and PRUH = 100%. Not available at time of report data collection closes 30 June 2015. PRUH - service not provided. Not available at time of report data collection closes 31 March 2015. PRUH - service not provided. Not available at time of report data collection closes 1 June 2015. Not available at time of report data collection closes 25 March 2015. PRUH - service not provided. Not available at time of report data collection closes 25 March 2015. PRUH - service not provided. King’s - service not provided. Audit not applicable to secondary care providers. 143 144 Audit Title Reporting period Participation DH PRUH Yes Yes % of cases submitted Inflammatory Bowel Disease – Biologics Audit 01/03/14 – 28/02/15 National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme – COPD Clinical Audit National COPD Audit Programme – COPD Organisational Audit National COPD Audit Programme – Pulmonary Rehabilitation Service Clinical Audit National COPD Audit Programme – Pulmonary Rehabilitation Service Organisational Audit National Diabetes Adult 01/02/14 – 30/04/14 Yes Yes 01/02/14 – 30/04/14 Yes Yes DH and PRUH = 100%. 12/01/15 – 10/04/15 Yes N/A Not available at time of report data collection closes 10 July 2015. 12/01/15 – 10/04/15 Yes N/A Not available at time of report data collection closes 24 April 2015. Yes N/A Not available at time of report data collection closes 20 March 2015 and 30 June 2015. PRUH - diabetes outpatient service not provided. National Diabetes Footcare Audit 2013/14: 01/01/13 – 01/03/14 2014/15: 01/01/14 – 31/03/15 14/07/2015 onwards Yes N/A National Paediatric Diabetes Audit 01/04/14– 31/03/15 Yes Yes Pregnancy Care in Women with Diabetes 01/01/14 – 31/12/14 Yes N/A Renal Registry 01/01/14 – 31/12/14 Yes Yes Rheumatoid and Early Inflammatory Arthritis – Clinical Audit and Organisational Audit 01/02/14 – 30/01/15 Yes Yes Not available at time of report data collection closes 31 July 2015. PRUH - diabetes footcare service not provided. 2014/15 Not available at time of report - data collection starts 1 April 2015. Not available at time of report data collection closes 12 February 2015. PRUH - pregnant women with diabetes are managed by Bromley Health Care. Not available at time of report data collection closes 1 July 2015. Not available at time of report data collection closes 30 April 2015. Mental Health (Care in Emergency Departments) 01/01/14 – 31/12/14 Mental Health Yes Yes Not available at time of report data collection closes 28 February 2015. DH = 48 patients and PRUH = 90 patients. Not available at time of report participation rate included in annual report, due to be Audit Title Reporting period Participation DH PRUH % of cases submitted Mental Health Clinical Outcome Review Programme: National Confidential Inquiry into Suicide and Homicide for people with Mental Illness Prescribing Observatory for Mental Health N/A N/A N/A N/A N/A N/A King’s - service not provided. National Audit of Dementia N/A N/A N/A National Hip Fracture Database 01/01/14 – 31/12/14 Yes Yes Older People (Care in Emergency Departments) 01/08/14 31/01/15 Yes Yes Sentinel Stroke National Audit Programme (SSNAP) Clinical Audit SSNAP – Organisational Audit British Society for Clinical Neurophysiology (BSCN) and Association of Neurophysiological Scientists (ANS) Standards for Ulnar Neuropathy at Elbow (UNE) testing National Audit of Intermediate Care National PROMs Programme 01/07/14 – 30/09/14 Yes Yes 26/06/14 – 18/07/14 01/04/14 – 01/05/14 Yes Yes National audit did not collect data 2014/15. Not available at time of report participation rate included in annual report, due to be published Sep-15. Not available at time of report participation rate included in annual report, due to be published May 2015. Quarterly reports produced. DH and PRUH HASU = 80-89%. DH and PRUH SU = 90%+. DH and PRUH = 100%. Yes N/A Not available at time of report participation rate included in annual report, due to be published Mar-15. PRUH – service not provided. N/A N/A N/A King’s - service not provided. 01/01/13 – 31/12/14 Yes Yes published June 2015. King’s - service not provided. The recommendations produced by the study are, however, reviewed for relevance to the Trust. Older people Fitting Child (Care in the Emergency Department) Epilepsy 12 – Clinical Audit Epilepsy 12 – Organisational Audit Women’s and children’s services 01/08/14 Yes Yes 31/01/15 01/01/13 – 30/04/13 01/01/14 Yes Yes Not available at time of report participation rate included in annual report, due to be published May 2015. DH = 92% and PRUH = 100%. Yes Yes DH and PRUH = 100%. 145 Audit Title Reporting period Participation DH PRUH Yes Yes % of cases submitted Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE-UK) National Neonatal Audit Programme Continuous 01/01/14 – 31/12/14 Yes Yes 01/01/12 – 31/12/14 Yes N/A Not available at time of report data collection closes 2 March 2015. Not available at time of report data collection closes 31 March 2015. PRUH - service not provided. Paediatric Intensive Care Audit Network DH and PRUH = 100%. NCEPOD Studies: NCEPOD Title Reporting period Participation DH PRUH Acute Yes Yes Sepsis 06/05/14 – 20/05/14 Gastrointestinal Haemorrhage 01/01/13 – 30/04/13 Yes Yes Lower Limb Amputation 01/10/12 – 31/03/13 Yes N/A* Tracheostomy Care 25/02/13 – 12/05/13 Yes N/A* % of cases submitted Clinical Questionnaire returned = 10/10 (100%) Case notes returned = 70% (7/10) Organisational questionnaire returned = 100% (3/3) Clinical Questionnaire returned = 100% (7/7) Case notes returned = 86% (6/7) Organisational questionnaire returned = 100% (1/1) Clinical Questionnaire returned = 33% (2/6) Case notes returned = 100% (6/6) Organisational questionnaire returned = 100% (1/1) Clinical Questionnaire returned: Insertion = 83% (40/48) Critical care = 73% (35/48) Ward care = 83% (40/48) Case notes returned = 8% (4/48) Organisational questionnaire returned = 100% (1/1) * Studies completed prior to PRUH integration into KCH – participation details not available. 146 National clinical audit reports were reviewed by the Trust and actions to improve the quality of healthcare: Key Rating Definition * + - One of the highest performing Trusts nationally e.g. ranked within top 5 nationally. King’s performance is similar to or above the national average for 67 – 100% of audit standards. King’s performance is similar to or above the national average for 66 – 34% of audit standards/ within expected range. King’s performance is similar to or above the national average for 0 – 33% of audit standards. N/A Not applicable – national average comparable data not available. = Audit Title Headline Results and/or actions taken Rating DH ICNARC Case Mix Programme - General Intensive Care Unit (ICU) Published: August 2014 Audit Period: 01/04/12-31/03/13 Sample Size: DH: 100% (1,903 patients) PRUH: 100% (423 patients) ICNARC Case Mix Programme - General Intensive Care Unit (ICU) Acute ICNARC confidential comparison of general ICUs identified DH mortality ratio within expected range and PRUH mortality ratio at control limits, based on 2012-13 data. PRUH = = = = Hospital mortality - ICNARC website, based on 2012-13 data Upon integration of PRUH into KCH, improvement actions were put into place, led by the Clinical Director for Critical Care and closely monitored by the Mortality Monitoring Committee. The ICNARC confidential comparison of general ICUs shows that DH and PRUH mortality ratios are within expected range. Published: January 2015 Audit Period: 01/04/13 – 31/03/2014 Sample Size: DH: 100% (2011 patients) PRUH: 100% (454 patients) The absolute standardised mortality number for the PRUH has gone down and remains within control limits. DH and PRUH are within expected range for unit-acquired MRSA and unit-acquired infection in blood and, even though DH has one of the highest number of patients, it has very low numbers of infections. DH and PRUH performance is within expected range for hospital mortality where risk of death is less 147 Audit Title Headline Results and/or actions taken Rating DH PRUH than 20% and hospital mortality where risk of death is greater than or equal to 20%. ICNARC Case Mix Programme - Liver Intensive Therapy Unit (LITU) Published: January 2015 Audit Period: 01/07/14 – 31/09/14 Sample Size: DH: 100% PRUH: Service not provided National Emergency Laparotomy Audit - organisational audit Published: May 2014 Audit period: 01/06/13-31/10/13 Sample Size: DH: 100% (1/1) PRUH: 100% (1/1) National Joint Registry Published: September 2014 Audit Period: 01/04/13-31/03/14 Sample Size: DH: 365 procedures PRUH: 141 procedures Orpington: 76 procedures (Oct13 to Dec-13 only) Case Ascertainment: King’s: 110% Paracetamol overdose Published: January 2015 148 The ICNARC confidential comparison of general ICUs shows that DH has an elevated mortality ratio within Liver. A formal response by ICNARC states that there is not a concern with the mortality ratio, that the increase is likely due to chance variation and that the risk prediction model may not perform as accurately with King’s specialist casemix. An internal mortality review is, however, planned within the Specialty to provide additional assurance that there are no quality of care issues. = N/A + = * + = + Current DH mortality performance for the period Jul-14 to Sep-14 DH performed better than all other London peer Trusts. PRUH had mixed results for this audit which is in line with the national picture. The audit data is currently under detailed review and an action plan will be developed across sites. DH, PRUH and Orpington are within expected range for 90 day mortality following hip and knee replacement and for hip and knee revision rate. King’s is one of five London Trusts awarded the Orthopaedic CQUIN for complex hip and knee surgery and revision of hip and knee surgery by NHS England. This is in part due to King’s performance in the NJR. DH performed in line with or above the national average for 4/5 measures. DH achieved the CEM standard of 100% for patients receiving N-acetylcysteine (NAC) within 8 hours of ingestion. DH Audit Title Headline Results and/or actions taken Rating DH Audit Period: 01/08/13 - 31/03/14 Sample Size: DH: 100% (50 patients) PRUH: 98% (49 patients) PRUH was below the national average for attaining the Medicines and Healthcare Products Regulatory Agency (MHRA) recommended treatment for paracetamol overdose. PRUH performed in line with or above the national average for 5/5 measures. PRUH performed in the upper quartile nationally for patients receiving NAC within 1 hour of arrival and for staggered overdoses receiving NAC within 1 hour of arrival. The data is currently under review by the clinical team at DH and PRUH and a detailed improvement plan is being developed. Pleural Procedures Published: October 2014 Audit Period: 01/06/14 - 31/07/14 Sample Size: DH: 20 patients PRUH: 11 patients Severe Sepsis and Septic Shock Published: September 2014 Audit Period: 01/08/13 - 31/03/14 Sample Size: DH: 100% (50 patients) PRUH: 86% (43 patients) DH performed in line with or above the national average for 6/11 audit criteria and performance is similar to or better than previous (2011) for 7/8 criteria re-audited. PRUH performed in line with or above the national average for 7/11 criteria. The data is under review by the Division and a trust-wide action plan is in development. = = DH performance is above the national average for the majority of criteria audited. + - Action in progress at DH to improve practice includes the implementation of ‘Sepsis: A Toolkit for Emergency Departments’, jointly developed by the College of Emergency Medicine and the UK Sepsis Trust. Performance at PRUH is below the national average for the majority of audit criteria. Improvements in practice have, however, been made for 7/11 criteria re-audited. Actions already taken at PRUH to improve practice include the implementation of the Adult Sepsis Management flowchart; the implementation of Symphony and PiMS, which include mandatory fields for vital signs; and the implementation of a sepsis box (currently in pilot phase). To improve practice further serum lactate measurement, blood pressure monitoring and urine output measurement will all be included in the junior doctor training going forwards. 149 Audit Title Headline Results and/or actions taken Rating DH TARN - Online Survival Data Published: Data available on-line (17/02/15) TARN data demonstrates that more trauma patients admitted to DH are surviving compared to number expected based on severity of injury. PRUH + N/A = N/A = = TARN data submission at the PRUH will start Q4, 2014/15. Actions taken to enable PRUH participation include the recruitment of two posts at PRUH allocated responsibility for TARN submission, training provided by TARN, local training provided by Data Systems Manager and roll out of Symphony and PiMS at PRUH. Current DH survival data for the period Jan-11 to Dec-14 Current DH survival data for the period 2013/14 and 2011/12 TARN - Major Trauma Dashboard Published: August 2014 Audit Period: 01/04/14 - 31/06/14 Sample Size: DH: Data not provided by TARN PRUH: PRUH is not a Major Trauma Centre Patient Information and Consent Published: November 2014 Audit Period: 13/01/14 – 04/04/14 Sample Size: 150 TARN data demonstrates mixed results for DH against the Major Trauma dashboard criteria compared to the national average. Areas for improvement include the proportion of patients: Transferred to MTC within 2 days of referral request With GCS<9 with definitive airway management within 30 minutes of arrival in ED Directly admitted patients receiving CT scan within 30 minutes of arrival at MTC With an ISS of more than 8 that have a rehabilitation prescription completed The monthly Trauma Performance meeting and Trauma Board review TARN data, review areas of below average performance, monitor performance against actions set for both DH and PRUH and co-ordinate a joint action plan to ensure successful data submission across sites. Blood and Transplant DH performed in line with or above the national average for 17/ 31 criteria and PRUH performed in line with or above the national average for 12/31 criteria. The key areas for improvement across all sites are: Audit Title Headline Results and/or actions taken Rating DH Clinical case notes audit: DH: 17 patients PRUH: 10 patients Patient survey: DH: 13 patients PRUH: 10 patients Staff survey: DH: 6 staff members PRUH: 4 staff members National Bowel Cancer Audit Published: December 2014 Audit Period: 01/04/12 - 31/03/13 Sample Size: DH: 116% (128 patients) PRUH: The audit report has published SLHT data only; data for PRUH has not been made available. PRUH Indication for transfusion documented Recorded patient unable to give consent Documented NHSBT leaflet given Documented reason for transfusion explained. Cancer DH performed in line with or above the national average for 10/15 criteria and in line with or better than previous (2011-12) for 10/15 criteria. As a result of actions implemented following the 2013 report, ‘CT scan reported’ has improved from 72.5% to 100% and ‘MRI scan reported’ has improved from 63% to 100%. = N/A + N/A + N/A The adjusted 90 day unplanned admission rate at DH is lower than all 6 London peer trusts and the adjusted 2 year mortality rate is the second lowest compared to all 13 peer trusts nationally. Areas for improvement: Length of stay > 5 days remains above the national average at DH (80.9% vs. 69.1%). National Lung Cancer Audit Report Published: December 2014 Audit Period: Patients first seen 01/01/11 31/12/13 (3 data items) Patients first seen 01/01/13 – 31/12/13 (11 data items) Sample Size: DH: 120% (114 patients) PRUH: The audit report has published SLHT data only; data for PRUH has not been made available. National Oesophago-Gastric The data is currently under review by the clinical team at DH and PRUH and a detailed improvement plan is being developed. DH achieved a rating of ‘good’ for 8/12 key process, nursing, imaging and clinical measures assessed by the audit, and a rating of ‘good’ for 11/12 key data completeness measures. DH performed in line with or above the national average for 9/12 criteria and in line with or better than previous performance (2013) for 7/10 re-audited criteria. Measures identified for improvement include patients receiving CT before bronchoscopy and NSCLC having surgery. The data is currently under review by the clinical team at DH and PRUH and a detailed improvement plan is being developed. Two additional items identified from the national audit data for improvement include PS0-1 Stage IIIB or IV NSCLC having chemotherapy and small cell receiving chemotherapy. The national audit reports data covering 2011-13 for these items and an additional review of the 2013 data only, extracted locally from the LUCADA system, demonstrates that improvements have already been made at DH for both items. Both PRUH and DH patients are referred to GSTT for all surgical 151 Audit Title Headline Results and/or actions taken Rating DH Cancer Audit Published: November 2014 Audit Period: 01/04/11 - 31/03/13 Sample Size: DH: >90% (78 patients) PRUH: The audit report has published SLHT data only; data for PRUH has not been made available. Myocardial Ischaemia National Audit Project (MINAP) Published: December 2014 Audit Period: 01/04/13 – 31/03/14 Sample Size: DH: 957 patients PRUH: 81 patients Cardiac Rhythm Management Published: December 2014 Audit Period: 01/04/13 – 30/06/14 Sample Size: DH: 100% (457 patients) PRUH: 100% (135 patients) Congenital Heart Disease 152 PRUH procedures relevant to this audit. Outcome measures are reported for GSTT, while DH-specific data is reported for tumour data completeness and case ascertainment only, both of which achieved a rating of ‘good’. GSTT achieved the joint lowest 30-day mortality of the 46 trusts in the audit, and the second lowest 90-day mortality of peer trusts. GSTT also recorded the third lowest adjusted complication rate amongst national and London peer trusts. Heart DH, which is a Heart Attack Centre, performed at or above the national average for 6/17 audit criteria of best practice. = = + + + N/A = N/A PRUH performed in line with or above the national average for 3/8 criteria (7 criteria applied to Heart Attack Centres only); 2 criteria not applicable. DH was below the national average for door-to-balloon time and call-to-balloon times. DH and PRUH performance against the criteria for secondary medication has decreased compared to the previous audit (2012/13) and is below the national average. The national audit does not currently provide patient outcomes or quality of care performance data and the British Heart Rhythm Society (BHRS) confirms that the numbers provided in the report cannot be taken as evidence of competence or ability to provide a safe, high quality service. King’s (DH and PRUH) undertakes in excess of the minimum numbers of cardiac implants expected by BHRS and NICE and is therefore not identified as an outlier. No mortality reported at 30 days post procedure or at 1 year. Published: April 2014 Audit period: 01/04/2012 – 31/03/2013 Sample Size: DH: 27 cases PRUH: Service not provided. National Audit of Percutaneous Coronary Interventional Procedures Data completeness has improved, or remains, at 100% for 13/15 (86%) mandatory data fields. Published: January 2015 Audit Period: 01/01/13 -31/12/13 Sample Size: DH: 1386 procedures The call-to-balloon time <150 minutes for direct admissions is below the national average, but similar to the national target of 79%, whilst for patients transferred in is both below the national average and the national target. DH performs better than the national average and exceeds the national target for door to balloon time in <90 minutes for direct admissions and patients transferred in from another hospital. Audit Title Headline Results and/or actions taken Rating DH PRUH: Service not provided. National Audit of Percutaneous Coronary Interventional Procedures Published: January 2014 Audit period: 01/01/12-31/12/12 Sample Size: DH: 1216 cases PRUH: Service not provided. ICNARC National Cardiac Arrest Audit Published: July 2014 Audit Period: 01/04/13-31/03/14 Sample Size: DH: 100% (148 patients) PRUH: Did not participate in 2013-14 audit period PRUH DH performed at or better than previous for all criteria reaudited. Following the implementation of actions in 2012, performance against all criteria relating to door-to-balloon time and call-to-balloon time has improved from below 90% to over 90% for all criteria, and exceeds the national target of 75%. Callto-balloon time <150 minutes (transfers in) has improved from 51% in 2011 to 90.5% in 2012. + N/A DH performed in line with or above the national average for: 13/16 criteria (81%) assessing reason resuscitation stopped (Alive – RSOC>20 minutes). 12/16 criteria (74%) assessing survival to hospital discharge. 13/16 criteria (81%) assessing favourable neurological outcome. = N/A The data shows that DH performed within expected range for survival. Denmark Hill Shockable Non-shockable Denmark Hill Actions to improve further are reported to and monitored by the 153 Audit Title Headline Results and/or actions taken Rating DH Inflammatory Bowel Disease (IBD) – Adult – Organisational Audit Published: September 2014 Audit period: 31/12/2013 Sample Size: DH: 100% (1/1) PRUH: 100% (1/1) Inflammatory Bowel Disease (IBD) – Adult – Clinical Audit Published: June 2014 Audit period: 01/01/13 - 31/12/13 Sample Size: DH adult audit: 27 patients DH patient experience: 7 patients PRUH adult audit: 17 patients PRUH patient experience: 7 patients Inflammatory Bowel Disease (IBD) –Paediatric – Organisational Audit Published: September 2014 Audit period: 31/12/2013 Sample Size: DH: 100% (1/1) PRUH: Specialist gastroenterology service not provided Inflammatory Bowel Disease (IBD) Paediatric – Clinical Audit 154 Deteriorating Patient Committee. Long Term Conditions DH adult service performed in line with the national average and London peer and has improved performance compared to previous (2010) with the implementation of a transitional care service for young people to support their transfer to adult services. PRUH = = + + = N/A = N/A To improve practice further at DH a second IBD nurse has been recruited and funding will be sought in 2015/16 for an additional IBD nurse, with a cross-site role. In addition Pharmacy will flag all patients who have not been appropriately prescribed bone protection or Heparin. PRUH adult service performed in line with the national average and has recently implemented a searchable database of adult IBD patients locally, which will further improve performance. In addition the inclusion of the IBD patient assessment on the nutritional assessment tool is under investigation. Adult in-patient care key indicator data: DH performance was similar to or above the national average for 4/7 criteria. PRUH performance was better than the national average for the majority of criteria. Adult patient experience key indicator data: DH was better than the national average for the majority of criteria, whilst PRUH performance was similar to or better than the national average for 4/7 criteria. Mortality data: None of the patients included in the DH sample died in hospital. 1 (6%) adult patient death was recorded for the PRUH. The death was not related to ulcerative colitis (national average mortality rate – adult audit = 0.8%). A detailed improvement plan has been developed that addresses the recommendations made by both the organisational and clinical audits. The national audit data shows that DH paediatric service performed in line with the national average. Actions in progress at DH include the development of the Paediatric Ulcerative Colitis Activity Index (PUCAI) assessment on EPR and participation in clinical trials. DH has applied to participate in two clinical trials, with national coverage. Paediatric inpatient care key indicator data: DH had mixed results for the audit. Audit Title Headline Results and/or actions taken Rating DH Published: June 2014 Audit period: 01/01/13 - 31/12/13 Sample Size: DH paediatric audit: 11 patients DH patient experience: 0 patients PRUH: Specialist gastroenterology service not provided National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme – Organisational Audit Published: November 2014 Audit Period: 01/02/14 – 30/04/14 Sample Size: DH: 100% PRUH: 100% National Diabetes Audit (NDA) Report Published: October 2014 Audit Period: 1/01/12 – 31/03/13 Sample Size: DH: 100% (5966 patients) PRUH: Diabetic outpatient service not provided. PRUH Mortality data: None of the patients contained in the DH sample died in hospital. A detailed improvement plan has been developed that addresses the recommendations made by both the organisational and clinical audits. DH achieved the highest organisational score compared to 15 national and London peer trusts. Out of 198 units participating nationally, DH ranked ninth best performing. PRUH achieved the same overall organisational score as the national median. Both sites achieved the highest possible domain scores for NonInvasive Ventilation and Managing Respiratory Failure and Oxygen Therapy. + = = N/A + + At the PRUH, to improve practice further an additional specialist respiratory nurse has been appointed and in-reach visits to respiratory patients in the Emergency Department and other wards is now included in the consultant job plan. In addition, COPD patients will be discussed at the existing multi-disciplinary team (MDT) meeting and the frequency of ward based specialist reviews will increase to twice daily. Performance improvements have also been driven forward at DH since the audit, with the provision of two new pulmonary rehabilitation centres in the local community. Action is also in progress regarding the implementation of electronic recordsharing with GP practices. Across all 6 NICE recommended treatment targets, DH performed 6th out of 17 national and London peer Trusts. The NDA report recommends that DH focuses its improvement strategy on HbA1c ≤58mmol/mol (7.5%), DH achieved 38.6% compared with the national average 62.2% and previous performance in 2011/12 of 43.8%. A DH action plan is in development to support further improvement. Overall, treatment targets and care processes for Lambeth and Southwark have improved since previous rounds of the audit. National Diabetes Inpatient Audit (NaDIA) Published: March 2014 Audit period: 16 – 20 Sep-13 Sample Size: Performance at DH has improved for 10/12 patient experience criteria from 2012 to 2013 and at PRUH performance has improved across the board, including in relation to medication safety and patient experience. Areas where DH appears to perform below national average 155 Audit Title Headline Results and/or actions taken Rating DH DH: 133 (100%) PRUH: 43 cases National Paediatric Diabetes Audit Published: October 2014 Audit period: 01/04/14 – 31/03/14 Sample Size: DH: 100% (135 patients) PRUH: 100% (112 patients) Pregnancy Care in Women with Diabetes (NPID) Published: October 2014 Audit Period: 01/01/2013 – 31/12/2013 Sample Size: DH: 100% (31 patients) PRUH: Service not provided by King’s (provided by Bromley Healthcare). include the number of episodes of mild hypoglycaemia and blood glucose above target range; both of these may reflect greater identification compared to other trusts due to the electronic data capture, which flags all blood results occurring outside of range. The PRUH results will improve further with new diabetes specialist staff currently being recruited. DH performance is within expected NICE target range, and similar to peer (Evelina Children’s Hospital, GSTT). PRUH performance is within the expected range and similar to London peers. Reference lines represent the upper and lower NICE HbA1c targets of 58 mmol/mol and 80 mmol/mol respectively. NICE recommends that women with diabetes take 5 milligrams (5mg) of folic acid while planning pregnancy and then up to 12 weeks gestation to reduce the risk of having a baby with a neural tube defect. 59% at DH used 5mg folic acid supplement prior to pregnancy compared with 19% in the London region and 33% nationally. NICE recommends that women with diabetes who are planning to become pregnant should aim to maintain their HbA1c below 43 mmol/mol (6.1%). 19% at DH had a first trimester HbA1c measurement below 43 mmol/mol compared with 9% in the London region and 11% nationally. NPID has defined 'adequately prepared for pregnancy' as taking folic acid (400mcg or 5mg) prior to pregnancy and having a first trimester HbA1c measurement of less than 53 mmol/mol. 44% were prepared for pregnancy at DH compared with 17% in the London region and 21% nationally. A trust-wide action plan will be developed to support further improvement and inclusion of Princess Royal University Hospital (PRUH) in the 2015 audit round. 156 PRUH = = + N/A Audit Title Headline Results and/or actions taken Rating DH Renal Registry Published: December 2014 Audit Period: 01/01/13 - 31/12/13 Sample Size: King’s: 100% (162 patients) PRUH: Service not provided. King’s has the 4th highest rate in England of patients starting on renal replacement therapy (RRT) who have diabetes, at 35.8%, however survival for patients on RRT is very similar to national average (89.8% vs. 91.0%), indicating good quality care. PRUH N/A N/A = + Compared to the 2012 data, patients presenting to a nephrologist less than 90 days before RRT initiation has increased from 18.8% to 21.7% at King’s and is above the national average (18.9%). Patients on home dialysis continues to exceed the NICE target of 15% at 18.3%, and is above the national average of 17.3%. King’s has the 4th highest level of satellite haemodialysis. Overall rates for hospital-acquired infections per 100 dialysis patient years (01/05/12 – 30/04/13) are all similar to or better than the national average. The median time on waiting list for kidney transplant has increased from 635 days in 2011 to 742 days in 2013. Anaesthesia Sprint Audit Published: March 2014 Audit period: 01/05/13 - 31/07/13 Sample Size: DH: 79% (31 patients) PRUH: 78% (76 patients) The data is currently under review by the clinical team at DH and PRUH and a detailed improvement plan is being developed. Older People DH had mixed results for this audit, whilst PRUH performed at or better than national average performance for the majority of audit criteria. An action plan has been developed at PRUH to improve performance further – education will be provided to all anaesthetic staff on the process for managing a proximal femoral fracture. In addition a laminated copy of the process, based on the Anaesthetic Sprint Audit of Practice standards, will be put up in trauma theatres and the anaesthetic department. The process includes the provision of peri-operative nerve block and the need to record in the patient notes if Bone Cement Implantation Syndrome (BCIS) occurs post implementation of the cement and the appropriate steps to be taken. Two snapshot audits will be undertaken, one to assess provision of nerve block for all general anaesthetic procedures and another to provide assurance of the 157 Audit Title Headline Results and/or actions taken Rating DH PRUH safety and efficacy of diamorphine use at the PRUH. National Hip Fracture Database (NHFD) National Report Published: September 2014 Audit Period: One year cohort: 01/01/1331/12/13 Three year cohort: 01/01/1131/12/13 Sample Size: DH: 154 patients PRUH: 371 patients Sentinel Stroke National Audit Programme (SSNAP) – Clinical Audit Published: October 2014 Audit period: 01/04/14 – 30/06/14 Sample Size: DH: 90+% (196 patients) PRUH: 80-89% (210 patients) SSNAP – Clinical Audit Published: January 2015 Audit period: 01/07/14 – 30/09/14 Sample Size: DH: 80-89% (190 patients) PRUH: 80-89% (194 patients) SSNAP Acute Organisational Audit Published: October 2014 Audit period: 01/07/14 Sample Size: DH: 100% (1/1) PRUH: 100% (1/1) 158 The audit data is currently under review at DH and an action plan will be developed. Both DH and PRUH performed above the national average for time to surgery, bone health medication and falls assessment. Both hospitals performed below national average for time taken to orthopaedic care and senior geriatric review. = = * + DH Hyper Acute Stroke Unit (HASU) achieved the 4th highest overall SSNAP score compared to all national peers. PRUH HASU achieved the 5th highest overall SSNAP score compared to national peers. * + DH achieved the highest organisational audit score nationally and performed above the national average for all six domains. * + Compared to the 2012/13 financial year best practice criteria attainment for the calendar year 2013 has improved from 0.2% to 14.5% at DH. Local data collection at DH shows that performance has improved further to the end Q3, 2014/15, with all 9 criteria met in 45.65% of cases. Performance at PRUH is 40% for the calendar year 2013. Actions are in place, led by the newly-established Hip Fracture Forum, to drive improvement in these areas and, whilst performance demonstrates improvement, the area remains under close internal scrutiny and is a Trust quality priority topic. DH Hyper Acute Stroke Unit (HASU) achieved the 3rd highest overall SSNAP score compared to all national peers. PRUH HASU achieved the 5th highest overall SSNAP score compared to national peers. The SSNAP data is routinely reviewed by the multidisciplinary team, with areas of underperformance identified and actions taken to improve practice. PRUH performed above the national average for the majority of the criteria. Audit Title Headline Results and/or actions taken Rating DH SSNAP - Mortality Data Published: November 2014 Audit period: 01/04/13 – 31/03/14 Sample Size: DH: 90%+ (762 patients) PRUH: 80-89% (816 patients) The standardised mortality ratio at both DH and PRUH is within the control limit. PRUH = = = = = = Standardised mortality ratio – DH Hyper Acute Stroke Unit (HASU) Standardised mortality ratio – PRUH Hyper Acute Stroke Unit (HASU) Asthma in Children Published: January 2015 Audit Period: 01/08/13 - 31/03/14 Sample Size: DH: 100% (50 patients) PRUH: 100% (50 patients) Epilepsy 12 Published: November 2014 Audit Period: Service Descriptor: 01/01/14 Clinical Audit: 0/1/01/13 – 30/04/13 Women’s & Children’s Health Denmark Hill (DH) performed in line with or above the national average for 14/22 measures. DH performed in the upper quartile nationally for administration of beta 2 agonist and IV hydrocortisone/oral prednisone. Princess Royal University Hospital (PRUH) performed in line with or above the national average for 16/22 measures. PRUH performed in the upper quartile nationally for the recording of respiratory rate and GCS score as well as discharge prescriptions for prednisone. The data is currently under review by the clinical team at DH and PRUH and a detailed improvement plan is being developed. DH was not identified as an outlier for any of the 12 performance indicators measured by the audit. Performance at PRUH was not identified as an outlier for the majority of the performance indicators (11 out of 12). It was, however identified as a negative outlier for Epilepsy Specialist Nurse (Indicator 2). 159 Audit Title Headline Results and/or actions taken Rating DH Patient Reported Experience Measures: 01/01/13 – 30/04/14 Sample Size: DH: 92% (9 patients) PRUH: 100% (7patients) PRUH DH performed in line or above the national average for 5/10 applicable indicators and PRUH for 6/11 applicable indicators. PRUH performance was similar to or better than for 7 of the previous indicators. DH did not participate in the first round. It is noted that data reliability is affected by small patient numbers. National Neonatal Audit Programme Published: October 2014 Audit Period: 01/01/13 - 31/12/13 Sample Size: DH: 100% (603 patients) PRUH: 100% (325 patients) Paediatric Asthma Published: March 2014 Audit period: 01/11/13 – 30/11/13 Sample Size: DH: 100% (32 patients) PRUH: 100% (18 patients) Paediatric Bronchiectasis Published: March 2014 Audit period: 01/10/13 - 30/11/13 Sample Size: DH: 100% (12 patients) PRUH: No patients diagnosed with bronchiectasis during the audit period. 160 A trust wide action plan is in development to support further improvement. DH performance is above the national average for all criteria audited and has shown improvements compared to the previous performance. + - + = + N/A Performance at PRUH is below the national average, although has improved for Retinopathy of Prematurity (ROP) screening (28% achieved 2013 report compared to 100% achieved in the 2014 report). A local review of the audit data found that PRUH performance is driven by data quality issues rather than quality of care issues. Training to be provided to all staff to ensure appropriate data collection across all criteria. DH and PRUH performed at or above the national average for the majority of criteria relating to initial assessment and treatment criteria. The discharge process has been identified for improvement at both sites. A trust-wide action plan is in place to improve performance across both sites. Actions include: a new Respiratory Clinic will be set up at the PRUH to include the treatment of difficult asthma cases, an audit of the appropriate management of paediatric asthma patients in the Emergency Department will be completed across sites, education and training will be provided if indicated, DH guidance will be rolled out at the PRUH, cases at PRUH will be reviewed to ensure that patients are being discharged and followed up appropriately, and the asthma link nurses at DH will be provided with training to ensure that device technique is assessed and a written asthma plan provided at discharge. DH performed at or above the national average for all criteria relating to diagnosis, consultation and exacerbations and the majority of standards relating to lung function (7/9 criteria). It is noted that the criterion below the national average maybe a data submission issue – under investigation by the Division. Other actions being progressed to improve performance further include the development of a discharge summary proforma that includes all the data items specified in the audit. Audit Title Headline Results and/or actions taken Rating DH Paediatric Intensive Care Audit Network (PICANet) Published: September 2014 Audit period: 01/01/13 – 31/12/13 Sample Size: DH: 100% (658 patients) PRUH: Service not provided. The audit identifies the mortality rate at Denmark Hill (DH) as being one of the lowest nationally, and second lowest amongst peer trusts. PRUH + N/A The standardised mortality ratio (adjusted) has improved to 0.83 (2013) from 0.96 (2012) and is the second lowest of all peer trusts. DH has the lowest rate of emergency admissions of all peer Trusts and emergency readmissions at DH have reduced compared to the previous audits. DH has improved year on year from 2.2% (2011) to 1.4% (2012) to 0.8% (2013). The data from the NHS England Consultant Outcomes Publication (2014) reviewed by Trust in 2014/15. Audit Title Headline Results and/or actions taken Cardiothoracic Surgery Acute In-hospital mortality rate (risk adjusted) – within expected range (DH only; service not provided at PRUH). Rating DH PRUH = N/A Data taken from: Society for Cardiothoracic Surgery in Great Britain & Ireland Published: October 2014 Period: 1st April 2010 - 31st March 2013. 161 Audit Title Headline Results and/or actions taken Interventional Cardiology Major adverse cardiac and cerebrovascular event (MACCE) rate – below expected range, i.e. better than expected (DH only; service not provided at PRUH). Data taken from: The British Cardiovascular Intervention Society (BCIS) Published: October 2014 Period: 01/01/12 – 31/12/13 Colorectal Surgery – Bowel Cancer Data taken from: The National Bowel Cancer Audit Published: October 2014 Period: 01/04/10 – 31/03/13 162 Adjusted 90-day mortality – within expected range (DH only; data relates to patients whose bowel cancer was diagnosed between April 2010 and March 2013, before PRUH integration). Rating DH PRUH = N/A = N/A Audit Title Headline Results and/or actions taken Orthopaedics – Hip and Knee Surgery Hip surgery - hospital risk adjusted 90-day mortality rate – within expected range, DH and PRUH Rating DH PRUH = = Data taken from: The National Joint Registry Published: October 2014 Period: 01/04/13- 31/03/14 Knee surgery - hospital risk adjusted 90-day mortality rate within expected range, DH and PRUH. = = 163 Audit Title Neurosurgery Headline Results and/or actions taken Rating DH PRUH = = 30-day Standardised Mortality Rate (risk adjusted) - within expected range (DH only; service not provided at PRUH). = N/A Within expected range for complications, below national average for transfusion rate and mortality (DH only; service not provided at PRUH). = N/A Mortality (risk adjusted) – within expected range (DH only; service not provided at PRUH). = N/A Data taken from: The Neurosurgical National Audit Programme Published: December 2014 Period: Timeframe not stated Urology – Nephrectomy (Surgical Removal of a Kidney) Data taken from: The British Association of Urological Surgeons Published: October 2014 Period: 01/01/12 – 31/12/13 Vascular Surgery Data taken from: The Vascular Society of Great Britain and Ireland Published: October 2014 Period: Timeframe not stated 164 Mortality following elective abdominal aortic aneurysm repair (risk adjusted) Audit Title Headline Results and/or actions taken Rating DH PRUH Mortality following carotid endarterectomy (risk adjusted) Bariatric Surgery In-hospital mortality rate – Mortality within expected range at DH and PRUH. = PRUH within expected range and better than national average for in-hospital mortality rate, post-operative stay and related readmissions and re-exploration for bleeding. N/A = Data taken from: The Bariatric Registry Published: October 2014 Period: 01/04/12 – 31/03/14 Thyroid and Endocrine Surgery Data taken from: The British Association of Endocrine and Thyroid Surgeons (BAETS) Published: October 2014 Period: 01/07/10 – 30/06/13 Oesophago-gastric, head and neck and lung cancers PRUH – second relevant clinician to submit data 2015/16. DH – relevant clinician did not submit any data. Not applicable – patients are referred to Guy’s & St Thomas’s for surgery. N/A N/A 165 Programme of local audits were reviewed by the Trust in 2014/15 Audit Title Liver Transplantation Published: April 2014 Audit period: 01/04/2003 – 31/03/13 Sample Size: DH: 100% (207 patients) PRUH: N/A. Service not provided. Headline Results and/or actions taken The audit demonstrates that adult patients treated at DH achieve: The lowest 90 day patient mortality rate (0%) and 90 day graft loss rate (0.8%) for elective first liver transplants and the joint lowest rate nationally for both criteria for super urgent transplants. A risk adjusted survival rate for elective and super urgent transplants that compares favourably to all other centres nationally, with DH achieving the highest rate of survival at 3 years and 5 years for elective transplants. The audit demonstrates that paediatric patients treated at DH achieve: A 90 day patient mortality rate and 90 day graft loss rate in line with or better than the national average for both elective and super urgent transplants. An unadjusted survival rate at 1 year, 3 years and 5 years that is above the national average for elective and super urgent transplants (2013 – 2013). National Care of the Dying Audit in Hospitals (NCDAH) Published: May 2014 Audit period: 01/05/13 – 31/05/13 Sample Size: DH: 98% (49 patients) PRUH: 100% (50 patients) Potential Donor Audit Published: May 2014 Audit period: 01/04/13 – 31/03/14 Sample Size: King’s (DH & PRUH): 100% of applicable cases Actions to improve further are incorporated into the Liver Mortality Monitoring Committee presentation and Liver performance meeting and not recorded in a separate action plan. Organisational Key Performance Indicators (KPIs): In line with the national picture, DH and PRUH had mixed results for KPI achievement. Clinical KPIs: DH at or better than the national average for the majority of KPI targets, whilst PRUH had mixed results. A trust-wide action plan is in development that addresses patient information; education and training; local audit on End of Life Care; the review of End of Life Care audit data from Specialty-level to Board-level; and the implementation of a King’s policy for deactivation of implantable cardioverter defibrillators. To improve the provision of services at PRUH a business case is in development for additional palliative care nursing staff. Recruitment will include an education lead and an End of Life Care lead. The audit is not running 2014/15. Trust-level data available (DH and PRUH). Total number of patients receiving a transplanted organ from donations at King’s rose from 109 in 2012/13 to 116 in 2013/14. Total number of kidneys successfully donated rose from 68 in 2012/13 to 73 in 2013/14; pancreas successfully donated rose from 8 in 2012/13 to 14 in 2013/14; livers successfully donated rose from 22 in 2012/13 to 26 in 2013/14 and hearts successfully donated from 6 in 2012/13 to 8 in 2013/14. An action plan to continue to drive improvement across sites has been developed and is monitored on a quarterly basis by the Trust’s Organ Donation Committee. 166 Patient Safety Audit Programme NICE Derogation Audit Programme The Patient Safety Audit Programme sets out King’s approach to ensuring that areas identified as high risk are subject to routine review and, where required, improvement. The Programme is a key component of King’s Risk Management Strategy and is reported through the Patient Safety Committee to the Trust’s Quality Governance Committee. The Patient Safety Audit Programme includes: Clinical record-keeping Consent Surgical Safety Checklist Discharge Moving and handling Falls assessment Patient observations (deteriorating patient) Clinical handover (nursing) Skin integrity and pressure ulcers Patient identification Infection prevention and control Nutrition Nasogastric and orogastric tube placement Availability of patient records Screening procedures and diagnostic test procedures Blood transfusion Hospital Acquired Thrombosis (HAT) Medicines management Resuscitation Piped medical gas administration Safeguarding Tracheostomy. King’s sometimes approves local practice that differs from NICE guidance. We call this a ‘NICE derogation’, and it is usually approved on the grounds that, because of its academic and research status, King’s is able to offer services beyond those of many other hospitals. These derogations are always subject to detailed scrutiny and local clinical audit to ensure that patient outcomes are better than or as expected. In 2014-15 the NICE Derogation Audit Programme has included audits of derogations to the following NICE guidance: CG122 Ovarian cancer CG154 Ectopic pregnancy and miscarriage CG95 Chest pain of recent onset CG112 Sedation in children and young people CG144 Venous thromboembolic diseases CG149 antibiotics for early onset neonatal infection CG151 Neutropenic sepsis CG55 Intra partum care CG62 Antenatal care IPG149 Division of ankyloglossia (tongue-tie) for breastfeeding CG156 Fertility: assessment and treatment of people with fertility problems CG171 Female urinary incontinence. 167 KCH Divisional Clinical Audit Programmes Each of King’s Divisions has a clinical audit programme in place: Ambulatory Care and Local Networks. Critical Care, Theatres and Diagnostics. Liver, Renal, Surgery and Orthopaedics. Networked Services. Trauma, Emergency and Acute Medicine. Women’s and Children’s. Four hundred and sixty six local clinical audit projects are reported in the Divisional Audit Programmes for 2014-15 and many hundreds of improvements in practice are made every year as a result of these programmes. Goals Agreed with Commissioners The following table indicates the goals and achievement for CQUINs at King’s: Goal Number National CQUIN Indicators Friends and Family Test – implementation of staff Friends and Family Test – Friends and Family early implementation outpatients Friends and Family Test – Increased or maintained response rate Q4 target N/A 2a NHS Safety Thermometer – Reduction in Falls at Denmark Hill Site 2b NHS Safety Thermometer – Reduction in Pressure Ulcers at PRUH No more than 3 injurious falls per month Grade 2 0.89 bedday rate Grade 3 0.04 bedday rate Grade 4 – 0 bedday rate 90% 1a 1 - Friends and Family 1b 2 2 – NHS Safety Thermometer 3 - Dementia 4. Improved coordination and delivery of care for people with Long Term Conditions 168 3a Find, assess & refer patients Q4 Actual N/A Achieved N/A N/A (Achieved) Inpatient 30% A&E 20% 60-80% varied Inpatient DH – 50% PRUH 43% A&E DH&PRUH 23% Failed in January but achieved in Feb and Mar Grade 2 – 0.81 Grade 3 0.04 Grade 4 – 0 bedday rate DH 97% PRUH 96% Achieved 3b Clinical leadership & staff training 3c Supporting of careers of people with dementia N/A Achieved 4a Improved coordination and delivery of care for people with Long Term Conditions: Care planning training and implementation (Diabetes and Respiratory at DH) 20% of care plans show a care plan – Diabetes 90% clinicians Audit in progress 79% clinicians trained Goal Number 4b 5. Improving Communication across primary and secondary care 5a 5b 6 – Alcohol and Smoking prevention and well being 7 – London Commissioning 6a National CQUIN Indicators Q4 target trained Q4 Actual Improved coordination and delivery of care for people with Long Term Conditions: COPD Bundles at PRUH Improving Communication across primary and secondary care – improving discharge summaries and provision of on call advice Shared access to patient records across primary and secondary care - Denmark Hill only : Anticoagulation - development of implementation plan to support NICE AF guideline requirements Screening of alcohol use & provision of brief advice and staff training – Denmark Hill 85% 92% N/A N/A Achieved TBA TBA* 80% screening and brief advice 75% training MAU – 85% screened / 71% brief advice ASU 89% screened / 80% brief advice Other wards 90% screened/ 83% brief advice 64% - Training 78% screened / 99% brief advice Maternity 42%% screened / 100% brief advice Not achieved - Training 6b Screening of alcohol use & provision of brief advice and staff training – PRUH 6c Screening of smoking use & provision of brief advice and staff training – Denmark Hill 6d Screening of smoking use & provision of brief advice and staff training – PRUH 7a 7 day working – Emergency Medicine (Denmark Hill) 80% screening and brief advice 45% Maternity at PRUH 75% training 80% screening and brief advice 75% training 80% screening and brief advice 45% Maternity at PRUH 75% training N/A MAU – 86% screened / 84% brief advice ASU 89% screened / 91% brief advice Other wards 90% screened/ 92% brief advice 83% Training 78% screened / 99% brief advice Maternity 42%% screened / 100% brief advice Not achieved - Training Not achieved 169 Goal Number Standards National CQUIN Indicators Consultant led communication – Emergency Medicine (both sites) Q4 target N/A 7c Emergency Departemnt – Clinical Decision Unit (PRUH) N/A Achieved DH Not achieved PRUH Achieved 7d Emergency Department – Shift Leader (PRUH) N/A Not achieved 7e Emergency Department – 24/7 access to the key diagnostics (PRUH) Emergency Department – Policies (PRUH) N/A TBA* N/A Achieved Emergency Department – National Early Warning System (NEWS) – both sites Clinical medication review of patients in health and ageing unit to improve the management of patients medicines after discharge – both sites N/A Not achieved DH Achieved PRUH 80% DH 70% PRUH 90% DH 66% PRUH 7b 7f 7g 8 – Clinical medication review 8a Q4 Actual NHS England CQUINs 9 – NATIONAL Cardiac Surgery 9a Inpatient waits within 7 days 35% Achieved 10 – Highly Specialist Services 10a 50% Not achieved, (37.5% achieved) 11 – NATIONAL Endocrine Coding 11a Providers of Highly specialised services will hold a clinical outcome collaborative audit workshop and produce a single Provider report. Outpatient Coding N/A 50% Achieved 12 – NATIONAL - HIV Telemedicine 12a Service model improvements in HIV services for ‘stable’ patients N/A 40% Achieved 13 - NATIONAL - Renal Dialysis 13a 35% Achieved 14 - LOCAL - Clinical Utilisation 14 Shared haemodialysis care – patient involvement in the tasks of haemodialysis To facilitate providers adoption and use of utilisation technology in managing patient flow, to optimise patients care in the level one neurorehabilitation 15 - LOCAL Specialised Orthopaedics 15 Complex cases of orthopaedic surgery (mainly revisions) are discussed in a network MDT 30% *Q4 Actual awaiting commissioner confirmation 170 1% Achieved Achieved Goal Number 16 LOCAL - Gynae MDT 16 17 LOCAL - Children's Asthma 17 18 LOCAL - HIV Clinical Trials 18 19 LOCAL - Children's Short Gut 19 National CQUIN Indicators Ensure that women being considered for surgery for the treatment of urinary and faecal incontinence, and those with recurrent prolapse are discussed in a sector / regional based MDT to ensure that they are treated in line with agreed protocols. Develop a comprehensive discharge bundle for patients and primary care to reduce readmissions Support trial entry or to work in partnership with another provide Q4 target 30% Q4 Actual Achieved 30% Achieved 40% Achieved To enable further discussion and improve the pathway for patients on the gastrointestinal failure pathway 40% Achieved 171 Part 3. An Overview of performance in 2013/14 against mandated national key standards All trusts are required to report against a core set of indicators, for at least the last two reporting periods, using a standardised statement set out in the NHS (Quality Accounts) Amendment Regulations 2012. Only indicators that are relevant to the services provided at King’s are included in the tables below. Indicator Data Source Period 1 Value Summary Hospital Mortality Index (SHMI) NHS IC Oct 12– Sept 13 National Targets & Indicators Jul 13 – Jun 94.0% 14 91% Palliative Care Indicator: % of patient death with palliative care coding. NHS IC Oct 12–Sept13 35.05% *6-week diagnostic waits PiMs/ CRIS March 2014 *Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the reporting period PiMs/ Oasis March 2014 172 Period 2 Value Actions taken to improve the result in year The Trust discusses these results monthly with the divisions at a special executive committee. Follow up actions have led to an improvement in scores. Oct 13- Sept 14 The Assistant Medical Director has audited a sample of patients to ensure that palliative care coding was appropriate and that the patients were in receipt of expert palliative care intervention. 33.95% 3.49% March 2015 5.5% Additional commissioner funding in Q4 to fund offsite work and additional onsite capacity in the evening and weekend. 92.3% March 2015 92.2% Additional national and commissioner funding across 14/15 to reduce admitted backlog and reduce waiting times in specific specialties in outpatients. Indicator Data Source Period 1 Value Period 2 Value Actions taken to improve the result in year *Maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers. Open Exeter Jan-Mar 2014 87.3% Jan-Mar 2015 84.2% Implemented a number of site service moves to increase capacity to achieve the wider 62 day target. CHKS Apr to Dec 13 3.7% Apr to Dec 14 Readmissions 28 day Patients aged 0-14 Patients aged 15+ CHKS Apr-Dec 13 Trust responsiveness to the personal needs of patients Q32 Were you involved as CQC KCH 2013/14 much as you wanted to be in decisions about your care and treatment? Q34 Did you find someone CQC KCH 2013/14 on the hospital staff to talk to about your worries and fears? Q36 Were you given CQC KCH 2013/14 enough privacy when discussing your condition or treatment? Q56 Did a member of staff CQC KCH 2013/14 tell you about medication side effects to watch for when you went home? Q62 Did hospital staff tell CQC KCH 2013/14 you who to contact if you 3.9% 4.5% 4.5% Apr to Dec 14 7.5 Sept 14 – Jan 15 7.0 5.5 Sept 14 – Jan 15 5.2 8.7 Sept 14 – Jan 15 8.0 4.7 Sept 14 – Jan 15 4.3 7.8 Sept 14 – Jan 15 7.3 Data is analyzed monthly to look for trends. Any issues are acted upon and raised to executives and commissioners where appropriate. In 2013/14 the Trust conducted an emergency readmissions audit with a GP and this will be repeated in 2014/15. Divisions are tasked with developing action plans to address issues raised by patients. These are monitored through the Patient Experience Committee and through Divisional performance meetings. Examples of improvement work include: The Trust dignity month which highlights innovative projects across the trust to improve patient dignity Introduction of patient and relative diaries in the Frank Cooksey Rehabilitation Unit to improve communication, particularly out or hours and at weekends. In Haematology, patients are now offered a pre-transplant information session which has been well received by patients. Development of new Discharge Policy to improve the discharge process for patients and improve the information that they receive Patient stories and patient video stories on our wards to *Figures for period March 2014 reflect the quarter 4 position. Figures for period March 2015 reflect the average of the monthly results between 01 April 2014 - 31 March 2015. 173 Indicator Data Source Period 1 Value Period 2 Value were worried about your condition or treatment after you left hospital? How likely are you to recommend our ward to friends and family if they needed similar care or treatment?" How likely are you to recommend our A&E 174 Actions taken to improve the result in year gather qualitative feedback to support service improvement. Trust Trust 2013/2014 2013/2014 Family & Friends Test Inpatient 2014/15 Note: average scoring FFT score changed to for DH % October Site = 62 2014. Data ranging updated to from 61 reflect new 68 scoring. Target Average % FFT score of for inpatients inpatients who would is 68 to recommend place across all King’s on sites = 93% top 20% with a high of London of 96% trusts Average % of inpatients who would not recommend across all sites = 2% Emergenc 2014/15 Note: y average scoring Divisions have developed action plans to address issues raised by patients who would not recommend King’s. Examples include: ‘Shh noise at night campaign’ on children’s wards introducing soft close bins Focused improvement work on our poorest performing wards for patient experience focussing on improving teamwork, reducing hospital harms, improving patient experience. Continued roll-out of ‘intentional rounding’ National and local response targets linked to CQUIN are on track to be met. Awaiting March results. A wide ranging improvement programme is underway to improve the patient experience of the ED on both sites. Indicator department/ to friends and family if they needed similar care or treatment?" Data Source Period 1 Value FFT score for DH Site = 45 ranging from 40 59 PRUH Site = 43 ranging from 10 – 79 Target FFT score for inpatients is 61 to place King’s on top 20% of London trusts Period 2 Value Actions taken to improve the result in year changed to % October 2014. Data updated to reflect new scoring. Average % of emergency who would recommend at the DH site = 84% versus 8% who would not recommend Average % of emergency patients who would recommend at the PRUH site = 78% versus 13% who would not recommend Actions include: Improving experience of arriving at the ED: To improve the ‘Meet and Greet’ function where a senior nurse ‘greets’ patients, the desk has been moved to improve visibility for patients and to give the nurse better oversight of the main reception area A review of signage has been undertaken Introduced curtained areas in the triage areas to improve privacy and dignity New patient information leaflet detailing steps in their journey, what to expect in the ED etc Increased use of volunteers across the department including in reception to support patients through their journey 175 Indicator Data Source % of staff employed who would recommend the Trust as a provider of care to their Family or Friends NHS IC Indicator Data Source % of patients admitted who were risk assessed for VTE NHS IC C-difficile infection rate per 100,000 bed days Patient safety incidents 176 NRLS Period 1 KCH 2013/14 Period 1 Value 78.3 Value Period 2 Value Workforce Q2 – 14/15 67% Period 2 KCH 2013/14 98.4% KCH 2013/14 Reportable cases Rate /100,000 bed days 49 Oct 13 – Mar 14 Value Patient Safety KCH 2014/15 97.44% 75 13.13 18.56 KCH 2014/15 Reportable cases Rate /100,000 bed days 8841 Apr-Sept 14 9844 Actions taken to improve the result in year We have focused on improving communications with staff in year, and this work has been reflected in our improved score in the survey. Actions taken to improve the result in year The specialist team monitors this on a regular basis. This ensures Kings remains a national leader in this field. The following actions have been taken to review CDIFF in 2013/14: Implementation of the DH’s two stage testing methodology Multidisciplinary review of all cases to identify lessons to be learnt An increased focus on cleaning standards including the secondment of the senior IC nurse Introduction of hydrogen peroxide vapour technology as an enhanced cleaning technology Much stronger focus on antibiotic prescribing including monthly antibiotic stewardship audits. Introduction of a antibiotic prescribing app to further improve antibiotic prescribing compliance. Introduction of a practice facilitator role in TEAM to improve communication between the division and the IPC team, better manage isolation facilities and improve training. Increased establishment of IPC nurses from 5.5 WTE to 7 WTE This is monitored through the quarterly safety report. Indicator reported to the National Reporting and Learning Service (NRLS) Patient safety incidents reported to the National Reporting and Learning Service (NRLS), where degree of harm is recorded as ‘severe harm’ or ‘death’, as a percentage of all patient safety incidents reported Rate per 1000 bed days published# Data Source Period 1 Value Period 2 Value Actions taken to improve the result in year NRLS Oct 13 – Mar 14 0.8% Apr-Sept 14 0.6 This figure is in line with that of other large acute teaching hospitals. All incidents were fully investigated and subject to a detailed root cause analysis. The current reporting rate is one of the highest amongst acute teaching hospitals and reflects the positive reporting culture at King’s. NRLS Oct 13 – Mar 14 36.1 Apr-Sept 14 40.7 5.7** * These figures accurately reflect data currently held by the NRLS on patient safety incidents at KCH, and discrepancies may exist with data previously published by the NRLS. Further information on the total number of incidents reported to the NRLS (which includes October 2012-March 2013 information) is yet to be published but is expected to report 8749 patient safety incidents for 2012/13 of which 34 (0.39%) resulted in death or severe harm. **These figures are those published by the NRLS at a point in time, which have subsequently been adjusted to the figures marked with one asterisk. 177 Indicator From local Trust data Oct 12 – March 13 April – Sept 2013 Most recent results for Trust Oct13Mar14 *Patient safety incidents reported to the National Reporting & Learning System 5206 8841 9844 Number of patient safety incidents Rate of patient safety incidents (number/1000 bed days) Not published 36.1 Percentage resulting in severe harm or death 0.9% 0.8% 40.77 0.6% Time period for most recent Trust results Best result nationally Worst result nationally National average April – Sept 2014 12020 35 Not published April – Sept 2014 74.9 0.24 Not published April – Sept 2014 0% 82.9% Not published *In relation to the rate of severe harm and death, that not all organisation apply the national coding of degree of harm in a consistent way which can make comparison of harm profile of organisations difficult. This Information has been taken from the most recently published [April 2014 Organisation Patient Safety Incident Report which covers the period April – September 2013. The comparative data relates to the ‘Acute Teaching Organisation’ Cluster rather than National Data in line with the published safety data. The data does not include PRUH figures as the figures cannot be disaggregated from the SLHT data for the period prior to acquisition on the 1st October. 178 Patient safety incidents resulting in severe harm or death with data previously published by the NRLS. The National Reporting and Learning Service (NRLS) was established in 2003. The system enables patient safety incident reports to be submitted to a national database on a voluntary basis designed to promote learning. It is mandatory for NHS trusts in England to report all serious patient safety incidents to the Care Quality Commission as part of the Care Quality Commission registration process. To avoid duplication of reporting, all incidents resulting in death or severe harm should be reported to the NRLS who then report them to the Care Quality Commission. Although it is not mandatory, it is common practice for NHS Trusts to report patient safety incidents under the NRLS’s voluntary arrangements. As there is not a nationally established and regulated approach to reporting and categorising patient safety incidents, different trusts may choose to apply different approaches and guidance to reporting, categorisation and validation of patient safety incidents. The approach taken to determine the classification of each incident, such as those ‘resulting in severe harm or death’, will often rely on clinical judgment. This judgment may, acceptably, differ between professionals. In addition, the classification of the impact of an incident may be subject to a potentially lengthy investigation which may result in the classification being changed. This change may not be reported externally and the data held by a trust may not be the same as that held by the NRLS. Therefore, it may be difficult to explain the differences between the data reported by the Trusts as this may not be comparable. The data provided above represents the most up-to-date data held by the NRLS on patient safety incidents in King’s, but for the reasons above differences may exist 179 Indicator From local Trust data 2014-15 2013-14 From Health and Social Care Information Centre Most recent results for Trust Time period for most recent Trust results Best result nationally Worst result nationally National average Domain 3: Helping people recover from episodes of ill health or following injury Emergency readmissions to hospital within 28 days of discharge: % of patients aged 0-15 readmitted within 28 days 3.90% 3.80% 3.80% 2013-14 0 14.94 3.11 % of patients aged over 15 readmitted within 28 days 4.50% 4.50% 4.50% 2013-14 0 17.15 4.51 100 77 96 0 30.8 16.1 Domain 4: Ensuring that people have a positive experience of care Responsiveness to inpatients’ personal needs (Source: national NHS inpatient survey) Percentage of staff who would recommend the provider to friends or family needing care Source: national NHS staff survey 75.1 2014 78.3% 2014 Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm Percentage of admitted patients risk97.4 98.4 98.4 2013-14 assessed for venous thromboembolism (VTE) Rate of clostridium difficile (number of infections/100,000 bed days). 180 13.13 15.53 15.53 2013-14 Performance against key national priorities As at quarter 4 the Trust self-certified a performance rating of ‘risks identified’ for 2014/15 against the Monitor Compliance Framework for Denmark Hill. This equates to a Monitor governance risk rating of ‘risks identified’ which is in line with the planned trajectory. 181 Appendix 1: Statements from Key External Stakeholders Healthwatch Southwark, Lambeth and Bromley’s response to King’s College Hospital NHS Foundation Trust Quality Accounts for 2014/15 This is a joint response to the King’s Quality Account 2014-2015 from Local Healthwatch Southwark, Lambeth and Bromley because we share services which operate across these boroughs. We appreciate the opportunity to comment on the quality of the services provided by King’s College NHS (Kings) at their main two sites: Denmark Hill (DH) and Princess Royal University Hospital (PRUH). We would also like to see more emphasis on carers and mental wellbeing. We are concerned about the information and governance of King’s, as this was rated as ‘red’, which is unsatisfactory and would like to see this improve in the next year. General comments Last year’s priorities for 2014-2015 We appreciate the work King’s is doing towards integrating two hospital systems, however we feel that there is still a lot of data missing from the Quality Accounts document (such data has been made available from other trusts such as Guys & St. Thomas FT and South London & Maudsley FT)1. On a wider point, we recommend it would be useful to have a model template to include formatting so it is easier for the public to compare Trust quality. We note the intention to improve all priority goals, reflected in 5 out of 6 priorities being carried over to this year’s priorities, although it does raise questions on how progress is moving forward. We hope that our comments and suggestions below are used to help shape this year’s priorities. The draft report generally relates to performance and outcomes at the DH site. Clear data of each site performance and activity needs to be documented for each priority, rather than just an overall indication of the trust performance. This masks the current differences between the two sites in how the service operates and the differences in performance. It is good to see comprehensive aims and measures for most of the priorities so it is not just reliant on a few measures. However, 1 To the best of our knowledge all relevant data is included. Additional data may be available on request 182 across the priorities, we feel that they are developed and approached in silos i.e. clinical, management and delivery aspects. Priority development should be considered in terms of patient-centred care and this would have a greater impact on patient experience. Working to reduce Preventative Ill-health: We would like to see everyone screened (instead of just key wards) and more focus on obesity. It is hard to comment on the progress made without seeing data on the long term and short term progress. Hip Fractures: Questions were raised around community physiotherapy, our feedback suggests that in the hospital physiotherapy is easier to access and of good quality; however when patients are back in the community, care and support can be variable. Discharge also plays a role for this patient cohort and again can be variable. We know the intention to improve is there, reflected in a priority focused solely on this, however we do not have enough information on its progress, or rather why it is not progressing. In relation to PRUH, considerable improvement still needs to take place especially on liaison and close working between orthopaedic surgeons and care of the elderly physicians for this older patient group. Discharge: We were very concerned that Older People, out of your three target groups, consistently performed badly across all the measures. They are an important group of users, particularly as you note the increasing acuity of patients you see. Some groups of Older People will not complain as much so they will not always have their voices heard, however King’s need to do more to engage with them to design services. Ongoing care plan is crucial after discharge. This includes a contact number that patients can get through to relevant professionals. From our intelligence and from our public meeting we held on QA, we have heard of patients getting through and then being signposted back to go back to their GP, where the GP may not have complete understanding, which causes anxiety for patients. It also appears there is a huge communication gap and authority of responsibility gap between hospitals and GPs. There needs to be an intermediary, including copies of discharge plans to both patients and GP. Cancer Experience: We think the partnership with Macmillan is great and helps to improve patient experience. The cancer line is a great initiative, although we are concerned about the operational hours as support is confined to working hours. Timings should be extended perhaps to 8am-8pm, 7 days a week, although we understand the resources and recommend this is explored. Falls: It is great that action is taken such as the Safe Care Forum to discover the root causes of falls and the preventative aspect to assess occurrences. Alongside this, we suggest that solution-focused initiatives for example salt shoes be explored as these can avoid slips, as well as exploring King’s comparator, Guys, on their root causes and how they are addressing it. We will be monitoring the root cause report that is soon to be published. Safer Surgery: We are concerned that there is no data available. We suggest that in future quarter 1-3 should be provided at the time of the draft report. We note the various activities that have taken place, but this needs to be distinguished between specialties and sites (DH / PRUH). We are very concerned that Trusts are still not meeting the basics of safety resulting in ‘never events’ taking place and we strongly encourage transparency. This year’s priorities for 2015-2016 We would like to see further progress on the priorities from last year, therefore we agree with the new set of priorities. Please also keep in mind our suggestions and considerations above, as they also relate to this year’s priorities. Working to reduce Preventative Ill-health: We could like to see an additional indicator here to link up with mental wellbeing or psychological/counselling support to help those who need it or those with dualdiagnoses. More quantifiable measures are needed for this measure. Falls: Again, it is difficult to ascertain if initiatives will be taking place at both sites or just at DH e.g. staff training. Discharge: Following our comments above, discharge plan needs to be clear and a decision made on who will follow-up before patients are discharged. There were suggestions a discharge officer could be considered to ‘checklist’. Feedback from our sources has highlighted the sometimes haphazard discharge process; Communication needs to be better with patients and timelier, with quantifiable measures, and better consistency and quality of discharge notes. Clerical and pharmacy 183 components also play a part in the discharge experience. We feel it is positive volunteers carry out follow-up calls after discharge; however the calls are not ‘full or detailed enough’ and could be used more effectively. These calls are great opportunities to have fuller conversation about care after hospital. They provide routes to develop a ‘flagging system’ for example if patients needed to speak to clinicians; this could be referred onto clinicians. It is also as a way to identify vulnerable people; particularly those who have no family or those who do not speak English well or share a different culture which could affect aftercare. We are not aware if this more holistic approach is captured. We would like to see information on the progress made and especially improvements to the older people group. We would like to see more information on PRUH progress as high priority is given but with little information. We are pleased to see the focus on discharge to social care institutions, however, we would ask that this approach does not rush carers into a placement decision and that the dialogue that takes place is managed sensitively to all parties and does not cause added stress, unintentional or not. We welcome the emphasis on integrated care, particularly SLIC and @home team. Medication Safety: It needs to be clear if this focus is on paediatrics or across the Trust. We would like to see a focus on older people because we are aware of many issues affecting this patient group. For example, the strength of medications may not be appropriate, many take a lot of medications and it can be confusing to understand reactions between different medications, or even if they should be on all their medications. We believe information on the current medication errors should be reported, i.e. baseline figures. On a wider note on 184 medication safety, we believe public awareness on medication safety will empower individuals to raise issues and/or to initiate dialogues with professionals around their medication. Other Comments: Audits / Clinical: The performance of DH site on national and local audits are impressive with most generally above average and selfidentified improvements. There is also clear distinction between PRUH and DH performance, CQUIN/National Indicators: Clear format specifying national and local targets and comparator data, however there is no data in the table, again Q3 results would be helpful for the draft report. It would also be helpful to include Guys’ as data can be benchmarked because it is a similar acute trust. Monitor / CQC: It would be helpful to mention CQC and Monitor investigations and reports and provide short updates with appropriate links. In summary, we are pleased that King’s are working towards consistent services and performance across its many sites. However, we would like to see continued improvements in patient-centred care across all its services, particularly around dignity, respect and patient experience, more electronic and less paperbased communication alongside administrative and clerical competence, and a clear line of command on where to go should any problems arise. Healthwatch Southwark, Lambeth, Bromley & Lewisham NHS Southwark Clinical Commissioning Group Thank you for sharing the KCH Quality Accounts with us and inviting us to comment on the draft document. I am able to set out below a summary of feedback from Southwark, Lambeth and Bromley CCGs. Commissioners participated in the stakeholder event you ran in January of this year where we were able to look at last year’s priorities and those for the coming year 2015/16 all of which commissioners endorse. NHS Southwark CCG have reviewed your Quality Accounts and are agreed that your priorities are broadly in line with our own and here put forward comments that include feedback from NHS Lambeth CCG, and also NHS Bromley CCG. On behalf of all commissioners we would like to acknowledge the commitment and focus that King’s have made in the past year through the clinical quality review group and senior nursing and medical attendance at this forum and at the quality of reports and presentations. We welcome the focus on preventable disease in the coming year which has also been encouraged through the local incentive scheme for acute trusts in order to work towards a cultural shift to disease prevention. We are pleased to see continuing work at improving the outcomes for patients following hip fracture at the PRUH. While acknowledging the significant improvements in the hip fracture pathway over last year at the Denmark Hill site there are existing concerns at the PRUH site. We would welcome a more specific target on the number of patients who are discharged to their own home, and who receive a bone health assessment across the trust. We support the continued work at improving the experience of care for patients discharged at both the Denmark Hill site and at the PRUH. While acknowledging that this is a whole system issue involving refocusing from discharge to a transfer of care to primary care we are encouraged to see specific focus on communication and reporting. Also in fostering a learning culture by improving the recording of adverse incidents linked to discharge. It is unclear if the trust has met the increase in 5 points that they were seeking. Perhaps showing the 2013/14 data beside the evaluation data may help this? Bromley is pleased to see that PRUH is specifically mentioned and highlighted in most of the sections and data. While they accept that the Trust operates across many sites with consistent values and standards, the CCG does wish to see PRUH data reported separately. It could also be added that at times it is not completely clear whether whole trust data is being reported or PRUH data and this could perhaps be clearer at times. While we acknowledge that there have been significant improvements to the quality of care at the PRUH site it would be good to see plans which address issues at that site around delays to direct access diagnostics, IST cancer improvement plans, and the PIMs migration issue and access to notes. The trust has laid out really clearly what audits they have participated in, and what results and actions have been taken. The only additional action we would like to see is in relation to the MINAP audit where no actions have been added. The audit of the Sepsis toolkit has raised the question of the trust appearing to be an outlier at Denmark Hill regarding an elevated mortality ratio within 185 liver. We are reassured to see in internal review of this in the coming year. We look forward to receiving the final version of your Quality Accounts and to hearing of the 186 impact of the actions you plan to implement in 2015/16. Mark McLaughlin Quality Consultant NHS Southwark CCG 20 May 2015 Appendix 2: 2014/15 Statement of the 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. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation trust boards should put in place to support the data quality for the preparation of the quality report. In preparing the Quality Report, directors are required to take steps to satisfy themselves that: the content of the Quality Report meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2014/15 and supporting guidance the content of the Quality Report is not inconsistent with internal and external sources of information including: board minutes and papers for the period 01 April 2014 to 31 March 2015 papers relating to Quality reported to the board over the period 01 April 2014 to 31 March 2015 feedback from governors at their meetings on 09 April and 14 May 2015 feedback from commissioners dated 20 May 2015 feedback from local Healthwatch organisations dated 11 May 2015 the trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated 22/10/2014 the latest national patient survey the latest national staff survey the Head of Internal Audit’s annual opinion over the trust’s control environment dated 19 May 2015 CQC Intelligent Monitoring Report dated 21 April 2015 the Quality Report presents a balanced picture of the NHS foundation trust’s performance over the period covered; the performance information reported in the Quality Report is reliable and accurate; there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Report, and these controls are subject to review to confirm that they are working effectively in practice; the data underpinning the 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 Monitor’s annual reporting guidance (which incorporates the Quality Accounts regulations) (published www.monitor.gov.uk/annualreportingmanu al) as well as the standards to support data quality for the preparation of the Quality Report (available at www.monitor.gov.uk/annualreportingmanu al). 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 Lord Kerslake Chair Roland Sinker Chief Executive Date: 26 May 2015 187 Independent Audit Assurance Independent auditor’s report to the council of governors of King’s College Hospital NHS Foundation Trust on the quality report We refer to these national priority indicators collectively as the ‘indicators’. We have been engaged by the council of governors of King’s College Hospital NHS Foundation Trust to perform an independent assurance engagement in respect of King’s College Hospital NHS Foundation Trust’s quality report for the year ended 31 March 2015 (the ‘Quality Report’) and certain performance indicators contained therein. This report, including the conclusion, has been prepared solely for the council of governors of King’s College Hospital NHS Foundation Trust as a body, to assist the council of governors in reporting King’s College Hospital 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 2015, 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 King’s College Hospital 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 2015 subject to limited assurance consist of the national priority indicators as mandated by Monitor: 188 Referral to treatment time, 18 weeks in aggregate, incomplete pathways; and Maximum 62 day waiting time from urgent GP referral to treatment for all cancers. 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 Monitor. 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’; the quality report is not consistent in all material respects with the sources specified in the guidance; 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 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 consider the implications for our report if we become aware of any material omissions. We read the other information contained in the quality report and consider whether it is materially inconsistent with the documents specified within the detailed guidance. 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. 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. 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; analytical procedures on monthly and departmental data; 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’ 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. 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’. 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 As set out in the ‘Statement on quality from the chief executive of the NHS Foundation Trust’ section on pages 107-109 of the Trust’s Quality Report, the Trust currently does not maintain monthly datasets for the 18 week referral to treatment incomplete pathway indicator. 189 As a result of the lack of data for 1 April 2014 to 28 February 2015, we have concluded that we are unable to test sufficiently the 18 week referral to treatment incomplete pathway indicator for the year ended 31 March 2015. Whilst we were not engaged to provide a separate conclusion on the data for the period from 1 March 2015 to 31 March 2015, the sample testing that we performed on that data as part of our work on the 18 week referral to treatment incomplete pathway indicator for the year ended 31 March 2015 indicated the data contained errors including incorrect start dates being used, lack of evidence supporting the existence of the pathway and pathways incorrectly remaining open at year end. Due to the range of errors identified we are unable to quantify the effect on the reported indicator for the year ended 31 March 2015. 190 ‘Basis for qualified conclusion’ section above, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2015: 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’; the quality report is not consistent in all material respects with the sources specified in the guidance; and the indicators in the quality report subject to limited assurance have not been reasonably stated in all material respects in accordance with the ‘NHS foundation trust annual reporting manual’. Deloitte LLP Qualified cconclusion Chartered Accountants Based on the results of our procedures, except for the effects of the matters described in the St Albans 28 May 2015 Annual Accounts FOREWORD TO THE ACCOUNTS King's College Hospital NHS Foundation Trust Annual Accounts 2014/15 These accounts, for the year ending March 31 2015, have been prepared by King's College Hospital NHS Foundation Trust in accordance with paragraphs 24 and 25 of Schedule 7 to the National Health Service Act 2006. Signed Roland Sinker Acting Chief Executive 26 May 2015 Statement of Chief Executive's responsibilities as the accounting officer of King's College Hospital 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 Monitor. Under the NHS Act 2006, Monitor has directed King's College Hospital NHS foundation trust to prepare for each financial year a statement of accounts in the form and on the basis set out in the Accounts Direction. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of King's College Hospital NHS foundation trust and of its income and expenditure, total recognised gains and losses and cash flows for the financial year. In preparing the accounts, the Accounting Officer is required to comply with the requirements of the NHS Foundation Trust Annual Reporting Manual and in particular to: • 194 observe the Accounts Direction issued by Monitor, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis; • make judgements and estimates on a reasonable basis; • state whether applicable accounting standards as set out in the NHS Foundation Trust Annual Reporting Manual have been followed, and disclose and explain any material departures in the financial statements; and • ensure that the use of public funds complies with the relevant legislation, delegated authorities and guidance; and • prepare the financial statements on a going concern basis. The accounting officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the NHS foundation trust and to enable him/her to ensure that the accounts comply with requirements outlined in the above mentioned Act. The Accounting Officer is also responsible for safeguarding the assets of the NHS foundation trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities. To the best of my knowledge and belief, I have properly discharged the responsibilities set out in Monitor's NHS Foundation Trust Accounting Officer Memorandum. Signed: Roland Sinker Acting Chief Executive Officer Date: 26 May 2015 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 King’s College Hospital 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 King’s College Hospital NHS Foundation Trust for the year ended 31 March 2015 and up to the date of approval of the annual report and accounts. Capacity to handle risk The Trust Board has overall accountability for the Trust’s Risk Management Strategy through the Trust’s Executive Directors. The Trust’s Medical Director provides the lead, and is supported by a centralised Patient Safety and Risk Management team. The Chief Operating Officer has accountability for the development, implementation and testing of the Trust’s business continuity plan. The Trust operates a unified approach covering both clinical and non-clinical risks which are recorded on a computerised risk register. The Trust is committed to providing a learning environment for all levels of staff, to ensure that good practice is developed and disseminated to all areas of the organisation. In March 2015, Monitor launched a formal investigation into the longstanding financial operational challenges at the PRUH. The regulator has decided to open a formal investigation to trigger a regulatory process that would enable Monitor to use its legal powers to underpin the changes the trust needs to make. Following the investigation, Monitor has agreed with King’s that the trust will: • develop and implement an effective shortterm recovery plan to deliver the required improvements at the PRUH that King’s planned to make when it took over the hospital; and • develop and implement a longer-term plan by working closely with other national and local health care organisations (including NHS England and local commissioners) to ensure patient services are improved, and also provided in a sustainable way for the future. The Trust already has methods of promoting good practice in place such as: • A commitment to individual appraisal and personal development planning for all staff; • Policies to encourage the open reporting and investigation of adverse incidents including near misses. In addition the web based incident reporting system allows anonymous reporting; 195 • • • • A commitment to root cause analysis of problems and incidents and the avoidance of blaming and ‘scape-goating’; A range of problem resolution policies and procedures, including capability, raising concerns or ‘whistle-blowing’, workplace stress, mediation, harassment and discipline, which are designed to identify and remedy problems at an early stage; A range of individual support mechanisms to encourage individuals to raise concerns about their own performance in ways which will not threaten their security or livelihood, e.g. appraisal, substance abuse policies, professional counselling and occupational health services; and A range of clinical and non-clinical audit mechanisms. All staff are trained in these policies as part of the corporate and local induction policies and updated via regular staff briefings and the Trust intranet. As part of the recovery plans being developed in collaboration with Monitor, these are being enhanced by strengthened governance arrangements to deliver financial cost improvements without adversely affecting patient safety and quality. These enhancements are outlined in the section on risk and control framework below, The Trust recognises that it is important to be outward looking and to learn and improve from the experience of other organisations and experts and where possible to benchmark the quality and performance of the services we provide to our patients. We do this through a variety of ways. We are members of external national groups and networks including but not limited to the Shelford Group which comprises leading NHS multi-specialty academic healthcare organisations, who are dedicated to excellence in clinical research, education and patient care. Foundation Trust Network; the Association of University Hospitals; CHKS and other external 196 sources of healthcare intelligence such as Dr Foster and CQC reports and inspections. The Trust uses the Healthcare Evaluation database (HED) which is set up to enable benchmarking internally and externally across a wide range of clinical effectiveness, patient experience and patient safety indicators. In addition, we seek both external and internal expertise such as the Department of Health, KHP partners and our Governors to provide an independent critical eye. The risk and control framework The Trust operates a cyclical mechanism for the identification, evaluation and control of risk, facilitated by means of a central risk register. This is a dynamic document which reflects corporate and local risks and their movement within the register. Local Risk Groups identify risks and potential hazards and formulate actions plans to deal with them. Each risk is scored on a common basis across the Trust for likelihood and potential impact. If risks cannot be satisfactorily resolved at a local level, they are considered by the relevant corporate risk management group. The existing Trust governance structure was implemented in 2010 following an extensive external review by the Trust’s internal auditors. The Trust plans a review of its governance framework commencing in May 2015. It is considered good practice for all foundation trust boards to review periodically the adequacy and effectiveness of governance. Monitor published new guidance during 2014 which set out the requirement for foundation trusts to demonstrate that their governance arrangements have been evaluated and reviewed independently at least once every three years. Given the challenges which the Trust is facing with regard to the delivery of its financial plans and following the appointment of a new Chair, the Trust considers it opportune to assure the Board and other stakeholders of the adequacy and effectiveness of its governance arrangements. Since the 2010 review, the quality governance framework has had at its centre the Quality & Governance Committee with a membership comprising the full Board with Commissioner representation. The quality and governance reporting committees: Patient Outcomes, Patient Safety, Patient Experience and Organisational Safety are chaired by Executive Directors, who are also accountable for reporting to the Quality & Governance Committee on a quarterly basis. The reporting structures and processes are embedded across all sites down to Divisional and speciality. This ensures that patient outcomes/clinical effectiveness, patient and organisational safety and patient experience at all sites are integrated within an existing and established quality governance monitoring framework and robust performance management infrastructure. Importantly, the relevant specialty and divisional clinical governance and associated committees operate across all sites have been required to implement the terms of reference and reporting procedures that are already in place at King’s. Compliance with this requirement will be subject to internal audit, which received a rating of ‘significant assurance’ in January 2015. Through a defined reporting programme the Quality and Governance Committee, which is a committee of the Board, and its reporting committees: Patient Safety, Patient Outcomes, Patient Experience and Organisational Safety, will receive progress reports and assurances from the various committees which feed into them. All of these committees are minuted and have in place action trackers which are updated after every meeting. The Board of the enlarged organisation continues to receive a monthly Performance Report and performance scorecard which provides up to date information of key quality indicators drilling down to site specific information - patient safety, patient experience and clinical effectiveness, highlighting current quality and safety issues and action being taken. A suite of other reports are received on a quarterly basis including a comprehensive Integrated Quality & Governance report, separate reports on patient safety, patient outcomes and patient experience which provide site specific information. A Nursing Performance report is presented together with a quarterly report from the Director of Infection Prevention and Control, who is also the Executive Director of Nursing and Maternity. The Director of Nursing provides a regular report to the Board of Directors on nursing numbers in comparison to an acuity based evaluation of safe staffing levels. The quarterly Quality and Governance Report is presented to the Quality and Governance Committee by the Medical Director, Director of Nursing & Midwifery (& DIPC), Director of Corporate Affairs and Chief Operating Officer. The report addresses the three dimension of quality – Patient Safety, Patient Outcomes, Patient Experience together with Organisational Safety across the enlarged organisation. It includes updates on quality priorities and driving improvement across the quality dimension: • Patient Outcomes: mortality monitoring and review of mortality outliers, progress against NCEPODs and participation in National Audits, updates on public health priorities, NICE Quality standards; • Patient Safety: profile and analysis of adverse incidents and progress against related improvement work streams, serious incidents and improvement actions, adverse incident benchmarking data, claims and inquests; • Patient Experience: National Surveys, monthly internal How Are Doing Survey, 197 • updates from patient opinion websites, complaints and PALS trends and analysis, service improvements, outcome of Ombudsman investigations, Local CQUIN, Friends and Family Test ; and Organisational Safety: analysis of health and safety incidents, inspection findings etc. The Divisional score cards include the quality dimensions and other specialist indicators. These are formally reviewed at the monthly Divisional performance review meetings led by the Chief Operating Office in partnership with the Medical Director and Nursing & Midwifery Director (& Trust DIPC). These discussions inform the monthly Performance Report and Trust score card which continue to be considered by the Board. The reports are structured so that the Board can drill down to site specific performance and quality information. Unresolved risks are passed to the Quality & Governance Committee to review the adequacy of, and progress against action plans and to consider acceptance or further resolution. If additional resources are required to reduce the risk to an acceptable level, this is considered by the Business Resource and Strategy Group and, if necessary by the Trust Finance and Performance Committee. Risks that have an above average consequence and likelihood are given priority in the resource allocation process. It is the Trust’s policy as defined within the Risk Management Strategy that its risk appetite is defined as all red risks are required to be reviewed by the Board of Directors. The Board has decided that all risks assessed as having a greater than average likelihood of occurrence with a potential impact of more than moderate harm, are not acceptable and require mitigation. The Board reviews the nature and assessment of these risks and the potential impact on delivery of the Trust’s Strategic priorities and careful consideration is given to whether the level of risk should be accepted or further 198 treatment plans put in place. The Board will seek additional assurance or take direct action where it considers that risks are not being adequately controlled or accepted. The Board Assurance Framework provides a high level management assessment process and record which enables the Trust to focus on the principal risks to delivering its strategic priorities and the robustness of internal controls to reduce or manage the risks to acceptable levels. The Assurance Framework is updated by the Executive Directors and reviewed by the Board on a quarterly basis. The sources of key controls and assurances, both internal and external, are reviewed for their adequacy and relevance and action plans are agreed. Information Governance is reviewed by the Quality and Governance Committee, who are advised by the Caldicott Guardian and the Senior Information Risk Owner. The Trust completes the annual Information Governance toolkit. In the submission made in March 2015, the Trust achieved at least a Level 2 rating on all requirements and scored a total of 73% across all indicators. The Trust has made significant efforts to ensure the security of the information it holds and transmits to and from its systems. These include the enforcement of encryption for any portable devices used on Trust systems, encryption for all Trust laptop computers and the implementation of ‘remote wipe’ functionality for smart phones in the event of their loss or theft. All Trust policies, procedures and business cases include an Equality Impact Assessment so that their implications can be considered by the Board of Directors. Major policy or strategic decisions are taken only after consultation with the Council of Governors, Staff Side representatives and public and patient stakeholders. The Trust holds community events to receive the views of Trust Members and the Annual Public meeting in September 2014 was very well attended. In order to address the risk and control implications of the Trust’s financial recovery plans, the Trust has further strengthened the existing arrangements. The frequency of full Board meetings has been increased to bimonthly and a new Savings Board established. The remit of the Savings Board is to • Receive monthly reports on progress of delivery against the target. • Hold programme sponsors and project managers to account to ensure progress is made in line with agreed timescales. • Ensure divisions and service lines are ready and able to realise benefits in line with changes implemented. • Allocate the Trust’s programme management and service improvement resource to scope, define and implement efficiency and savings ideas and projects raised by divisions as part of the executive review process. • To ensure there is no increase to clinical risk or decrease in quality of care as a result of changes implemented by reviewing the clinical risk assessment of CIPs, specifically those schemes that have been given a high-risk rating. • To provide leadership, advice and guidance to sponsors and project managers including unlocking issues or barriers preventing progress and adjudicating on any contentious issues. • To ensure service changes align to Trust strategy and values. Membership includes all Executive Directors and other relevant senior managers and meetings are chaired by the CEO. All divisions have committed to completion of a risk assessment of CIP schemes contained within their plans. These are signed off and reviewed by each Divisional Manager, Head of Nursing, Finance Manager and Clinical Director as a regular item on the agenda of their Divisional Board. Consequently 15/16 CIP schemes are routinely risk assessed and RAG rated by divisions and logged onto the central repository for CIP plans. The Savings Board reviews the detail of these clinical risk assessments of CIPs, specifically those schemes that have been given a ‘High-Risk’ rating. In November 2013, the Board of Directors held a risk workshop facilitated by KPMG to reassess the key strategic risks facing the Trust. This workshop informed revision of the Board Assurance Framework, which is reviewed by the Board on a quarterly basis. Each risk is scored on a likelihood and impact matrix and cross-referenced to the Trust’s strategic aims. Following this review the three highest scoring risks were identified as: a) Financial Constraints – The need to invest in additional quality and safety measures at the PRUH together with the pressures to meet emergency access and referral to treatment time targets has caused significant financial pressures. The Trust has addressed this risk by appointing a Transformation and Turnaround Director and external support from PwC to increase the focus on delivering cost improvements. The Financial Recovery Plans for the next one, two and five years will be overseen by the Trust Board. b) Failure to deliver workforce capacity and capability – there is a risk of sub-optimal staffing levels due to the levels of vacancies, capacity increases and a shortage of suitably qualified applicants. This is being addressed by recruitment plans at Divisional levels, a Recruitment Delivery Manager to improve ‘time to hire’ cost and vacancy rate and the development of an overseas recruitment capability through KCH Commercial Services. c) Failure to provide enough capacity to meet demand levels leading to target failure – 199 the Trust is working with McKinsey and SE London commissioners to produce a new design for emergency pathways and to assess the levels of demand and capacity across both acute and primary care health sectors. The outcomes of these action plans on the assessed risk are considered by the Board on a monthly basis as part of the finance & performance reports. The Board will self-certify the validity of its Corporate Governance Statement. A number of compliance assessments review the adequacy of the governance arrangements. These will review the Trust’s ability to meet its financial and operational targets in light of the longstanding problems at the PRUH and content and timelines of the recovery plans required to address them. Assurance on compliance with relevant regulations, internal policies and procedures is undertaken through the Trust’s committee structure for example CQC registration via the QGC and fire regulations through the Health and Safety Committee. Compliance assessments are also undertaken by Internal Audit. The CQC inspected all Trust sites in April 2015. The final report is awaited and action plans will be developed and monitored by the Board, to implement any areas of improvement identified. The Foundation Trust is fully compliant with the registration requirements of the Care Quality Commission (CQC). On-going compliance with the registration requirements is monitored through the Trust’s Quality Governance Framework. The underpinning management committees: Patient Outcome, Patient Safety, Patient Experience and Organisational Safety Committees have specific responsibility within their terms of reference for reviewing and 200 monitoring compliance against the CQC’s Fundamental Standards, the NHS Outcomes Framework and previously the NHS Litigation Authority’s Acute Risk Management Standards. To support this and to maintain a strong focus, the Trust has appointed Assurance and Regulatory Performance teams The Assurance team work closely with Divisions in supporting the registration of services or new locations with the CQC and assessing compliance with the Essential Standards/Outcomes. The Trust has implemented a Quality Monitoring system and assessment tool, mirroring the CQC’s inspection methodology, in order to assess compliance with CQC Fundamental Standards. As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employer’s contributions and payments into the Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations. Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with. The foundation trust has undertaken risk assessments and Carbon Reduction Delivery Plans are in place in accordance with emergency preparedness and civil contingency requirements, as based on UKCIP 2009 weather projects, to ensure that this organisation’s obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with. Review of economy, efficiency and effectiveness of the use of resources The Board of Directors ensures that resources are used economically, efficiently and effectively by means of monthly finance and performance reports. These are considered in detail by the Finance and Performance Committee which is a committee of the Board, chaired by Non-Executive Directors. The Audit Committee receives regular reports from the Trust’s Internal Auditors, KPMG LLP and its External Auditors, Deloitte LLP. The Trust has prepared a one year recovery plan and will be submitting two and five year plans to Monitor during 2015. As part of the plan, the Department of Health has made available a working capital facility to cover any liquidity issues whilst the measures are implemented. Respecting and Protecting Patient Information The Information Governance Steering Group (IGSG) is responsible for reviewing the effectiveness of King’s information governance systems and processes. It reports directly to the Quality and Governance Committee and receives reports from the Patient Records Committee and the Data Quality Steering Group. The IGSG is chaired by King’s Senior Information Risk Owner (SIRO) and members include the Caldicott Guardian, Director of ICT, Information Security Manager, Freedom of Information Lead/Deputy SIRO, Information Governance & Records Manager and Patient Records Service Managers. The IGSG agenda is driven by Information Governance Toolkit requirements. It works to ensure the highest practical standards and systems for the confidential handling of patient information and personal data within King’s. During the year 2014/15 there were five serious incidents related to a confidentiality breach, the details of which and the actions taken are summarised below. Incident 1 Description: August 2014: a computer was discovered to be missing presumed stolen from the Day Surgery Unit, Denmark Hill campus. Computer was password protected and policy in place that data not saved to local drive. Potential risk that data was saved onto local drive, not known how many individuals might be affected, possibly < 500 Action taken by the Trust: reported to ICO. Recommendation made to bring forward a project to prevent data being saved on local computer drives and for local management to improve security measures including Kensington locks, locks on office doors and swipe card restrictions. Further action required by ICO: o/s Incident 2 Description: September 2014: five desktop computers were stolen from a paediatric research area at Denmark Hill campus. Number of people affected not known, but possibly <100. Action taken by Trust: The incident was reported to the police and to the ICO. Physical security measures were reinforced and the project to prevent data being saved on local computer drives commenced, with priority given to areas where incidents have occurred previously. Further action required by ICO: No further action required Incident 3 Description: September 2014: patient handover sheets were left in public area at the Princess Royal Hospital, Bromley, found and handed in promptly by member of the public. Repeat of type incident within 12 month period. <30 people affected. Action taken by Trust: Reported to the ICO. Caldecott Guardian identified the locum responsible and spoke to his agency regarding refreshing his IG training. He then followed up with Trust-wide Communications and specific discussion in the Junior Doctor Forums. 201 Further action required by ICO: No further action required Incident 4 Description: Three sets of interview notes lost from the KCH site of a joint KCH/KCL research project. Action taken by Trust: Full investigation and search carried out, it is considered that the lost information is likely to have been put in the confidential waste. Study protocols have been reviewed. Sensitive information is no longer stored on site; now taken to the study main office at end of each day. All of the study’s staff have taken HSCIC training modules: Introduction to Information Governance and Information Governance: The Beginner's Guide. They have also taken HSCIC’s module on Secure Handling of Confidential Information. Further action required by ICO: o/s Incident 5 Description: Near miss; blood test results for 120 patients faxed in error to another hospital via NHS mail’s secure faxing service. Error immediately identified by other hospital and originator informed. Fax went to secure area at receiver Trust and was immediately contained, reported and securely destroyed thus preventing any disclosure of confidential information. Action taken by Trust: Review of protocols and guidance about the use of fax. Corporate risk register entry review. Further action required by ICO: o/s 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. 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. 202 The Board’s clinical plans and core quality priorities have been developed in consultation with a wide range of internal and external stakeholders including senior clinical teams, Commissioners, Health Overview and Scrutiny Committees, Healthwatch Governors and members of the enlarged organisation. The Board receives regular reports on all aspects of quality through monthly performance reports and scorecards, and quarterly reports on patient safety, patient outcomes and patient experience and organisational safety. The Board also receives a separate quarterly Quality and Governance Report which includes detailed analyses of all serious complaints and adverse incidents together with actions taken and related service developments/ improvements. The Board considers the Assurance Framework and the Trust Risk Register on a quarterly basis and agrees actions as necessary to mitigate risks. The data included within the Quality Report is subject to audit by both internal and external audit to assure the Board that the underlying data is robust. This is supplemented by regular clinical audits of data within specialities and national audits. Further information on the data included in the Quality Report can be found on pages 103-190. A review of elective waiting data (Referral to Treatment Time) by KPMG revealed some weaknesses in accurately recording the date patients are placed on the waiting list. In order to address these issues, the Trust has appointed a RTT coordinator to oversee the process. The Quality & Governance Committee monitors the three dimensions of quality, Patient Safety, Patient Outcomes which addresses clinical audit and effectiveness, Patient Experience and Organisational Safety through a series of management committees chaired by executive directors. This is underpinned by a robust performance management and reporting structure which provides the Board and the Corporate and Divisional management teams with up to date information of the key quality indicators. This enables a strong Board focus on all aspects of quality and is the vehicle through which the Trust’s quality priorities and Monitor’s Quality Governance Framework are monitored. The Trust’s centralised patient safety, clinical effectiveness, patient experience and assurance teams work closely together, to ensure that the processes for the identification, analysis, monitoring and reporting of quality issues are robust, systematic and responsive to the changes in the regulatory environment. 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 Trust Board, the Audit Committee, the Finance and Performance Committee and the Quality and Governance Committee and a plan to address weaknesses and ensure continuous improvement of the system is in place. The Board reviews the proceedings of all its committees at every meeting and considers and approves the arrangements for risk management in the Trust including the risk framework incorporated in the Trust’s Risk Management Strategy. Committee chairs draw the Board’s attention to any matters arising from the proceedings of their committees which have risk implications at each Board meeting. All Board committees produce an annual report and Committee Self-Assessment which covers establishment, composition, reporting structure, the work plan, resources and meeting arrangements which are reviewed by the Board. The Internal Auditors issued one report in the year which gave a rating of ‘No Assurance’ to the system of appointing short term administrative staff. This was due to the authorisation process not being correctly followed in a significant number of cases. The Trust has re-emphasised the correct process and instigated additional controls to prevent this from happening in the future. Conclusion No significant internal control issues have been identified by either the Trust’s internal processes or by assurance reviews undertaken by external bodies with the exception of the findings of the Monitor investigation review in relation to the PRUH and the consequent effect on the Trust’s overall financial and operational stability and the two areas of reduced assurance identified by Internal Audit, which are outlined above. Signed: Roland Sinker Acting Chief Executive Officer Date: 26 May 2015 203 Independent Auditor’s financial statements of King’s College Hospital NHS Foundation Trust In our opinion the financial statements: give a true and fair view of the state of the Group and Trust’s affairs as at 31 March 2015 and of the Group’s and Trust’s income and expenditure for the year then ended; have been properly prepared in accordance with the accounting policies directed by Monitor – Independent Regulator of NHS Foundation Trusts; and have been prepared in accordance with the requirements of the National Health Service Act 2006. The financial statements comprise the Group Statement of Comprehensive Income, the Group and Trust Balance Sheets, the Group and Trust Statements of Cash Flow, the Group and Trust Statements of Changes in Taxpayers’ Equity and the related notes 1 to 28. The financial reporting framework that has been applied in their preparation is applicable law and the accounting policies directed by Monitor – Independent Regulator of NHS Foundation Trusts. Emphasis of matter – Going concern We have considered the adequacy of the disclosures made in the directors’ statement contained within the Strategic Report on page 29 and the disclosures made in Note 1 in respect of the Group’s ability to continue as a going concern. The Group incurred a net deficit of £51.9m during the year ended 31 March 2015 and is projecting a further significant deficit for 2015/16 of £70.5m, together with a cost improvement plan of £86.3m. The Group has identified additional funding of £80m is required before the end of 2015/16 to 204 support the Trust, £59.7m of which has been agreed. 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, the forecasted deficit and reliance on future funding being arranged indicate the existence of a material uncertainty which may give rise to significant doubt over the Group’s ability to continue as a going concern. The financial statements do not include the adjustments that would result if the Group was unable to continue as a going concern. We describe below how the scope of our audit has responded to this risk. Our opinion is not modified in respect of this matter. Qualified 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 Audit Code for NHS Foundation Trusts except that: we have qualified our conclusion on the quality report in respect of the 18 week referral to treatment incomplete pathways indicator; and as noted in the section ‘matters on which we are required to report by exception’, we have been unable to conclude that King’s College Hospital NHS Foundation Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. 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. Risk Going concern Given the uncertainties in respect of the Group’s funding and reliance of external funding, which are explained above in the Emphasis of matter - Going concern, we considered going concern to be a significant risk. The Group is forecasting a deficit of £70.5m for 2015/16 and discussions with management have highlighted the requirement to obtain further funding before the end of 2015/16 to support the Group. How the scope of our audit responded to the risk We reviewed the Group’s financial performance in 2014/15 including its achievement of planned cost improvements in the year. We held discussion with management to understand the funding arrangements that have been agreed, confirming to signed loan agreements. Discussions were held regarding management’s expectation around further funding requirements. We reviewed the Group’s cash flow forecasts and the Group’s financial plan submitted to Monitor. We held discussions with management to understand the current status of contract negotiations with its commissioners. We reviewed the annual report and financial statement disclosures in Note 1 made by the Group in respect of the material uncertainties in respect of going concern. We have included an emphasis of matter paragraph above in respect of this matter. NHS revenue and provisions In 2014/15, income from activities amounted to £888m as per Note 2, with NHS debt of £62m. Of this debt, £13m has been provided for. There are significant judgments 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 and Commissioning for Quality and Innovation revenue to recognise the judgemental nature of provisions for disputes with commissioners and other counterparties. The settlement of income with CCGs continues to present challenges, leading to disputes and delays in the agreement of year end positions. We evaluated the design and implementation of controls over recognition of Payment by Results income, with IT specialists performing the testing of the systems controls. We performed detailed substantive testing of the recoverability of overperformance income and adequacy of provision for underperformance through the year, and evaluated the results of the agreement of balances exercise. 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. 205 Risk How the scope of our audit responded to the risk We reviewed the key changes and any open areas in setting 2015-16 tariffs, and considered whether, taken together with the settlement of current year disputes, there were any indicators of inappropriate adjustments in revenue recognised between periods. Property valuations At the beginning of 2014/15 the Group held property assets of £445m within Property, Plant and Equipment at a modern equivalent use valuation and £75.7m of land, as per Note 10. The valuations are by nature significant estimates which are based on specialist and management assumptions and which can be subject to material changes in value. In the current year the Trust had a net revaluation gain of £2.4m to land and £14.4m to buildings and dwellings. We evaluated the design and implementation of controls over property valuations, and tested the accuracy and completeness of data provided by the Group to the valuer. We used internal valuation specialists to review and challenge the appropriateness of the key assumptions used in the valuation of the Group’s properties, including through benchmarking against revaluations performed by other Trusts in 2014/15. We assessed whether the valuation and the accounting treatment of the uplift was compliant with the relevant accounting standards, and in particular whether impairments should be recognised in the Income Statement or in Other Comprehensive Income. The description of risks above should be read in conjunction with the significant issues considered by the Audit Committee discussed on page 71. Our audit procedures relating to these matters were designed in the context of our audit of the financial statements as a whole, and not to express an opinion on individual accounts or disclosures. Our opinion on the financial statements is not modified with respect to any of the risks described above, and we do not express an opinion on these individual matters. 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. 206 We determined materiality for the Group to be £8.7m, which is below 1% of revenue and below 3% of equity. We agreed with the Audit Committee that we would report to the Committee all audit differences in excess of £173,000, as well as differences below that threshold that, in our view, warranted reporting on qualitative grounds. We also report to the Audit 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 group audit was scoped by obtaining an understanding of the Group and its environment, including internal controls, and assessing the risks of material misstatement at the Group level. The focus of our audit work was on the Trust, with work performed at the Trust’s head offices in Denmark Hill. All testing for the Group was performed by the main audit engagement team, led by the audit partner. The Trust’s subsidiaries were also subject to a full audit. These entities account for 0.2% of the group’s net assets and 1.7% of the group’s deficit. They were also selected to provide an appropriate basis for undertaking audit work to address the risks of material misstatement identified above. Our audit work was executed at levels of materiality applicable to each individual entity which were lower than group materiality and ranged from £1,200 to £30,400 (2014 £1,400 to £23,200). At the Group level we also tested the consolidation process and carried out analytical procedures to confirm our conclusion that there were no significant risks of material misstatement of the aggregated financial information of the remaining components not subject to audit or audit of specified account balances. 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 part of the Directors’ Remuneration Report to be audited has been properly prepared in accordance with the National Health Service Act 2006; and the information given in the Strategic Report and the Directors’ Report for the financial year for which the financial statements are prepared is consistent with the financial statements. Matters on which we are required to report by exception Use of resources The Group has described the following matters in its Annual Governance Statement which we consider to be relevant to the Group’s arrangements to secure economy, efficiency and effectiveness: the risks to the Group in respect of its financial performance and liquidity in 2014/15 and plan for 2015/16; the Monitor financial risk rating as at 31 March 2015 and those forecasted for 2015/16; the enforcement actions taken by Monitor in March 2015; weaknesses in the Trust’s arrangements to ensure the quality of reported data. As a result of these matters, we have been unable to conclude that King’s College Hospital NHS Foundation Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. Annual Governance Statement and compilation of financial statements Under the Audit Code for NHS Foundation Trusts, 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 have nothing to report in respect of these matters. 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. 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: 207 materially inconsistent with the information in the audited financial statements; apparently materially incorrect based on, or materially inconsistent with, our knowledge of the Group acquired in the course of performing our audit; or otherwise misleading. In particular, we have considered 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 the 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 Audit Code for NHS Foundation Trusts and International Standards on Auditing (UK and Ireland). Those standards require us to comply with the Auditing Practices Board’s Ethical Standards for Auditors. 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 King’s College Hospital NHS Foundation Trust, as a body, in accordance with paragraph 4 of Schedule 10 of the National Health Service Act 208 2006. 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. 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 Group’s and 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 FCA (Senior statutory auditor) for and on behalf of Deloitte LLP Chartered Accountants and Statutory Auditor St Albans, United Kingdom 28 May 2015 Consolidated Statement of Comprehensive Income for year ended 31 March 2015 note Operating income and costs Operating income from continuing operations Operating expenses from continuing operations Operating surplus Finance income and costs Finance income Finance expense - financial liabilities Finance expense - unwinding of discount on provisions Public Dividend Capital Dividends payable Net finance costs Share of profit of Associates/Joint Ventures accounted for using the equity method Gain from transfer by absorption 2 1,083,782 3 (1,099,712) (15,930) 892,054 (871,87 5) 20,179 5 6 18 213 (25,252) (153) (11,450) (36,642) 169 (17,059) (165) (10,195) (27,250) 757 - 1,278 65,542 (250) (52,065) 59,749 (52,065) 59,749 (5,595) 26,261 (280) (31,679) (2,139) 59,758 117,368 (52,065) (52,065) 59,749 59,749 11.2 Movement in fair value of investment property and other investments Corporate tax expense (Deficit)/surplus from continuing operations (Deficit)/surplus of discontinued operations and the gain/loss on disposal of discontinued operations (Deficit)/surplus for the year Other comprehensive income, that will not be reclassified subsequently to income and expenditure Impairments Revaluations Share of comprehensive income from associates and joint ventures Other recognised gains and losses Remeasurements of net defined benefit pension scheme liability/asset Other reserve movements Fair value gains/(losses) on available-for-sale financial investments Recycling gains/(losses) on available-for-sale financial investments Total comprehensive (expense)/income for the year Allocation of (losses)/profits for the year (a) (Deficit)/surplus for the year attributable to: (i) non-controlling interest; and (ii) owners of the parent Total Group 2014-15 2013-14 £000 £000 7 21 (b) Total comprehensive (expense)/income for the year attributable to: (i) non-controlling interest; and (31,679) 117,368 (ii) owners of the parent Total (31,679) 117,368 The Trust has taken advantage of the exception afforded by the Companies Act to omit the Statement of Comprehensive Income for the Foundation Trust parent. The deficit relating to the parent Trust for the year ended 31 March 2015 is £59.409m (2014: surplus £61.623m). 209 Statements of Financial Position as at 31 March 2015 note Non-current assets Intangible assets Property, plant and equipment Investment property Investment in associates (and joint controlled operations) Other investments Trade and other receivables Other financial assets Other assets Total non-current assets Current assets Inventories Trade and other receivables Other financial assets Non-current assets for sale and assets in disposal groups Cash and cash equivalents Total current assets Total assets Current liabilities Trade and other payables Borrowings Other financial liabilities Provisions Other liabilities Total current liabilities Financed by: Taxpayers' equity Public Dividend Capital Revaluation reserve Available for sale investments reserve Other reserves Merger reserves Income and expenditure reserve Total taxpayers' equity Trust 31 March 2015 £000 31 March 2014 £000 9 10 11 3,495 612,695 - 1,769 571,616 - 3,495 612,695 - 1,769 571,616 - 11 4,386 7,272 627,848 3,598 4,167 581,150 250 8,645 625,085 250 5,278 578,913 17,090 98,040 - 15,292 118,135 - 17,090 99,046 - 15,292 118,390 - 43,445 158,575 786,423 54,535 187,962 769,112 42,663 158,779 783,848 54,185 187,867 766,780 (164,095) (7,624) (1,239) (10,189) (183,147) (137,329) (4,289) (1,144) (9,989) (152,751) (163,944) (7,435) (1,239) (10,189) (182,807) (137,240) (4,289) (1,144) (9,989) (152,662) (24,572) 603,276 35,211 616,361 (24,008) 601,077 35,205 614,118 (222,570) (6,295) (228,865) 374,411 (206,565) (6,886) (213,451) 402,910 (221,082) (6,295) (227,377) 373,700 (204,882) (6,886) (211,768) 402,350 231,316 165,236 (22,141) 374,411 228,136 144,997 29,777 402,910 231,316 165,236 (22,852) 373,700 228,136 144,997 29,217 402,350 13 12 13 14 15 17 18 16 Net current (liabilities)/assets Total assets less current liabilities Non-current liabilities Trade and other payables Borrowings Other financial liabilities Provisions Other liabilities Total non-current liabilities Total assets employed: Group 31 March 31 March 2015 2014 £000 £000 17 18 The notes on pages 11 to 49 form part of these accounts. The financial statements on pages 191-257 were approved and authorised for issue by the Board on 26 May 2015 and signed on its behalf by: Signed: Roland Sinker Date: 26 May 2015 Acting Chief Executive 210 Statement of Changes in Taxpayers' Equity for the year ended 31 March 2015 Public Dividend Capital £000 Income and expenditure reserve £000 Revaluation reserve £000 Total reserves £000 228,136 - 29,777 (52,065) 144,997 - 402,910 (52,065) Transfers by normal absorption: transfers between reserves - - - - Impairments - - (5,595) (5,595) Revaluations - property, plant and equipment - - 26,261 26,261 Transfer to retained earnings on disposal of assets - 427 (427) - Share of comprehensive income from associates and joint ventures - - - - Gains/losses on available-for-sale financial investments - - - - Other recognised gains and losses - - - - 2,900 - - 2,900 Public Dividend Capital repaid - - - - Public Dividend Capital written off - - - - 280 (280) - - Balance at 31 March 2015 231,316 (22,141) 165,236 374,411 Balance at 1 April 2013 Surplus for the year 135,678 - 35,132 59,749 87,536 - 258,346 59,749 65,262 (65,542) 280 - Impairments - - (2,139) (2,139) Revaluations - property, plant and equipment - - 59,758 59,758 Transfer to retained earnings on disposal of assets - 438 (438) - Share of comprehensive income from associates and joint ventures - - - - Gains/losses on available-for-sale financial investments - - - - Other recognised gains and losses - - - - 27,196 - - 27,196 Public Dividend Capital repaid - - - - Public Dividend Capital written off - - - - Other reserve movements - - - - 228,136 29,777 144,997 402,910 Group Balance at 1 April 2014 Deficit for the year Public Dividend Capital received Other reserve movements Transfers by normal absorption: transfers between reserves Public Dividend Capital received Balance at 31 March 2014 211 Statement of Changes in Taxpayers' Equity for the year ended 31 March 2015 Public Dividend Capital £000 Income and expenditure reserve £000 Revaluation reserve £000 Total reserves £000 228,136 - 29,312 (52,490) 144,997 - 402,445 (52,490) Transfers by normal absorption: transfers between reserves - - - - Impairments - - (5,595) (5,595) Revaluations - property, plant and equipment - - 26,261 26,261 Transfer to retained earnings on disposal of assets - 427 (427) - Share of comprehensive income from associates and joint ventures - - - - Gains/losses on available-for-sale financial investments - - - - Other recognised gains and losses - - - - 2,900 - - 2,900 Public Dividend Capital repaid - - - - Public Dividend Capital written off - - - - 280 (280) - - Balance at 31 March 2015 231,316 (23,031) 165,236 373,521 Balance at 1 April 2013 Surplus for the year 135,678 - 35,711 58,705 87,536 - 258,925 58,705 65,262 (65,542) 280 - Impairments - - (2,139) (2,139) Revaluations - property, plant and equipment - - 59,758 59,758 Transfer to retained earnings on disposal of assets - 438 (438) - Share of comprehensive income from associates and joint ventures - - - - Gains/losses on available-for-sale financial investments - - - - Other recognised gains and losses - - - - 27,196 - - 27,196 Public Dividend Capital repaid - - - - Public Dividend Capital written off - - - - Other reserve movements - - - - 228,136 29,312 144,997 402,445 Trust Balance at 1 April 2014 Deficit for the year Public Dividend Capital received Other reserve movements Transfers by normal absorption: transfers between reserves Public Dividend Capital received Balance at 31 March 2014 212 Statement of Cash Flows for the year ended 31 March 2015 Group Note Cash flows from operating activities Operating (deficit)/surplus from continuing operations Operating (deficit)/surplus from discontinued operations Operating (deficit)/surplus Non-cash income and expense Depreciation and amortisation Impairments loss on disposal Decrease/(increase) in trade and other receivables Increase in inventories Increase in trade and other payables Increase in other liabilities Decrease in provisions Tax paid Other movements in operating cash flows Net cash generated from operations Cash flows from investing activities Interest received Purchase of intangible assets Sales of intangible assets Purchase of property, plant and equipment Sales of property, plant and equipment Cash flows attributable to acquisitions or disposals of business units and subsidiaries (not absorption transfers) Net cash used in investing activities Cash flows from financing activities Public Dividend Capital received Loans received from the Independent Trust Financing Facility Other loans received Loans repaid to the Independent Trust Financing Facility Other loans repaid Capital element of PFI and other service concession payments Other capital receipts Interest paid Interest element of PFI and other service concession obligations PDC dividend paid Cash flows attributable to financing activities of discontinued operations Net cash (used in)/generated from financing activities (Decrease)/increase in cash and cash equivalents Cash and cash equivalents at 1 April Cash and cash equivalents transferred by normal absorption Cash and cash equivalents at 31 March Trust 2014-15 £000 2013-14 £000 2014-15 £000 2013-14 £000 (15,930) (15,930) 20,179 20,179 (15,609) (15,609) 20,477 20,477 22,154 4,535 285 17,257 (1,798) 28,882 200 (649) (250) (37) 54,649 16,925 2,648 430 (70,647) (1,739) 47,434 4,437 (2,775) 2 16,894 22,154 4,535 285 16,779 (1,798) 28,821 200 (649) (250) 54,468 16,925 2,648 430 (70,803) (1,739) 47,362 4,437 (2,775) 16,962 213 (2,664) (46,614) 131 169 (804) (34,068) 17 147 (2,664) (46,614) 131 104 (804) (34,068) 17 (48,934) (1,504) (36,190) (3,125) (52,125) (34,751) 2,900 27,196 2,900 27,196 22,000 (1,012) (78) 33,600 1,683 (1,012) (123) 22,000 2,864 (1,012) (78) 33,600 (1,012) (123) (3,199) 95 (1,452) (2,005) 168 (730) (3,199) 95 (1,375) (2,005) 168 (730) (23,443) (12,616) (16,310) (9,138) (23,443) (12,616) (16,310) (9,138) (16,805) 33,329 (13,864) 31,646 (11,090) 14,033 (11,522) 13,857 54,535 43,445 40,502 54,535 54,185 42,663 40,328 54,185 213 Notes to the accounts 1. Accounting policies Monitor has directed that the financial statements of NHS foundation trusts shall meet the accounting requirements of the Foundation Trust Annual Reporting Manual (FT ARM), which shall be agreed with HM Treasury. Consequently, the following financial statements have been prepared in accordance with the FT ARM 2014-15 issued by Monitor. The accounting policies contained in that manual follow International Financial Reporting Standards (IFRS) and HM Treasury's Financial Reporting Manual (the FReM) to the extent that they are meaningful and appropriate to NHS foundation trusts. They have been applied consistently in dealing with items considered material in relation to the accounts. 1.1. Accounting convention These accounts have been prepared under the historical cost convention modified to account for the revaluation of property, plant and equipment, intangible assets, inventories and certain financial assets and financial liabilities. 1.2. Acquisitions and discontinued operations Activities are considered to be ‘acquired’ only if they are taken on from outside the public sector. Activities are considered to be ‘discontinued’ only if they cease entirely. They are not considered to be ‘discontinued’ if they transfer from one public sector body to another. 214 consolidated within the entity's financial statements. In accordance with IAS 1 Presentation of Financial Statements, restated prior period accounts are presented where the adoption of the new policy has a material impact. The King's College Hospital Charity is an independent charity and is not under the control of the Foundation Trust. Therefore, the charity has not been consolidated within these accounts. 1.4. Subsidiaries Subsidiary entities are those over which the Foundation Trust is exposed to, or has rights to, variable returns from its involvement with the entity and has the ability to affect those returns through its power over the entity. The income, expenses, assets, liabilities, equity and reserves of subsidiaries are consolidated in full into the appropriate financial statement lines. The capital and reserves attributable to non-controlling interests are included as a separate item in the Statement of Financial Position. The amounts consolidated are drawn from the draft financial statements of the subsidiaries for the year. Where subsidiaries' accounting policies are not aligned with those of the Foundation Trust then the amounts are adjusted during consolidation where the differences are material. 1.3. Charitable funds The Foundation Trust has a wholly owned subsidiary company, KCH Commercial Services Ltd, who wholly own Agnentis Ltd and KCH Management Ltd. The accounts for this company have been consolidated into the Foundation Trust annual accounts. For 2014-15, the divergence from the FReM that NHS charitable funds are not consolidated with NHS Foundation trusts' own returns is removed. Under the provisions of IAS 27 Consolidated and Separate Financial Statements, those charitable funds that fall under common control with NHS bodies are The primary statements and notes to the accounts have been presented with separate 'Group' and 'Trust' columns. The Trust has taken advantage of the exemption afforded by the Companies Act to omit the Statement of Comprehensive Income for the Foundation Trust parent. The deficit relating to the parent Trust for the year ended 31 March 2015 is £52.490m (2014 : surplus £58.705m). Where the difference between the 'Group' and 'Trust' figures is considered immaterial, the 'Trust' version of the note has been omitted. 1.5. Associates Associate entities are those over which the foundation trust has power to exercise a significant influence. Associate entities are recognised in the foundation trust's financial statements using the equity method. The investment is initially recognised at cost. It is increased or decreased subsequently to reflect the foundation trust's share of the entity's profit or loss or other gains and losses (e.g. revaluation gains on the entity's property, plant or equipment) following acquisition. It is also reduced when any distribution (e.g. share dividends) are received by the foundation trust from the associate. 1.6. Joint ventures Joint ventures are arrangements in which the Trust has joint control with one or more other parties, and where it has the rights to the net assets of the arrangement. Joint ventures are accounted for using the equity method. 1.7. Joint operations Joint operations are arrangements in which the Trust has joint control with one or more other parties, and has the rights to the assets, and obligations for the liabilities, relating to the arrangement. The foundation trust includes within its financial statements its share of the assets, liabilities, income and expenses. 1.8. Income Income in respect of services provided is recognised when, and to the extent that, performance occurs and is measured at the fair value of the consideration receivable. The main source of income for the foundation trust is contracts with commissioners in respect of health care services provided under the Department of Health's Payment by Results rules-based system and local agreements for non-mandatory tariff activity. Where income is received for a specific activity which is to be delivered in the following financial year, that income is deferred. Income from the sale of non-current assets is recognised only when all material conditions of sale have been met, and is measured as the sums due under the sale contract. The foundation trust has accounted for income for incomplete spells of patient activity at 31 March. The work in progress is derived from patients admitted before the year end but not discharged as at 31 March. The calculation is based on the number of bed days and the average bed price. The foundation trust receives income under the NHS Injury Cost Recovery Scheme, designed to reclaim the cost of treating injured individuals to whom personal injury compensation has subsequently been paid e.g. by an insurer. The foundation trust recognises the income when it receives notification from the Department of Work and Pensions' Compensation Recovery Unit that the individual has logged a compensation claim. The income is measured at the agreed tariff for the treatments provided to the injured individual, less a provision for unsuccessful compensation claims and doubtful debts. 1.9. Expenditure on employee benefits Short-term employee benefits Salaries, wages and employment-related payments are recognised in the period in which the service is received from employees. The cost of annual leave entitlement earned 215 but not taken by employees at the end of the period is recognised in the financial statements to the extent that employees are permitted to carry-forward leave into the following period. Pension costs Past and present employees are covered by the provisions of the NHS Pension Scheme. The Scheme is an unfunded, defined benefit scheme that covers NHS employers, general practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. It is not possible for the foundation trust to identify its share of the underlying scheme liabilities. Therefore, the scheme is accounted for as a defined contribution scheme. Employers pension cost contributions are charged to operating expenses as and when they become due. Additional pension liabilities arising from early retirements are not funded by the scheme except where the retirement is due to illhealth. The full amount of the liability for the additional costs is charged to operating expenses at the time the foundation trust commits itself to the retirement, regardless of the method of payment. 1.10. Expenditure on other goods and services Expenditure on goods and services is recognised when, and to the extent that they have been received, and is measured at the fair value of those goods and services. Expenditure is recognised in operating expenses except where it results in the creation of a non-current asset such as property, plant and equipment. 1.11. Property, plant and equipment Recognition 216 Property, plant and equipment is capitalised if: it is held for use in delivering services or for administrative purposes; it is probable that future economic benefits will flow to, or service potential will be supplied to the foundation trust; it is expected to be used for more than one financial year; the cost of the item can be measured reliably; and the item has cost of at least £5,000; or collectively, a number of items have a cost of at least £5,000 and individually have a cost of more than £250, where the assets are functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under single managerial control; or items form part of the initial equipping and setting-up cost of a new building, ward or unit, irrespective of their individual or collective cost. Where a large asset, for example a building, includes a number of components with significantly different asset lives, the components are treated as separate assets and depreciated over their own useful economic lives. Valuation All property, plant and equipment is measured initially at cost, representing the cost directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the manner intended by management. All assets are measured subsequently at fair value. Land and buildings are stated in the statement of financial position at their revalued amounts, being the fair value at the date of revaluation less any impairment. Revaluations are performed with sufficient regularity to ensure that carrying amounts are not materially different from those that would be determined at the end of the reporting period. Fair values are determined as follows: land and non-specialised buildings – market value for existing use; and specialised buildings – depreciated replacement cost. Properties in the course of construction for service or administration purposes are carried at cost, less any impairment loss. Cost includes professional fees but not borrowing costs, which are recognised as expenses immediately, as allowed by IAS 23 for assets held at fair value. Assets are revalued and depreciation commences when they are brought into use. Operational equipment other than IT equipment, which is considered to have nil inflation, is valued at net current replacement cost through annual uplift by the change in the value of the GDP deflator. Equipment surplus to requirements is valued at net recoverable amount. All land and buildings are restated to fair value using professional valuations in accordance with IAS16 every five years. A three year interim revaluation is also carried out. The last asset valuations were undertaken in 2014 as at the prospective valuation date at 31 March 2015. Valuations are carried out by professionally qualified valuers in accordance with the Royal Institute of Chartered Surveyors (RICS) Appraisal and Valuation Manual. The valuations are carried out primarily on the basis of Depreciated Replacement Cost (DRC) for specialised operational property (e.g. NHS patient treatment facilities) and Existing Use Value for non-specialised operational property. The value of land for existing use purposes is assessed at Existing Use Value. For non-operational properties including surplus land, the valuations are carried out at Market Value. The Department of Health has adopted the Modern Equivalent Asset approach (MEA) for its DRC valuations rather than continuing with identical replacement. The MEA approach used to value the property will normally be based on the cost of a modern equivalent asset that has the same service potential as the existing asset and then adjusted to take account of obsolescence. In the past, functional obsolescence has not been reflected in asset valuations for the NHS. Functional obsolescence examines a building’s design or specification and whether it may no longer fulfil the function for which it was originally designed or whether it may be much more basic than the MEA. The asset will still be capable of use but at a lower level of efficiency than the modern equivalent asset, or may be capable of modification to bring it up to a current specification. Other common causes of functional obsolescence include advances in technology or legislative change. The obsolescence adjustment will reflect either the cost of upgrading, or if this is not possible, the financial consequences of the reduced efficiency compared with the modern equivalent. The MEA approach incorporates the Building Cost Information Service Index to determine an increase or decrease in building costs which impact on the asset valuation. Additional alternative Open Market Value figures have only been supplied for operational assets scheduled for imminent closure and subsequent disposal. The carrying values of property, plant and equipment are reviewed for impairment in 217 periods if events or changes in circumstances indicate the carrying value may not be recoverable. The costs arising from financing the construction of the property, plant and equipment are not capitalised but are charged to the Statement of Comprehensive Income in the year to which they relate. All impairments resulting from price changes are charged to the Statement of Comprehensive Income. If the balance on the revaluation reserve is less than the impairment the difference is taken to the Statement of Comprehensive Income. The valuation included the Foundation Trust's PFI scheme. Subsequent expenditure Subsequent expenditure relating to an item of property, plant and equipment is recognised as an increase in the carrying amount of the asset when it is probable that additional future economic benefits or service potential deriving from the cost incurred to replace a component of such item will flow to the enterprise and the cost of the item can be determined reliably. Where a component of an asset is replaced, the cost of the replacement is capitalised if it meets the criteria for recognition above. The carrying amount of the part replaced is derecognised. Other expenditure that does not generate additional future economic benefits or service potential, such as repairs and maintenance, is charged to the Statement of Comprehensive Income in the period in which it is incurred. Depreciation Items of property, plant and equipment are depreciated over their remaining useful economic lives in a manner consistent with the consumption of economic or service delivery benefits. Freehold land is considered to have an infinite life and is not depreciated. Property, plant and equipment which has been reclassified as 'Held for Sale' ceases to 218 be depreciated upon the reclassification. Assets in the course of construction and residual interests in off-Statement of Financial Position PFI contract assets are not depreciated until the asset is brought into use or reverts to the foundation trust, respectively. Buildings, installations and fittings are depreciated on their current value over the estimated remaining life of the asset as advised by the District Valuer. Leaseholds are depreciated over the primary lease term. Equipment is depreciated on current cost evenly over the useful economic life of the asset. Standard useful economic lives are estimated for each major category of equipment and individual lives will only be applied where it is clear that the standard lives are materially inappropriate. The major categories and their useful economic lives are: vehicles - 7 years; furniture - 10 years; office and IT equipment - 5 years; soft furnishings - 7 years; short life medical and other equipment - 5 years; medium life medical equipment - 10 years; long life medical equipment - 15 years; mainframe-type IT installations - 8 years. Revaluation gains and losses Revaluation gains are recognised in the revaluation reserve, except where, and to the extent that, they reverse a revaluation decrease that has previously been recognised in operating expenses, in which case they are recognised as operating income. Revaluation losses are charged to the revaluation reserve to the extent that there is an available balance for the asset concerned, and thereafter charged to operating expenses. Gains and losses recognised in the revaluation reserve are reported in the Statement of Comprehensive Income as an item of 'other comprehensive income'. Impairments In accordance with the ARM, impairments that arise from a clear consumption of economic benefits or service potential in the asset are charged to operating expenses. A compensating transfer is made from the revaluation reserve to the income and expenditure reserve of an amount equal to the lower of (i) the impairment charged to operating expenses; and (ii) the balance in the revaluation reserve attributable to that asset before the impairment. An impairment that arises from a clear consumption of economic benefit or service potential is reversed when, and to the extent that, the circumstances that gave rise to the loss is reversed. Reversals are recognised in operating income to the extent that the asset is restored to the carrying amount it would have had if the impairment had never been recognised. Any remaining reversal is recognised in the revaluation reserve. Where, at the time of the original impairment, a transfer was made from the revaluation reserve to the income and expenditure reserve, an amount is transferred back to the revaluation reserve when the impairment reversal is recognised. Other impairments are treated as revaluation losses. Reversals of 'other impairments' are treated as revaluation gains. De-recognition Assets intended for disposal are reclassified as ‘Held for Sale’ once all of the following criteria are met: the asset is available for immediate sale in its present condition subject only to terms which are usual and customary for such sales; and the sale must be highly probable. As at 31 March 2015, the foundation trust did not hold any assets intended for disposal. Donated, government grant or other grantfunded assets Donated and grant funded property, plant and equipment assets are capitalised at their fair value on receipt. The donation/grant is credited to income at the same time, unless the donor has imposed a condition that the future economic benefits embodied in the grant are to be consumed in a manner specified by the donor, in which case, the donation/grant is deferred within liabilities and is carried forward to future financial years to the extent that the condition has not yet been met. The donated and grant funded assets are subsequently accounted for in the same manner as other items of property, plant and equipment. Private finance initiative (PFI) transactions PFI transactions which meet the IFRIC 12 definition of a service concession, as interpreted in HM Treasury’s FReM, are accounted for as “on-Statement of Financial Position” by the trust. In accordance with IAS 17, the underlying assets are recognised as property, plant and equipment at their fair value, together with an equivalent finance lease liability. Subsequently, the assets are accounted for as property, plant and equipment and/or intangible assets as appropriate. The annual contract payments are apportioned between the repayment of the liability, a finance cost and the charges for services. The service charge is recognised in operating expenses and the finance cost is charged to Finance Costs in the Statement of Comprehensive Income. 219 Components of the asset replaced by the operator during the contract (‘lifecycle replacement’) are capitalised where they meet the foundation trust’s criteria for capital expenditure. They are capitalised at the time they are provided by the operator and are measured initially at their fair value. The element of the annual unitary payment allocated to lifecycle replacement is predetermined for each year of the contract from the operator’s planned programme of lifecycle replacement. Where the lifecycle component is provided earlier or later than expected, a short-term finance lease liability or prepayment is recognised respectively. Where the fair value of the lifecycle component is less than the amount determined in the contract, the difference is recognised as an expense when the replacement is provided. If the fair value is greater than the amount determined in the contract, the difference is treated as a ‘free’ asset and a deferred income balance is recognised, and is released to the operating income over the shorter of the remaining contract period or the useful economic life of the replacement component. Assets contributed by the foundation trust for use in the scheme continue to be recognised as items of property, plant and equipment in the foundation trust’s Statement of Financial Position. 1.12. Intangible assets Recognition Intangible assets are non-monetary assets without physical substance, which are capable of sale separately from the rest of the trust’s business or which arise from contractual or other legal rights. They are recognised only when it is probable that future economic benefits will flow to, or service potential be provided to, the trust; where the cost of the asset can be measured reliably. 220 Software Software that is integral to the operating of hardware, for example an operating system, is capitalised as part of the relevant item of property, plant and equipment. Software that is not integral to the operation of hardware, for example application software, is capitalised as an intangible asset. Internally generated intangible assets Internally generated goodwill, brands, mastheads, publishing titles, customer, lists and similar items are not capitalised as intangible assets. Expenditure on research is not capitalised: it is recognised as an operating expense in the period in which it is incurred. Expenditure on development is capitalised only where all of the following can be demonstrated: the technical feasibility of completing the intangible asset so that it will be available for use; the intention to complete the intangible asset and use it; the ability to sell or use the intangible asset; how the intangible asset will generate probable future economic benefits or service potential; the availability of adequate technical, financial and other resources to complete the intangible asset and sell or use it; and the ability to measure reliably the expenditure attributable to the intangible asset during its development. Measurement Intangible assets are recognised initially at cost, comprising all directly attributable costs needed to create, produce and prepare the asset to the point that it is capable of operating in the manner intended by management. Subsequently intangible assets are measured at fair value. Revaluation gains and losses and impairments are treated in the same manner as for Property, Plant and Equipment. Intangible assets held for sale are measured at the lower of their carrying amount or ‘fair value less costs to sell’. Amortisation Intangible assets are amortised over their expected useful economic lives in a manner consistent with the consumption of economic or service delivery benefits. 1.13. Inventories Inventories are valued at the lower of cost and net realisable value. The cost of inventories is measure using the First In, First Out method. This is considered to be a reasonable approximation to current cost due to the high turnover of stocks. 1.14. Cash and cash equivalents Cash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than 24 hours. Cash equivalents are investments that mature in 3 months or less from the date of acquisition and that are readily convertible to known amounts of cash with insignificant risk of change in value. These balances exclude monies held in the Foundation Trust's bank account belonging to patients. Account balances are only set off where a formal agreement has been made with the bank to do so. In all other cases overdrafts are disclosed within payables. Interest earned on bank accounts and interest charged on overdrafts is recorded as, respectively, interest receivable and interest payable in the periods to which they relate. Bank charges are recorded as operating expenditure in the periods to which they relate. 1.15. Financial instruments and financial liabilities Recognition Financial assets and financial liabilities which arise from contracts for the purchase or sale of non-financial items (such as goods or services), which are entered into in accordance with the foundation trust’s normal purchase, sale or usage requirements, are recognised when, and to the extent which, performance occurs, i.e. when receipt or delivery of the goods or services is made. Financial assets or financial liabilities in respect of assets acquired or disposed of through finance leases are recognised and measured in accordance with the accounting policy for leases described below. All other financial assets and financial liabilities are recognised when the Trust becomes a party to the contractual provisions of the instrument. De-recognition All financial assets are de-recognised when the rights to receive cash flows from the assets have expired, or the trust has transferred substantially all of the risks and rewards of ownership. Financial liabilities are de-recognised when the obligation is discharged, cancelled or expires. Classification Financial assets are categorised as Loans and receivables or ‘Available-for-sale financial assets’. Financial liabilities are classified as 'Other Financial liabilities'. Loans and receivables Loans and receivables are non-derivative financial assets with fixed or determinable payments which are not quoted in an active market. They are included in current assets. 221 The foundation trust’s loans and receivables comprise: cash at bank and in hand, NHS debtors, accrued income and ‘other debtors’. Loans and receivables are recognised initially at fair value, net of transactions costs, and are measured subsequently at amortised cost, using the effective interest method. The effective interest rate is the rate that discounts exactly estimated future cash receipts through the expected life of the financial asset or, when appropriate, a shorter period, to the net carrying amount of the financial asset. Interest on loans and receivables is calculated using the effective interest method and credited to the Statement of Comprehensive Income. Available-for-sale financial assets Available-for-sale financial assets are nonderivative financial assets which are either designated in this category or not classified in any of the other categories. They are included in long-term assets unless the Trust intends to dispose of them within 12 months of the Statement of Financial Position date. Available-for-sale financial assets are recognised initially at fair value, including transaction costs, and measured subsequently at fair value, with gains or losses recognised in reserves and reported in the Statement of Comprehensive Income as an item of 'other comprehensive income'. When items classified as ‘available-for-sale’ are sold or impaired, the accumulated fair value adjustments recognised are transferred from reserves and recognised in 'Finance Costs' in the Statement of Comprehensive Income. 222 Financial liabilities All financial liabilities are recognised initially at fair value, net of transaction costs incurred, and measured subsequently at amortised cost using the effective interest method. The effective interest rate is the rate that discounts exactly estimated future cash payments through the expected life of the financial liability or, when appropriate, a shorter period, to the net carrying amount of the financial liability. They are included in current liabilities except for amounts payable more than 12 months after the Statement of Financial Position date, which are classified as long-term liabilities. Interest on financial liabilities carried at amortised cost is calculated using the effective interest method and charged to Finance Costs. Interest on financial liabilities taken out to finance property, plant and equipment or intangible assets is not capitalised as part of the cost of those assets. Determination of fair value For financial assets and financial liabilities carried at fair value, the carrying amounts are determined using discounted cash flow analysis. Impairment of financial assets At the Statement of Financial Position date, the Trust assesses whether any financial assets, other than those held at ‘fair value through income and expenditure’ is impaired. Financial assets are impaired and impairment losses are recognised if, and only if, there is objective evidence of impairment as a result of one or more events which occurred after the initial recognition of the asset and which has an impact on the estimated future cash flows of the asset. For financial assets carried at amortised cost, the amount of the impairment loss is measured as the difference between the asset’s carrying amount and the present value of the revised future cash flows discounted at the asset’s original effective interest rate. The loss is recognised in the Statement of Comprehensive Income and the carrying amount of the asset is reduced through the use of a bad debt provision. The carrying amount of the financial assets is reduced when the outstanding debt is greater than 6 months and payment has not been agreed with the respective debtor. Due to the complexities of Private Patient debt recovery the reduction in these debts is based on outstanding debts greater than one year where payment has not been agreed with the respective debtor. 1.16. Leases Finance leases Where substantially all risks and rewards of ownership of a leased asset are borne by the NHS Foundation Trust, the asset is recorded as property, plant and equipment and a corresponding liability is recorded. The value at which both are recognised is the lower of the fair value of the asset or the present value of the minimum lease payments, discounted using the interest rate implicit in the lease. The asset and liability are recognised at the commencement of the lease. Thereafter the asset is accounted for an item of property plant and equipment. The annual rental is split between the repayment of the liability and a finance cost so as to achieve a constant rate of finance over the life of the lease. The annual finance cost is charged to Finance Costs in the Statement of Comprehensive Income. The lease liability, is de-recognised when the liability is discharged, cancelled or expires. Operating leases Other leases are regarded as operating leases and the rentals are charged to operating expenses on a straight-line basis over the term of the lease. Operating lease incentives received are added to the lease rentals and charged to operating expenses over the life of the lease. Leases of land and buildings Where a lease is for land and buildings, the land component is separated from the building component and the classification for each is assessed separately. 1.17. Provisions The Foundation Trust recognises a provision where it has a present legal or constructive obligation of uncertain timing or amount; for which it is probable that there will be a future outflow of cash or other resources; and a reliable estimate can be made of the amount. The amount recognised in the Statement of Financial Position is the best estimate of the resources required to settle the obligation. Where the effect of the time value of money is significant, the estimated risk-adjusted cash flows are discounted using the discount rates published and mandated by HM Treasury. Clinical negligence costs The NHS Litigation Authority (NHSLA) operates a risk pooling scheme under which the foundation trust pays an annual contribution to the NHSLA which in return settles all clinical negligence claims. The contribution is charged to expenditure. Although the NHSLA is administratively responsible for all clinical negligence cases the legal liability remains with the Foundation Trust. The total value of clinical negligence provisions carried by the NHSLA on behalf of the foundation trust is disclosed at note 18. Non-clinical risk pooling The foundation trust participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the foundation trust 223 pays an annual contribution to the NHS Litigation Authority and, in return, receives assistance with the costs of claims arising. The annual membership contributions, and any excesses payable in respect of particular claims are charged to operating expenses as and when they become due. 1.18. Contingencies A contingent asset is a possible asset that arises from past events and whose existence will be confirmed by the occurrence or nonoccurrence of one or more uncertain future events not wholly within the control of the foundation trust. A contingent asset is disclosed where an inflow of economic benefits is probable. Contingent liabilities are not recognised, but are disclosed in Note 19, unless the probability of a transfer of economic benefits is remote. Contingent liabilities are defined as: possible obligations arising from past events whose existence will be confirmed only by the occurrence of one or more uncertain future events not wholly within the entity's control; or present obligations arising from past events but for which it is not probable that a transfer of economic benefits will arise or for which the amount of the obligation cannot be measured with sufficient reliability. IAS 32. A charge, reflecting the cost of capital utilised by the foundation trust, is payable as public dividend capital dividend. The charge is calculated at the rate set by HM Treasury (currently 3.5%) on the average relevant net assets of the NHS foundation trust during the financial year. Relevant net assets are calculated as the value of all assets less the value of all liabilities, except for: donated assets (including lottery funded assets); average daily cash balances held with the Government Banking Services (GBS) and National Loans Fund (NLF) deposits, excluding cash balances held in GBS accounts that relate to a short-term working capital facility; any PDC dividend balance receivable or payable. In accordance with the requirements laid down by the Department of Health (as the issuer of PDC), the dividend for the year is calculated on the actual average relevant net assets as set out in the ‘pre-audit’ version of the annual accounts. The dividend thus calculated is not revised should any adjustment to net assets occur as a result the audit of the annual accounts. 1.20. Value added tax Where the time value of money is material, contingencies are disclosed at their present value. 224 1.19. Public dividend capital Most of the activities of the Foundation Trust are outside the scope of VAT and, in general, output tax does not apply and input tax on purchases is not recoverable. Public Dividend Capital (PDC) is a type of public sector equity finance based on the excess of assets over liabilities at the time of establishment of the predecessor NHS Trust. HM Treasury has determined that PDC is not a financial instrument within the meaning of Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT. 1.21. Corporation tax The Finance Act 2004 amended S519A Income and Corporation Taxes Act 1988 provided power to the Treasury to make certain non-core activities of Foundation Trusts potentially subject to corporation tax. This legislation is effective from September 12 2005. Any outstanding payments of corporation tax as at the end of the financial year are provided for in the Statement of Comprehensive Income. The Foundation Trust did not incur Corporation Tax in 2014-15 as the Trust did not generate any taxable income. The corporation tax in the accounts relate to the subsidiary. 1.22. Foreign exchange The functional and presentational currencies of the Trust are sterling. A transaction which is denominated in a foreign currency is translated into the functional currency at the spot exchange rate on the date of the transaction. The Foundation Trust does not have material foreign currency transactions. Exchange gains or losses on monetary items (arising on settlement of the transaction or on re-translation at the Statement of Financial Position date) are recognised in income or expense in the period in which they arise. Exchange gains or losses on non-monetary assets and liabilities are recognised in the same manner as other gains and losses on these items. 1.23. Third party assets Assets belonging to third parties (such as money held on behalf of patients) are not recognised in the accounts since the NHS Foundation Trust has no beneficial interest in them. However, third party assets are disclosed in Note 24 to the accounts in accordance with the requirements of the HM Treasury Financial Reporting Manual. 1.24. Losses and special payments Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way that individual cases are handled. Losses and special payments are charged to the relevant functional headings in expenditure on an accruals basis, including losses which would have been made good through insurance cover had NHS bodies not been bearing their own risks (with insurance premiums then being included as normal revenue expenditure). However the losses and special payments note is compiled directly from the losses and compensations register which reports on an accrual basis with the exception of provisions for future losses. 1.25. Segmental analysis The foundation trust has a number of business divisions which are aggregated under one reportable segment being the provision of healthcare. The Foundation Trust provides Private Patient, Research and Development and Training and Education services within this healthcare sector, but as they do not have a material impact they are aggregated under this one reportable segment. Note 2 entitled "Other Operating Income" includes the relevant income figures for these services. 225 The subsidiary figures have not been disclosed separately in this note as the figures have been considered to be not material. the reasons outlined above, including planned reductions in activity commissioned from the Trust and the need to reduce the underlying cost base of the Trust to continuously align capacity and demand. 1.26. Going concern IAS 1 requires management to undertake an assessment of the NHS Foundation’s Trusts ability to continue as a going concern. Due to the materiality of the financial issues, the Board has carefully considered whether the accounts should be prepared on the basis of being a ‘Going Concern’. The Board considered the advice in the Government Reporting Manual that “The anticipated continuation of the provision of a service in the future, as evidenced by inclusion of financial provision for that service in published documents, is normally sufficient evidence of going concern.” The Trust has prepared its financial plans and cash flow forecasts on the assumption that support funding will continue to be received through the Department of Health/Monitor. These funds are expected to be sufficient to prevent the Trust from failing to meet its obligations as they fall due and to continue until adequate plans are in place to achieve financial sustainability for the Trust. The current economic environment for all NHS Trusts and NHS Foundation Trusts is challenging with on-going internal efficiency gains necessary due to annual tariff (price) reductions; cost pressures in respect of national pay structures; non-pay and drug cost inflation; as well as nationally set contract penalties for contract performance deviations, combined with local commissioner (CCG) QIPP targets such as reducing activity through local area networks. The Trust has incurred a deficit of (£52.1m) for the year ended 31 March 2015. The Directors consider that the outlook presents significant challenges in terms of cash-flow for 226 The Trust has secured £59.7m of Interim Revolving Working Capital Support Funding from Monitor/DoH to support the Trust’s revenue position for working capital. This funding will be required for the duration of the financial year whilst the internal savings plans are embedded. The Trust is facing a period of unprecedented change over the coming years and planning undertaken by the Trust has recognised that without significant change, the Trust will remain in deficit during the foreseeable future. Positive cash balances are likely to be maintained throughout the period through successfully securing commitments to necessary funding from external bodies (DoH/Monitor) and contracts with the lead commissioners which give assurance of income flows. The significant risks facing the Trust are summarised as follows: 1) The Trust has prepared a cash flow forecast which shows a minimum level of headroom of £3m. The Trust has developed its financial plans to include the agreed interim funding and thus continue on a going concern basis. 2) There is uncertainty over whether the Trust can deliver its financial plans including efficiency savings of £86m, which has been assumed in its financial plan for 2015/16. This is a level of savings which is extremely challenging and must be supported with adequate clinical focus and engagement in quality process improvement against agreed and appropriately detailed and delivery plans. There is thus a material uncertainty which may cast significant doubt as to the Trust’s ability to continue as a going concern and therefore it may be unable to realise its assets and discharge its liabilities in the normal course of business. The financial statements do not include any adjustments that would result if the going concern basis were not appropriate. After making enquiries, the directors have concluded that there is sufficient evidence that services will be continue to be provided and that there is financial provision within the forward plans of commissioners. This provision will also be dependent on both acceptance and delivery of the financial recovery plans and continuation of support from the Department of Health. The Directors have a reasonable expectation that this will be the case and have therefore prepared these financial statements on a going concern basis. 1.27. Critical accounting judgements and key sources of estimation uncertainty In the application of the foundation trust’s accounting policies, management is required to make judgements, estimates and assumptions about the carrying amounts of assets and liabilities that are not readily apparent from other sources. The estimates and associated assumptions are based on historical experience and other factors that are considered to be relevant. Actual results may differ from those estimates. The estimates and underlying assumptions are reviewed on an on-going basis. Revisions to accounting estimates are recognised in the period in which the estimate is revised if the revision affects only that period or in the period of the revision and future periods if the revision affects both current and future periods. Management has made the following critical judgements in the process of applying the entity’s accounting policies and this has had a significant effect on the amounts recognised in the accounts: 1) Land and buildings have been valued on a modern equivalent asset basis as at 31st March 2015 by an independent professionally qualified valuer (see note 1.11). In between formal valuations, management make judgements about the condition of assets and review their estimated lives; 2) In recognising provisions and in addition to widely used estimation techniques, judgement is required when determining the probable outflow of economic benefits relating to early voluntary retirement pension and injury benefit liabilities; and 3) Management has used their judgement to decide when to write-off receivables or to provide against the probability of not being able to collect debt. The following are the key sources of estimation uncertainty at the end of the reporting period, that have a significant risk of causing a material adjustment to the carrying amounts of assets and liabilities within the next financial year: 1) Clinical Income from activities includes an estimate in respect of income relating to patient care spells that are part-completed at the year end (see note 1.8); 2) Estimations as to the recoverability of receivables have been made in determining the carrying amounts of these assets. 3) The use of estimated asset lives in calculating depreciation (see note 1.11 and 1.12); and 4) Provisions for early voluntary retirement pension contributions and injury benefit obligations are estimated using expected 227 life tables and discounted at the pensions rate of 2.2%. 1.28. Early adoption of standards, amendments and interpretations No new accounting standards or revisions to existing standards have been early adopted in 2014/15. 1.29. Future changes in accounting policy The following changes to standards issued by the IASB have not been implemented in these accounts. The foundation trust does not expect these changes to have a significant impact in the period of initial application. Change published Published by IASB Financial year for which the change first applies IFRS 9 Financial Instruments October 2010 Uncertain. Not likely to be adopted by the EU until the IASB has finished the rest of its financial instruments project. IFRS 13 Fair Value Measurement May 2011 Adoption delayed by HM Treasury. To be adopted from 2015/16. IAS 36 (amendment) – recoverable amount disclosures May 2013 To be adopted from 2015/16 (aligned to IFRS 13 adoption) Annual Improvements 2012 December 2013 Effective from 2015/16 but not yet EU adopted Annual Improvements 2013 December 2013 Effective from 2015/16 but not yet EU adopted IAS 19 (amendment) – employer contributions to defined benefit pension schemes November 2013 Effective from 2015/16 but not yet EU adopted IFRIC 21 Levies May 2013 EU adopted in June 2014 but not yet adopted by HM Treasury. * This reflects the EU-adopted effective date rather than the effective date in the standard. 228 2. Operating income 2. 1 Income from activities by classification Elective income Non-elective income Outpatient income Accident and emergency income Other NHS clinical income* Private Patient income Other non-protected clinical income Total income from activities Other operating income Total operating income Group 2014-15 2013-14 £000 £000 160,444 183,300 153,000 28,000 364,508 12,648 3,703 905,603 178,179 1,083,782 128,598 145,188 122,874 22,028 312,044 13,149 6,157 750,038 142,016 892,054 * Other NHS clinical income includes HIV/AIDS funding, NSCG funding for liver services, bone marrow transplant funding, critical care funding from CCGs, off-tariff drugs and devices, renal dialysis, direct access, community midwifery, community dental services, national screening programmes, RTA funding and IVF services. Other operating income includes the following: Research and development Education and training Received from NHS charities: donations for capital acquisitions Received from NHS charities: other charitable and other contributions to expenditure Non-patient care services to other bodies Other** Rental revenue from operating leases Total Group 2014-15 2013-14 £000 £000 11,474 49,101 134 12,117 49,652 32 10 89,153 26,912 1,395 178,179 312 69,836 9,795 272 142,016 ** Other income includes NHS provider-to-provider services, clinical excellence awards, staff nursery, car parking, accommodation and commercial rents. 2. 2 Income from activities arising from commissioner requested and non-commissioner requested services Under the terms of its Provider License, the trust is required to analyse the level of income from activities that has arisen from commissioner requested and non-commissioner requested services. Commissioner requested services are defined in the provider license and are services that commissioners believe would need to be protected in the event of provider failure. This information is provided in the table below: Group 2014-15 2013-14 £000 £000 Commissioner requested services Non-commissioner requested services Total 911,092 172,690 1,083,782 779,310 112,744 892,054 229 2.3 Operating lease income Rental revenue from operating leases Future minimum lease payments due on leases of buildings expiring - not later than one year - between one and five years - later than five years Total 2.4 Group 2014-15 2013-14 £000 £000 1,395 272 31 March 2015 £000 31 March 2014 £000 1,392 760 2,152 1,230 839 135 2,204 Income from activities by type Group 2014-15 2013-14 £000 £000 NHS Foundation Trusts NHS Trusts Clinical Commissioning Groups and NHS England Department of Health NHS Other (including Public Health England and Prop Co) Non-NHS Local Authorities Private patients Overseas patients (non-reciprocal) Injury costs recovery* Other** Total 1,574 1,313 862,345 7,200 2,123 700 1,382 720,658 1,934 5,136 12,648 3,703 4,277 5,284 905,603 201 13,149 6,157 3,055 2,802 750,038 * NHS Injury Scheme income is subject to a provision for doubtful debts of 18.9% to reflect expected rates of collection. The total outstanding claims against this scheme at 31 March 2015 were £10.403m (31 March 2014: £8.735m), and a provision of £1.966m (31 March 2014: £1.380m) was raised against this amount. ** Non-NHS Other income includes patient care provided to devolved administrations, personal contributions for IVF treatment and services to prisons. 2.5 Income relating to overseas visitors Income recognised this year Cash payments received in-year Amounts added to provision for impairment of receivables Amounts written off in-year 230 Group 2014-15 2013-14 £000 £000 3,703 1,100 2,256 2,305 6,157 1,261 2,381 3,078 3. Operating expenses 3.1 Operating expenses by type Group 2014-15 £000 Drug inventories consumed Supplies and services - clinical Supplies and services - general Establishment Transport Premises Rentals under operating leases - minimum lease payments PFI service costs Clinical negligence Purchase of healthcare from non-NHS bodies Services from NHS bodies NHS Foundation Trusts NHS Trusts Other NHS bodies Non-cash movements on non-current assets Depreciation on property, plant and equipment Amortisation on intangible assets Impairments and reversals of property, plant and equipment Loss on disposal of property, plant and equipment Non-cash movements on provisions Increase in provision for impairment of receivables Audit fees payable to the external auditor Statutory audit Regulatory reporting Other auditor remuneration Non-Executive Director benefits Other* Total operating expenses (excluding employee benefits) Employee benefits Executive Director benefits Other employee benefits Redundancy costs Total employee benefits Total 2013-14 £000 117,959 96,228 3,848 4,538 10,991 26,571 11,998 43,468 20,796 31,970 90,028 79,702 3,453 4,220 9,156 31,215 8,625 39,511 13,336 25,808 6,091 12,399 17 2,403 3,999 2 21,148 1,006 4,535 285 16,226 699 2,648 430 13,333 4,597 128 19 137 52,321 479,794 141 2 155 138 35,814 372,308 1,642 618,276 619,918 1,601 497,966 499,567 1,099,712 871,875 * Other operating expenses include expenditure on consultancy costs, leasing equipment, training and legal fees. 231 3.2 Operating leases Rentals under operating leases include the following: Hire of plant and machinery Rental of buildings Total Group 2014-15 £000 2013-14 £000 8,343 3,655 11,998 6,069 2,556 8,625 2014-15 £000 2013-14 £000 7,809 19,958 1,783 29,550 8,038 22,823 1,336 32,197 3,272 3,544 55 6,871 2,594 5,190 115 7,899 Future minimum lease payments fall due as follows: Hire of plant and machinery - not later than one year - between one and five years - later than five years Total hire of plant and machinery Rental of buildings - not later than one year - between one and five years - later than five years Total rental of buildings 3.3 Better Payment Practice Code - measure of compliance The Better Payment Practice Code requires the Foundation Trust to aim to pay all undisputed invoices by the due date or within 30 days of receipt of goods or a valid invoice, whichever is the earlier. The Foundation Trust's performance against this target was as follows: Group Group 2014-15 2013-14 Number £000 Number £000 Non-NHS trade invoices: 169,034 492,506 Paid in the year 147,920 384,944 90,009 380,084 Paid within target 86,196 304,352 53% 77% Percentage paid within target 58% 79% NHS trade invoices 4,239 139,395 Paid in the year 3,399 108,086 1,685 117,504 Paid within target 1,887 90,460 40% 84% Percentage paid within target 56% 84% 3.4 Late Payment of Commercial Debts (Interest) Act 1998 Compensation paid to cover debt recovery costs under this legislation 3.5 Audit fees (external auditors) There was no limitation on auditor's liability in 2014-15 or in 2013-14. 232 2014-15 £000 2013-14 £000 4 3 4 Employee benefits and staff numbers 4.1 Employee benefits Group 2014-15 Salaries and wages Social security costs Employer contributions to NHS Pensions Other pension costs Agency and contract staff Gross employee benefits Less income where netted off expenditure from: NHS bodies Other bodies Total Total £000 477,863 36,427 52,486 54,961 621,737 £000 475,621 36,427 52,486 564,534 Other £000 2,242 54,961 57,203 (601) (1,218) 619,918 (601) (1,218) 562,715 57,203 Group 2013-14 Salaries and wages Social security costs Employer contributions to NHS Pensions Other pension costs Agency and contract staff Gross employee benefits Less income where netted off expenditure from: NHS bodies Other bodies Total 4.2 Employee numbers Total £000 393,316 30,310 43,622 733 34,013 501,994 £000 331,127 30,310 43,622 733 405,792 Other £000 62,189 34,013 96,202 (1,842) (585) 499,567 (1,842) (585) 403,365 96,202 Group 2014-15 Group 2013-14 Total Other Total Average employee numbers Medical and dental Administration and estates 1,802 2,104 805 1,947 997 157 1,533 1,720 Healthcare assistants and other support staff Nursing, midwifery and health visiting staff 936 3,678 927 3,419 9 259 707 2,992 16 8 8 13 1,601 10 1,315 11,462 1,415 8 8,529 186 2 1,315 2,933 1,364 7 655 8,991 Nursing, midwifery and health visiting learners Scientific, therapeutic and technical staff Social care staff Other Total 233 4.3 Staff sickness absence 2014-15 Number 83,183 10,280 8.1 Total days lost Total staff years Average working days lost 2013-14 Number 54,665 8,436 6.5 Average sickness absence days are provided by the Department of Health, and are calculated using calendar years, rather than financial years. 4.4 Early retirements due to ill health Early retirements on the grounds of ill-health 2014-15 Number 6 2013-14 Number 7 Early retirements on the grounds of ill-health £000 170 £000 353 The cost of ill-health retirements is borne by NHS Pensions. 4.5 Termination benefits 4.5a By number of cases: Exit package cost band (including any special payment element) Less than £10,000 £10,000 - £25,000 £25,001 - £50,000 £50,001 - £100,000 £100,001 - £150,000 £150,001 - £200,000 Greater than £200,000 Total 4.5b 2014-15 Compulsory redundancy - Other departures agreed 7 1 1 9 2013-14 Total 7 1 1 9 By value of payments: 2014-15 Exit package cost band (including any special payment element) Less than £10,000 £10,000 - £25,000 £25,001 - £50,000 £50,001 - £100,000 £100,001 - £150,000 £150,001 - £200,000 Greater than £200,000 Total 234 Total 14 6 3 23 Compulsory redundancy £000 - Other departures agreed £000 27 14 36 77 2013-14 Total £000 27 14 36 77 Total £000 61 115 97 273 4.5c Other departures agreed are as follows: 2014-15 Number £000 Contractual payments in lieu of notice Exit payments following Employment Tribunal or court orders 9 77 - - Of which: Non-contractual payments made to individuals where the payment value was more than 12 months of their annual salary 2013-14 Number £000 Contractual payments in lieu of notice Exit payments following Employment Tribunal or court orders 16 - 112 - - - Of which: Non-contractual payments made to individuals where the payment value was more than 12 months of their annual salary 4.6 Salary and pension entitlements of senior managers 4.6a Median salary disclosures 2014/2015 (bands of £5,000) Band of highest paid director's total remuneration Median total remuneration (£) Ratio 255 - 260 38,067 6.8 2013/2 014 (bands of £5,000) 245 250 37,947 6.6 The above note discloses the median remuneration of the Trust's staff and the ratio between this and the mid-point of the banded remuneration of the highest paid director. The calculation is based on full-time equivalent staff of the reporting entity at the reporting period end date on an annualised basis. 4.6b Business related travel and subsistence expenses Four Executive Directors received travel and subsistence expenses totalling £7,218 (2013-14: five, £4,609). One Non-Executive Directors received travel and subsistence expenses totalling £721 (2013-14: two, £710). Two Governors received travel and subsistence expenses totalling £482 (2013-14: three, £539). 235 4.6 Salary and pension entitlements of senior managers 4.6c Remuneration 2014-15 Name Angela Huxham Chief Executive Chief Financial Officer Executive Director of Operations Interim Chief Operating Officer Executive Medical Director Executive Director of Nursing, Midwifery and Infection Control Executive Director of Workforce Development Co-opted members of the Trust's board Jane Walters Director of Corporate Affairs Jacob West Director of Strategy Pedro Castro** Interim Director of Strategy David Dawson Interim Director of Strategy Trudi Kemp Director of Strategy Ahmad Toumadj Interim Director of Estates and Capital Steve Leivers ** Director of Transformation and Turnaround Pedro Castro** David Dawson Trudi Kemp Steve Leivers** Jeremy Tozer** Ahmad Toumadj 236 Salary & Fees (bands of £5,000) Other remuneration (bands of £5,000) Total (bands of £5,000) Salary & Fees (bands of £5,000) 55 - 60 10 - 15 10 - 15 10 - 15 10 - 15 10 - 15 - - 55 - 60 10 - 15 10 - 15 10 - 15 10 - 15 10 - 15 55 - 60 10 - 15 10 - 15 10 - 15 10 - 15 10 - 15 - 125 - 130 - 55 - 60 10 - 15 10 - 15 140 - 145 10 - 15 10 - 15 255 - 260 150 - 155 185 - 190 5 - 10 105 -110 20 - 22.5 42.5 - 45 20 - 22.5 35 -40 105 - 110 255 - 260 210 - 215 230 - 235 5 - 10 235 - 240 245 - 250 150 - 155 185 - 190 85 - 90 32.5 - 35 32.5 - 35 50 -52.5 25 - 30 105 - 110 245 - 250 210 - 215 215 -220 245 - 250 155 - 160 155 - 160 70 - 72.5 40 - 42.5 - 230 - 235 200 - 205 150 -155 145 - 150 35 - 37.5 67.5 - 70 - 185 - 190 210 - 215 130 - 135 55 - 60 15 - 20 70 - 75 15 - 20 20 - 25 117.5 - 120 145 - 147.5 - - 250 - 255 55 - 60 15 - 20 215 - 220 15 - 20 20 - 25 125 - 130 100 - 105 125 - 130 - 47.5 - 50 30 - 32.5 - - 170 - 175 130 - 135 - Total (bands of £5,000) Title Chairman and Non-Executive Directors Professor Sir George Alberti Chairman Graham Meek Vice Chairman Faith Boardman Non-Executive Director Marc Meryon * Non-Executive Director Professor Gulam J. Mufti Non-Executive Director Sue Slipman Non-Executive Director Chris Stooke Non-Executive Director Executive Directors Tim Smart Simon Taylor Roland Sinker Jeremy Tozer ** Michael Marrinan Dr Geraldine Walters 2013-14 Pension Related Other Benefits remuneration (bands of (bands of £2,500) £5,000) Pension Related Benefits (bands of £2,500) Interim Director of Strategy Interim Director of Strategy Director of Strategy Director of Transformation and Turnaround Interim Chief Operating Officer Interim Director of Estates and Capital 1 April 2014 - 30 June 2014 1 July 2014 - 30 September 2014 1 October 2014 - 31 March 2015 9 March 2015 - 31 March 2015 23 March 2015 - 31 March 2015 1 March 2015 - 31 March 2015 None of the Non-Executive or Executive Directors received benefits in kinds in 2014-15 or 2013-14. * Marc Meryon has waived his fee. ** S. Leivers and J. Tozer are employed through an external company to provide the services noted. The amount included reflects the amount paid to the company for these services. This applied to P. Castro during the period he was at the Trust. 4.6d Pension entitlements at 31 March 2015 Name Real increase in pension at age 60 £000 (bands of £2,500) Real increase in pension lump sum at age 60 £000 (bands of £2,500) Total accrued pension at age 60 £000 (bands of £5,000) Lump sum at age 60 £000 (bands of £5,000) 2.5 - 5.0 0 - 2.5 0 - 2.5 2.5 - 5 5 - 7.5 15 - 20 60 - 65 35 - 40 2.5 - 5 0 - 2.5 10 -12.5 2.5 - 5 5 - 7.5 2.5 - 5 - 17.5 - 20 10 - 12.5 - CETV at start of year £000 CETV at end of year £000 Real Normal increase Retirement in CETV Age £000 190 -195 115 - 120 143 1,196 865 183 1,264 - 40 40 (865) 65 60 60 60 - 65 55 - 60 190 - 195 170 - 175 1,309 - 1,442 - 133 - 60 60 55 - 60 15 - 20 - 165 -170 55 - 60 - 284 85 355 - 70 (85) 60 60 65 Title Non-Executive Directors Non-Executive Directors do not receive pensionable remuneration. Executive Directors Roland Sinker Executive Director of Operations Simon Taylor Chief Financial Officer Michael Marrinan Executive Medical Director Executive Director of Nursing, Midwifery and Infection Dr Geraldine Walters Control Angela Huxham Executive Director of Workforce Development Co-opted members of the Trust's board Jane Walters Director of Corporate Affairs Trudi Kemp Director of Strategy Jacob West Director of Strategy During the 2014-15 the total value of employer contributions to the pension scheme in respect of Board member directors was £114k (2013-14: £138k). Simon Taylor - Real Increase in CETV is proportioned over the time in the Pension Scheme. A Cash Equivalent Transfer Value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member’s accrued benefits and any contingent spouse’s pension payable from the scheme. A CETV is a payment made by a pension scheme or arrangement to secure pension benefits in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits that the individual has accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity to which disclosure applies. The CETV figures and the other pension details include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS pension scheme. They also include any additional pension benefit accrued to the member as a result of their purchasing additional years of pension service in the scheme at their own cost. CETVs and other disclosures are provided by NHS Pensions, and are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries. The real increase in CETV reflects the increase in CETV effectively funded by the employer. It takes account of the increase in accrued pension due to inflation, contributions paid by the employee (including the value of any benefits transferred from another scheme or arrangement) and uses common market valuation factors for the start and end of the period. 237 4.7 Pension costs Past and present employees are covered by the provisions of the NHS Pensions Scheme. Details of the benefits payable under these provisions can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions. The scheme is an unfunded, defined benefit scheme that covers NHS employers, GP practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The scheme is not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS Body of participating in the scheme is taken as equal to the contributions payable to the scheme for the accounting period. In order that the defined benefit obligations recognised in the financial statements do not differ materially from those that would be determined at the reporting date by a formal actuarial valuation, the FReM requires that “the period between formal valuations shall be four years, with approximate assessments in intervening years”. An outline of these follows: a) Accounting valuation A valuation of the scheme liability is carried out annually by the scheme actuary as at the end of the reporting period. This utilises an actuarial assessment for the previous accounting period in conjunction with updated membership and financial data for the current reporting period, and are accepted as providing suitably robust figures for financial reporting purposes. The valuation of the scheme liability as at 31 March 2015, is based on valuation data as 31 March 2014, updated to 31 March 2015 with summary global member and accounting data. In undertaking this 238 actuarial assessment, the methodology prescribed in IAS 19, relevant FReM interpretations, and the discount rate prescribed by HM Treasury have also been used. The latest assessment of the liabilities of the scheme is contained in the scheme actuary report, which forms part of the annual NHS Pension Scheme (England and Wales) Pension Accounts, published annually. These accounts can be viewed on the NHS Pensions website. Copies can also be obtained from The Stationery Office. b) Full actuarial (funding) valuation The purpose of this valuation is to assess the level of liability in respect of the benefits due under the scheme (taking into account its recent demographic experience), and to recommend the contribution rates. The last published actuarial valuation undertaken for the NHS Pension Scheme was completed for the year ending 31 March 2012. The Scheme Regulations allow contribution rates to be set by the Secretary of State for Health, with the consent of HM Treasury, and consideration of the advice of the Scheme Actuary and appropriate employee and employer representatives as deemed appropriate. c) Scheme provisions The NHS Pension Scheme provided defined benefits, which are summarised below. This list is an illustrative guide only, and is not intended to detail all the benefits provided by the Scheme or the specific conditions that must be met before these benefits can be obtained: The Scheme is a “final salary” scheme. Annual pensions are normally based on 1/80th for the 1995 section and of the best of the last three years pensionable pay for each year of service, and 1/60th for the 2008 section of reckonable pay per year of membership. Members who are practitioners as defined by the Scheme Regulations have their annual pensions based upon total pensionable earnings over the relevant pensionable service. With effect from 1 April 2008 members can choose to give up some of their annual pension for an additional tax free lump sum, up to a maximum amount permitted under HMRC rules. This new provision is known as “pension commutation”. Annual increases are applied to pension payments at rates defined by the Pensions (Increase) Act 1971, and are based on changes in retail prices in the twelve months ending 30 September in the previous calendar year. From 2011-12 the Consumer Price Index (CPI) has been used and replaced the Retail Prices Index (RPI). 5 Early payment of a pension, with enhancement, is available to members of the scheme who are permanently incapable of fulfilling their duties effectively through illness or infirmity. A death gratuity of twice final year’s pensionable pay for death in service, and five times their annual pension for death after retirement is payable. For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the liability for the additional costs is charged to the employer. Members can purchase additional service in the NHS Scheme and contribute to money purchase AVC’s run by the Scheme’s approved providers or by other Free Standing Additional Voluntary Contributions (FSAVC) providers. Finance revenue Interest on bank accounts Interest on loans and receivables Total 6 Finance expenses Interest on Loans from the Independent Trust Financing Facility Finance costs on PFI and other service concession arrangements Main finance cost Contingent finance cost Total 7 Impairments Changes in market price - charged to operating expenses Changes in market price - charged to the revaluation reserve Total Group 2014-15 2013-14 £000 £000 143 101 70 68 213 169 Group 2014-15 2013-14 £000 £000 1,809 749 17,279 6,164 25,252 12,313 3,997 17,059 Group 2014-15 2013-14 £000 £000 4,535 5,595 10,130 2,648 2,139 4,787 239 Asset valuations were undertaken in 2014 as at the prospective valuation date of 31 March 2015. The valuation resulted in an increase in revaluation reserve of £2.441m for land owned by the Trust and an overall increase to buildings and dwellings revaluation reserve value of £17.746m. A net impairment amount of £4.535m has been charged to the Statement of Comprehensive Income. This is as a result of a decrease in value of certain buildings leading to an impairment of £5.439m. This impairment has been offset by the reversal of prior year impairments of £0.904m where buildings values has increased in 2014/2015. The buildings which decreased in value include Imaging block (£2.557m), Binfield Court (£257k), Orpington Medical Record (£226k), PRUH Medical Record (£768k), PRUH Education Centre (£161k) and other buildings including professional fees (£566k). 8 Share of operating profit in associates and joint ventures Group 2014-15 2013-14 £000 £000 1,357 (600) (266) 1 492 Viapath Group LLP Kings College Hospital Clinics LLC (KCHC) NIHR/Wellcome Trust Clinical Research Facility King’s Hewitt Fertility Centre 9 Intangible non-current assets 9.1 Intangible non-current assets - current year 1,278 (361) 917 Software licences £000 Development expenditure £000 Total Cost or valuation At 1 April 2014 Additions purchased Reclassifications Upward revaluation/positive indexation Disposals At 31 March 2015 9,344 2,664 90 (3,760) 8,338 687 20 707 10,031 2,664 90 20 (3,760) 9,045 Amortisation At 1 April 2014 Transfer by absorption from SLHT Charged during the year Reclassifications Upward revaluation/positive indexation Disposals At 31 March 2015 7,575 1,006 22 (3,760) 4,843 687 20 707 8,262 1,006 22 20 (3,760) 5,550 3,495 3,495 - 3,495 3,495 48 (11) 37 - 48 (11) 37 Group and trust Net book value Purchased Total at 31 March 2015 Revaluation reserve balance At 1 April 2014 Indexation movement in year At 31 March 2015 £000 Development expenditure represents the implementation cost of the Activity Based Costing project, which was completed in 2006-07, and is still in use. 240 9.2 Intangible non-current assets - prior year Group and trust Cost or valuation At 1 April 2013 Transfer by absorption from SLHT Additions purchased Reclassifications At 31 March 2014 At 1 April 2013 Transfer by absorption from SLHT Charged during the year Reclassifications At 31 March 2014 Net book value Purchased Total at 31 March 2014 Revaluation reserve balance At 1 April 2013 Indexation movement in year At 31 March 2014 Software licences £000 Development expenditure £000 Total 4,820 3,721 803 9,344 687 687 5,507 3,721 803 10,031 3,423 3,455 697 7,575 685 2 687 4,108 3,455 699 8,262 1,769 1,769 0 1,769 1,769 48 0 48 0 0 48 0 48 £000 241 10 Property, plant and equipment 10.1 Property, plant and equipment - current year Land £000 Buildings excluding dwellings £000 Cost or valuation At 1 April 2014 Additions purchased Additions leased Additions donated Reclassifications Disposals Upward revaluation/positive indexation Impairments/negative indexation Reversal of impairments At 31 March 2015 75,680 2,441 78,121 442,513 5,681 16,790 5,654 (5,595) 465,043 2,470 545 3,015 14,725 30,216 500 (16,799) (1,188) 27,454 68,533 4,974 1,635 105 (8,753) 917 67,411 14,264 3,472 50 (181) (1,700) 15,905 1,809 52 (5) (8) 32 1,880 619,994 44,395 1,635 550 (90) (10,461) 8,401 (5,595) 658,829 Depreciation At 1 April 2014 Charged during the year Reclassifications Disposals Upward revaluation/positive indexation Impairments/negative indexation Reversal of impairments At 31 March 2015 - 4 13,770 (17,084) 3,347 37 58 (58) - (1,188) 1,188 - 41,383 5,254 39 (8,337) 456 38,795 6,354 1,882 (61) (1,700) 6,475 637 184 (8) 14 827 48,378 21,148 (22) (10,045) (17,860) 4,535 46,134 Net book value Owned - purchased Owned - donated On balance sheet PFI Total at 31 March 2015 62,217 2,514 13,390 78,121 222,867 13,177 228,962 465,006 2,546 469 3,015 26,665 789 27,454 21,856 1,763 4,997 28,616 9,373 57 9,430 1,031 22 1,053 346,555 18,791 247,349 612,695 Revaluation reserve balance At 1 April 2014 Revaluation and indexation in year At 31 March 2015 39,614 2,441 42,055 95,707 17,144 112,851 1,132 603 1,735 - 8,268 44 8,312 - 228 18 246 144,949 20,250 165,199 Group and Trust 242 Dwellings Assets under construction Plant & machinery Information technology Furniture & fittings Total £000 £000 £000 £000 £000 £000 11 Investments 11.1 Subsidiary undertakings, associates and joint ventures held The Foundation Trust's principal subsidiary undertakings, associates and joint ventures as included in its consolidated accounts are set out below. The Trust’s unconsolidated investment holding in its subsidiary undertaking, KCH Commercial Services Ltd, is £0.25m (2013/14:£0.25m) The accounting date of the financial statements for the subsidiaries is 31 March 2015, and for the associate, 31 December 2014. For the associate undertaking that has a different accounting year-end date, interim accounts to 31 March 2015 have been consolidated. Country of Incorporation Beneficial interest Principal activity UK 100% Holding company UK UK 100% Healthcare services 100% Software consultancy and supply UK UAE 33.3% Healthcare services 49% Specialist outpatient healthcare treatment 35% Research 54% Research 50% Assisted Conception Directly owned subsidiary undertakings KCH Commercial Services Ltd Indirectly owned subsidiary undertakings KCH Management Ltd Agnentis Ltd Associates Viapath Group LLP (Viapath) Kings College Hospital Clinics LLC (KCHC) Joint operations NIHR/Wellcome Trust Clinical Research Facility* (CRF) Equity UK Constructions King’s Hewitt Fertility Centre** UK * The Foundation Trust entered into a joint operation with King's College London and South London and Maudsley NHS Foundation Trust for the construction and use of premises known as the NIHR/Wellcome Trust Clinical Research Facility, which opened in November 2012. The Foundation Trust has capitalised 54% of the cost of the building, and equipment assets therein based on the construction proportion. The Foundation Trust recognises 35% of revenue and expenditure generated by the facility, based on the equity proportion as stipulated in the Collaboration Agreement. ** The Foundation Trust entered into a joint operation with Liverpool Women’s NHS Foundation Trust through the development of satellites to improve access to the Assisted Conception Unit (ACU) and improve the best outcomes in London. The joint operation started in December 2014. 11.2 Carrying value of investments held Balance of 1 April Acquisitions in year Share of profit / (loss) Other equity movements Balance at 31 March 2014-15 2014-15 2014-15 2013-14 Viapath KCHC Total Total £000 £000 £000 £000 2,094 1,504 3,598 816 - - - 1,504 1,357 (600) 757 1,278 - 31 31 - 3,451 935 4,386 3,598 243 11.3 Interests in associates accounted for using the equity method Total gross assets of the entity as at 31 March Total gross liabilities of the entity as at 31 March Total revenues for the year ending 31 March Profit/(loss) for the year ending 31 March 11.4 2014-15 Viapath £000 2014-15 KCHC £000 2014-15 Total £000 2013-14 Total £000 37,471 (34,655) 97,058 4,125 7,112 (1,172) 28 (1,201) 44,583 (35,827) 97,086 2,924 38,075 (36,508) 92,524 3,834 2014-15 CRF £000 2014-15 KHFC £000 2014-15 Total £000 2013-14 Total £000 4,682 1,044 (266) 342 (341) 861 1 5,024 (341) 1,905 (265) 5,025 1,060 (361) Group and Trust Consumables Energy £000 £000 Total £000 Interests recognised in relation to joint operations Assets as at 31 March Liabilities as at 31 March Revenues for the year ending 31 March (Loss)/profit for the year ending 31 March 12 Inventories 12.1 Inventories - current year Drugs £000 At 1 April 2014 Additions Inventories consumed and expensed Transfer by absorption from SLHT At 31 March 2015 12.2 4,893 119,379 (117,912) 10,385 95,332 (94,999) 14 712 (714) 15,292 215,423 (213,625) 6,360 10,718 12 17,090 Inventories - prior year Drugs £000 At 1 April 2013 Additions Inventories consumed and expensed Transfer by absorption from SLHT At 31 March 2014 244 Group and Trust Consumables Energy £000 £000 Total £000 3,566 90,535 (90,028) 7,767 73,846 (72,601) 310 (323) 11,333 164,691 (162,952) 820 4,893 1,373 10,385 27 14 2,220 15,292 13 Trade and other receivables 13.1 Trade and other receivables Group 31 March 2015 £000 31 March 2014 £000 Trust 31 March 31 March 2015 2014 £000 £000 Current Trade receivables due from NHS bodies Receivables due from NHS charities Other receivables due from related parties Capital receivables Provision for impaired receivables Deposits and advances Prepayments (non-PFI) Accrued income Interest receivable PDC dividend receivable VAT receivable Other receivables Total current receivables 40,156 212 4,021 (18,321) 2,027 7,581 27,913 11 362 3,753 30,325 98,040 68,120 199 840 95 (7,576) 1,527 4,739 22,243 11 3,267 24,670 118,135 40,156 212 4,021 (18,321) 2,027 7,579 27,913 11 362 3,752 31,156 98,868 68,120 199 840 95 (7,576) 1,527 4,739 22,243 11 3,266 25,021 118,485 Non-current Receivables with related parties - revenue Non-NHS receivables - revenue Total non-current receivables Total 5,459 1,813 7,272 105,312 2,596 1,571 4,167 122,302 6,832 1,813 8,645 107,513 3,707 1,571 5,278 123,763 The majority of trade is with NHS England and Clinical Commissioning Groups. As these bodies are funded by Government to buy NHS patient care services, no credit scoring of them is considered necessary. The largest debtor at 31 March 2015 was NHS England, with outstanding invoices totalling £8.058m. 13.2 Receivables past their due date but not impaired By up to three months By three to six months By more than six months Total 13.3 Provision for impairment of receivables Balance at 1 April Amount written off during the year Amount recovered during the year Increase in receivables impaired Balance at 31 March Group and Trust 31 March 31 March 2015 2014 £000 £000 10,894 7,612 16,469 34,975 17,842 11,263 11,063 40,168 Group and trust 31 March 31 March 2015 2014 £000 £000 7,576 (2,588) (655) 13,988 18,321 4,666 (1,687) (1,751) 6,348 7,576 245 13.4 Impaired receivables past their due date Group and trust 31 March 31 March 2015 2014 £000 £000 By up to three months By three to six months By more than six months Total 14 Cash and cash equivalents Opening balance Net change in year Closing balance Made up of Cash with Government Banking Service Commercial banks and cash in hand Cash and cash equivalents as in statement of financial position Patients' money held by the Foundation Trust, not included above 15 10,582 59 7,680 18,321 Group 31 March 31 March 2015 2014 £000 £000 Trust 31 March 31 March 2015 2014 £000 £000 54,535 (11,090) 43,445 40,502 14,033 54,535 54,185 (11,522) 42,663 40,328 13,857 54,185 40,117 3,328 51,060 3,475 40,117 2,546 51,060 3,125 43,445 54,535 42,663 54,185 8 12 8 12 Trade and other payables Group 31 March 31 March 2015 2014 £000 £000 Current Receipts in advance NHS trade payables Amounts due to other related parties Other trade payables Capital payables Social security costs Other taxes payable Other payables Accruals PDC dividend payable Total 1,651 9,735 41,600 1,741 5,460 5,757 8,272 89,879 164,103 All trade and other payables are current; there are no non-current balances. 246 713 531 6,332 7,576 1,428 5,619 967 36,922 3,410 5,260 5,744 9,607 67,568 804 137,329 Trust 31 March 31 March 2015 2014 £000 £000 1,651 9,735 41,536 1,741 5,460 5,757 8,240 89,824 163,952 1,428 5,619 967 36,829 3,410 5,260 5,744 9,588 67,591 804 137,240 16 Deferred income Group and trust 31 March 31 March 2015 2014 £000 £000 Current Deferred income Total 10,189 10,189 9,989 9,989 All deferred income is current; there are no non-current balances. 17 Borrowings Group 31 March 31 March 2015 2014 £000 £000 Trust 31 March 31 March 2015 2014 £000 £000 Current Loans from the Independent Trust Financing Facility Other loans Obligations under PFI contracts Total current borrowings 3,868 206 3,550 7,624 1,012 78 3,199 4,289 3,868 17 3,550 7,435 1,012 78 3,199 4,289 65,974 1,488 155,108 222,570 230,194 47,842 1,700 157,023 206,565 210,854 65,974 155,108 221,082 228,517 47,842 17 157,023 204,882 209,171 Non-current Loans from the Independent Trust Financing Facility Other loans Obligations under PFI contracts Total non-current borrowings Total 247 18 Provisions 18.1 Provisions - current year Group and trust Total £000 Early Departure costs £000 At 1 April 2014 Arising during the year Utilised during the year non-cash Utilised during the year cash Reversed unused Unwinding of discount At 31 March 2015 8,030 382 7,307 - 562 207 90 - 71 175 (90) - - (90) - (816) (125) 153 7,534 (746) 144 6,705 (70) (123) 9 585 - (2) 244 1,239 747 248 - 244 3,215 3,080 7,534 2,988 2,970 6,705 227 110 585 - 244 Total £000 Early Departure costs £000 Legal claims £000 £000 Other £000 10,209 7,600 165 2,309 135 431 555 5 279 426 115 90 71 (197) (187) (10) - - (2,607) (526) 165 8,030 (547) 157 7,307 (13) (129) 8 562 (2,047) (262) 90 (135) 71 1,144 749 234 90 71 3,161 3,725 8,030 2,993 3,565 7,307 168 160 562 90 71 Expected timing of cash flows: No later than one year Later than one year and not later than five years Later than five years Total 18.2 Redundancy £000 Other £000 Provisions - prior year Group and trust At 1 April 2013 Transferred by absorption from SLHT Arising during the year Utilised during the year non-cash Utilised during the year cash Reversed unused Change in discount rate Unwinding of discount At 31 March 2014 Expected timing of cash flows: No later than one year Later than one year and not later than five years Later than five years Total 248 Legal claims £000 18.3 Provisions - further information Clinical negligence £194.211m (31 March 2014: £141.982m) is included in the provisions of the NHS Litigation Authority at 31 March 2015, in respect of the estimated clinical negligence liabilities of the Foundation Trust. Pensions The measure of the Foundation Trust's pension liability for early retired staff was recalculated in 2012-13, using the Office for National Statistics life expectancy tables. Expected future cash flows have been discounted using the real discount rate of 2.2% (set by HM Treasury) to determine the full liability. Legal claims The provision is based upon information provided by the NHS Litigation Authority and refers to non-clinical claims against the Foundation Trust (e.g. public and employer's liability cases). Other The Foundation Trust has provided £0.244m (31 March 2014: £0.071m) for outstanding Employment Tribunal cases and associated legal fees. 19 Contingencies Group and Trust 31 March 31 March 2015 2014 £000 £000 Contingent liabilities Non-clinical legal claims 96 97 The above contingencies refer to non-clinical legal claims, dealt with by the NHS Litigation Authority on behalf of the Foundation Trust. The Foundation Trust has no contingent assets. 20 Contracted capital commitments Group and Trust 31 March 31 March 2015 2014 £000 £000 38,657 Property, plant and equipment 45,550 These contracts include the Critical Care Unit (£33.552m), the Helipad (£3.703m), HV Infrastructure (£698k), Sitewide Infrastructure (£282k), Liver Portakabins Replacement (£360k) and Building refurbishment (£62k). It is anticipated that all these projects will be completed in the next financial year except the Critical Care Unit. 21 Revaluation reserve Group and trust At 1 April Transfers by absorption from SLHT Impairments Revaluations Disposals At 31 March Intangibles £000 48 (11) 37 Property, plant and equipme nt £000 144,949 (5,595) 26,261 (416) 165,199 31 March 2015 31 March 2014 Total £000 144,997 (5,595) 26,261 (427) 165,236 Total £000 87,536 280 (2,139) 59,758 (438) 144,997 249 22 PFI - additional information 22.1 On SoFP liabilities 31 March 2015 £000 31 March 2014 £000 431,926 448,902 Of which liabilities are due: - not later than one year - later than one year and not later than five years - later than five years Total Finance charges allocated to future periods Net PFI liabilities 20,512 81,355 330,059 431,926 (273,268) 158,658 20,479 78,954 349,469 448,902 (288,680) 160,222 Of which liabilities are due: - not later than one year - later than one year and not later than five years - later than five years Total 3,550 13,168 141,940 158,658 3,199 12,135 144,888 160,222 Gross PFI liabilities 22.2 Commitments Commitments in respect of the service element will fall due: - not later than one year - later than one year and not later than five years - later than five years Total 250 Group and Trust Group and Trust 31 March 31 March 2015 2014 £000 £000 40,153 171,486 1,025,534 1,237,173 36,627 156,228 994,343 1,187,198 22.3 PFI Schemes King's College Hospital The PFI consisted of two phases: phase 1 (construction of the new Golden Jubilee Clinical Wing) and phase 2 (refurbishment of the existing Ruskin Wing). The project enabled the centralisation of acute services on the Denmark Hill site following the transfer of services from Dulwich Hospital and Mapother House. As part of the scheme, HpC (King's College Hospital) plc also took responsibility for the provision of site-wide catering, domestic and portering services from April 2000. As a result recurrent revenue savings were achieved. The project has been financed by a means of a wrapped, index linked bond guaranteed by MBIA-AMBAC and debt and equity capital provided by Costain, Skanska, Sodexho and Edison Capital. The contract period is 38 years. The annual payments by the Trust are dependent on availability and service quality standards being met. The commitments above include an inflationary increase of 2.63% based on the rate used for 2014-15. Princess Royal Hospital - Building PFI Under the building PFI, United Healthcare (Bromley) Ltd provided the land, building and site-wide hard and soft facilities management at the Princess Royal Hospital. The capital funding is a combination of senior debt and equity finance. The senior debt financing was originally provided by way of loan from Commerzbank AG (and others). There was a refinancing process in 2004 which involved the issue of 3.018% index-linked guaranteed secure bonds, repayable in 66 six monthly instalments which commenced in 2004 and will end in 2036, and are subject to half yearly indexation in line with RPI. Princess Royal Hospital - Managed equipment services PFI The MES PFI Scheme agreement dated 22 March 2002 is a 30 year PFI agreement and relates to the purchase of medical equipment, and the installation, maintenance and replacement of this and other clinical equipment. This agreement is between (1) The Trust, (2) United Healthcare (Bromley) Limited and (3) Healthsource (Bromley) Limited and commenced on the 1st of January 2003. 23 Financial instruments 23.1 Risk profile and management Financial risk management Financial reporting standard IFRS 7 requires disclosure of the role that financial instruments have had during the period in creating or changing the risks a body faces in undertaking its activities. Because of the continuing service provider relationship that the Foundation Trust has with NHS England and clinical commissioning groups, and the way those commissioners are financed, the Foundation Trust is not exposed to the degree of financial risk faced by business entities. Also financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which the financial reporting standards mainly apply. The Foundation Trust has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the Foundation Trust in undertaking its activities. The Foundation Trust's treasury management operations are carried out by the finance department, within parameters 251 defined formally within the Foundation Trust's standing financial instructions and policies agreed by the board of directors. This treasury activity is subject to review by the internal auditor. Currency risk The Foundation Trust is principally a domestic organisation with the great majority of transactions, assets and liabilities being in the UK and sterling based. The Foundation Trust holds a 49% share in an associate organisation, King's College Hospital Clinics LLC (KCHC), operating in the United Arab Emirates. The Trust, via its wholly owned subsidiary, KCH Commercial Services Ltd, has taken out a loan denominated in Emirati Dirhams (AED) for the initial setup costs of KCHC. The Foundation Trust therefore has exposure to currency rate fluctuations on the interest payments and capital repayment of the loan. At 31 March 2015, the outstanding loan amount was £1.677m (31 March 2014: £1.683m). Interest rate risk 67% of the Foundation Trust's financial assets and 99.5% of its financial liabilities carry nil or fixed rates of interest. The Foundation Trust is not, therefore, exposed to significant interest-rate risk. The two tables below show the interest rate profiles of the Foundation Trust's financial assets and liabilities. Credit risk Because the majority of the Foundation Trust's revenue comes from contracts with other public sector bodies, the Foundation Trust has low exposure to credit risk. The maximum exposures as at 31 March 2015 are in receivables from customers, as disclosed in the trade and other receivables note. Liquidity risk The Foundation Trust’s operating costs are incurred under contracts with clinical commissioning groups and NHS England, which are financed from resources voted 252 annually by Parliament. The Foundation Trust funds its capital expenditure from loans obtained from Independent Trust Financing Facility. The Foundation Trust is currently exposed to liquidity risk due to its requirement for working capital support. The Trust has secured £59.7m of Interim Revolving Working Capital Support Funding from Monitor/DoH but agreement is required from Monitor regarding the amount that may be drawn down on a monthly basis. The Directors have reasonable expectation that the Trust will continue as a going concern (note 1.26). 23.2 Financial assets Total Floating rate Fixed rate Noninterest bearing £000 £000 £000 £000 133,283 160,095 43,445 54,535 - 89,838 105,560 - 85,957 107,022 Group Gross financial assets at 31 March 2015 at 31 March 2014 Trust Gross financial assets at 31 March 2015 128,628 42,663 at 31 March 2014 161,207 54,185 The weighted average interest rate for total financial assets was 0.2% (2014-15: 0.3%). The weighted average period for which fixed years was unlimited (2014-15: unlimited). The non-interest bearing weighted average term years was nil (2014-15: nil). 23.3 Financial liabilities Total Floating rate Fixed rate Noninterest bearing £000 £000 £000 £000 388,964 340,862 1,677 1,683 236,035 216,832 151,252 122,347 236,034 216,831 151,279 122,258 Group Gross financial liabilities at 31 March 2015 at 31 March 2014 Trust Gross financial liabilities at 31 March 2015 387,313 at 31 March 2014 339,089 The weighted average interest rate for total financial liabilities was 8.0% (2013-14: 8.6%). The weighted average period for which fixed years was unlimited (2013-14: unlimited). The non-interest bearing weighted average term years was nil (2013-14: nil). 23.4 Fair values of financial assets by category Group Trade and other receivables Cash and cash equivalents Total Trust 31 March 2015 £000 31 March 2014 £000 31 March 2015 £000 31 March 2014 £000 89,838 43,445 133,283 105,560 54,535 160,095 85,957 42,663 128,6420 107,022 54,185 161,207 253 23.5 Fair values of financial liabilities by category Group Borrowings (excluding finance leases and the PFI liability) Obligations under PFI arrangements Trade and other payables excluding non-financial liabilities Provisions under contract Total Trust 31 March 2015 £000 31 March 2014 £000 31 March 2015 £000 31 March 2014 £000 71,536 158,658 50,632 159,948 69,859 158,658 48,948 159,948 151,412 7,534 389,140 122,252 8,030 340,862 151,262 7,534 387,313 122,163 8,030 339,089 Fair value is not significantly different to book value, because in the calculation of book value the expected cash flows have been discounted by the HM Treasury discount rate of 2.2% in real terms. 23.6 Maturity of financial liabilities Group In one year or less In more than one year but not more than two years Trust 31 March 2015 £000 31 March 2014 £000 31 March 2015 £000 31 March 2014 £000 160,084 127,684 159,934 127,594 7,669 7,102 7,669 7,102 24,183 197,204 389,140 23,681 182,395 340,862 24,183 195,527 387,313 23,681 180,712 339,089 In more than two years but not more than five years In more than five years Total 24 Third party assets At 31 March 2015, the Foundation Trust held £7,570 (31 March 2014: £11,618) cash at bank and in hand that related to monies held by the Foundation Trust on behalf of patients. This has been excluded from the cash at bank and in hand figure reported in the accounts. 25 Events after the reporting period There have been no material adjusting or non-adjusting events after 31 March 2015. 254 26 Related parties King's College Hospital NHS Foundation Trust is a body corporate established by order of the Secretary of State for Health. During the year, none of the Board members, the Foundation Trust's governors, members of the key management staff or parties related to them have undertaken any material transactions with the Foundation Trust. The Department of Health is regarded as a related party. During the year, the Foundation Trust has had a significant number of material transactions with the Department, and with other entities for which the Department is regarded as the parent department. The main local commissioners are Lambeth, Southwark, Lewisham, and Bromley Clinical Commissioning Groups (CCGs). Significant commissioning is also carried out by NHS England. In addition, the Foundation Trust has transacted with a large number of other CCGs and NHS Trusts, as well as the NHS Litigation Authority and the NHS Business Services Authority (including NHS Supply Chain). The Foundation Trust has also received revenue and capital payments from a number of charitable funds, principally the King's College Hospital Charitable Fund. The Foundation Trust has entered into the following material related party transactions: Department of Health NHS England NHS Bexley CCG NHS Bromley CCG NHS Croydon CCG NHS Dartford, Gravesham And Swanley CCG NHS Greenwich CCG NHS Lambeth CCG NHS Lewisham CCG NHS Medway CCG NHS Southwark CCG NHS Wandsworth CCG NHS West Kent CCG Guys And St Thomas NHS Foundation Trust Income £000 10,290 405,033 36,305 161,359 19,583 10,922 19,400 83,386 32,440 3,496 106,204 2,355 10,824 7,060 Expenditure £000 6 16 2,329 Receivables £000 7,595 8,058 2,051 3,629 743 782 1,049 1,732 668 433 4,941 438 823 3,573 Payables £000 54 5,213 South London and Maudsley NHS Foundation Trust 1,147 1,572 1,714 719 Lewisham and Greenwich NHS Trust 5,158 8,039 5,024 NHS Litigation Authority 20,796 2,310 NHS Blood and Transplant 1,609 7,439 12 982 HM Revenue and Customs 36,427 3,753 11,217 King's College Hospital Charitable Fund 761 328 Viapath Group LLP 14,972 33,934 3,130 1,969 Kings College Hospital Clinics LLC 632 632 NHS Pension Scheme 52,486 186 Kings College London 4,691 7,484 4,182 6,460 There were many transactions with King’s College London in respect of education, training and research and development. 255 27 Losses and special payments Group and Trust Losses of cash due to: - theft, fraud etc - overpayment of salaries Bad debts and claims abandoned in relation to: - private patients - overseas visitors - other Damage to buildings, property etc due to: 2014-15 Number Value £000 2013-14 Number Value £000 2 119 1 43 3 21 0 11 93 613 36 131 2,305 66 364 696 - 236 3,078 - 20 883 10 2,556 13 1,097 5 3,330 Special, ex-gratia, payments due to: - loss of personal effects Total special payments 33 33 15 15 20 20 12 12 Total losses and special payments 916 2,571 1,117 3,342 - theft, fraud etc Total losses In 2014-15 there were no cases where the loss or special payment exceeded £250,000 (2013-14: 0). Losses and special payments are disclosed on an accruals, rather than a cash, basis, but exclude provision for future losses. 256 28 Split by site The information below provides a split of the Trust's income and expenditure between the Denmark Hill Site (including new services on the Orpington Site) (KCH) and the Princess Royal University Hospital (including Beckenham Beacon, Queen Mary's Sidcup and existing Orpington Sites) (PRUH). KCH 2014-15 £000 PRUH 2014-15 £000 Total 2014-15 £000 850,535 (849,069) 1,466 233,247 (250,643) (17,396) 1,083,782 (1,099,712) (15,930) 213 (11,780) (144) (9,539) (21,250) (13,472) (9) (1,911) (15,392) 213 (25,252) (153) (11,450) (36,642) 757 (250) - 757 (250) (19,277) (32,788) (51,065) KCH 2013-14 £000 PRUH 2013-14 £000 Total 2013-14 £000 769,843 (752,754) 17,089 122,211 (119,121) 3,090 892,054 (871,875) 20,179 169 (10,520) (151) (8,479) (18,981) (6,539) (14) (1,716) (8,269) 169 (17,059) (165) (10,195) (27,250) Share of profit of associates accounted for using the equity method 1,278 - 1,278 Deficit from continuing operations (614) (5,179) (5,793) Operating income from continuing operations Operating expenses of continuing operations Operating surplus Finance income Finance expense - financial liabilities Finance expense - unwinding of discount on provisions PDC Dividends payable Net finance costs Share of profit of associates accounted for using the equity method Corporate tax expense Deficit from continuing operations Operating income from continuing operations Operating expenses of continuing operations Operating surplus Finance income Finance expense - financial liabilities Finance expense - unwinding of discount on provisions PDC Dividends payable Net finance costs 257 To clarify details in this report please contact: Foundation Trust Office King’s College Hospital NHS Foundation Trust Denmark Hill London SE5 9RS Email: [email protected] 258
