annual report and accounts 2014/15

Annual report and accounts 2014/15

University College Hospital

Eastman Dental Hospital

Royal National Throat, Nose and Ear Hospital

HeartHospital

National Hospital for Neurology and Neurosurgery

Royal London Hospital for Integrated Medicine

3Annual Report and Accounts 2014/2015

University College London Hospitals NHS Foundation TrustAnnual Report and Accounts 2014/15

Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006


1 Introduction 6

2 Directors’ report 12

3 Strategic report 16

a) Strategic context 16

b) Our capital programme, activity and capacity 18

c) Performance 22

d) Quality governance 34

e) Corporate and social responsibility 35

f) Savings and activity plans 38

g) Risks and uncertainties 40

4 Delivering top quality care, education and research 48

a) Our patients 48

b) Our staff 50

5 Organisation structure 62

6 Remuneration report 82

Appendices

1 UCLH staff survey results 89

2 Quality report 91

3 Annual governance statement 151

4 Annual accounts 163

Contents

6 University College London Hospitals NHS Foundation Trust

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1 Introduction

UCLH (University College London Hospital NHS Foundation Trust) is situated in the heart of London. Our mission is to deliver top-quality patient care, excellent education and world-class research.In 2004 we became one of the first NHS foundation trusts. This means that while we remain firmly part of the NHS we have more control to manage our own budgets and shape the services we provide to better reflect the needs and priorities of our patients and local community. Through our Council of Governors we are able to listen to the views of patients,

local people, staff and partners and by doing so, offer patients faster, better and more responsive healthcare. Greater involvement from patients, public, and staff brings lasting improvements to patient services and better health for communities.

Our values of safety, kindness, teamwork and improving are at the heart of everything we do, both for our patients and for our staff.

We provide academically-linked acute and specialist services, both to the local population and to patients from across England and Wales and abroad.

We balance the provision of nationally recognised, specialist services with delivering high-quality acute services to the local populations of Camden, Islington, Barnet, Enfield, Haringey and Westminster.

We are proud of our close partnership with

2014/15 A year in numbers

6 hospitals1. University College

Hospital, including:

� Macmillan Cancer Centre

� ●Elizabeth Garrett Anderson Wing

� ●Hospital for Tropical Diseases

� ●Institute of Sport, Exercise and Health

2. National Hospital for Neurology and Neurosurgery

3. Eastman Dental Hospital

4. Royal National Throat, Nose and Ear Hospital

5. Heart Hospital

6. Royal London Hospital for Integrated Medicine

8,000+

£934 million

Number of staff

Turnover

Number of Foundation Trust members

Number of beds

1,093

19,224


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131,000attendances at A&E

What we do

Outpatients

1,010,950

Patients seen per year

Inpatients

170,000

131,000

1,000,000+

Babies born

Visits to our Emergency Department

Clinical trials and studies

6,734

1,200+Patients recruited for research studies in a typical year

12,000

University College London (UCL), which is consistently reported as one of the best performing universities in the world. UCL’s facilities are embedded across much of our hospital campus and the partnership is linked through a large number of joint clinical and academic appointments.

We are one of the country’s five biomedical research centres and were a founding member of UCLPartners, designated as one of the UK’s first Academic Health Science Centres.

We have a turnover of £934 million and contracts with over 90 commissioning bodies. On average we see over 1,000,000 outpatients, 131,000 A&E attendances and admit over 170,000 patients each year. We employ over 8,000 staff working across all of our hospital sites.

UCLH delivers clinical services from six hospital sites: University College Hospital National Hospital for Neurology and Neurosurgery (NHNN)

Eastman Dental Hospital (EDH) The Royal National Throat Nose and Ear Hospital (RNTNEH)

The Heart Hospital (HH) The Royal London Hospital for Integrated Medicine (RLHIM).

University College Hospital includes: University College Hospital Macmillan Cancer Centre (Cancer Centre) Elizabeth Garrett Anderson Wing (EGA) Hospital for Tropical Diseases (HTD) Institute of Sport, Exercise and Health (ISEH).

Investing in the future

Confidence in our services

� A new specialist centre for services currently provided at the Eastman Dental Hospital and the Royal National Throat, Nose and Ear Hospital � The rebuilding of our Emergency Department

£20 millionLeonard Wolfson Experimental Neurology Centre dedicated to carrying out first-in-human studies opened in the National Hospital for Neurology and Neurosurgery

£250 million

Inpatients would recommend us to family and

friends

Staff would recommend us if their

family and friends needed treatment

Funding secured for new Proton Beam Therapy centres at UCLH and the Christie NHS Foundation Trust in Manchester

further major developments in the pipeline

97% 83%64%national average

2


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The year in pictures

April

December

August

May

September

January

The President of Ireland, Michael D Higgins, visited UCLH as part of the first official visit to the UK by an Irish head of state.

An innovative new approach to cancer care that will see patients receive world-class treatment from specialist hubs at every stage of their journey was given the green light to go ahead, with UCLH designated as a centre for certain types of cancer.

The new Leonard Wolfson Experimental Neurology Centre opened for clinical studies and trials.

The vocational rehabilitation team at the NHNN won an award for its success in helping neurological patients get back to work, and their daily routine.

A research programme led by UCLH and UCL to pioneer the next generation of cancer therapies secures £30m of investment to help develop a new technology called t-cell therapy.

UCLH is one of six hospital trusts in north London to form a partnership and create the North Thames Genomics Medicine Centre to support the delivery of the Prime Minister’s 100,000 Genome Project.


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1,000,000+outpatients seen at UCLH

June

February

October

July

November

March

Health Secretary Jeremy Hunt visited University College Hospital to learn more about work to improve the accountability of clinicians and communication with patients and families.

University College Hospital is the safest hospital in England after NHS England published new data on nurse staffing levels and systems of patient safety.

A Channel 4 documentary followed four UCLH patients taking part in trials of some of the most advanced cancer treatments in the world.

The Public Health Minister praised the work of UCLH during a visit to see the UK’s first paediatric female genital mutilation (FGM) clinic at the EGA.

Her Royal Highness, The Duchess of Cornwall, visited teenagers with arthritis at University College Hospital to learn how the world’s first dedicated research programme is helping understanding of how and why arthritis and other rheumatic conditions affect teenagers.

The Department of Health gave the approval for the new proton beam therapy centre to go ahead by announcing the preferred contractors for the building and supply of equipment. The new centre will treat hundreds of patients each year at University College Hospital from 2018.


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Foreword

This report was written immediately after the General Election, resulting in greater certainty about the political direction of the NHS. The Conservative Party has committed to increase funding to the NHS by £8bn over the next five years. However, the NHS is expected to make efficiencies of £22bn over the same period. This situation is likely to result in the need for UCLH to make substantial cost improvements year on year by eliminating waste and improving patient pathways. This will be challenging, with the level of cost improvement at least equivalent to that delivered over recent years.

Despite the financial challenges facing the NHS, UCLH recorded a small surplus again this financial year. This was achieved following recognition that additional funds should be provided to address the higher costs of delivering specialist services. There is widespread recognition that the specialist tariff is no longer fit for purpose, and UCLH will engage with Monitor and NHS England (NHSE) to ensure that the future tariff reflects the additional costs incurred.

The UCLH Board has taken the view that we should implement an ambitious five-year programme to transform the way we deliver services. Our UCLH Future programme will focus on how we can continue to improve the quality and value of all aspects of services to our patients, matching the best performing hospitals in the NHS and globally. To do that we need to rethink how we deliver care – shortening clinical pathways, and significantly improving core operational processes (first patient contact, admissions and bookings, ward procedures, bed managements, patient flow and customer service) to enhance patient and staff experience. We will be investing in service redesign and new technology, together with training and development for all staff. Our ambitions are high as we want to deliver improvements at scale and with pace.

In 2014/15 we overcame most of our operating challenges. Although meeting the A&E four-hour target has proved challenging, our performance has been among the best in London, and the best among the major teaching hospitals against which we

compare our performance. That target is a barometer of how we perform across all of our hospitals and of how we work in partnership with our commissioners in Camden and Islington and our local GPs.

The issues around Referral to Treatment (RTT) times were felt across the health service, and in 2014/15 patient demand led to a backlog of patients waiting longer than 18 weeks for treatment. Through close work with our commissioners and much hard work by staff to reconfigure our resources, we have almost cleared the backlog. The future challenge will be to sustain our performance.

We did not achieve the 62-day wait for cancer treatment following GP referral in any quarter in 2014/15. A number of other hospitals with specialist cancer services have also seen deterioration against these standards through 2014/15. Breaches at UCLH have resulted mainly from issues outside of our direct control: late referrals from other trusts, patient choice and pathway complexity issues. There are, however, some breaches due to capacity or administrative delays. In November we introduced a new process that provides much fuller analysis of breaches, allowing us to understand all delaying factors on the pathway, not just the primary breach reason. We have a recovery plan in place which forecasts achievement of the 62 day wait for cancer treatment from July 2015, although this is dependent on being able to reduce late referrals from other trusts.

In recent years we have seen a huge increase in patients who want their care at UCLH, particularly in the more specialist services such as cancer and neuroscience. Demand has risen at a rate substantially higher than the average for the NHS, reflecting our increasing reputation as a preferred provider for patients. This creates tension with commissioners as to whether such growth and activity can be afforded, and we will continue to work closely with them to agree a sustainable future which builds on the national direction of patient care leading to integrated budgets.

Despite these difficulties, there have been exciting developments in many of our services. NHS England

Welcome to our Annual Report. Despite the challenges facing the NHS as a whole, UCLH has maintained its reputation in the eyes of both patients and staff. We continue to work hard to build on our vision: delivering top-quality care for patients; providing excellent education; and developing our world-class research partnership with UCL. Our strategy is to balance specialist services for patients from around the country with the best possible general care for those living in our local community.


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£178mawarded in external grant funding to the Biomedical Research Centre

confirmed our plans to make UCLH a centre for the specialist treatment of five rare types of cancer, and our cardiac services have now moved to Barts. We should take this opportunity to express our gratitude to the staff of the Heart Hospital for all the excellent care that they and their predecessors have delivered over their time in UCLH.

The foundations are being laid to develop our cancer care: demolition of the Rosenheim Wing to make way for one of the UK’s first proton beam therapy (PBT) centres is almost complete, part of Phase 4 of our development plans approved by the UCLH Board this year. One of the world’s most advanced forms of radiotherapy, PBT will be available at UCLH in 2018. Elsewhere, we have agreed capital investments to expand A&E and to improve capacity at the NHNN, and our plans are well-advanced to bring ear nose and throat services together with specialist dental provision for patients in a new development on the University College Hospital campus site. Our partnership with UCL – now fifth in the world rankings due to its strength in biomedicine – continues to flourish.

We continue to be vigorous in our pursuit of better care, delivered more efficiently, and have undertaken benchmarking against other leading teaching hospitals to understand how we compare and how we can improve. Against the best trusts in the UK we compare favourably, performing well above average in quality outcomes, financial performance and workforce. However, benchmarking has indicated that we need to improve a number of administrative issues around day-to-day operations, for example outpatient bookings. We are focused on reducing delays for outpatients and creating better ways of delivering care with individual patients at the heart of all we do.

We remain deeply grateful to our staff for all of their efforts to improve the quality of care and service at UCLH against a very challenging backdrop. Our hospitals and staff are among the best in the NHS, underpinned by our core values: safety, kindness, teamwork, improving. We are determined to improve and develop still further to ensure that all of our services are truly world-class.

Sir Robert Naylor Chief Executive

Richard Murley Chairman


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UCLH has continued to progress parallel clinical strategies in 2014/15: to provide excellent services to our local community, and to develop three specialist areas of cancer services, neurosciences and women’s health with the aim of becoming world-leaders in these areas. We will deliver these while maintaining focus on our delivery of excellent core medical, emergency and surgical services.

At the same time we are exploring various opportunities for further local collaborative work to underpin the principles outlined in the Five Year Forward View (NHSEs vision for the future NHS) and the Dalton Review (The Department of Health’s exploration of new options and opportunities to help the best leaders and organisations in the NHS to do more for patients). We have demonstrated this through our support for Camden Clinical Commissioning Group’s (CCG) application for Vanguard funding during 2015, and our own application with sector partner organisations, to help drive greater cancer leadership in networked, excellent care and early diagnosis.

Following an extensive, commissioner-led public consultation, on 21 October 2014 commissioner approval was granted to the cancer and cardiovascular proposals which will see UCLH become a specialist centre for the treatment of certain rare types of cancer. Cardiac services move from the Heart Hospital to Barts Health was completed in May 2015 and UCLH will become a centre for five specialist cancer services – brain, prostate and bladder, head and neck, oesophago-gastric and blood cancers. Moving malignant haematology inpatient services from the Royal Free London to UCLH is scheduled for completion by December 2015.

We worked in close collaboration with Bart’s Health NHS Trust to develop robust plans for the transfer of all cardiovascular services. A consultation was undertaken with a focus on supporting staff and patient safely during the transfer process.

To support implementation of the London Cancer reconfiguration, in January 2015 the UCLH Board approved the full business case for Investing in Cancer and Surgical Services and for the development of PBT. This capital investment, worth approximately £360m will enable us to establish a state-of-the-art facility, providing Europe’s largest inpatient haematology centre, critical care beds, imaging, and a short-stay surgical centre alongside one of the UK’s first PBT centres. Development is due to commence during 2015. The new PBT centre is supported by the Department of Health which has invested £250m in funding to us and The Christie NHS Foundation Trust.

UCLH is a founding and active member of

UCLPartners, an academic health science partnership, supporting healthcare for over six million people in parts of London, Bedfordshire, Essex and Hertfordshire. Its member organisations, from higher education and the NHS, form one of the world’s leading resources in medical discovery, healthcare innovation and education. The partnership saw significant achievements during 2014/15, including its successful re-designation as an Academic Health Science Centre, a world-leading partnership for medical discovery, modelled on creating six academic medical centres, designed to boost UK life sciences.

UCLH is a lead partner in the centres focused on cancer, cardiovascular disease and neurosciences. The Clinical Research Network for North Thames, aligned with UCLPartners, is the highest-performing network for patients recruited to clinical trials, giving more people in our region access to the latest medical treatments and technologies. In December the partnership, including UCLH, was designated one of the country’s new centres to deliver the 100,000 genomes project, to improve diagnosis and treatment for patients with cancer and rare diseases. UCLPartners facilitated the process which led to NHSEs approval of the plans for UCLH to become a specialist cancer centre for the region.

In August 2014, we saw the launch of UCLH@Home, a service run by an outsourced provider, that supports patients who are clinically stable to complete the remainder of their care and/ or treatment at home if they choose to do so following an assessment with their consultant. The newly established UCLH@Home team, recruited using values based recruitment, includes a range of specialties including nurses, physiotherapists and occupational therapists that will be based in the community. This innovative service helps to support our ambition of bringing health and social care together and offers our patients more independence, closer proximity to their family and friends and, importantly, access to community care in the privacy of their own homes.

To further enhance this service, UCLH@Home launched a six month pilot project (funded by the Department of Health’s Homeless Hospital Discharge Fund) for patients eligible for Pathway to Home, a specialist service for the homeless established in 2009. This patient group will complete their treatment at Olallo House, a hostel located near Euston station, and will remain under the care of the specialist consultant, receiving an agreed number of daily visits by support teams. They will also be visited by the Pathway specialist homeless team to help secure onward accommodation once discharged.

We have been working with our peer

2 Directors’ report


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6,734babies born at UCLH

organisations in the Shelford Group , a collective of 10 leading NHS multi-specialty academic healthcare organisations dedicated to excellence in clinical research, education and patient care, to benchmark and assess our procurement and supply chain capability and develop a programme to deliver savings and efficiencies in our non-pay spend through procurement which involves clinicians to select the right equipment at the right cost. In the first of these trials surgical gloves were selected by auction which will now be supplied to all of the Shelford Group of trusts, creating efficiencies of scale. We will now focus on 24 of the highest value and highest clinical preference categories.

At UCLH, we have significant strategic development ambitions that will enable us to deliver efficient and high quality patient care into the future (see page 16). In addition to these strategic projects and maintaining and investing in our existing buildings and equipment, we also encourage smaller scale schemes where the investment will deliver increased efficiency in the future.

Plans are underway to invest in the co-location of the EDH and the Royal National Throat Nose and Ear hospital. If approved by the board, we will be able to improve patient pathways, increase clinical innovation and optimise operational efficiency. To read more about our strategic initiatives see page 16 (strategic report).

Over the coming year, we will develop and deliver plans to establish an infrastructure that supports the development of an integrated care pathway. We have proposed to commissioners, to house and support a new integrated team who would play a key role in overseeing and supporting the on-going development of pathways via different London cancer tumour

site work-streams. Adopting this sector-wide view is crucial to shortening pathways whenever possible.

The performance challenges addressed over the last 12 months have reinforced our commitment to our strategic direction. We will be actively driving a number of priorities in 2015/16, including greater collaborative working with partners, developing common care standards across UCLH, investing more in our informatics capability and matching capacity to demand through partner collaboration.

We will consolidate the services we are able to provide through significant capital investment. For example, the Board has committed to an investment of c£20m, partially funded by charitable donations, to provide additional operating theatres and inpatient bed capacity on the NHNN site. This will enable delivery of the London Cancer reconfiguration of brain cancer, as well as supporting increasing demand in specialist neurosurgery including spinal surgery.

The best interest of our patients remains at the core of our business and we strive to ensure the services we provide are reflective of their needs. Services that are no longer working well for patients will be transferred or removed. A clinically-led review of our ophthalmology services highlighted sustainability issues arising from low patient volumes, a shortage of specialist clinicians and the limitation of the current equipment and outpatient facilities. As a result, the UCLH Board made the decision to divest its non-specialist ophthalmology services. Elective, secondary care ophthalmology services will transfer to The Royal Free London during 2015/16.

Our greatest asset is without a doubt the people who choose to work for us. We are committed to supporting disabled people to ensure that they are given full and fair consideration in their applications


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for employment at UCLH and are not disadvantaged throughout the process in line with our recruitment and selection procedure.

We have in place a Managing Disability Policy, approved in February 2014, which ensures that staff who declare a disability are given appropriate support, if required, in the workplace. This policy applies to new and existing staff who declare a disability. The Training Policy ensures that disabled staff are encouraged to access training and career development, with appropriate support as required.

UCLH works in partnership with staff to ensure that the views of staff are taken into account when making decisions which are likely to affect their interests, including updates on performance and other issues of concern. The monthly Joint Partnership Forum provides an opportunity to be involved in the development of policies. UCLH also seeks the views of all staff through the annual staff survey.

We strive to keep staff informed of the financial performance and wider economic factors affecting the financial performance at UCLH and communicate through the chief executive’s Team Brief to all employees, as well as regular communication through the leadership forum, reports to the council of governors, our intranet and other channels.

Accounting policies for pensions and other retirement benefits are set out in note 1.4 to the accounts on page 177 and details of senior employees’ remuneration can be found in the remuneration report on page 82.

Statement of Directors’ responsibility The directors’ are responsible for preparing the annual report and financial statements which taken together with the strategic report for 2014/15 provide a fair, balanced and understandable analysis of UCLH’s activities and provide the information necessary for our patients, regulators and stakeholders to assess our performance during the year and our plans for the future. Directors who held office during the year were:

Richard Murley, Chairman Sir Robert Naylor, Chief executive

Non-executives Professor Sir Alasdair Breckenridge Dr Harry Bush Dr Rima Makarem Kieran Murphy Professor Sir John Tooke Dr Diana Walford Caspar Woolley (from 1 January 2015)

Executives Richard Alexander, finance director Dr Geoff Bellingan, medical director, surgery and cancer

Professor Katherine Fenton , chief nurse Dr Jonathan Fielden, medical director, medicine Dr Gill Gaskin, medical director, specialist hospitals Neil Griffiths, deputy chief executive (from 2 June 2014)

Professor Tony Mundy, medical director, corporate

Directors are asked to declare any interests on a register of interests on appointment or during their appointment. The register is held by the trust secretary and is published annually. It is available on our website or from the trust secretary. Contact details can be found on page 79. Board members’ details together with declarations of their relevant interests, and committee membership are detailed on pages 69 to 74.

Directors must also meet a new fit and proper persons test introduced in November 2014, set out in the CQC standards. The chairman considers that all board members met this during 2014/15.

So far as UCLH’s directors are aware, there is no relevant audit information of which the auditors are unaware. The 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.

Signed on behalf of the Board of Directors

Sir Robert Naylor Chief Executive 27 May 2015


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150+ work experience students


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3 Strategic report

3a. Strategic context

UCLH is committed to delivering top-quality patient care, excellent education and world-class research.In November 2011, the Board reviewed the organisation’s service strategy and agreed to focus on a parallel approach of providing excellent services to our local community while working to develop three specialist service areas with the potential to become world leading:

Cancer services neurosciences women’s health.

In order to deliver world leading excellence in these three specialties, it is essential to sustain a strong base in core medical and surgical specialties. Any strategic intent to grow the priority specialist services must be run alongside appropriate investment in core medical and surgical services and in the delivery of high quality local care to the population we serve. Our focus on developing these services will ensure that our patients always remain at the core of everything we do.

We are proud of our ability to deliver first-class medical and surgical services to our local population, Greater London and the south east. These include dermatology, gastrointestinal, gynaecology, infectious disease, rheumatology, trauma and orthopaedics as well as urology.

We are committed to supporting the implementation of the cancer and cardiac reconfiguration proposals which will result in UCLH becoming a sector hub for some specialist cancers and Bart’s Health NHS Trust the sector-wide centre for cardiac services.

Our patients also benefit from leading hearing, balance, dental and head and neck services at the EDH and the RNTNEH.

Clinical research underpins all aspects of our high-quality services, and will be a key driver for our service developments over the next 10 years. We have already gained a national and international reputation in a number of areas of significant research and have continued to see a year-on-year growth in the number of patients participating in clinical trials across a number of specialities. We will look to grow and develop our relationship with UCL and other academic and charitable partners, supporting our key strategic aims and vision.

We remain committed to the strategy which we

set out in our strategic plan submission to Monitor in June 2014, focused on the strategic intent of continuing to develop the three UCLH specialist service areas.

The Five Year Forward View and Dalton Review describe how hospital service provision could develop in the near future. We will use both to help to refine our strategy as a provider of both nationally leading specialist activity and excellent services to our local population. The implications of this for partnership working and organisational form are highly significant and will require the Board to review and refresh its strategy and plans for delivering care to the local population while working in close consultation with our local CCGs, during the first half of the year. Later in this document we set out the work that we have already started through submission of collaborative Vanguard bids in response to the strong messages from the Five Year Forward View.


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400+ UCL medical student placements

Changes in our local health economyThe planned acquisition of Barnet and Chase Farm NHS Trust by The Royal Free London NHS Foundation Trust was completed on 1 July 2014. This reconfiguration was fully expected and to date there has been no clear impact on UCLH services. However, the scale of change created by this acquisition is likely to have on-going implications for the configuration and delivery of services in the north of our local health system which we will need to continue to monitor in close collaboration with our partners at The Royal Free London.

The closure of several Accident & Emergency Departments in west London may have contributed to the continued increase in attendances at the UCLH department. These changes in service delivery, and on-going plans to change urgent care services, could affect us in the coming year and will be monitored closely during 2015/16.

We will continue to work closely with our local health economy on delivering high-quality, highly efficient care for the local population. We have been playing an active role in developing schemes that use new organisational forms and tariffs to generate better care for our patients.

As part of our approved mandate to help lead specialist cancer delivery across the sector, UCLH has submitted a bid for Vanguard funding with partner organisations. This proposes further development of existing networked cancer care with a significant focus on early diagnosis and radical cross-organisational service redesign to ensure our patients have access to the best cancer service available.

We have strongly supported Camden CCG’s application for Vanguard funding. In the opening quarter of 2015/16 our medicine board medical director, Dr Jonathan Fielden, will finalise a “local hospital strategy” for approval by our Board of Directors. We will continue to consult closely with our local CCGs and health partners on this work, aligning it with their Vanguard funding proposal.

The strategy will incorporate the learning and progress from a number of specific schemes that we are already implementing with Camden and Islington CCGs. We coordinate this integration and improvement work with our local CCGs at our monthly Service Redesign Group. Initiated by Camden CCG and UCLH this group enables us to carve out a space within the contract structure where we can drive through the implementation of schemes that could otherwise be lost in more technical contract discussions and debates. At the group we are developing schemes that use new contractual models (alliance contracts, lead provider arrangements)

and tariff structures (in particular outcome-based payments).

The current agenda of the group represents an ambitious work programme for 2015/16:

Adult diabetes paediatric diabetes musculoskeletal services chronic obstructive pulmonary disease frail elderly.

This plan will help to ensure patients receive care where they need it most and reduce unplanned hospital admissions.

We are also working with health and social care partners to use resources and infrastructure to deliver better care at the right time for Camden residents. Towards the end of 2014/15 we saw much clearer evidence that all organisations were starting to share data and produce analysis that would help reduce unnecessary admissions and delayed transfers of care. All parties are keen to refine the current better care fund schemes so that additional resource can be injected at points in care pathways that avoid admission and get patients out of hospital faster.

Equally, our intention is to continue to work together with Camden CCG as a provider member of the Camden System Resilience Group – a partnership working group, comprising stakeholders across the Camden health and social care economy, which provide oversight and assurance on urgent, emergency – elective and non-elective capacity planning. In 2014/15 we played an active role in the setting up of this group, initiating and helping to develop a Camden health economy wide performance dashboard reporting tool which looks at capacity and performance across all providers in Camden. This work has already highlighted a gap in the provision of step-down facilities (the process that monitors a patient’s progression through the healthcare system) in the local area which is needed to enable less acute patients to move more quickly from the acute hospital setting. Many of our delayed transfers of care are due to lack of step-down facilities.

We will also use the System Resilience Group to continue to press for the commissioning of suitable neuro-rehabilitation provision in support of the smooth flow of patients along the stroke pathway. At present we face persistent problems with the transfer of patients from our hyper-acute stroke unit to their local stroke units which has a knock-on impact to patient flow in the rest of the University College Hospital wards and the NHNN.


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3b. Our capital programme, activity and capacityWe are using our capital programme to consolidate services at two locations, namely NHNN for the development of neurosciences and University College Hospital campus for cancer and all other services. These issues are more fully described in the section on service developments earlier in the directors report.

We remain committed to improving patient experience and outcomes through investment in buildings and equipment. We proactively manage risk through use of the capital programme to address issues raised through our services’ risk registers. We retain a contingency of capital funding to address any unforeseen issues that come up during the year. We also continue to respond to opportunities that present themselves during the year in areas such as research and development and these initiatives are added to the capital programme when their funding sources are firmed up.

Activity growthWe have had continued growth in our patient activity and income in recent years.

We expect to see similar levels of activity growth in 2015/16, with the expectation that income growth will be significantly less than activity growth as a result of the efficiency requirement placed upon NHS providers.

To a degree this is similar to growth being seen across the health service as a whole, although with part of our strategic focus being in specialised services this does mean that our anticipated growth levels are higher than the average for the NHS. Innovations in healthcare, particularly in cancer and neurosciences, have enabled us to better treat patients and increase their life expectancy where historically, this had not been possible.

We are also seeing our share of acute sector work increase over time. Growth in income levels in our strategic priority specialties is marked, particularly for cancer services and neurosciences. 55 per cent of our activity is under contract with NHSE as specialised commissioners. NHS England’s clearly stated intention is to reduce the number of trusts providing specialised services, centralising care far more in regional hubs. We expect that this will result in a net increase in flows of referrals and activity. It will be important for our future sustainability as an organisation that

NHSE’s funding mechanisms support their strategic intention to consolidate specialist care in this way.

Our current assessment is we believe that we can maintain our share of activity in our sector and London, although we are mindful of the potential impact that The Royal Free London acquisition of Barnet and Chase Farm trust might have on local service configuration.

In agreeing our activity plans with commissioners we have been clear where we have put additional activity into our plans to correct deficits in 2014/15 run-rates and where it is required to deal with growth in 2015/16.

The growth levels that we are anticipating represent a significant challenge in terms of required staffing levels and capacity in our physical assets such as beds and theatres.

BedsDemand for beds continues to increase as more patients are referred to UCLH. Seasonal demand for our services means that the number of beds we require changes through the year: winter pressures mean that we expect more demand for beds in the winter than we do in the summer.

Based on our current forecasts of patients, we don’t currently have enough beds to see all of our patients and meet all of our waiting times targets. We do however have a range of initiatives that we will introduce across 2015/16 that we forecast will give us sufficient bed capacity to deliver emergency and referral to treatment waiting times targets throughout the year. These are a combination of bed capacity creating schemes and efficiency measures (mostly reducing the length of time that patients need to stay with us). Key schemes that we are implementing are:

UCLH@HomeThis scheme delivers care at home to patients who no longer need to be in an acute setting but do require regular monitoring and care. We will be increasing the number of patients who will benefit from this service.

Use of Clinical Decision Unit and Ambulatory CareThis scheme makes use of areas to avoid admissions to beds in University College Hospital for appropriate types of patient. The Clinical Decision Unit allows us to observe patients without admitting them to an overnight ward. Our ambulatory care pathways enable us to see patients in a setting more akin to an outpatient appointment once they have been


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8,118Twitter followers

discharged from A&E, again avoiding the need to admit them to an overnight ward.

Outsourcing to the independent sector This scheme makes use of operating theatres and beds at private healthcare facilities when UCLH capacity is at its limit. This only happens when patients agree to be seen at a private hospital.

Length of stay reduction We have identified that we can reduce our length of stay for both elective and emergency patients. This is a key strand of our transformation programme.

TheatresTheatre capacity at UCLH is similarly pressured. We have a target to achieve 85 per cent utilisation in our theatres. We monitor performance against this through our performance framework. At present a shortage of recovery space, exacerbated by delays in being able to discharge patient back to wards, is a principal driver of our theatre utilisation being at around 75-80 per cent. In addition we will work on a range of issues to improve our theatre utilisation,

including tighter management of lists that are released by specialties, minimising the number of lists that start late, and looking for opportunities to organise lists so that short operations can be fitted into lists that otherwise may finish early.

Winter plansIn 2014/15 we put in place additional staff and processes to improve our resilience and patient care during the winter months. These were funded by recurrent Camden CCG system resilience funds and some non-recurrent funding from NHSE. All schemes met with the NHSE best practice guidance for non-elective resilience plans and in the main supported extended day and seven day working for supporting clinical services, improved support for discharge processes, improved patient flow in particularly vulnerable patient groups like the elderly, mental health, paediatrics and stroke and to avoid delays and manage surges in the emergency department.

The following schemes worked well, and we have put them forward for continued recurrent funding via Camden CCG’s recurrent system resilience funds. As we no longer have a summer lull in emergency


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patient activity, we believe most of these need to be continued for the entire year to ensure year round resilience.

Extended and seven day working in clinical support teams:

Additional therapy and junior doctor staff available at the weekends on the hyper acute stroke unit

additional pharmacists and pharmacy technicians to improve turnaround of medications for patients, particularly those ready for discharge

additional therapists to support medical and care of the elderly patients who are admitted to non-medical wards

University College Hospital afternoon phlebotomy service to ensure blood tests are dealt with quickly

additional porters to work directly with the imaging departments to avoid delays in transferring patients from wards to their imaging slots

additional consultant radiologist to improve reporting of acute and emergency patients imaging requests

additional nursing staff overnight in recovery.

Improved support for discharge processes: Saturday opening of the patient lounge pharmacy technician working to make up blister packs needed for patients’ discharge

weekend discharge nurse to improve weekend discharges and prepare for Monday’s discharges.

Improved support for vulnerable patient groups: Additional consultant paediatrician working in the emergency department to improve response times and avoid unnecessary admissions

additional mental health liaison nurses working within the emergency department and in University College Hospital to support improved response times and support given to patients attending or admitted with mental health problems

purchasing overnight stays in specialised centres for patients admitted with alcohol problems, to enhance their recovery in the right environment

nurse practitioner working to support rapid assessment and discharge of patients attending on the stroke pathway, but actually having another condition – ‘stroke mimics’.

Avoiding delays and managing surges: Additional emergency department senior registrar to increase number of senior decision makers in the department to avoid delays

third consultant in the emergency department at the weekends to deal with the increase attendances now occurring at weekends

additional nurse in the emergency department to support streaming to ensure patients are sent to the correct section of the department according to their care needs

additional GP hours at the front door of the emergency department and working as part of the urgent treatment centre team

staffing to keep elective surgical bed bases open at the weekend if we get a surge in emergency admissions

started seven-day therapy services for emergency service patients, giving weekend access to care which can help patients get home sooner

reduced waiting times for routine physiotherapy outpatients from 20 weeks to 8.5 weeks, and for urgent cases from two weeks to one week.

We will continue to work with our system partners, particularly via the System Resilience Group, to ensure our current relative success in performance from this year’s work across the urgent care pathway is resilient for the future.

Workforce: key challenges 2014/15Our key workforce development challenges for 2015/16 will be two-fold: building capacity and building capability to deliver our strategic developments. Our focus will include seven-day and out-of-hours working, new models of ambulatory, urgent and unscheduled care agreed with our partners, productive outpatients, integrated care pathways, the transfer of the HH services to Barts Health and our strategic plan for cancer including PBT.

Retaining and recruiting staff is one of the biggest investments we will make and one of the most challenging corporate tasks we face. The quality of our staff is key to delivering excellent patient outcomes and experiences. Our new action plan for national and international recruitment will be critical to our ability to fill the vacancies we have now and the new skills need that we forecast and is vital to the future retention of our workforce. We will also focus our efforts on improving staff experience in order to improve patient experience, developing a safe, supported and engaged workforce, deliver an aspirational approach to organisational development, improving and innovating to deliver excellent workforce processes, while using our unique position within UCLPartners to support staff with high-quality education, learning and development.


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19,224UCLH members


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3c. PerformanceInfection controlWe have demonstrated good performance on infection control in 2014/15, when we had three cases of MRSA. The number of Clostridium difficile cases that our commissioners have confirmed as contributed to by lapses in healthcare has been nine at time of publication, bearing out our assessment that we did all that we could to avoid many of the cases that we report as a result of our comprehensive testing regime. Nonetheless we are maintaining through 2015/16 all of the preventative work that we have put in place to minimise the risk of Clostridium difficile cases, in particular our upgraded deep-clean regime and the use of hydrogen peroxide vapour cleaning.

Waiting timesDuring the past year we have responded to significant challenges in delivering key access targets, in particular the 18 week RTT waiting times targets and 62-day cancer target.

We were in breach of the three headline RTT targets throughout most of 2014. As a result of significant investment and enormous commitment from our clinical and management teams, we reduced the number of patients waiting for more than 18 weeks to a low enough level to meet the open pathways’ (the status of a patients healthcare journey until it has completed) target in November 2014. We also invited the intensive support team into UCLH, they have provided expert knowledge and assurance around the robustness of our RTT reporting and management. We were able to meet the non-admitted treatment target in February 2015 and are currently on track to deliver the admitted treatment target from June.

Through a process of restructure and development we have now built a sustainable platform for providing shorter waits for our patients, based on:

Clear roles and responsibilities for the delivery of short waiting times

more rigorous meetings to target patient waiting lists at all levels of the organisation, ensuring more proactive operational management of waiting lists

greater discipline in booking patients according to protocols that are shown to deliver shorter waiting times

significant improvements to our operational reporting capability on patient waiting times, in particular much stronger PTL reporting and far tighter controls around our validation of patient

pathway information specialty level RTT demand and capacity modelling and forecasting.

We do, however, continue to face a very high demand for both our elective and non-elective inpatient services. In the face of this demand, and with limited options for rapidly increasing our inpatient capacity, we must mitigate the risk that insufficient bed and theatre capacity will lead to specialty-level breaches of the RTT standards.

Across 2014 we also missed the headline cancer access target of treating cancer patients within 62 days of referral from their GP. We have taken some key steps to improve our position against this target, although like all major tertiary centres our future continued compliance remains dependent upon partner trusts delivering improvements on their stages of patient cancer pathways. In response to this, we have developed a detailed action plan to deliver compliance by Q3 of 2015/16. This was agreed with Monitor and our local and specialist commissioners. Key actions include:

Put in place medical director-led PTL meetings for all cancer pathways

improved the breach analysis process we have in place for pathways at our hospitals, and have started a process for improving the learning about delays at referring hospitals. This will give UCLH a much richer understanding of all delays that contribute to breaches. We are now reviewing these breach analyses in collaboration with commissioners to help ensure a much greater system wide approach to improvement

developed timed pathways which show the milestones that need to be met for each pathway to be compliant with the 62 day standard and structured a clear performance framework and accountable lead for each element of the pathway and compliance with standards

working with referring trusts to understand the issues and streamline pathways where possible. This is happening on a number of levels, with some trusts the discussions are being led by clinical teams, whereas in other areas we are pursuing more formal communications with commissioner involvement.

In addition we have taken on more of a system leadership role within our cancer network, and in 2015/16 we aim to continue developing the infrastructure to support a system wide pathway development. UCLH currently funds the majority of the London Cancer Pathway board directors who work across the whole sector on individual tumour


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28stands at our research open day

pathways. In addition, we have made an offer to commissioners, pending funding, to house and support this network-wide team who would play a key role in overseeing and supporting the on-going development of pathways via different London cancer tumour site work-streams. This sector wide view will be crucial for shortening pathways where possible.

Along with most other trusts nationally, we have not consistently met the operational standard that 95 per cent of our patients are seen in our emergency department within four hours. We have however performed better than the average for London and nationally. We have made significant improvements in reducing the number of patients waiting longer than four hours that are within the remit of the emergency department itself, but continue to count a high number of patients waiting longer than four hours on account of lack of bed capacity in University College Hospital towards the end of Quarter 4 when performance improved. Achieving the four hour A&E standard, ensures that our patients are being seen and treated quickly.

A key action in 2015/16 will be to secure the capacity required to deliver against all access targets. We have also made good progress in the past year in developing closer working relationships with

our CCGs, community providers and social care colleagues in developing schemes that will reduce the call upon our acute services. This includes commissioning additional capacity in facilities that have, perhaps, been under-commissioned in recent years, such as step-down and neuro-rehabilitation beds. Improving the flow through the hospital will provide a better experience for our patients meaning that those needing a bed in inpatients rehab or in the community, will be able get this quickly reducing their waiting time for treatment.

The performance challenges that we have addressed over the course of 2014/15 have reinforced our commitment to our strategic direction which will drive a number of priorities in 2015/16, most notably:

A commitment to collaborative working with a range of partners

development of common care delivery standards across the organisation, that is an agreement on a UCLH way of running our core operations

investment in our informatics capability matching capacity to demand through collaborative work with partners and securing agreement for our phase 4 and 5 building developments.


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Table 1: Performance against the top ten objectives

Objectives DeliverableProgress made

Full Good Partial None

1. Improve patient safety

Reduce hospital acquired infections, pressure ulcers, falls and missed medications

Implement plans for 24/7 care where appropriate

Improve sharing of learning

2.Deliver excellent clinical outcomes

Improve outcomes against Trust and specialty specific measures

Reduce avoidable admissions

Access standards and right staff across emergency pathways

3. Deliver high quality patient experience and customer service excellence

Standards for patient experience, as customers

Making a Difference Together (MaDT) programme improve patient experience

Make it easy for patients to give us timely feedback and act on it

4. Reduce waiting times

Reduce the time patients wait for treatment after referral to our services

Meet the cancer waiting time targets

Reduce waiting time to be seen as outpatient

5. Achieve sustainable financial health

Achieve key financial targets

Agree a financing strategy for capital developments

Develop collaborative, robust relationships with commissioners and commercial partners

6. Develop a transformational strategy based on patient pathways

Working with stakeholders to develop integrated services

Lean transformation

Standardise patient pathways

7. Develop research and development and education

Strategy to improve education

Combine leadership of all research activities

Implement recruitment strategy for clinical academic appointments


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85.9%per cent appraisal rate at UCLH

Objectives DeliverableProgress made

Full Good Partial None

8. Enable staff to maximise their potential

Staff experience of working at UCLH

Appraisal and mandatory training

Design and implement organisational development programme

9. Progress strategic developments

Business case for phase 4 and 5

Implement cardiac and cancer strategy

Expansion of maternity and neuroscience services

10. Other key strategic developments

Develop and implement ICT strategy

Deliver improved pathology services with commercial partner

Develop new strategy for procurement and logistics


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Table 2: Performance against commissioning for quality and innovation (CQUIN) schemesWe performed well against the CQUIN schemes that we agreed with commissioners for 2014/15, delivering improvements in quality across schemes designed to enhance our role in prevention, our general nursing care for patients, our care for specific groups of patients, and processes and outcomes in a number of our specialised services.

CQUIN What we had to doDid we achieve? (Position at time of publication)

Pressure Ulcers We had to show a reduction in hospital acquired pressure ulcers.We also had to highlight areas with a high incidence of community acquired pressure ulcers and work closely with our commissioners to provide knowledge and training on prevention

We achieved all of this CQUIN apart from in Q3 and Q4 when we were slightly above our target for hospital acquired pressure ulcers.

Dementia We had to ensure processes were in place to identify, assess and refer any patients aged over 75 years who was found to potentially have dementia following an emergency admission. We had to ensure staff were appropriately trained and ensure carers of patients with dementia were supported.

100 per cent of the CQUIN.

Friends and Family test We had to ensure that all our patients had the opportunity to have their say in whether they would recommend the Trust’s inpatient, day case and outpatient services to their family and friends.In addition, we had to ensure that we captured a significant proportion of patients’ responses to the Friends and Family Test for inpatient and emergency services.We also had to make sure our staff had the opportunity to have their say in whether they would recommend this Trust to their friends and family.

We achieved all of this CQUIN apart from one of the measures where we just missed the March target by two per cent for the Inpatient Friends and Family test response rate.


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17floors in the University College Hospital Tower


Smoking prevention We had to set up a Trust wide governance structure for smoking prevention. We had to set up processes to screen elective patients attending pre-assessment clinics and refer them to smoking cessation services if they were smokers.We also had to increase the number of staff undertaking smoking cessation.

We achieved all of this CQUIN apart from one of the measures where we were below the target for carrying out smoking assessments in one of our pre assessment clinics.

Alcohol prevention We had to set up processes to screen patients in A&E for alcohol abuse, for patients screening positive we had to provide advice and communicate this to the patient’s GP.

We achieved all of this CQUIN except for in Q1 where we did not communicate to GPs in the required time.

Domestic violence We had to ensure that all relevant staff had the appropriate training for dealing with domestic violence.We also had to implement a process for screening patients to identify if they are victims of domestic violence and ensure we developed new guidelines and referral pathways.


Specialised workshops We were required to host four clinical outcome collaborative audit workshops for a diagnostic service for rare neuromuscular disorders (all ages), lysosomal storage disorder service (children), rare mitochondrial disorders service (all ages) and McArdle’s disease service (children).


Cardiac surgery We had to ensure a certain proportion of patients who were referred as semi urgent, to have coronary artery bypass grafting (CABG) were seen within seven days of electronic referral.


Endocrinology We had to develop processes to ensure diagnostic coding in Specialised Endocrinology in an outpatient setting was being done.



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Perinatal Pathology We had to ensure that a proportion of perinatal pathology cases had their final report following examination done within 42 calendar days and a proportion of all perinatal autopsies should have been issued within 56 days.


Retinopathy of prematurity We had to ensure processes were in place to increase our Retinopathy of Prematurity (ROP) screening rates for neonatal babies still in hospital.


Fetal medicine We had to ensure that a high proportion of newly suspected /diagnosed lethal or major fetal abnormalities or other life-threatening fetal disorders were referred to the fetal medicine centre and seen within three working days.


Quality, Innovation, Productivity and Prevention (QIPP) schemes

We had to improve patient experience for our adult patients following an elective peri-acetabular Osteotomy (PAO) surgery and help them manage their condition.


We had to ensure that a defined patient pathway was in place for Gioblastoma and we reduced patients' length of stay in hospital following the surgery.


We had to ensure that patients diagnosed with Multiple Sclerosis were registered to OptiMiSe Platform, which is a toll that enables them to self-care, self-monitor and manage their condition in the long term.


Following the national tariff consultation we have agreed with commissioners the tariff that will be paid for the activity we undertake in 2015/16. Details have not yet been finalised in relation to CQUIN – however, it is likely that there will not be a formal CQUIN programme, with this replaced by a set of quality objectives within the CCG contract which we would agree with commissioners. This could progress the 2014/15 plans to improve our identification and management of domestic violence, alcohol abuse and smokers. It could also include a range of plans to improve discharge for patients leaving our wards such as timely discharge summaries to GPs and patients being given appropriate medications advice.


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10key objectives to improve performance

Governance ratingIn 2014/15 UCLH’s governance rating was assessed as green (no governance concern) for quarters one and two. Following quarter two the rating was changed to performance under review. This was driven by deterioration in performance against a number of national standards. In May, Monitor updated our status to green ‘no evident concerns’.

As part of our 2014/15 planning, we declared expected risks against RTT and Clostridium difficile standards, and projected achievement of all other standards. We predicted that our top risk rating would be maintained through the financial year. We were correct that there were risks around RTT, however, we also saw a decline in performance of our cancer standards in year. This is what drove the overall risk rating to be moved to performance under review. The detail around where we predicted risks and where risks were realised in year is shown below:

Table 3

Target or Indicator (per Risk Assessment Framework)Threshold or target YTD

Risk declared at Annual Plan

14/15 Performance Issues in Year

Referral to treatment time, 18 weeks in aggregate, admitted patients

90% Yes Yes

Referral to treatment time, 18 weeks in aggregate, non-admitted patients

95% Yes Yes

Referral to treatment time, 18 weeks in aggregate, incomplete pathways

92% Yes Yes

A&E Clinical Quality- Total Time in A&E under 4 hours 95% No Yes

Cancer 62 Day Waits for first treatment (from urgent GP referral) 85% No Yes

Cancer 62 Day Waits for first treatment (from NHS Cancer Screening Service referral)

90% No Yes

Cancer 31 day wait for second or subsequent treatment – surgery 94% No Yes

Cancer 31 day wait for second or subsequent treatment – drug treatments

98% No No

Cancer 31 day wait for second or subsequent treatment – radiotherapy

94% No No

Cancer 31 day wait from diagnosis to first treatment 96% No Yes

Cancer 2 week (all cancers) 93% No No

Cancer 2 week (breast symptoms) 93% No No

Clostridium Difficile -meeting the Clostridium Difficile objective 71 Yes No

We have detailed action plans in place to recover RTT and cancer performance, and by end of 2014/15 we were achieving two out of the three RTT standards, with full compliance expected by end of Q1 2015/16. There is a similar level of focus on cancer performance which we expect to be compliant with by Q2 of 2015/16. We did recover A&E targets in Q4 (after being non-compliant in Q2 and Q3) and expect to maintain this through 2015/16.


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Table 4: Our top ten objectives for 2015/16 Following consultation with a range of stakeholders we have agreed our top ten objectives for 2015/16 and once again, delivering improved patient safety is top of the list.

Objectives

Improve patient safety Achieve hospital acquired infection targets

Deliver “Sign up to Safety” campaign

Deliver progress towards 24 / 7 working

Deliver excellent clinical outcomes

Maintain upper decile Standard Hospital Mortality Index results

Agree an integration strategy with CCGs

Avoid increase in levels of emergency admissions

Deliver high quality patient experience and customer service

Maintain patient survey satisfaction ratings

Reduce the number of outpatient cancellations

Avoid increase in the number of inpatient cancellations

Enable staff to maximise their potential

Reduce the level of nursing vacancies

Maintain/achieve improvements in staff satisfaction survey

Improve the effectiveness of performance appraisals for all staff

Reduce waiting times Achieve the 18 week RTT targets

Meet cancer waiting times targets

Achieve the 95 per cent per cent four hour A&E standard

Achieve sustainable financial health

Agree contracts with commissioners

Deliver cost improvement programme

Improve cash-flow performance

Develop and implement year 1 of our transformation strategy

Standardise and improve patient pathways

Agree preferred option for future IT infrastructure

Agree strategy for organisational development

Develop the research agenda

Increase the number of participants in clinical trials

Move the Clinical Research Facility to new premises

Progress clinical academic appointments with UCL

Develop education Develop plans for the UCLH Institute

Improve staff compliance with mandatory training

Improve satisfaction with medical education programmes

Progress service developments

Progress phase 4/5 developments

Implement cardiac/cancer strategy

Continue Emergency Department expansion project


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4UCLH values: kindness, safety, teamwork, improving

Strategic report conclusionThe strategic report brings together all of the most relevant information about UCLH, our strategy and future plans, performance over the past year, our successes and the principal risks we manage.

The Finance Director’s report on pages 32 to 33 reviews our financial performance during 2014/15 and also includes a statement that the accounts are prepared on a going concern basis. Our annual accounts can be found on pages 163 to 214, and have been prepared under a direction issued by Monitor under the National Health Service Act 2006.

Sir Robert NaylorChief Executive27 May 2015


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Finance Director’s report for the year ended 31 March 2015 The financial environment in which this and every NHS Trust operates was extremely challenging in the year just ended and looks even more so in the year we now face. The ability of UCLH to maintain both high quality complex specialist patient care and financial balance remains dependent upon proper remuneration for specialist services, pending significant revision to the reimbursement models and to the way care is delivered. UCLH is contributing to both of these critical change programmes. It is in this context that we are pleased to be able to report a surplus for the year ended 31 March 2015, slightly better than our plan.

The financial pressure caused by serving an aging population with growing expectations led by technology and drug advances is well documented. For UCLH in the year just ended this drove a requirement for new efficiencies to be found representing around a four per cent financial improvement. The continuing increase in demand for our services created very significant operational challenges in both patient waiting times and the efficient flow through the hospital of patients admitted under emergency conditions. Addressing these issues, which are of fundamental importance to patients, was prioritised above the delivery of financial efficiencies. One example of the adverse financial impact of this was the need to treat UCLH patients in non-UCLH facilities at higher cost. Our internal efficiency programme delivered £34m of the targeted £38m but this financial shortfall was covered by the fact that the financial pressures of winter were funded by commissioners and there were no exceptional pressures such as epidemic level outbreaks of flu or infections.

Seven per cent growth in clinical activity income to £774m, together with a consistent level of underlying other operating income, increased total operating income to £934m1. Total non-NHS income1 represented around 5 per cent of total operating income2.

The first half of the year was especially challenging financially as we were missing our targets and

intervention was required by the executive to recover performance back to an acceptable position. The reported net surplus of £2.4m was a little better than our plan, but includes additional support for specialist activity at levels not expected to be replicated in 2015/16. Taking account of the reported surplus and our relatively healthy cash balance the regulator grades our current financial sustainability at level three (on a scale3 from one – high financial risk, to four- low financial risk).

Our balance sheet remains relatively healthy, with a cash balance at the end of the year of £93m, representing around five weeks of expenditure. However, we also have current borrowing of £324m including the PFI (which is a particularly expensive kind of debt), and will require significant further borrowing to deliver our strategic development programme. The closing cash balance is also £37m down on the previous year, driven to a large extent by very significant difficulties in collecting cash from commissioners relating to the growth in demand we experienced and to a lesser extent from other NHS Trusts with severe cash flow problems. Our cash balance underpins only a small component of the Trust’s plans for estate development necessary to meet the continuing demand primarily in specialist services

1 before impairments (and impairment reversals) to fixed assets, and accounting for donations for assets over their useful life (the primary financial measure used by the Board of Directors)2 this meets the requirement of the Health and Social Care Act that NHS income must be greater than non-NHS income. Non-NHS income reduced in the year as we have prioritised delivery of NHS targets. 3 Monitor’s Continuity of Services Rating


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800 clinical staff have undergone face to face dementia training

in line with the national agenda to centralise complex specialist care – we have also secured, but not yet drawn down, short-term and long-term borrowing of £346m which is required to support that development programme. That programme is at risk pending the revision to reimbursement models previously referred to. It is worth noting that with a significant part of our estate financed under the Private Finance Initiative (PFI) we already carry a higher than average level of debt.

Looking forward, in common with most major teaching hospitals, the efficiency target to achieve financial breakeven significantly exceeds that which can be delivered without system level service redesign. Reluctantly we will therefore be planning for a financial deficit in 2015/16 whilst doing our utmost to minimise it with the first year of our UCLH Future programme. This multi-year change programme will focus on designing the care models with not only better patient quality but also financial efficiency in mind. We also plan to underpin much of that change with improved information technology. This, combined with our strategic development programme, promises an exciting and challenging period ahead.

2014/15 Annual AccountsThe accounts are attached at appendix 4 on page 163, the results in a format used for the Board for monitoring financial performance are included as part of note 2 to the accounts on page 182.

AuditorsOur auditors are: Deloitte LLP, St Albans

As far as the directors are aware there is no relevant audit information of which the auditors are unaware and the directors have taken all reasonable steps to make themselves aware of relevant audit information and to establish that the auditors are aware of that information. The finance director and his senior staff have provided the auditors and the Audit Committee with all relevant information they are aware of, and have through the financial year raised and discussed such issues with the auditors.

Going ConcernThe directors have given serious consideration to the application of the going concern concept to UCLH given the deteriorating financial context within the trust and the wider NHS They have assessed the trust’s

ability to continue operating on a going concern basis in two ways:a. Monitor, the sector regulator for health services in

England, states that anticipated continuation of the provision of a service in the future is sufficient evidence of going concern, on the assumption that upon any dissolution of a foundation trust the services will continue to be provided. The directors consider that there will be no material closure of NHS services currently run by UCLH (with the exception of the agreed transfer of cardiac services to Barts health in April 2015) in the next business period (considered to be 12 months) following publication of this report and accounts.

b. In relation to UCLH as an entity, the directors have a reasonable expectation that UCLH has adequate resources to continue to service its debts and run operational activities for at least the next business period (considered to be 12 months) following publication of this report and accounts, despite currently planning on the basis of a significant deficit in 2015/16. UCLH has sufficient cash to ensure its obligations are met over this time period. There remains significant uncertainty about the trust’s financial sustainability over a longer time period than the 12 months considered here, particularly as a result of underfunding of specialist services. This and other funding issues will need resolution in order for the trust to be confident of remaining a going concern beyond the time period assessed here.

For these reasons, the directors continue to adopt the going concern basis in preparing the accounts.

Better Payment PracticeUCLH aims to pay its suppliers within 30 days of receipt of goods or a valid invoice (whichever is later) in line with the Better Payment Practice code and monitors performance against this target. In 2014/15 we paid 63 per cent by value of invoices within this target (2013/14 64 per cent).

Richard Alexander Finance Director27 May 2015


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3d. Quality governance UCLH’s Quality and Safety Committee (QSC) ensures oversight of clinical risks and provides assurance to the Board on the quality of clinical care. To do this it reviews, complaints, claims and incidents. It also monitors compliance with CQC standards.

The quality and safety team, led by the director of quality and safety, share learning across UCLH from these activities and from patient feedback via complaints to promote and maintain a safe environment for patients and staff. This is delivered through quality forums, a quarterly quality and safety bulletin and at divisional governance meetings.

Further assurance of our current systems and processes has been gained from our internal assessments, for example through internal audit and through our ‘improving care walkarounds’. UCLH produces an annual quality report, the production of which is led by the director of quality and safety. The report includes the quality objectives set to improve patient safety, experience and outcomes. How these were met can be found in section 3 of the quality report.

Quality performanceExcellent patient care remains our top priority and we continue our focus on our three strands of quality; safety, effectiveness (clinical outcomes) and patient experience. For 2014/15 we successfully delivered against the main priorities in our quality report (also known as the quality account) including improving the care of patients with dementia, reducing falls with harm and hospital acquired pressure ulcers and continuing to improve ways to share learning from incidents and complaints. We continued our focus on patient experience through our local real time survey system. In July 2014 University College Hospital was noted to be the safest hospital in England after NHSE published data on the staffing levels and systems of patient safety. This year we continued work on improvements identified from the CQC visit in November 2013: improving the security of patient records and developing new nursing documentation to improve the quality of nursing records. We are proud of the improvements we have made in outpatient services but acknowledge there is still much to be done. More information can be found in the quality report.

Information governanceLast year’s annual report highlighted risks associated with patient identifiable data being transferred

to, or held by, UCL research personnel without appropriate technical or procedural controls in place, potentially leading to unintentional disclosures of sensitive personal data. UCL has since implemented a data warehouse solution that enables strict security access controls that have been accredited to the most widely recognised international security standard (ISO 27001). Further to this, UCLH is working closely with UCLPartners to develop a jointly agreed set of data sharing protocols.

There is still the need to continue to embed good information governance practice throughout UCLH on a consistent and on-going basis. To that end, we have recently undertaken a review of information risk and developed a strategy which includes our intention to eliminate the use of fax, roll-out the use of secure email, adopt a clear desk/paper-light policy and make use of secure data warehouse facilities and solutions to keep staff and patient information anonymous to enable the lawful use of data for clinical research.

Information risksInformation risks are monitored by an Information Governance Group. All incidents are investigated to ensure that we identify the underlying causes and to enable us to improve our processes. We are required to report information risks and data losses.

There were no serious incidents involving personal data reported to the information commissioner’s office in 2014/15. A summary of other personal data related incidents that we record internally is shown in table 5.

Table 5: summary of other personal data related to incidents in 2014/15.

Category Nature of incident Total

i Loss of inadequately protected electronic equipment devices or paper documents from secured NHS premises.

1

ii Loss of inadequately protected electronic equipment devices or paper documents from outside secured NHS premises.

1

iii Insecure disposal of inadequately protected electronic equipment devices or paper documents.

0

iv Unauthorised disclosure. 14

v Other. 0


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2,000members of staff have undergone dementia training online

3e. Corporate and social responsibilityEquality and diversityUCLH is committed to the principles of diversity, equality and human rights in every aspect of its employment and delivery of patient care. Our Diversity, Equality and Human Rights Policy specifies our commitment to equality and fairness for all our staff and patients and not to discriminate on any protected characteristic including age, disability, gender reassignment, pregnancy and maternity, marriage and civil partnership, race, religion or belief, sex or sexual orientation.

Human rights are central to our commitment to eliminating discrimination, not only in terms of our policies and processes but in creating the right environment and making it everyone’s responsibility to achieve the fundamental principles of fairness, respect, equality, dignity and autonomy. This environment can foster improved working relationships and directly improve the experience and outcomes for our patients.

The responsibility for developing and ensuring this agenda, including meeting our legal obligations in line with equality legislation and national guidance, rests with a Diversity and Equality Steering Group that reports through the director of workforce to the Executive Board and on to the Board of Directors.

There has been a calendar of events for 2014/15 to promote equality and human rights across UCLH. Staff awareness events have included deafness, mental health awareness and faith, through presentations and face-to-face sessions. Work has been undertaken with the National Apprenticeship Scheme to develop supported internships for individuals with learning disabilities to enable them to secure employment. The focus of these programmes of work has yielded results over the course of the year at an organisational and individual level:

In 2014/15, 14 apprentices took up posts working in UCLH

we became the first organisation in the UK to be awarded the International Disability Management Standards Council’s certificate for the work undertaken in relation to absence and disability management

the employee relations team and occupational health team won Team of the Year in the ENEI Diversity Award (Employers Network for Equality and Inclusion)

the teams were the finalist in the Healthcare

People Management Awards award for HR Team of the Year

members of staff from UCLH were named as finalists in the National Diversity Awards and the ENEI Diversity Champion of the year. In addition, a member of staff was awarded the NHS Employers “Personal Fair Diverse Champion of the Year”.

We recognise that embedding diversity and equality into our culture requires effective leadership. We are strengthening our leadership skills as a consequence of this.

In the year ahead, UCLH will continue to engage with external partners within the NHS and the local community to create programmes of work to not only meet our requirements under the Equality Act, but to go further in creating an environment which achieves the fundamental principles of fairness, respect, equality, dignity and autonomy.

UCLH employs around 8,000 staff, for more information about how our staff delivers top quality care to patients and how they are supported and developed, please see section 4.


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Sickness absenceThere had been an upward trend in the level of sickness absence from 2.7 per cent in July 2014 to 3.9 per cent in December 2014. In part, this reflected a more rigorous approach to collecting data. Our sickness absence at the end of March 2015 was 3.3 per cent, the same rate as recorded at the same time period last year.

Sustainability and environmental performanceWe continue to make progress in improving the environmental cost and social impact of our work, such as maximising our contribution to people’s health and wellbeing through for example local employment and welcoming public places. As well as the wider social benefits these changes bring, these improvements also contribute towards UCLH’s objectives to boost quality, efficiency and performance.

Our direction is clearly defined by policies for sustainable development, carbon, and waste management which integrate the latest requirements and guidance from UCLH’s Sustainable Development Unit. UCLH has already met its 2015 target of reducing carbon emissions by 10 per cent (per patient contact), and we are now working hard to cut emissions by more than 28 per cent against our 2007/08 baseline. This represents a target of 22,539 tCO2e (absolute tonnes of carbon dioxide equivalent) to be achieved by 2020. Currently we are short of that target, with absolute emissions of 30,722 tCO2e.

Table 6: UCLH absolute carbon emissions in Tonnes

31,304 30722.05 t

28173.6

10,000

15,000

20,000

25,000

30,000

35,000

2007/08 2014/15 Target

CO2

t Abs

olut

e

2007/08

2014/15

Target

UCLH has long been accredited to the Carbon Trust Standard. This is a mark of excellence providing independent verification for our carbon footprint.

Our reported carbon footprint includes those sources where we have a good understanding of emissions. Not included at this stage are emissions from procurement and our supply chain plus transport and travel, which will be integrated into the much more demanding 2020 reduction target. We are working to quantify emissions from these sources and towards developing effective plans to minimise and reduce emissions from these highly significant areas.


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1,400nominations for UCLH celebrating excellence awards

Carbon intensityOur carbon footprint has been determined in relation to patient contacts (defined as the sum of inpatients and outpatients) and has demonstrated a continuous improvement each year, based on 2007/08 baseline figures. Due to increasing utility prices over the period, the reduction in cost per patient contact (energy and water), although reduced from 2007/08, is not as significant as the reduction in carbon per patient contact.

Table 7: UCLH carbon footprint per patient contact

0.05

0.03

0.00

0.01

0.01

0.02

0.02

0.03

0.03

0.04

0.04

0.05

0.05

2007/08 2014/15

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t per

pa�

ent

2007/08

2014/15

Recent progress to manage our sustainability performance includes:

Our Cancer Centre was awarded a BREEAM (Building Research Establishment Environmental Assessment Method for buildings and large scale developments) excellent rating and includes building features such as sophisticated lighting controls, automated blinds, and efficient equipment and water management systems. We are now looking at optimising the building management system which will further reduce our carbon emissions

we actively collaborate with other NHS trusts to reduce the impact and cost of energy, waste and transport. We are a leading member of the Camden Climate Change Alliance. This year we raised awareness on sustainability with staff, patients and local stakeholders through our open day event, the successful Green Ward Competition and we have been active in the NHS Sustainability Day

the UCLH Sustainability Steering Group is an essential forum in continually evolving and implementing our policies around sustainable development. The group consists of senior members from across the organisation responsible for meeting sustainability targets within functional areas from procurement, clinical, pharmacy, radiography, information systems, estates and facilities management

as a member of the Shelford Group, we are collectively working towards sustainable procurement.


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3f. Savings and activity plans We face increasingly challenging financial years ahead and the UCLH Future programme will help to prepare us for extremely demanding efficiency targets over the next five years. It is clear that this will continue to be a period of enormous challenge for us.

Over the past four years UCLH has broadly achieved its savings targets; however, this fifth year has proved more difficult with us achieving £34m against a savings target of £38m. Our cost improvement programme for 2015/16 and beyond will be tough and we need to respond at pace and scale to meet ever increasing expectations. This will take renewed effort and new skills to deliver the required level of transformative change required.

To help us secure a sustainable future through a period of increasing financial challenge, the UCLH Future programme will help to prepare us for demanding efficiency targets over the next five years, where there will be a continued expectation for us to reduce the cost of treating each patient whilst minimising the impact upon quality. It is clear that this will continue to be a period of enormous challenge for us and a focus on value for money will be at the heart of the UCLH Future programme.

One of the highlights of the QEP programme has been work completed through the Productive Outpatients Programme (PoP). The programme was developed at UCLH, recognising the need for a structured approach to engaging, training and empowering front-line staff to redesign and improve services to reduce waiting times for patients and provide a more responsive service. One hundred and five clinical teams have participated in the programme to date (59 per cent of all teams), which has improved 955 clinics across the organisation and around 260,000 patients’ experience each year. During the past year every team at the RNTNEH participated in the programme, impacting all 248 of these clinics. Headline achievements:

Ninety three per cent of clinics have improved their new patient to follow-up patient rates creating the capacity for patients to have their first consultation more quickly

sixty four per cent of clinics have increased productivity by improving patient attendances

teams seeking to reduce waiting times for clinic appointments have achieved this with the degree of reduction ranging from 87 per cent to 30 per cent

delays for patients and waiting times in clinic have reduced

new service models have been introduced to cut response time for patients and, in some cases, deal with cases without the patient having to travel to and from hospital. These include:

� Remote review, where results are clinically reviewed and decisions made without the patient needing to be present (e.g. in GI medicine and vascular surgery) which has had a significant impact on reducing waiting times

� nurse led clinics (e.g. ear nose and throat services)

� audiology led clinics (e.g. audiovestibular medicine)

� telephone consultations (e.g. pancreatobiliary medicine)

� introduction of one-stop services (e.g. allergy and penile cancer)

� a one-stop shop for cochlear implant patients which means they can be seen in a single visit to hospital, rather than wait six weeks between tests and appointments.

We will take forward elements of this programme into the transformation work but at scale and with pace.

What our patients are saying about the programme:

“Very impressive process – the NHS at its very best. Minimal waiting time, all staff polite and explained what was happening. Consultant very knowledgeable and instilled confidence” Patient, adult audiovestibular medicine.

“Efficient informative courteous.” Patient, colorectal surgery.


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574subscribers to our YouTube channel

Home for Lunch A multi-disciplinary team approach that has led to a three-fold increase in morning discharges was rolled out to wards across UCLH this year.

The Home for Lunch project sees a multi-disciplinary team come together each afternoon to give patients a better planned discharge process. A short film and resource pack was created to support clinical teams implement steps that streamline prompt discharge and avoid delay on the day, an issue patients and carers have flagged as in need of improvement.

Each day the whole ward team has a 20 minute meeting around the patient status board, led by the ward sister, charge nurse or their co-ordinator for the day, focusing on how patients’ discharge can be made smoother for them – for example, the ward pharmacist and each orthopaedic medical team attends to arrange take-home medication there and then, occupational therapy and physiotherapy team members contribute, and a member of the integrated discharge team ensures all actions are followed up and arrangements are in place.

Prior to the project, just 10 per cent of patients were getting home before midday, which increased to more than 30 per cent within a month of starting. The initiative has now been extended to several wards across UCLH’s sites.

Sam Oussedik, consultant orthopaedic surgeon and clinical lead for Home for Lunch, said: “Patient feedback told us that patients weren’t happy waiting till later in the day to be discharged. By bringing together clinical input from each of the medical teams involved in the patient’s care we’ve been able to reduce the time patients have to wait with us, and free up capacity.”

UCLH Future During the second half of 2014/15 we started to develop a longer term transformation plan; an ambitious programme we are calling UCLH Future. This will focus on how we can continue to improve the quality of all aspects of services to our patients – matching the best performing hospitals in the NHS and globally.

To do that we will need to re-think how we deliver care – shortening clinical pathways, and significantly improving core operational processes from first patient contact to admission and bookings, and patient flow – to improve patient and staff experience.

We will be investing in service re-design and new technology, together with training and development for all staff. The key objectives are to achieve financial sustainability and improve the quality of service. Meanwhile we will be working hard to make sure 2015/16 is also successful financially providing the foundation for the longer term.

Commercial opportunities UCLH has a long standing history of effective commercial relationships that have delivered benefits to the wider organisation. These have included our partnership with the Hospital Corporation of America (HCA) which has been in effect since 2007 and our more recent Pathology Joint Venture with The Doctors Laboratory and the Royal Free London.

Pathology Joint VentureUCLH, Royal Free London and The Doctors Laboratory this year launched Health Services Laboratories (HSL), a pathology joint venture which will improve care for patients and deliver better value for the health economy. Health Services Laboratories will bring together the best from both the independent and public sectors to provide a wide range of benefits for patients, staff, clinicians, academics and the founding partners.

We will continue to explore opportunities to develop and expand on our existing commercial relationships over the coming years.

Central to our recently approved investment case for cancer and surgery (Phase 4) is the proposal to partner with a private healthcare provider to deliver private haematology and surgical services. These negotiations will be further developed during 2015/16. In addition we will also be seeking to partner with a third party to optimise the opportunity to deliver a private PBT service alongside the Department of Health funded centre, due to open in late 2018.

Other commercial opportunities include an enhanced private patient surgical service at NHNN, the possibility to further develop private maternity services, potentially as part of a joint venture and the opportunity to leverage value from both existing and underutilised estate. Private patient activity represents just one per cent of UCLH’s turnover. Our priority as always remains services for NHS patients.


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3g. Risks and uncertainties

Risk managementUCLH operates in a highly political, financially challenging, technologically complex and competitive environment. All of these factors combine to create a context of significant risk for UCLH.

Effective risk management is fundamental to how we run our business and underpins the delivery of UCLH’s objectives. It is essential in helping us progress the implementation of our mission statement which is focused on the provision of top-quality patient care, excellent education and world-class research.

Our approach to risk management is to identify, at an early stage, key risks which either exist as part of our day-to-day operations or potentially will be created as a result of decisions taken by UCLH, and to develop actions to eliminate or mitigate to an acceptable level the impact and/or likelihood of such risks materialising.

A key aspect of UCLH’s operating environment and its core business is the provision of high-quality services to patients. Patient safety is a critical component in our duty to care for individuals and it is a primary issue impacting the ongoing status and reputation of the organisation. Therefore the maintenance of patient safety stands out as a key risk to be managed and is at the heart of the UCLH values launched in 2012.

Risk management processes are embedded throughout UCLH at all levels and these assist

managers and clinicians in identifying and understanding the risks they face in delivering business objectives and in ensuring that the key controls we have in place to manage those risks are effective. These processes form an integral part of the day-to-day business activities of the organisation.

Roles and responsibilitiesThe executive board, which reports to the Board, is responsible for UCLH’s system of risk management and internal control. The Board has established a risk scoring system to evaluate individual risks, the outcome of which informs:

The risks which are expected to be managed at local level and at both executive and clinical board level

the risks which need to be visible to the Board.

This is achieved through the evaluation of risks using a risk scoring system with impact and likelihood measurements. Under this classification system significant risks, which would have a high adverse impact if they materialised, are considered by the Board.

In order to identify and manage risks effectively, a risk management framework is in place within a defined governance structure working through divisions, clinical boards, the Risk Coordination Board (RCB), QSC (in respect of patient safety and clinical risk), the Executive Board and the Board.

The risk management framework incorporates three aspects in relation to:

Governance accountability risk management process.


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6editions of GP Links, our GP newsletter, published every year

More information on these areas is set out in the three sections below.

Tabel 8

Governance Responsibilities Board Executive

Board of Directors The Board of Directors is ultimately accountable for ensuring that UCLH is complying with its license. An important element of this is its review of the risk management framework and the effectiveness of internal controls.

Audit Committee The Audit Committee reviews the effectiveness of the system of integrated governance, internal control and risk management, across the whole of the organisation’s activities (both clinical and non-clinical).

Finance and Contracting Committee

The Finance and Contracting Committee monitors UCLH’s financial performance and key financial risks, ensuring effective mitigation strategies are in place.

Quality and Safety Committee

The Quality and Safety Committee monitors risks related to patient safety, clinical outcomes and the quality of services for patients. It has a number of sub-groups reporting to it, with responsibility for patient safety such as the Patient Safety and Risk Steering Group and the Adult and Children Safeguarding committees.

Executive Board The executive board is responsible for identifying UCLH’s significant risks and for overseeing the management of those risks. The Executive Board, led by the chief executive, is responsible for ensuring that an open and fair culture is developed and sustained throughout UCLH as an essential foundation for effective risk management.

Risk Co-ordination Board The Risk Co-ordination Board is a sub-committee of the Executive Board. Its purpose is to coordinate risk identification and management activity within UCLH across the full range of clinical, financial, organisational, reputational and environmental risks.

Clinical Boards and corporate services

Clinical Boards and corporate services report to the Executive Board and are responsible for planning and managing both clinical and non-clinical services, which are delivered through operating units known as divisions and directorates in the area of corporate functions. Clinical Boards have a key role in ensuring effective risk management processes are in place across the range of services for which they are responsible, as is also the case for corporate functions.

Divisions and corporate functions

Divisions and directorates in the area of corporate functions represent the organisational ‘business units’ that deliver clinical and non-clinical services and are responsible for managing risk in their own areas.


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Accountability Responsibility for risk management within the UCLH devolved management structure is aligned to the area of the organisation to which the risks belong and therefore can effectively be managed. It is the responsibility of the Board of Directors and Executive board to focus largely on strategic risk management and to oversee the effective management of operational risk through UCLH’s risk management framework. It is the role of the clinical boards, divisions and corporate directorates to primarily focus on operational risk management activity. The most significant risks are escalated to the Board through the clinical boards and RCB.

The responsibilities and accountability arrangements for risk management are summarised below:

Chief executiveThe chief executive has overall responsibility for risk management at UCLH. Effective risk management has been delegated within the management structure to the medical directors of the clinical boards for all risks across the full range of functions and services in their areas, and to the corporate directors for their respective areas.

Deputy chief executive The deputy chief executive chairs the RCB, a monitoring and assurance committee, which reports through to the Board via the executive board. The deputy chief executive has a leadership role for driving and improving risk management throughout UCLH.

Corporate medical directorThe chief executive has nominated the corporate medical director as the executive responsible for clinical risk management. He is responsible for managing the work of the quality and safety department working closely in conjunction with the director of quality and safety.

Medical directors (clinical boards)The medical directors of the Medicine Board, the Specialist Hospitals Board and Surgery & Cancer Board are responsible for effective risk management activities in their respective Boards/areas.

Other executive directors (i.e. finance director and chief nurse)These directors are responsible for ensuring that effective risk management is in place within their areas and, like all directors, for contributing towards the wider management of risk across all areas of the organisation in all services and functions.

UCLH risk management UCLH employs an experienced risk manager, responsible to the director of quality and safety, who leads on the risk management programme. This systematically recognises, reports, analyses and evaluates all types of risk with a view to promoting processes to control and/or minimise risk throughout the organisation.

A quarterly process of identifying and updating risk registers is in place across UCLH. This process captures risks inherent in our business and enables the risks to be identified, classified and scored using UCLH’s standard risk scoring matrix.

The risk scoring matrix consists of an impact and likelihood scoring methodology using rankings of one to five for each component. Impact and likelihood scores are assigned and the product of these scores generates a total risk score which determines whether the risk is rated as red (risks scored 16 and above), amber (risks in the range 8 –15) or green (risks with a rating below a score of eight).

Clinical boards, divisions and corporate directorates are responsible for ensuring that risk management plans are in place. The RCB brings together a quarterly report for the Executive Board and for the Board which focuses on red risks.

There is a sophisticated format of reporting, which incorporates a risk table showing initial risk, current risk and target risk, movement in the current risk score since the previous report and the planned date for achieving the target risk rating. During the year there have been a number of significant developments in relation to the management of risks across the organisation. These include the more significant engagement of clinical boards and directorates in the process, further improvements of the reporting format, improvements to the quality of the accompanying commentary to the risk report and a new approach to handling strategic risk.


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256,381video views on the UCLH YouTube channel


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Strategic risks to delivery of our key prioritiesThe following outlines the principal strategic risks from our strategic key priorities and key future operational targets, mitigation and current status.

Strategic key priorities

Risk Mitigation/ current status

Achieve sustainable financial health

Achieve key financial targets.

The planned contingency may prove insufficient to cover a potential shortfall in Cost Improvement Programme (CIP) delivery and the identified external issues. Specialist commissioner affordability of activity growth; outcomes to the issue of flaws in specialist tariff services/research and development market forces factor.

The planned contingency together with some non-recurrent was sufficient to cover the CIP shortfall and all other operational concerns during the year. Specialist tariff funding remains a significant risk for the future.

Agree a financing strategy for future capital developments.

The desired capital investment scenario may prove unaffordable – the deteriorating financial outlook for the NHS in general and specifically for UCLH in relation to the withdrawal in 2015/16 of top-up funding to support the additional cost of specialist work may jeopardise some elements of our strategic development programme.

UCLH has developed a comprehensive long term financial planning model and continues to work actively to manage the financial risk of the tariff – an independent group to review the specialist tariff has been agreed to be set up by NHSE and Monitor.

Progress service developments

Implement cardiac strategy

Implementation delayed by missing milestones in preparation for transfer due to management capacity.Operational or financial stability during implementation period.

Implementation to start in April/May 2015: dates agreed with Barts Health and detailed planning has commenced. All external approvals secured and financing of Barts build agreed. Workforce consultation and appointments largely complete.

Implement cancer strategy

Commissioner (local and NHSE) decisions regarding process commissioner approval required for the haemato-oncology activity outside BMT and AML level 2. This was outside the scope of the London Cancer cardiac-cancer business case. The Royal Free have applied for this.Agreed with London Clinic to use their capacity for thoracic as interim during the cardiac moves.Clinical capacity being made available. Staffing aspects of each of the five cancer moves.

Business planning process with London Cancer, commissioners and north central London/north east London trusts. Regular cross sector meetings – medical director led with senior engagement from the above. CCG and NHSE endorsement of the cancer-cardiac business case and recent NHSE confirmation of passing gateway one and two and gateway three for urology and OG.Project management team appointed and in place. Working with London Cancer and the five tumour pathway directors to ensure all five cancers moves on track and provide robust governance to the moves.Capital funding changes required and work to facilitate increased capacity and move of The Royal Free Haemoncology.


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£250millionfunding for PBT

Strategic key priorities

Risk Mitigation/ current status

Develop strategic cases for expansion of neuroscience services.

The strategic, long-term focus is on a rebuild of Queen Square House, jointly with UCL and potentially GOSH.

Complexity of the relationships with partners may cause delay in the strategic plan.

Proposed structural change in tariff may impact on viability of the case which will then depend heavily on external funding / philanthropy.

There is a summary plan and the Queen Square 20 year clinical strategy has been completed. An interim plan to provide bed, theatre and critical care capacity for the next five years has been agreed by the Board.Completed initial work for strategic case. Project team established for interim plan which is proceeding.Feasibility study on a joint UCLH/UCL approach to philanthropy is underway. Lessons learnt from previous strategic projects (including Phase 4 and Phase 5 OBCs) has informed development of the governance structure of this project.Complexity of relationships with partners and associated funding may cause delay.

The following operational objectives and risks are considered key:

Objective Risk Mitigation/ current status

Reduce the time that patients wait for treatment after referral to our services.

Risk of insufficient bed availability, theatre, outpatient and endoscopy capacity across all sites risks reputation, increased waiting times and risk of breach to RTT targets.

UCLH has delivered against two of the three national targets. The last remaining target (admitted) is expected to be delivered in June.We are developing a sustainability plan to underpin 2015/16 delivery.

Meet the cancer waiting time target.

Increasing tertiary referral cancer patients at UCLH (as a consequence of natural growth rate and London Cancer agenda) increases risk of late referrals. Strategic developments increase the number of cancer patients discussed / treated at UCLH (via London Cancer pathway redesign work) Pressures on bed flow & diagnostics due to overall capacity contributes to risk of cancellations.

New breach protocol designed to enhance depth of analysis and understanding of factors contributing to patient waits. New template for mapping pathway milestones (appointments, diagnostics, decisions and treatment) piloted with sarcoma as an exemplar and all divisions will have in place for all cancer pathways.Working relationship in place with key referring organisations especially cancer unification board. Continue weekly monitoring of referrals, continue correspondence with referring trusts. Work with stakeholders including referring organisations to ensure appropriate pathways re-aligned.Ensure increased demand forms part of strategic planning for cancer expansion. Increase resourcing in corporate cancer functions to meet demand.


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Objective Risk Mitigation/ current status

Meet four hour Accident and Emergency target.

Numbers of patients in the ED exceeds the space and resources available and that the needs for bed availability outstrip for admitted patients available bed resources and risk of reputation from not achieving 95 per cent compliance with the four hour target for ED patients leading to a risk to reputation, safety and patient confidentiality.

Local management measures to improve operational focus and improved flow have been introduced together with an expansion in facilities including increased numbers of majors cubicles and significant investment in additional staff.

Longer-term comprehensive expansion of facilities has been agreed and the programme is being implemented. Completion is due in 2017.

To reduce the nursing vacancy rate.

In the context of a national shortage of nurses, staff turnover, difficulty recruiting and service expansion are compounding nurse shortages at ward level which may impact on the quality of care.

Steps taken to reduce the vacancy rate include an international recruitment campaign, changes to the recruitment strategy to ensure that the conversion rate (application to person in post) is as high as possible and offering rotational programmes to increase recruitment and retention. Weekly review by the chief nurse and director of workforce is in place.

The risk management purpose and strategy outlines the strategic intent and structures that support risk management. As part of the Board’s continuing commitment to improving risk management these processes have been strengthened and the strategy is under review. An updated Risk Strategy has been approved and is being implemented.

Assurance and the assurance frameworkThe Board Assurance Framework (BAF) provides evidence to the Board that the controls that manage the risks to the delivery of the top 10 objectives are being monitored and shortfalls in gaps in control or assurance addressed.

The BAF is updated on a quarterly basis by the leads in conjunction with the risk manager. The Audit Committee performs an oversight and scrutiny role in relation to risk and assurance. It receives regular reports from the DCEO in his role as chair of the RCB. Audit Committee members receive training to support them in their roles in dealing with risk issues on the committee and in their wider roles as non-executive directors of UCLH.

Internal audit has confirmed that we have had a well-functioning Assurance Framework in place throughout 2014/15. During the course of the year, UCLH has sought to further develop the framework and this process has involved consultation with internal audit and a joint presentation between

internal audit and the deputy director of quality and safety to the Board. Internal audit has confirmed it is satisfied with the developments to the Assurance Framework and the improved links to the operational risk registers and is satisfied that there has been suitable management and committee scrutiny of the Assurance Framework and the risks, controls and assurances contained within it.

The Board has agreed to a revised approach to the BAF – focusing on strategic objectives and strategic risks and this will be implemented in 2015/16.

Quality governance The key elements of the quality governance arrangements are as described in Monitor’s Quality Governance Framework; strategy, capabilities and culture, processes and structure and measurement. UCLH considers that there are robust structures and processes in place to ensure required standards are met, action is taken to address sub-standard performance, there are plans to drive continuous improvement which is based on best practice and that risks to quality of care are identified and managed.

The QSC ensures oversight of clinical risks and provides assurance to the Board on the quality of clinical care. To do this it reviews, complaints, claims and incidents. It also monitors compliance with CQC standards.

The quality and safety team, led by the director


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33UCLH governors

of quality and safety, share learning across UCLH from these activities and from patient feedback via complaints to promote and maintain a safe environment for patients and staff. This is delivered through quality forums, a quarterly quality and safety bulletin and at divisional governance meetings.

Further assurance of our current systems and processes has been gained from our internal assessments, for example through internal audit and through our ‘improving care walkarounds’. UCLH produces an annual quality report, the production of which is led by the director of quality and safety. The report includes the quality objectives set to improve patient safety, experience and outcomes and our quality performance measures and assurances. Further information is also provided in the Annual Governance Statement.

Clinical audit The UCLH Clinical and Quality Improvement Committee (CQIC) develop a draft clinical audit programme which is approved by the Executive Board and the Board. Delivery of the programme is monitored by the CQIC and reported to the QSC, which provides assurance to the Audit Committee that clinical audit is being delivered effectively. Clinical audits cover national mandated audits and UCLH priorities, including audits in response to clinical policies e.g. venous thromboembolism (deep vein thrombosis or VTE) and divisional audits.

Clinical audit is monitored locally at divisional governance committees; this ensures practice changes are implemented and re-audited where appropriate. The annual clinical audit report provides an update on clinical audit across UCLH.


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4 How we deliver top-quality patient care, excellent education and world-class research

4a. Our patients UCLH is committed to improving the quality of care we provide and the hospital working environment by listening to our patients and staff and working closely with our partners and stakeholders.

Making a Difference Together Campaign2014/15 has been the last year of a three year campaign to transform patient and staff experience at UCLH. The aims of the Making a Difference Together (MaDT) Campaign are to:

Positively change patient and staff experience develop a values-based culture within UCLH ensure UCLH becomes as renowned for its outstanding patient and staff experience as for its excellence in clinical outcomes, education and research.

We have made substantial progress against these aims and, in the last year, have maintained focus on ensuring our work leaves lasting benefits for patients and staff. UCLH has also been preparing for MaDT’s next phase, ‘Patients as Customers’, in line with our 2014/15 annual objectives.

The emphasis of the MaDT campaign this year has been key areas for improvement identified by staff and patients. These are:

Improving Pain Management projectBuilding on an earlier small pilot introducing multidisciplinary support to inpatients in University College Hospital, the UCLH Charity and Camden CCG approved joint funding for a more comprehensive, two year pilot. This will provide patients with complex pain the support they need, both as an inpatient and after leaving hospital, developing their self-management skills and improving links with primary and community services. An education package was launched in May 2014, which has already demonstrated improvements in nursing staff knowledge and skills in pain management, and subsequent improvements in patient experience.

UCLH Patient Experience programmeIn April 2014, we launched a six month programme to support services across UCLH to develop staff skills and knowledge to improve patient experience. Across five teams who completed the programme, improvements of up to 19 per cent were seen in overall patient experience scores and improvements of up to 13 per cent in the response to the Friends and Family Test question. Staff knowledge and confidence

in knowing how to improve patient experience also showed substantial improvement. Learning from this programme has since been used to run in-situ coaching/workshops with teams across outpatient services, and a patient experience toolkit has been developed to provide support to teams across UCLH.

Patient Information projectSince August 2013, all inpatients now receive a welcome pack on arrival. See page 49 for more information.

Embedding our values and behaviours by incorporating them into our processes A values-based recruitment screening tool for new starters has been introduced to help us identify applicants who share our vision and values. The values are now also included in our appraisal process to encourage existing staff to discuss their values and behaviours in addition to their objectives. This helps us to ensure that UCLH staff are as committed to delivering a great patient experience as they are to delivering great clinical outcomes.


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12copies of Inside Story, the staff magazine, published every year

Patient and public involvementThe views of patients, carers and members of the public matter to UCLH. They are important and we want to listen to and involve patients and the local community in the decisions we take so that we can make the improvements that matter to them. Working together through Patient and Public Involvement (PPI) is one of the ways we deliver our objective of providing quality patient care.

Use of PPI has continued to increase across the organisation over the last 12 months. Staff are supported through our PPI toolkit, which provides practical advice in planning and facilitating PPI activity. It also gives guidance for how the feedback should be shared both within the organisation to influence improvement and how outcomes could be fed back to those who participated. Some of this involvement is around large scale change, such as UCLH’s Phase 4 development, where there will be changes to the delivery of services for a number of patient groups.

Managers and clinicians worked together with medical students to ensure that patient feedback was central to the development of the new Short Stay Surgery Centre. Recognising that a wide range of patients undergo short stay surgery, a number of methods were used to capture the experience of recent patients in order to influence and shape service improvement. This included patient experience diaries, surveys and focus groups. A patient who attended one of the focus groups who wished to remain anonymous said: “I wouldn’t be here without UCLH so I’ll be forever grateful. There is room for improvement though so it’s nice to see the hospital listening to patients and it’s great to be able to give something back.” Patient stories were also videoed and the short films created from this were viewed more widely among staff at UCLH, sparking conversations around the things we can do immediately to improve the patient experience.

A number of our divisions are now setting up new patient groups to work in partnership with staff at both a strategic and an operational level. For example, Cancer Services are establishing a new cancer patient and public advisory group. When looking for people to appoint to the group, we approached our Foundation Trust members; the membership is one of the core ways in which we engage with our patients, carers and members of the public.

Real time survey feedback collected across UCLH also enables us to listen to the experiences of recent patients with 47,190 surveys completed last year. Some of the improvements made following patient feedback include calming music being played in the waiting area for antenatal clinics, and improvements to a number of patient information leaflets, including our patient and visitor comment card.

Patient informationWe launched our patient welcome packs in August 2013 and this year have built upon their success with patients. They contain information about the ward as well as items to help keep patients safe and comfortable including an eye mask and ear plugs to aid sleep. Feedback collected recently from both patients and staff has been extremely positive, with patients saying:

“The pack was really reassuring – I hadn’t seen anything like it anywhere else. I’ve used all items and really like the paper and pen.”

“The information pack was excellent – very brilliant, makes you feel special and important – makes you feel like you’re going to a classy place.”

Based on suggestions from staff and patients changes have been made to the pack, including improving the information included in the booklet and the addition of a toothbrush and toothpaste in all packs.


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4b. Our staff Our staff are an integral part of delivering our vision as an organisation to deliver top-quality patient care, excellent education and world-class research. Our aim is to deliver success through people. We understand the importance of having all our people focused on excellent outcomes; staff who care, teach and research; managers who manage; and leaders who lead.

As an organisation we want to: Enable staff to deliver their very best care for people who care work in partnership to delivery-focused, proven workforce practices

ensure our workforce resource is focused on delivering excellent patient care.

Keeping staff informedUCLH is committed to keeping staff up to date with news and developments through a number of internal communications channels. A monthly leadership forum is attended by the UCLH divisional clinical directors and divisional managers which provides an opportunity to discuss key strategic and operational issues and developments.

UCLH-wide communications include: Team briefing: staff receive the chief executive’s core brief every month

Inside Story: UCLH’s monthly staff magazine is attached to payslips

Insight: the intranet is kept up-to-date to provide staff with information that is important and/or of interest, including UCLH policies and procedures such as counter fraud and corruption, expenses, employment checks and whistleblowing raising concerns policies

leadership forum: a monthly meeting of our senior managers that includes guest speakers to bring staff up to speed about the direction the organisation is taking

daily news emails: staff receive a daily email update on UCLH news and developments

annual report summary leaflet: all staff receive a four-page summary of the annual report in July informing them of UCLH’s performance – including financial and economic factors affecting our performance. Staff are encouraged to give feedback and discuss issues around performance with their line managers.

At a local level, staff are kept informed about matters

affecting them at team meetings. An established team meeting structure sees medical directors meeting with divisional managers and divisional clinical directors in their clinical board on a regular basis. Divisions have a structure of team meetings.

UCLH works in partnership with staff to ensure that the views of staff are taken into account when making decisions which are likely to affect their interests, including updates on performance and other issues of concern. A monthly Joint Partnership Forum provides one opportunity for this with sub-committees to ensure that staff are involved in the development of policies. UCLH also seeks the views of all staff through the annual staff survey.

Our staff have been instrumental in supporting other work streams including MADT, Living our Values, the Diversity and Equality Agenda, Improving Staff Experience and ensuring staff views are represented and acted upon.

Work continued throughout 2014/15 on our strategic priorities:

Improve staff experience in order to improve patient experience: Building on the correlation between UCLH as an employer of choice for staff and a provider of choice for our patients, managing a campaign to ensure that each and every time patients have contact with UCLH, they will have a positive experience.

Develop a safe, supported and engaged workforce: Fully involve staff and their representatives in the significant changes ahead, enabling them to participate and act in a way that furthers the organisation’s and their own goals and aspirations, in a challenging environment that is both safe and supportive.

Simplify and embed fit-for-purpose workforce processes: Ensure processes, systems and information make it easier for managers to engage in, and manage, workforce issues including recruitment, temporary staffing, occupational health, staff benefits, employee relations, learning and development, pay and reward and information.

Improve compliance and performance on key workforce metrics: These include mandatory training, appraisals, reporting and levels of sickness absence, health and safety and staff experience.


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8non-executive directors

Reduce workforce costs and improve productivity: Through removing waste, increasing productivity, appropriate skill mix and management of our pay systems, while improving patient outcomes, safety and experience.

Embed leadership development: Develop and implement a systematic approach that focuses on developing a vibrant community of confident and competent leaders at all levels of the organisation.

Ensure that UCLH actively engages in fit-for-purpose education commissioning: Building on the principles of Liberating the NHS – Developing the Healthcare Workforce, ensure that UCLH plays an increasing and productive role in the proposed NHS education and workforce development system to deliver the UCLH workforce of the future. In March 2014, we appointed Emma Taylor as our director of education to help deliver this work.

Key achievements this year include: During 2014/15, we received substantial interest from candidates in our whole time equivalent posts. We have continued with our focus on the recruitment of nurses, midwives and nursing assistants.

following the procurement and implementation of a new state-of-the-art online recruitment

candidate management system, UCLH has seen benefits from closer management of recruitment activity, resulting in reductions in the overall length of time to hire

we have also continued to use enhanced learning technology for all staff. In 2014/15 more than 65,000 training courses were completed via eLearning

the ‘Liberating Sisters to Lead’ programme continues to help free up more time for ward sisters for patient-centred activities and clinical leadership

strengthening the focus on recognising and rewarding high performance, delivered in a way that is consistent with our values, by introducing processes into our staff appraisal to more closely link pay with performance

the roll out of the eRostering system to most clinical teams now provides real-time information on staffing availability and skill-mix across the organisation, ensuring we have the right number of staff at the right grades on wards in relation to the needs of the patient

an 85.9 per cent appraisal rate across UCLH a statutory and mandatory training compliance of 89.6 per cent across UCLH

the third year of our annual Celebrating Excellence Awards saw an increase in nominations to 1,400, an increase of 40 per cent. This year the patient-nominated awards have been increased so that there is now one award for clinical staff and one award for non-clinical staff.


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Health and safetyUCLH’s health and safety committee meets on a bi-monthly basis, it receives and reviews information on incidents or injuries, for example, violence, moving and handling. Incidents involving exposure to blood borne viruses (i.e. sharps injuries and splashes) are reviewed by the UCLH Infection Control Committee, which meets quarterly.

The health and safety team reviews all health and safety-related incidents that have been recorded and ensures that lessons are learned and disseminated across the organisation. Key health and safety policies have been reviewed and revised during 2014/15. The Health and Safety Committee also reviews all RIDDORs (incidents occurring under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations) reported to the health and safety executive.

There has been a fifth audit of the organisation’s risk assessment process, including staff and visitor slips, trips and falls, manual handling, violence and aggression, Control of Substances Hazardous to Health (COSHH), lone working and stress. The audit checked whether divisions had up-to-date risk assessments in place, audited the quality of the risk assessments and whether risk assessments had been risk rated and placed on the appropriate risk register. To drive improvement, each division is provided with detailed feedback on the quality of their risk assessments. The Health and Safety Committee continues to focus on physical assaults against staff to ensure that this type of incident is avoided wherever possible. Proactive support is offered to all staff involved in a physical assault by the occupational health team.

The UCLH local questions attached to the NHS annual staff survey show a continued reduction in the number of injuries caused by inoculation incidents. However there has been a slight increase in the number of staff who have been injured or felt unwell as a result of:

Manual handling from 9.5 per cent to 11.1 per cent

slips, trips or falls from 3.3 per cent to 3.8 per cent exposure to dangerous substances from 1.5 per cent to 1.7 per cent.

The staff survey for 2014 also shows that the level of work-related stress has increased to 41 per cent and is now above the national average of 37 per cent. We will be looking into ways we can address this and support our staff throughout 2015/16.

Support for staffThe staff psychological and welfare service provides support to all staff, to help them cope with change both at work and at home, support career development and enable access to a range of services, including welfare services. The occupational health and safety department supports a healthy workforce in a number of ways: by assessing whether staff are fit and safe to work, by advising on workplace adjustments; leading action to help staff improve their own health – for example ceasing to smoke – and by supporting staff to return to work after a period of sickness. UCLH provides proactive early intervention services to staff with musculoskeletal issues and stress or mental health issues, in line with NICE guidance. Line managers are contacted each time a member of their staff is recorded as absent for musculoskeletal disorders, stress or mental health issues, and are reminded of the service available to support every colleague.

The NHS Staff SurveyWe are committed to ensuring frequent and structured staff engagement. In 2014, all staff, including honorary consultants, received an electronic copy of the annual staff survey. More than 2,900 staff responded to the survey, allowing robust divisional action plans to be developed and embedded. We have continued to perform well in many areas, particularly around staff engagement (which is closely linked to quality, safety and patient experience) where we remain in the top 20 per cent of all acute trusts.

UCLH was in the top 20 per cent of all acute trusts for 10 of the 29 key findings, was better than average for a further four, average for eight key findings and in the bottom 20 per cent for seven key findings. Since 2013, our performance has significantly improved in three key findings, including the percentage of staff appraised in the year and the number of staff experiencing physical violence from staff in the past year. Since 2012, our performance has significantly deteriorated in one key finding, namely the number of staff receiving equality and diversity training in the past year.


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170,000+patients admitted to UCLH

Table 9: UCLH staff survey results 2003 – 2014 (compared to English acute trusts)

0%

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2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Perc

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top 20% average bo�om 20%

The top and bottom scored answers can be seen in table 9.

We scored significantly well on questions relating to patient care and to new questions on staff agreeing that feedback from patients is used to make informed decisions in their directorate or department, and on staff agreeing that they would feel secure raising concerns about unsafe clinical practice. Forty seven per cent of staff also agreed that they had a well-structured appraisal. Thirty seven per cent of staff reported that there is good communication between senior management and staff.

We had more key findings in the bottom 20 per cent of all acute trusts this year than in previous years. We have identified staff to staff bullying and harassment, equal opportunities and discrimination as key priority areas for action, and an action plan is being developed.

The other key findings for which UCLH is in the bottom 20 per cent of all acute trusts are as follows:

The percentage of staff working extra hours – this key finding combines staff working extra paid and unpaid hours and remedial action is taken on this at a local level, often in parallel with data on work-related stress

the percentage of staff suffering work-related stress – remedial action is taken on this at a local level

the percentage of staff receiving health and safety training in the last 12 months and the percentage having equality and diversity training in the last 12 months – our mandatory training policy does not require staff to repeat all health

and safety training and equality and diversity training every 12 months.

The score for staff recommending UCLH as a place to work or receive treatment remains in the top 20 per cent of all acute trusts. Seventy per cent of staff would recommend UCLH as a place to work and 83 per cent would be happy with the standard of care provided by the organisation if a friend or relative needed treatment.

Other key findings in the top 20 per cent of all acute trusts were the

number of staff who agreed that their role makes a difference to patients, who were able to contribute towards improvements at work and who feel that incident reporting procedures are fair and effective. UCLH also had one of the lowest (best) rates for staff who experienced physical violence from patients, relatives or the public.

One of the most telling aspects of the 2014 results is the variation in performance between and within our boards and corporate departments. In May 2014, the Board received a report outlining the actions in relation to the scores that compare less favourably with other acute trusts and agreed an action plan focusing on reducing harassment, bullying and abuse from other staff, staff experiencing discrimination and perceptions around equal opportunities. Those same themes remain the areas where our scores are the lowest. The action plan focused on taking local action in hot spots to reduce bullying and harassment. In the main, the plan contained one-off initiatives that sought to educate and inform and those are unlikely to be sufficient to address the causes of bullying and harassment and the interdependent risk factors that are likely encouraging and sustaining its incidence.

In 2015 we intend to focus on action we can take through cultural change that encourages and incentivises environments where leaders further commit to UCLH’s values and behaviours that will improve our staff’s health and wellbeing.

Transformation is accelerated by positive organisational health that sets the conditions for organisational effectiveness. To assess the gap, UCLH


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will adopt a three stage approach: Using an organisation effectiveness framework to identify the main issues to transformation for our staff, and where we can make the most effective positive change that accelerates the transformation work plan

work with divisional and project teams to identify their specific issues

create a targeted work plan that will be measured as part of the divisional/project agenda in the second half of 2015/16.

Equality and diversityWe recognise the importance of a diverse workforce and have a number of practices and procedures in place to encourage inclusivity in all we do. A dedicated equality and diversity group oversee our commitment to equality and proactively evaluate our commitment to further inclusion across our workforce. We seek information from applicants when they apply for a job at UCLH on any reasonable adjustments that may be required during the interview process. Where applicable these reasonable adjustments are made in conjunction with the recruiting manager. Where a disabled applicant demonstrates that they meet the essential criteria of a person specification, they are guaranteed an interview to demonstrate their abilities beyond the initial application stage. We also work with the NHS Leadership Academy to offer management and leadership career development and training to all under-represented groups, including staff with disabilities. We have a ‘managing disability policy’ that was developed in conjunction with our occupational health team, and other relevant external organisations, and it supports our staff with disabilities. It is a framework for adjustments that may need to be made for staff with disabilities – including provision of equipment, adjustments to work load and paid time off for medical appointments.

As part of the recognition of the importance of

a diverse workforce we have identified the gender split for senior managers, from band 7 managers to director-level, in the organisation. See table 10. We actively apply and use benchmarks provided by specialist groups including Stonewall to evaluate areas we can improve and have been keen to inform national frameworks including the new Workforce Race Equality Standards.

Table 10: Our leadership profile by gender

Board of Directors: 25% (f=4; m=12)

Consultants: 41% (f=231; m=326)

Very Senior Managers: 33% (f=4; m=8)

Band 9: 51% (f=22; m=21)

Band 8D: 56% (f=33; m=26)

Band 8C: 61% (f=62; m=39)

Band 8B: 69% (f=151; m=67)

Band 8A: 72% (f=257; m=101)

Band 7: 79% (f=893; m=234)

Developing our staff UCLH offers a range of leadership development and ‘soft skills’ training programmes. One such programme is ‘Leading for Improvement’, a multidisciplinary programme aimed at middle managers at UCLH. This is now in its 12th cycle and more than 260 staff have participated in this programme. Managers on the programme are introduced to the latest thinking on leadership practice, gain an overview of their own leadership styles and personality preferences, and learn techniques to engage and motivate their teams. The skills required to lead local and organisational change programmes, manage projects, and lead service improvement are equally high on the learning agenda.

By the end of March 2015 we will have supported


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14new UCLH apprentices

14 new apprentices to start at UCLH, with two of those starting higher level apprenticeships within employment. In 2015/16 we seek to increase the number of apprenticeships offered and extend the staff groups who currently participate in apprenticeships. Also over 150 work experience students gained experience at UCLH, essential for their aspiring careers in healthcare.

Our accredited programme, Developing Skills for Service Quality, facilitated 60 staff members to gain essential qualifications and enhance skills in their existing roles in 2013/14. This City and Guilds accredited qualification is equivalent to completing five GCSE’s. Now in its 15th cycle, that adds up to more than 225 staff undertaking and completing this programme.

Volunteers in the University College HospitalThere is an established volunteer service at UCLH, offering a range of services that enhance our patents experience. This service is currently under review as we intend to increase substantially both the numbers of volunteers and roles we have in place.

We have successfully implemented a service located within the Cancer Centre and intend to emulate the success of some of the roles developed in conjunction with both service users and staff within the Cancer Centre, across all our hospital sites.

Cancer Centre case studySixty one volunteers are working with teams across the Cancer Centre, with more roles being developed and 25 new volunteers waiting to start. These include volunteer roles that have been in place since our opening in April 2012 such as welcomers and guides but also encompass more innovative roles, including red cell haematology ‘befrienders’, ad hoc volunteering roles for the University College Hospital Cancer Fund’s corporate partners and joint projects with the volunteering service at UCLH.

Key figures: The volunteer team of 61 have given around 24,300 hours of their time since the centre opened. This has been hugely valued by our patients

volunteers give on average 16 hours of their time

each month we have a waiting list of around 100 people interested in volunteering

seventy per cent of volunteers surveyed said that the most important thing for them as a volunteer is to feel like they are making a difference

almost half of the volunteers surveyed have been with us for more than two years. The main sources of recruitment have been: UCL, doit.org website, Inspired website, Team London website, Cancer Centre website, Macmillan website and word of mouth

our volunteers are relatively diverse in age and background. However, they are predominately female.

EducationWe provided placements for more than 400 UCL medical students last year. The students are attached to several different specialties throughout the fourth, fifth and sixth years of their course. Links with UCL Medical School have been strengthened as we work to improve undergraduate education. Many of our students return as postgraduate doctors in training and some go on to become UCLH consultants.

The Medical and Dental Education Service oversees the training of more than 500 doctors and dentists in training at UCLH. The department supports clinical teams in ensuring doctors and dentists in postgraduate training are appropriately supervised and their training needs, as set out in the relevant curricula, are met. Needs are met through a network of educational supervisors and placement leads, and we offer training to these staff to support them in their roles.

We are continually expanding our portfolio of courses and training opportunities for trainees and trainers in order to improve the training we offer. A monthly induction is held for all new doctors and dentists in training, with the aim of giving them both a real welcome and the information they need to be able to look after our patients safely when they step on to the wards for the first time.

Nursing trainingUCLH this year welcomed 175 undergraduate and postgraduate pre-registration nursing and midwifery (N&M) students from our higher education institution (HEI) partners City, Kings College London and London South Bank University.

UCLH N&M representatives have participated in a range of key stakeholder events and focus groups within our Local Education and Training Board (LETB) to shape the design of standards for preceptorship


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and the Return to Practice (RTP) initiative, as well as trainee nurse consultant posts across the sector. In addition successful education bids to our LETB included salary supported training places for the emergency nurse practitioner and operating department practitioner programmes, support to establish the provision of the Overseas Nursing Programme (ONP) at UCLH, funding for 30 places for existing staff to access ONP and the establishment of a dedicated clinical practice facilitator role for ONP/RTP.

UCLH was one of the first London hospital trusts to implement the new London Nursing Practice Assessment Document in June 2014. The UCLH 2nd Mentor Conference was well attended and lead mentor guidelines for supporting students in practice were launched this year.

In 2014 our Recruit 500 campaign supported UCLH student-only day which saw 56 students into newly qualified nurse posts across the organisation.

UCLH has long recognised the importance of its N&M Assistants.

Other initiatives this year included:

Clinical Health Apprenticeships are now entering their fifth cohort

the third UCLH/Royal College of Nursing (RCN) Nursing Assistants Conference was held on 21 May 2014 at the RCN headquarters

five pre-nursing nursing assistants have been employed within UCLH as part of the Health Education England scheme to provide budding student nurses with healthcare experience.


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2,900+responses to the national staff survey


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4b. Research and development Research at UCLH has been embedded as part of our core business and central to our reputation as a national and international clinical research leader. This can be seen in the rise in clinical trials and recruitment of patients to research and in the development of research as part of our performance management.

Ten research leads, made up of professors and clinical research leaders, were appointed this year to promote research within their clinical area. UCLH also introduced the concept of research hubs to provide infrastructure support to researchers, and as part of a new system for allocating NHS support funding.

The UCLH Research Hubs Board is chaired by Dr Patrick O’Brien and the hub leads support the strategic coordination of clinical research. They work to ensure research is part of UCLH’s performance management, by identifying staff requirements and promoting delivery of high quality studies.

Biomedical Research CentreOur National Institute for Health Research University College London Hospitals Biomedical Research Centre (BRC) is now more than half way through its £100m five year funding period. The BRC has been tasked by the National Institute for Health Research (NIHR) to focus more on experimental medicine and to develop closer working and partnerships with industry.

Over the last year BRC funded infrastructure leveraged £178m in external grant funding to support further research at UCL and UCLH and increased the

value of collaborative contracts by 16 per cent over the last year. The BRC invested a further £20m over the last year in infrastructure for groundbreaking research including research into MRI and motor neurone disease progression, multi-dimensional characterisation of patients presenting with stroke, biomarkers in juvenile arthritis, weight-loss surgery and remote ischaemic precondition and survival in heart attack patients.

Long term investment by the BRC in projects likely to have a high impact on patient care is yielding results. Highlights include:

Establishment of research projects at the Stevenage Bioscience Catalyst where we have funded lab space to enable researchers to access drug development expertise and facilities

go-ahead for the building of a laboratory to enable researchers to develop and manufacture tracers for use in UCLH’s positron emission tomography–magnetic resonance imaging (PET-MRI) facility

opening of the Cardiometabolic Phenotyping Unit for early phase cardiovascular studies.

The BRC has become a leader in the involvement of UCLH patients and the public in the design and delivery of research and in setting research priorities. The BRC secured funding from Health Education North Central and East London and the Wellcome Trust to develop support for researchers to give them the skills and funding to involve lay people in their work.

UCLH has played a major part in the success of the BioResource initiative, which is gathering 10,000 DNA samples from people with and without disease, to help researchers find out how genes influence disease. Over 3,000 participants have been already been recruited and some people are already involved in research studies.

UCLPartnersUCLH has been the driving force for research across UCLPartners and particularly behind successful bids for funding and recognition, with UCLPartners redesignated an Academic Health Science Centre and the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames now well established.

Embedded researchers are now working alongside our service managers, identifying clinical challenges that need to be addressed by research.

Recruiting to research studies and trialsUCLH continues to lead in research, with over


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65,000+online training courses completed by staff

1,487 studies currently recruiting or following up participants. We have increased our recruitment and over the last year, 14,451 participants were recruited to studies at UCLH. This growth looks set to continue with 311 new research studies starting over the last year.

UCLH research support has worked hard to ensure that patients benefit more quickly from research breakthroughs. The NIHR has set trusts a target to increase the number of studies which recruit patients within 70 days of a study proposal first being approved. UCLH performance improved dramatically against this target in 2014/15 – more than 72 per cent of studies were reaching the 70 day target in October 2014 compared with just 20 per cent in the first quarter of 2013/14.

Clinical Research FacilityThe NIHR Clinical Research Facility (CRF) has been increasingly busy with recruitment of participants to research studies increasing by 25 per cent in the last year and around 300 people attending the facility each month. The CRF has been tasked with focusing more on experimental medicines and there has been an increase in early phase studies – now more than 80 per cent of studies currently being set up are phase I or II. The facility has a growing reputation as a centre for world-leading research. Over the last few months, it has played host to the world’s first in-human use of three experimental drugs to determine the correct dosing to be used when treating patients. It is also the only UK site for several studies.

Supporting our staff’s innovative ideasThe UCLH innovation office, which helps UCLH staff develop innovative products, inventions or services, entered its second year. Examples of ideas brought forward by UCLH staff include: devices for helping treat balance disorders, and software apps for audiology patients and to facilitate better active patient involvement in pain management. The office also helps staff with intellectual property queries including helping frame responses to research funder queries.

Research successes: UCLH is to play a lead role in delivery of the Prime Minister’s 100,000 Genome Project which aims to position the UK as the first country in the world to sequence 100,000 whole human genomes. We are part of a partnership with other trusts in north London which will work together to create the North Thames NHS Genomics Medicine Centre

UCLH is leading on the critical care theme of the

NIHR Health Informatics Collaboration which will enable the collaborative sharing of routinely collected NHS data to facilitate more effective clinical research

healthcare technology investment company Syncona invested £30m into a new company called Autolus to develop and commercialise next-generation engineered T-cell therapies for haematological and solid tumours. These therapies are based on the work of BRC, supported Dr Martin Pule who is a consultant at UCLH and a clinical haematologist at the UCL Cancer Institute

the BioAid collaboration with the Imperial and King’s Biomedical Research Centres has taken off with over 300 patients recruited to date at UCLH. The aim is to create a registry of 5,000-10,000 adults presenting with infectious disease and build up a research databank of samples from patients with the opportunity to approach them with future opportunities to take part in new research projects.

Other highlights: Researchers at UCLH, with colleagues from Imperial College, found that a high dose of the drug simvastatin significantly reduces brain shrinkage in people with secondary progressive multiple sclerosis. The study received a lot of media coverage, as up until now successful clinical trials have mainly focused on treatments for the relapsing-remitting form of multiple sclerosis

the National Institute for Clinical Excellence adopted recommendations of Dr Rachel Batterham, head of obesity and bariatric surgery, that weight loss surgery should be offered to thousands more people in order to tackle an epidemic of type 2 diabetes

UCLH was the top recruiting site in the CALORIES trial, which investigated the optimum route for providing nutrition to critically ill patients and the result paves the way for new studies to address the dose and timing of nutritional support in patients in intensive care units

the first patient was dosed in a trial to test whether a diabetes drug may help slow down Parkinson’s disease at the Leonard Wolfson Experimental Neurology Centre at the NHNN

paediatric surgeons and doctors from UCLH will benefit from a £10 million award from the Wellcome Trust and the Engineering and Physical Science Research Council to develop better tools, imaging techniques and therapies in future operations on unborn babies


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preparatory work for a trial of a drug to treat Alzheimer’s disease is making good progress with the trial scheduled to start in April 2016.

Public engagement for research and developmentUCLH has made great strides to ensure patients and the public are aware of its research and of the opportunities to get involved.

At the beginning of the year, we launched UCLH Research Gateway, a search engine on the UCLH website that enables members of the public to quickly find out what research studies are recruiting volunteers at UCLH. Probably the first of its kind, the gateway was featured in the Guardian online. Our research open day at University College Hospital attracted hundreds of visitors to 28 stalls, school tours, competitions and interactive activities.

This awareness raising has meant we have been able to build up a pool of patients and UCLH members interested in research, and put researchers in touch with patients. We have provided briefing sessions and seminars for UCLH patients interested in research.

We ran 15 workshops for 180 researchers across UCLPartners to train researchers in the involvement of patients and the public in the design and conduct of research. A fund to support the active involvement of patients and the public distributed over £20,000, and we provided a service to researchers helping them to access lay people when they are drawing up a research proposal.

Nurse led researchUCLH took further steps in its efforts to be a centre of excellence for N&M led research in 2014/15 through establishing the N&M research themes. Each theme has a dedicated lead who supports nurses to undertake research that contributes to a fledgling research programme.

Closer links were established with HEI partners in order to progress plans for clinical academic posts for N&M. This has resulted in a number of successful external funding opportunities for nurse researchers including an NIHR CLAHRC fellowship. N&M has forged strong alliances with the NIHR CLAHRC and are participating in two applied research projects, home for lunch and ward accreditation. The numbers of nurses undertaking research programmes has increased with two completed doctoral programmes and 10 undertaking doctoral studies. The fourth research in clinical practice conference was held in 2014/15 showcasing the work of these nurse researchers many of whom presented work on the national and international stage.


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6hospitals in UCLH


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55a. UCLH governance

Membership Being a member gives people an opportunity to get involved at UCLH.

At the end of March 2015, we had 19,224 members, including staff. We met our target to increase our public membership by three per cent and to maintain our patient membership numbers during the year.

Table 11: Membership figures

Constituency Last year This year

Public 2,556 2,720

Patient 8,817 8,843

Staff 7,342 7,661

Total 18,715 19,224

We have three membership constituencies and all members, aged 18 and over, are eligible to vote for or stand as governors.

Public members: Individuals aged 14 or over living in one of the 32 London Boroughs or the City of London.

Patient members: A patient, or unpaid carer of a patient, who has attended any UCLH hospital. Patients must be aged 14 or over: carers e.g. a parent of a younger patient can become a member.

Public and patient membership is an opt-in scheme. Individuals eligible to be public or patient members must not be eligible to be members of the staff constituency.

Staff members: All staff who have a contract to work with UCLH for at least 12 months; employees of UCL or contractors who provide services to UCLH are automatically members.

Staff can opt-out if they wish. This right is explained on appointment and on the staff intranet. Three members of staff have opted out.

Our membership development strategy We have a membership development strategy which aims to build a strong membership who are informed,

engaged and involved in the work of UCLH and one that is representative of the communities we serve. We also want to keep members informed about our services, strategy and what their governors are doing.

To support the delivery of that strategy a number of recruitment campaigns have taken place across our hospitals sites involving governors and members,

Organisation structure


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1Institute of Sport, Exercise and Health

application forms are also sent with a letter from the chairman to all new patients. There are application forms in local libraries and GP surgeries and an online application form accessible via our website.

All members receive a copy of UCLH News, the magazine for members; this is regularly translated into Bengali, Chinese and Turkish and can be made available in larger print. The magazine includes information about up and coming MembersMeets, highlights from UCLH and information about what governors have been doing. Members are also regularly communicated with through email.

The membership office hosted a series of local community events including dementia awareness talks in Camden with the Somali Cultural Centre, at the Chinese Community Centre (CCC) and with the Cypriot community. It also had membership stands at events including at Camden CCGs annual public meeting. Governors who attend these events use them as an opportunity to find out what members are interested in.

The NHS Advocacy Service informed the CCC about their service and how it can support their community when it attends UCLH. The membership development manager, also delivered talks about membership and governors to young students undertaking work experience placements at UCLH.

During the year, governors chaired seven MembersMeet seminars at which clinical staff gave talks on health topics including diabetes, infection control and pain. In February, a MembersMeet was held on the priorities for UCLH in 2015/16 and the strategic plans for patient services. The governor chair also spoke about their role and members were able to raise issues and ask questions. These events are publicised on the UCLH website, by both Healthwatch Camden and Islington, in the Francis Crick Institute Community newsletter, and are tweeted by UCLH.

Governors also held a surgery at the UCLH annual open event to give patients and members the opportunity to talk to them.

Members also get involved, examples include: Filling over 400 bags with information leaflets and materials provided by UCLH Charity, which were handed out at the annual open event in December

giving a patient perspective at an experience event to help shape a ward accreditation scheme

undertaking Patient Led Assessments of the Care Environment (PLACE) inspections which focus on the quality of the care environment

participating in web chats on health service topics, for example arthritis

engaging in a cancer patient and public advisory

group, working with staff to improve how it manages its cancer and haematology services.

In the coming year we will review our membership strategy and will monitor progress of any action plan developed from that review through the council of governors.

Members who wish to contact governors can do this at [email protected]. This information, as well as the telephone number and postal address are published in UCLH News and on the UCLH website and on all information sent to members.

Council of governors The council of governors (council), previously the governing body, work closely with UCLH to help shape and support its future strategy and ensure that we focus on those issues that bring benefit to patients. It also helps ensure that the views of members and stakeholders in the wider health community it represents are taken into account.

Our council, established in July 2004, is greatly valued by the Board. It has developed into a highly effective body dealing with both its statutory duties and other issues of importance to patients and service users. It is made up of 33 governors; 23 elected governors who represent the public, patients, carers and staff; and 10 appointed stakeholder and partner governors.

Elections In July 2014 contested elections were held in six seats using the single transferable vote rules as set out in our constitution. The Electoral Reform Services oversaw the election process which cost £25,870.32.

Who are the council? During the year the composition of the council changed. Judith Ellis stood down as the partnership governor for London South Bank University in July 2014. Peter Brayshaw, appointed governor of Camden Council, sadly passed away on 18 December 2014, he will be greatly missed. Patient governors, Christine Chapman, Andrea Kennedy and Bill McAllister’s terms ended in August 2014. Governors elected in July took up their seats on 1 September 2014.

Tables 12 and 13 give details of the governors in post during 2014/15 and their attendance at council meetings. Governors normally hold office for three years and are eligible for re-election or re-appointment at the end of their first term. Governors may not hold office for more than six consecutive years.


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Table 12: Elected governors – patients, public and staff

NameTerm of office three years unless stated otherwise

Meetings attended

Public governors

*David Coulter 1 September 2014 3/4

Dan Whitaker 28 January 2013 For 2 years 7 months 4/4

Fazul Chowdury 1 September 2013 1/4

*Diana Scarrott 1 September 2014 4/4

Patient governors – London

Veronica Beechey 1 September 2013 4/4

John Bird 1 September 2012 4/4

*Dee Carter 1 September 2012 4/4

Emma Dalton 1 September 2013 4/4

John GreenReplacing Bill McAllister

1 September 20141 September 2011

3/30/1

John Knight 1 September 2012 ^2/4

Christine Mackenzie Replacing Andrea Kennedy


3/31/1

*Fiona McKenzie 1 September 2013 4/4

Andrew Todd-Pokropek 1 September 2013 3/4

Patient governors – Non- London

*Joan Bell 1 September 2012 2/4

Annabel KanabusReplacing Christine Chapman


3/31/1

*Stuart Shurlock 1 September 2013 4/4

Patient carer governor

*Rosalind Jacobs 1 September 2014 4/4

Staff governors

Darren Barnes 1 September 2012 1/4

Fiona Henderson 1 September 2013 3/4

Sheila Hinton 1 September 2012 2/4

*Tom Hughes 1 September 2013 3/4

Andrei Morgan 1 September 2013 3/4

Stephen Rowley 1 September 2013 2/4

*re-elected/reappointed for a second term of three years

^unable to attend one meeting due to access


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6,933,809page views to the UCLH website

Table 13: Appointed and partnership organisation governors

Name ConstituencyTerm of office three years unless stated otherwise

Meetings attended

Danny BealesPreviously Peter Brayshaw

Camden Council 1 February 2015Started 19 August 2013

0/02/3

Claudia Webbe Islington Council 1 July 2012 2/4

Warren TurnerPreviously Judith Ellis

London South Bank University

15 October 2014Started 1 January 2013

2/20/1

Mike Hanna University College London 1 November 2013 1/4

Janet Kitchen Friends of UCLH 1 July 2012 2/4

*Philip Brading UCLH Charities Committee 1 September 2014 3/4

*James Mountford UCLPartners 12 October 2014 1/4

Mary Clegg Camden/Islington CCGs 1 March 2014 1/4

*Denise Bavin GP Commissioning Consortia 14 September 2014 3/4

Vacant NHSE (London) n/a n/a

Register of interests On election or appointment to the council, governors must sign a code of conduct and declare any interests that are relevant and material or declare interests should a conflict arise during the course of their term. The register is maintained by the trust secretary and was presented at the November meeting. The governors’ register of interests is published annually and is available at www.uclh.nhs.uk on our council of governors’ page or in hard copy from the trust secretary. In addition, governors must meet a ‘fit and proper’ persons test as set out in our provider licence. All new and reappointed governors met this requirement during 2014/15.

Role of governors The chairman of the Board also chairs the council. The council holds the non-executive directors to account for the performance of the Board and is responsible for appointing or removing the chairman and non-executive directors and deciding on their remuneration. The council has the final decision on significant transactions; appoints or removes UCLH’s external auditors; receives the annual report, quality report, accounts and auditors report; approves changes to the constitution; and gives its views on the development of our forward plan.

The council elects one of its members to be the lead governor. The lead governor acts as a main


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point of contact for the chairman, trust secretary and the audit chair, and between Monitor and the other governors for any communication that might, in very specific circumstances, be necessary. The lead governor, Fiona McKenzie, has held this position since September 2011.

“The council of governors has been busy over the last year. Governors have pursued a variety of activities focused on helping UCLH understand and improve the experience of our patients and carers. This includes a substantial piece of work completed by a governor and members mapping the experience of our multiple sclerosis patients, which has led to changes in these services. Other examples include setting up patient involvement groups in neurology and support for improving patient information. Governors and members sit on committees and groups across UCLH and I know their insights are very much appreciated. Governors continue to build strong relationships with staff while maintaining their independence, allowing us to constructively challenge but also work in partnership with the Board to deliver high quality care.

“This year governors were encouraged and supported to take part in training to help them carry out their duties and this proved valuable when the council discussed and approved a proposal to develop a new facility for the treatment of surgery and cancer. The governors also reviewed the way the council worked and discussed the areas where it wanted to improve effectiveness.

“On behalf of the council, I would like to acknowledge the work done by UCLH staff; it has been a privilege to work with committed and engaged staff across the organisation.”

Fiona McKenzie, lead governor

The chairman and the lead governor seek the views of governors when preparing the agendas for council meetings, which cover a wide range of subjects including clinical and financial performance, service strategy and patient safety and experience. For these meetings governors can request presentations on specific issues and during the year this included emergency pressures and winter planning. The council

also considers reports from a governors’ group, on high-quality patient care and from governors who contribute to UCLH committees.

Also, briefing seminars are held on key topics to support governors in their role. In 2014/15 nine were held. They included UCLH’s strategic plans for Phase 4, Phase 5, and PBT developments and sessions on scrutiny and ensuring safe and patient centred care. Governors are also invited to attend networking events both locally and nationally.

The lead governor also holds regular meetings with governors and meets regularly with the chairman and trust secretary to keep in touch with opinion and further enhance communication between the council and board members and in February, a governors’ social network forum was launched to help governors share information and collaborate better.

What happened during the year Governors have worked together to deliver their key statutory responsibilities. During the year there were three formal public meetings (21 July, 22 September, and 24 November) and an annual members’ meeting in September. There are also confidential or extraordinary meetings. With the exception of an extra meeting held on 19 January these meetings are on the same dates as public meetings.

At a public meeting in July the council approved changes to UCLH’s constitution which saw the governing body renamed council of governors and an increase in the number of non-executive directors on the Board. The constitution sets out the arrangements for governors and the Board to deal with any issues when they have a concern

at the same meeting in July, the council agreed the chairman’s annual objectives and a decision not to increase the remuneration of the chairman and non-executive directors. The council had been involved in the process of appraising the chairman which was managed through the nomination and remuneration committee

in a confidential meeting in July, the council supported a recommendation of the UCLH audit committee to reappoint the external auditors; governors had previously met with the auditors and chair of the audit committee to ask questions about the 2013/14 annual statements and report

the council formally received the annual report, accounts and auditors report at its meeting in September

the council appointed a new non-executive director and reappointed two non-executive directors at a confidential meeting in November

at an extraordinary meeting in January, the


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7.5millionin-coming phone calls last year

council approved the cases for the development of phase 4 above ground and PBT, the former was a significant transaction as defined in our constitution

governors met with a non-executive director before each public meeting to talk about their role and responsibilities on board committees, and engaged with non-executives at walkrounds and other UCLH events

the governors have a representative to observe at each public board meeting and are members of board committees which focus on patient safety and experience

the council supported the NHSE case for transforming cancer and cardiac care in north and east London and subsequently governors visited the new Barts cancer facility due to open in 2015/16

governors attended two seminars in February with medical directors and the deputy chief executive and chief executive to discuss our annual forward plan and a seminar in March with corporate directors to discuss how the estates, facilities, procurement and ICT work supports the clinical divisions in its delivery of patient care

the council had representatives involved in the appointment process of the chief nurse and governors met with the newly appointed deputy

chief executive and director of workforce to discuss their main priorities for the coming year

governors discussed a change in the current provision of ophthalmology care to our patients with the clinical service lead.

Board directors attend council meetings to better understand the issues that concern governors and attend or present at briefing seminars where they meet more informally with governors. In addition, the council and board hold an annual joint meeting, which in 2014 discussed improving the outpatient service. In 2015, it will discuss the UCLH Future transformation programme. Board members attendance at the council meetings can be found in table 15 on page 75.

Papers for the public meetings are published on the UCLH website. Members and the public who attend meetings have an opportunity to complete a question form on issues raised at the meeting, or on any other issue, which is subsequently answered by UCLH.

Training Governors are supported to carry out their duties. On joining UCLH, each governor receives an induction covering their responsibilities, how UCLH operates and an introduction to NHS finance, and performance


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management. Governors meet with the chairman and the lead governor respectively and new governors also attend externally facilitated core skills training.

In addition specific training is offered to help further support governors to understand their responsibilities. During the year, governors attended training on accountability, and finance and business skills. These sessions held jointly with Camden and Islington NHS Foundation Trust provide an opportunity for governors in the local health economy to network.

Governor expensesGovernors can claim expenses for carrying out their role, for example for attending council meetings, training or networking events. During the year ten governors were reimbursed for travel, subsistence, mileage or incidental expenses in accordance with our policy. Information about our expenses policy can be obtained from the trust secretary.

Council of Governors Nomination and Remuneration Committee This committee, chaired by a governor, makes recommendations to the council on the appraisal, remuneration and on the appointment of non-executive directors, including the chairman. It also acts as the appointment committee for the non-executive director nominated by UCL and for those non-executive directors being considered for reappointment.

The committee met four times during the year including a meeting in May to consider remuneration and in November to consider two reappointments. The Council unanimously approved the recommendations that remuneration should not be increased and that Dr Harry Bush and Dr Diana Walford both be reappointed.

During the year the committee also discussed the structure, size and composition of the Board with the chairman. It supported a revision to the constitution to increase the number of non-executives directors by one, agreed the role specification for that post and established a non-executive director (NED) appointment panel.

Membership of the committee is reviewed each year in October. Members and attendance at the committee is set out below, meeting dates were 1 May, 3 July, 10 November, and 16 March 2015. The trust secretary supports the committee.

Table 14

Member Attendance

David Coulter (Chair) 4/4

Joan Bell* 3/3

John Bird 4/4

Peter Brayshaw* 2/3

Philip Brading 1/1

Christine Chapman* 1/1

Emma Dalton 0/1

Judith Ellis* 2/2

John Green 1/1

Sheila Hinton 3/4

John Knight 0/1

Fiona McKenzie* 3/3

James Mountford 1/4

*no longer members at end March 2015.


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67 millionsent and received emails

Non-executive appointment panelNew appointments for NEDs (including the chairman) are made for a three year term following a process of open competition.

In September a NED appointment panel of six members was set up. The panel was chaired by the chairman and comprised governors David Coulter, Fiona Henderson, John Knight, and NEDs Harry Bush and Rima Makarem.

An external advisor from Russell Reynolds Associates, and the trust secretary and head of workforce compliance supported the process. The panel recommended to the council that Caspar Woolley be appointed. He took up post in January 2015.

The panel met on three occasions. The chairman and four panel members attended all of the meetings; all other members attended two meetings.

Our Board of Directors The Board, led by the chairman, sets the vision and values, and the strategic direction of UCLH. The Board works collectively for the organisation and is responsible for its decisions and performance working to ensure that UCLH delivers a high-quality and safe service. Decisions taken by the Board include the approval of strategy and major investments taking into account the views of the council and other key partner organisations.

The Board operates as a unitary team; it comprises eight non-executive directors, chosen for their wide range of knowledge, skills and experience, including the chairman; and eight executive directors, including the chief executive. The director of workforce attends board meetings but has no voting rights.

There is a clear division of responsibilities between the chairman and the chief executive. In summary:

The chairman leads the Board and ensures its effectiveness. This includes ensuring that the Board receives timely and clear information to enable board members to fulfil their statutory responsibilities

the chief executive is accountable to the Board on all matters not reserved to the Board and for running all aspects of the operational business.

Our constitution and regulatory framework sets out the matters reserved to the Board, and those which it has delegated to Board committees and to the chief executive for the management of UCLH. The chief executive is supported by the executive directors for both the overall day-to-day management of services

and the delivery of our strategy. Directors can also access independent professional advice should they need it to discharge their responsibilities; this is facilitated by the trust secretary.

Who are the Board members Board members’ details together with declarations of their relevant interests, and committee membership are detailed on the following pages. The Board considers that this information regarding each director’s expertise demonstrates the balance and completeness of the board and that the balance of skills is appropriate to the requirements of UCLH.

Non-executive directors Seven of the NEDs, including the chairman, are UCLH members who live or work in the London area or are patients of UCLH. The eighth director is nominated by UCL. Non-executive directors are appointed by the council initially for a period of three years; this may be extended for a further three years. In exceptional circumstances a non-executive director could serve for a further year. The Board considers all its non-executive directors to be independent.

Richard Murley – ChairmanRichard was appointed as chairman in July 2010 having previously served as a non-executive director from November 2008. He was reappointed in November 2012 for a further three years commencing in July

2013. Richard is a qualified solicitor and has worked in the City of London for more than 30 years. He is a vice-chairman of Rothschild where he has worked since 2006. Between 2003 and 2005, he was director general of the Panel on Takeovers and Mergers, regulating the conduct of takeovers of public companies in the UK. As well as chairing the Board, Richard is a member of the Finance & Contracting Committee, the Quality & Safety Committee, the Investment Committee and the Performance Committee.

Declaration of interests: Executive vice-chairman, global Financial Advisory, NM Rothschild & Sons Limited

Trustee, Crisis Board member, UCLPartners.


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Professor Sir Alasdair BreckenridgeAlasdair joined the Board in November 2012. He was chairman of the Medicines and Healthcare products Regulatory Agency from 2003 until the end of December 2012, and was previously Professor of Clinical Pharmacology

at the University of Liverpool. Between 1987 and 1999 he was a member, or chairman, of local and regional health authorities in the north west of England, including chairman of the North West Regional Office. Alasdair has been involved in regulation and governance for many years. Alasdair is a member of the Finance & Contracting Committee, the Quality & Safety Committee and the Performance Committee.

Declaration of interests: Member of the Council, Academy of Medical Sciences

Partner, NDA Partners Consultancy work with IMS.

Dr Harry Bush CB, vice-chairmanHarry was appointed to the Board in February 2012; he was reappointed in February 2015 for a further three years. He has extensive senior management experience at HM Treasury and in the economic regulation of

the aviation industry. He was most recently a member of the Civil Aviation Authority Board with executive responsibility for the Authority’s economic output. Prior to that, he held a number of senior posts at HM Treasury during a long career there. Harry was appointed vice-chair of the Board and is chair of the Finance & Contracting Committee. He is a member of the Audit, Investment and Performance Committees.

Declaration of interests: Director, Directgreen Property Management Ltd Director, H2B2 Ltd Non-executive director, The Airline Group Ltd Non-executive director, NATS Holdings Ltd. Director, NATS Employee Sharetrust Ltd Part-time advisory consultant, KPMG.

Dr Rima MakaremRima joined the Board in July 2013. She has extensive experience in healthcare and the pharmaceutical industry. She currently runs her own interim management and consultancy business and holds a portfolio of non-executive

positions. These include: trustee of UCLH Charity; board director at Anchor Trust; and associate board member/ chair of the Risk Assurance Committee at Health Education South London. She was until recently the audit chair at NHS London and at NHS Haringey before that. Previously Rima, was director of competitive excellence at GlaxoSmithKline and prior to that, a management consultant. Rima holds a PhD in Biochemistry and an MBA from INSEAD business school. Rima chairs the Audit Committee and Quality & Safety Committee and is a member of the Performance Committee.

Declaration of interests: Director and owner, Healthpeak Limited Non-executive director, Anchor Trust Trustee, UCLH Charity Associate member and chair of the Risk Assurance Committee, South London Local Education & Training Board.

Kieran MurphyKieran was appointed to the Board from January 2014 for a period of three years. He graduated from Cambridge University and began his career as a civil servant at HM Treasury. Subsequently he joined Kleinwort Benson where he spent 15 years

as a senior corporate finance adviser, culminating in leadership of the worldwide industrial sector investment banking business. Kieran joined the corporate finance advisory firm Gleacher Shacklock as a partner in 2004 and is now a senior adviser there. He is also a board member at City University, London, where he chairs the Strategy Implementation and Performance Committee. Kieran chairs the Investment Committee and is a member of the Audit, Finance and Contracting and the Performance Committees.

Declaration of interests: Board member, City University Non-executive director, Kingspan Group plc Non-executive director, Aliaxis S.A.


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1,400+on-going research trials and studies

Professor Sir John TookeJohn joined the Board in February 2010 as the UCL nominee; he was reappointed for a three year term in August 2013. He is Vice Provost (Health) at UCL and Head of the UCL School of Life & Medical Sciences. John joined UCL in 2009 from the Peninsula

College of Medicine and Dentistry, which he led from inception. He was a Wellcome Trust senior lecturer in Medicine and Physiology and honorary consultant physician at Charing Cross and Westminster Medical School before moving to Exeter in 1987. John is a past chair of the Medical Schools Council and the UK Healthcare Education Advisory Committee. In 2011 he was elected president of the Academy of Medical Sciences and is a member of the Prime Minister’s Council for Science and Technology. Until July 2014, John chaired the QSC. John will stand down from the Board in 2015.

Declaration of interests: Non-executive director and chair of the Medical Advisory Panel, BUPA

President of the Academy of Medical Sciences Non-executive board member, Francis Crick Institute

Academic director, UCLPartners Academic Health Science Centre

Director, Academic Health Solutions Ltd Director, Global Medical Excellence Cluster Director, Medical Schools Council Assessment Chair, UCL Medical School Education Consultancy Co-chair, Centre for the Advancement of Sustainable Medical Innovation

Member, National Institute of Health Research Advisory Committee

Member, Council for Science and Technology Member, Foundation for Science and Technology Member, Mayor of London’s Advisory Partnership, MedCity London

International advisory board member, Hamad Medical Corporation, Qatar.

Dr Diana Walford CBEDiana joined the Board in December 2011; she was reappointed for a further three years from December 2014. She has a distinguished record at the highest level in the civil service, NHS and higher education. During her career

she served the NHS as deputy chief medical officer for England, director of healthcare for the NHS Management Executive, director of the Public Health Laboratory Service and non-executive director of the NHS Blood and Transplant Authority. Diana is also a qualified haematologist and epidemiologist and was an honorary consultant haematologist at the Central Middlesex Hospital. Most recently, she was the principal of Mansfield College, Oxford University. Diana chairs the Performance Committee which was established in November 2014. She is a member of the Audit Committee and the Quality & Safety Committee.

Declaration of interests: Deputy chairman, Council of the London School of Hygiene and Tropical Medicine

Trustee, Sue Ryder.

Caspar WoolleyCaspar was appointed to the Board for an initial three year period commencing January 2015. Caspar is a Cambridge graduate who started his career as a design engineer. He founded and is a Board member at Hailo Network Ltd, the taxi app. He also served

as the chief executive officer of E-Courier (UK) Ltd and led the eCourier.co.uk management team. He was also vice president for Fleet at Avis. Previously, he served as the head of business development for The John Lewis Partnership. He served as vice president of operations at buy.com (UK) Ltd. He has been an independent non-executive director of GAME Digital plc since 16 May 2014. He has also been a governor at a foundation trust. Caspar is a member of the Investment Committee and the Performance Committee.

Declaration of interests: Non-Executive Director, GAME Digital plc Director, Hailo Network Holdings Ltd and subsidiaries


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Executive directorsExecutive directors are appointed by the Remuneration Committee of the Board of Directors on permanent contracts.

Sir Robert Naylor – Chief ExecutiveRobert Naylor has been chief executive at UCLH since November 2000. He led the development of one of the largest building projects in the NHS to create the world-class University College Hospital,

which was handed over to UCLH in two phases in 2005 and 2008. In April 2012 UCLH opened the third phase of development – the new University College Hospital Cancer Centre. In recent years UCLH has achieved many accolades for high-quality care, most notably in the Dr Foster league tables. In collaboration with UCL, UCLH is recognised as one of the leading academic medical centres in the world. It was designated one of the five Biomedical Research Centres and is a founding member of UCLPartners, an Academic Health Science Centre. Robert was awarded a knighthood for services to healthcare by Her Majesty The Queen in the New Year Honours List 2008. He has been a chairman of a number of national and regional committees and was awarded an honorary doctorate by Greenwich University in 2009.

Declaration of interests: Member of the Board, NHS Providers (formerly the Foundation Trust Network)

Member, NHS Confederation Policy Board Member, NHS Procurement and Efficiency Board (Carter Review).

Richard Alexander – Finance DirectorRichard joined UCLH in April 2007 from Oracle Corporation, one of the world’s largest software companies. His 15 year career at Oracle, ultimately as a vice-president, included three years in India establishing a Global

Financial Information Centre in Bangalore, and two years in the Netherlands as country finance director. Richard began his career at Mars Confectionery before joining Zenith Data Systems and then Oracle. Richard has a mathematics degree from Oxford University and is a chartered management accountant. Richard has

been appointed as CFO at Imperial College Hospital NHS Trust.

Declaration of interests: Board member, North Central London Local Education & Training Board, until 18 March

Board member, Health Data Insight Former employee and shareholder, Oracle Corporation.

Dr Geoff Bellingan – Medical Director for Surgery and CancerGeoff was appointed as medical director in September 2009. He trained as a chest physician and then in intensive care in which he has been a consultant at UCLH since 1997. He obtained his

PhD studying inflammatory cell biology as a Medical Research Council training fellow at the University of Edinburgh and received a clinician scientist award to continue his research at UCL. He is a reader in intensive care medicine at UCL and leads on several multinational clinical trials in acute respiratory distress syndrome and critical care. Geoff has a strong interest in medical leadership. He became divisional clinical director for theatres and anaesthesia in 2006 and from 2008/09 he was divisional clinical director for emergency services. As medical director for surgery and cancer, Geoff has a particular interest in the strategic plans for cancer care across north and east London, working closely with London Cancer, Macmillan and a number of other major partners, and is the clinical lead for the new Phase 4 project, which incorporates the UK’s first PBT unit, expansion of theatres and a new cancer hospital.

Declaration of interests: Co-director, London Intensive Care Ltd Director, Radiology Reporting On-Line LLP Board member and general secretary, European Board of Intensive Care Medicine

Member, Adult Critical Care Clinical Reference Group

Member, Patient Safety Committee, Royal College of Physicians

Member, Medical Equivalence Committee, Faculty of Intensive Care Medicine.


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105clinical teams participated in the Productive Outpatients Programme

Professor Katherine Fenton OBE – Chief Nurse Katherine Fenton was appointed as chief nurse in January 2011. Previously she was director of clinical standards and workforce/chief nurse at South Central Strategic Health Authority. Katherine’s other roles have

included the posts of director of nursing and patient services at Southampton University Hospitals NHS Trust and at Barts and the London NHS Trust (now Barts Health). Katherine led the development of the Safer Care Tool which helped to establish safe numbers of nurses based on the acuity and the dependency of patients. Katherine is chair of the Shelford Chief Nurses group, which is leading the way on Safe Nurse Staffing and Ensuring Great Ward Sisters. She also chairs the UCLPartners Chief Nurses Group. In January 2013 Katherine was awarded an OBE for services to nursing and healthcare. Katherine retired in January 2014 but covered the role on a part time basis until April 2015. This follows a career spanning over 30 years in nursing and midwifery.

Declaration of interests: Visiting professor at London City and London Southbank Universities.

Dr Jonathan Fielden – Medical Director, MedicineJonathan joined UCLH in July 2012 from The Royal Berkshire NHS Foundation Trust where he was medical director from 2009/12, care group director, Urgent Care (2011-12) and

director of medical education and development (2008–10). He is also a consultant in intensive care, having been appointed as a consultant in anaesthesia and intensive care medicine in Reading in 1998. He trained in Bristol, Sydney, and Portsmouth and Southampton and has developed a strong interest in medical leadership, health policy and models of care designed around and for patients promoting integration and enhancing value and sits on a number of national committees advising in the area. Jonathan has held national positions within the Royal College of Anaesthetists and the BMA (where he was deputy chairman, 2004-06 and chairman, 2006-09, of the Central Consultants and Specialists Committee). He has worked with the Department of Health, ministers and secretaries of state on the Payment by Results

initiative, medical leadership, quality as part of the NHS Future Forum, the national stakeholder group and the NHS Top Leaders programme.

Declaration of interests: Secondary care specialist on the Governing Body of Aylesbury Vale Clinical Commissioning Group

Employer member, National Advisory Committee on Clinical Excellence Awards

Mentor, Healthbox Europe Member, National Stakeholder Forum Board member, Health Services Laboratories Board trustee, Nuffield Trust His wife is director of transformation at the BMA.

Dr Gill Gaskin – Medical Director for Specialist HospitalsGill Gaskin was appointed medical director of the Specialist Hospitals Board in January 2010, leading clinical services at the NHNN, the HH, the EDH, the RNTNEH and in women’s

health and paediatric and adolescents. Gill graduated from Cambridge and trained in renal and general medicine at Hammersmith Hospital and the Royal Postgraduate Medical School, completing a PhD on the biology of systemic vasculitis. Between 1995-2010 she held consultant-level posts at Imperial College, Hammersmith Hospitals and Imperial College Healthcare Trusts, with additional responsibilities as director of postgraduate medical education and professional development, clinical director and latterly director for the medicine clinical programme group. She was renal training programme director for North London for four years and was also a member of the London Workforce Advisory Forum. Gill is a member of the Faculty of Medical Leadership and Management and is a participant in the NHS Top Leaders Programme.

Declaration of interests: Honorary consultant, Imperial College Healthcare NHS Trust

Chair, Shelford Medical Directors’ Group (one year from May 2014)


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Neil Griffiths – Deputy Chief Executive Neil Griffiths was appointed deputy chief executive in June 2014. Neil has over 20 years hospital management and leadership experience having joined the NHS from Bristol University in 1992. He has held

operational, commercial and strategic roles in a number of different hospitals, including Lewisham, St Mary’s (now part of Imperial), East Kent, the Royal National Orthopaedic and UCLH between 2003-08, during which time he was director of the HH, the newly opened University College Hospital and Strategic Development. In addition to his NHS hospital experience Neil has spent the last six years working in the private healthcare sector and most recently as a member of the healthcare management consultancy team at McKinsey & Company. Neil helped develop the McKinsey Hospital Institute in the UK which was created to support NHS hospitals identify improvement opportunities and with the delivery of change and productivity programmes. As well as a number of functional leadership responsibilities, an

important component of the role of deputy CEO is the development and implementation of a UCLH wide transformation programme, helping to prepare UCLH for the future.

Declaration of interests: Former employee, McKinsey & Company.

Professor Tony Mundy – Medical Director, Corporate Tony has been a medical director since 2001. Since November 2006 he has been the corporate medical director with UCLH-wide responsibility for quality and safety and for research and

development. He is the UCLH responsible officer for the revalidation of doctors under the GMC registration regulations. He was previously clinical director of urology and nephrology and then medical director for medicine and surgery from 2001 to 2006. Tony is a professor of urology in the University of London and director of the Institute of Urology.

Declaration of interests: No interests to declare.

Board meetings and committees The UCLH committee structure is set out below. Terms of reference set out the responsibilities of each committee and this structure monitors and provides assurance to the Board on the delivery of our objectives and other key priorities.

Board of Directors

Executive Board

Finance & Contracting Committee

Quality & Safety

Committee

Remuneration Committee

Investment Committee

Performance Committee

Audit Committee

Council of Governors

UCLH also has a treasury advisory group that meets as and when required


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Board of Directors The Board met on 14 occasions during the year; eight meetings were ordinary meetings held in public; five were confidential strategic meetings and one was a meeting to approve the financial statements. The Board holds a confidential meeting each month if required. Board papers for the public meetings are published on the UCLH website. Meeting dates during 2014/15 were 9 April; 14 and 23 May; 11 and 24 June; 9 and 25 July; 10 September; 12 November; 10 December; 14 January; 11 February; and 3 and 11 March.

The chairman also meets routinely throughout the year with the non-executive directors without the executive present.

Governors receive copies of the agenda and minutes of the public meetings, as well as the monthly performance report. In addition governors receive a summary from the chairman of issues discussed at confidential meetings.

The Board agenda is set by the chairman in consultation with the trust secretary. The agenda includes reports from the standing committees of the board. It also receives presentations from senior managers including, in 2014/15, safeguarding children and vulnerable adults, infection control, and a series of presentations focussing on patient safety. At the February and March meetings, patient stories were also presented to the Board.

Director attendance at the Board and the council is shown in the following table.

Table 15

Member Board Council

Non-executive directors

Richard Murley 14/14 4/4

Alasdair Breckenridge 12/14 3/3

Harry Bush 13/14 4/4

Rima Makarem 13/14 2/3

Kieran Murphy 12/14 4/4

John Tooke 7/14 1/3

Diana Walford 12/14 2/3

Caspar Woolley 3/4 1/1

Executive directors

Robert Naylor 13/14* 4/4

Richard Alexander 13/14 2/3

Geoff Bellingan 12/14 4/4

Katherine Fenton 10/14 1/3

Jonathan Fielden 14/14 3/3

Gill Gaskin 12/14 3/3

Neil Griffiths 11/11 3/3

Tony Mundy 9/14 2/3

*Not in attendance for part one of a meeting.

£934mannual turnover


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Audit Committee The audit committee provides independent assurance to the board on the audit, assurance and risk processes within UCLH. It reviews the adequacy and effectiveness of the systems of integrated governance – corporate, clinical and financial; and of internal control and risk management in place to support the achievement of the UCLH objectives.

The chair of the audit committee is Rima Makarem. Membership comprises four independent non-executive directors (including the committee chair). The audit chair has significant audit committee experience. Harry Bush and Kieran Murphy have substantial financial expertise. Diana Walford is a distinguished medical expert. The internal and external auditors, Baker Tilly and Deloitte LLP respectively, the finance director, deputy chief executive and the trust secretary regularly attend meetings; other executive directors and senior managers of UCLH attend to provide assurance as required. Baker Tilly, the local counter-fraud service provider attends four times a year and the chief executive attends annually when the committee reviews the financial statements. The Committee met seven times in 2014/15 meeting dates were 22 April, 23 May, 24 July, 23 September, 20 November in 2014, and 22 January and 26 March in 2015.

Table 16: Members’ attendance at Audit Committee

Member Attendance

Rima Makarem – Chair 7/7

Harry Bush 6/7

Kieran Murphy 5/7

Diana Walford 5/7

The committee is well placed to fulfil its assurance role. Members are familiar with the work of other board committees: finance and contracting; investment; performance; and quality and safety. This broad coverage of knowledge strengthens its effectiveness.

The external and internal audit partners and the local counter-fraud specialist have direct access to the committee; the committee members held private meetings with both the external audit partner and with the head of internal audit during the year.

What the committee did in 2014/15 The committee undertakes the work set out in its

terms of reference and seeks information from management that it deems necessary to perform its duties. A full description of the duties and responsibilities of the audit committee can be found in its terms of reference available on the UCLH website. During the year the committee:

Approved an internal audit (IA) plan and received a number of IA reports from Baker Tilly. Focusing on those giving limited assurance it reviewed the appropriateness and implementation of management’s response to the findings. Reports covered issues ranging from staffing audits (job planning and work appraisals) to financial control audits and audits related to patient care.

Reports considered include: An IA report on the upgrade of the Carecast patient administration system, which had received an amber/red outcome. Members sought further assurance from management on the quality of the data used to measure performance and whether it was fit for purpose. Overall management gave reasonable assurance on data collection and


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actions to strengthen controls will be taken where appropriate

an IA report on medical appraisal and job planning received a red opinion. A follow-up report from management gave some assurance that a revised job planning sign off process better recorded the sessional commitment of medical staff however; a recommendation to automate the process had still not been actioned. Management would focus on how it might further improve job planning completion rates in 2015/16.

reviewed quarterly reports on the financial statements and the scope of the external audit from the external auditors. It also considered the 2014/15 annual report, quality report, the integrity of the financial statements and the annual governance statement before submission to the board for approval

reviewed a report on whistleblowing (raising concerns) which explained the policies and other mechanisms in place to support our staff. It sought further information from management on how concerns raised outside UCLH to other organisations, for example the CQC, were dealt with. The committee was assured that every episode is investigated and responded to if the details are provided to UCLH

discussed changes in accounting policy and the impact on the financial statements with specific focus on the accounting treatment of S106 obligations

discussed regular reports on losses, waivers of the tender process, and special payments noting the improvement in financial control following the implementation of a new procurement system

approved changes to the standing financial instructions and scheme of delegation. It was assured that these documents maintained appropriate financial governance

reviewed the policy for the engagement of external auditors in non-audit work policy; it did not change

received reports on the corporate risks, risk ratings and mitigating actions from the risk register and considered the Board assurance framework quarterly. The committee discussed the high-level risks and actions, in particular those relating to the emergency care and RTT targets (specifically the impact of the emergency department building programme on patient care in A&E and patient flow through University College Hospital), nursing vacancies and recruitment, and ICT project delivery

reviewed and commented on reports that would change the approach to reporting on risk and assurance. On risk, the committee supported a revision of the risk classification matrix. On assurance, the new approach would assist the Board to better understand the key risks to the delivery of its strategic objectives and how they might be mitigated (see risk section on page 40)

considered the quarterly and annual reports of the local counter-fraud specialist focussing particularly on emerging fraud risks and on allegations of fraud

requested a report on progress made to improve strategic project management and was assured that a checklist had been developed to ensure appropriate governance structures and clear documentation records were in place for each project. It sought further improvement of the process by the addition of a section on expected outcomes

monitored the performance and independence of the external auditors and the effectiveness of internal audit and the local counter fraud function, and reviewed its own effectiveness

the Committee held a workshop session to provide them with a deeper understanding of the purpose and processes behind the development of the new ICT strategy and the complexity and risks to its delivery, and an annual session on risk and assurance jointly with board members to help improve the strategic focus of the board assurance framework.

External auditorsDeloitte LLP provides the external audit service to UCLH and reports to the Council through the committee. They have been our auditors since 2011/12 and were reappointed for a further one year by the council in July 2014. The total cost of the service for the audit of the financial statements and quality report for the year was £170,000 (£156,000 in 2013/14). The committee undertakes an assessment of the auditors’ effectiveness and independence each year, including a review of non-audit services. The outcome of the assessment considered Deloitte to have appropriate skills and independence for the role.

The auditors may provide non-audit services with the agreement of the Audit Committee and governors, in these circumstances there is a policy in place to safeguard the auditors’ objectivity and independence. During the year Deloitte provided a small piece of consultancy work in relation to a potential capital financing opportunity, and a review of the Quality Account as required by the regulator,

97per cent of inpatients who would recommend us


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Monitor. The auditors opinion and report on the financial

statements is on page 166 and within appendix 4. it is also in the Quality Report on page 147.

There are a number of other board committees which support the Board, a summary of these can be found below:

Remuneration Committee (RC)The RC sets pay and employment policy for the executive directors and other senior staff designated by the Board, and considers the performance of the executive directors. The RC sets remuneration with due regard to benchmarking information and survey data of other comparative senior posts within the NHS sector. All non-executive directors are members of the RC. The RC met on two occasions in 2014/15 on 14 May and 11 March to consider recommendations on remuneration.

Richard Murley, Alasdair Breckenridge Harry Bush, and Diana Walford attended both meetings. Rima Makarem, Kieran Murphy and Casper Woolley attended the meeting in March. The workforce director attended both meetings and the chief executive and deputy chief executive attended one meeting each in an advisory capacity. Details of salary and pension entitlements for the directors of UCLH are set out in the remuneration report section on page 82.

Finance and Contracting Committee (FCC) The FCC provides oversight and scrutiny of all aspects of financial management and assurance to the board on the management of financial risk. To achieve its aims the FCC examines financial performance and reviews costing and benchmarking work. It also oversees UCLH’s approach to contracting and considers longer term financial performance and planning issues.

The FCC met 11 times in 2014/15.

Investment Committee (IC)This committee advises the Board on investment decisions. It reviews the annual capital programme and reports to the Board on major capital investment proposals. In conducting an independent review of investment proposals, it considers strategic fit and ensures business cases have been appropriately assessed with regard to risk. In addition, the IC reviews medium-term investment strategy, including the financial and economic aspects of the estate strategy.

The committee met 14 times during the year.

Quality and Safety Committee (QSC) This committee is responsible for ensuring that effective arrangements are in place for the oversight and monitoring of all aspects of clinical quality and safety including identifying potential risks to the quality of clinical care. The Board relies on the QSC to provide advice on clinical quality, patient safety and risk and for assurance on areas of clinical governance and audit. It focuses on promoting a culture of openness and organisational learning and on behalf of the Board, it reviews compliance and receives assurance in meeting regulatory standards set by the CQC.

The QSC met 11 times in 2014/15.

Performance Committee (PC)The PC monitors and reviews progress in the achievement of UCLH’s objectives and considers the risks to their delivery and plans to address those risks drawing to the attention of the board any issues in meeting the objectives.

The committee met three times during the year.

Board, committee and directors’ evaluation Evaluation and development is considered by the Board to be important. The Board evaluates its committees using comprehensive self-assessment questionnaires followed by discussion. The evaluation provides a baseline assessment against which each committee can measure performance annually. The evaluation indicates that the committees are generally working well with good interaction between board members. In 2015/16 the Board will formally commission an independent external review.

As well as formal meetings the Board holds four seminars a year which support its development. Topics in 2014/15 were:

‘Patients as customers’ – to gain a greater awareness about the themes raised in complaints and how lessons can be learned and disseminated across UCLH

the past five years of UCLH clinical activity and future strategy

working in partnership in the local health economy

the Five Year Forward View – what it means for UCLH and its partners.

All directors have an annual appraisal. The chairman meets regularly with individual non-executive directors and reviews their performance. The annual review of the chairman is completed jointly


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by a governor (chair of the nomination and remuneration committee) and the vice chairman. The outcome of both the non-executive directors and chairman’s appraisal is reported to the council annually. In the event a non-executive director’s performance is not acceptable the council can terminate the appointment.

The chief executive reviews the performance of the executive directors and, following discussion with the non-executive directors, the chief executive is appraised by the chairman. The outcome of these appraisals is reported to the board’s remuneration committee.

Contacting the Board To contact the Board there is a dedicated email address [email protected], as well as a telephone and postal address; details are published on the UCLH website www.uclh.nhs.uk.

Compliance with the Code of Governance The NHS Foundation Trust Code of Governance is based on the principles of the UK Corporate Governance Code issued in 2012., it contains recommendations to assist trusts in improving their governance practices. It covers matters relating to directors, governors, audit, effectiveness and relationships.

UCLH has applied the principles of the Code (recently revised in July 2014) on a comply or explain basis.

Our approach to how we meet the Code is described throughout the report and a summary of where the detail can be found of those issues we are required to disclose is listed in table 17. Where any explanation is required this is set out on the following page.

Table 17

Code reference

Section Page/s

A.1.1 Set out in ‘what happened during the year’ and ‘our board of directors’

66 and 69

A.1.2 Set out in who are the board members 69-78

A.5.3 Set out in who are the council 63-66

Additional requirement

Set out in tables 12 and 13 and table 15 64-6575

B.1.1 Set out in who are the board members 69

B.1.4 Set out in who are the board members 69-74


Set out in Non-executive directors 69

B.2.10 Set out in council of governors nomination and remuneration committee and board remuneration committee

68-69 and 78

B.3.1 Set out in Richard Murley - Chairman 69

B.5.6 Set out in our membership development strategy

62-63

B.6.1 Set out in board, committee and directors’ evaluation

78

B.6.2 Not applicable – external evaluation will be undertaken in 2015/16

C.1.1 Set out in statement of Directors’ responsibility

14

C.2.1 Set out in the Risk Management and the Annual Governance Statement 2014/15

40-42 and 153

C.2.2 Set out in what the Audit Committee did in 2014/15

76

C.3.5 Not applicable, the council accepted the audit committee recommendation

C.3.9 Set out in audit committee, what the committee did in 2014/15 and external auditors

76-78

D.1.3 Set out in the Remuneration report 82

E.1.4 Set out in Council what happened during the year

66-67

E.1.6 Set out in our membership development strategy

62-63

E.1.8 Set out in Board of Directors 63 and 79


Set out in Membership 62-63

50per cent reduction in pressure ulcers in two years


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Explanation

Relating to the Board A 4.1 The Board has not appointed a SID. It considers it has effective processes in place to raise issues of concern other than through the normal route of chairman or chief executive. It has a vice-chairman and an elected lead governor to act with ‘independence of mind’, both of whom provide a channel through which directors and governors would be able to express concerns. Harry Bush was appointed vice-chairman in March 2013, and Fiona McKenzie was elected lead governor in July 2011. She was re-elected to the position in July 2014.

B1.1 The Board considers all its non-executive directors to be independent in both character and judgement despite one of its directors being the appointed representative of UCL medical school. The test of independence is made both at interview and annually at their performance evaluation. John Tooke, UCL nominee is considered to be independent of the executive and is able to provide a balance and objective opinion on matters relating to UCLH’s business.

B.6.3 See Section A.4.1 above, the Board has not appointed a SID. The Chairman’s annual evaluation is undertaken jointly by a governor (chair of the council’s nomination and remuneration committee) and the vice chairman (a non-executive director).

Relating to the council and the remuneration of non-executive directors B.5.6 Governors have not formally canvassed the opinion of the members and stakeholders they represent on the forward plan but they and other individuals have held a members meeting on the plan and have engaged with the community on key strategic developments. A slide pack on the forward plan has been uploaded to UCLH’s website.

UCLH partially meets the provision in D.2.3 relating to the market-testing of remuneration levels for non-executive directors and the chairman. UCLH participates in Foundation Trust Network (now NHS Providers) remuneration surveys and other industry benchmarking exercises. However, it would approach advisors were it to consider a material change to remuneration.


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114per cent score in staff survey; the safest in the NHS


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6 Remuneration report

Annual Statement on Remuneration – Chair of Remuneration CommitteeAll decisions regarding the pay of senior managers are made by the Trust’s Remuneration Committee. The Committee is responsible for determining and agreeing, on behalf of the Board, the broad policy for the remuneration of the Trust’s senior manager. The Committee is also responsible for considering the performance of the Chief Executive and Executive Directors including the setting of objectives and regular review of performance against them.

In October 2014 the Remuneration Committee agreed an unconsolidated, non-pensionable uplift of 1% to base salaries for senior managers whose terms and conditions were not covered by nationally determined contracts. This was an increase commensurate with staff on nationally determined contracts and dependent on each Director’s satisfactory performance against agreed objectives.

In regards to new appointments in 2014/15, the Trust appointed a new Deputy Chief Executive on the 2nd June 2014 with no change to the level of remuneration attached to the position. No other Executive Directors started in post during this period.

Richard MurleyChairman University College London Hospitals NHS Foundation TrustChair of the Remuneration Committee27 May 2015

Annual Report and Policy on Remuneration The salary and pension entitlements for senior managers and directors for the financial year are shown in tables 19 and 20 respectively. The remuneration table also shows the notional increase in pension benefits that have accrued during the year, calculated in line with Monitor and HMRC guidance. The pensions table includes the real increase of pensions during the reporting year, the value of accrued pension at the end of the reporting year, the value of ‘cash equivalent transfer value’ (CETV) and the real increase of CETV during the financial year.

The remuneration and expenses for the UCLH Chairman and non-executive directors are determined by the Council of Governors, taking account of the guidance issued by organisations such as the NHS Confederation and the NHS Appointments Commission. Remuneration for UCLH’s most senior managers (executive directors who are members of the Board of Directors, and other directors) is determined by UCLH’s remuneration sub-committee, which consists of the chairman and the non-executive directors.

Table 18 includes a description of each component of the Senior Manager Remuneration. The only non-cash element of senior managers’ remuneration packages is pension-related benefit accrued under the NHS Pensions Scheme. Contributions are made by both the employer and employee in accordance with the rules of the national scheme which applies to all NHS staff in the scheme. Pay levels are informed by salary levels in the wider market place. Affordability, determined by corporate performance and individual performance, are also taken into account. Terms and conditions are consistent with the new NHS pay arrangements.


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Table 18: Description of components of Senior Manager RemunerationComponent Applicable Description

Basic salary inclusive of London weighting

All senior managers

Agreed at appointment by the Remuneration Committee.

Non consolidation Payment

All senior managers

In October 2014 the Remuneration Committee agreed an unconsolidated, non-pensionable uplift of 1% to base salaries for senior managers whose terms and conditions were not covered by nationally determined contracts. This was an increase commensurate with staff on nationally determined contracts and dependent on the director’s satisfactory performance against agreed objectives.

Clinical Excellence Award (CEA)

Applicable to Medical Directors only

The Clinical Excellence Awards (CEA) scheme is intended to recognise and reward those consultants who contribute most towards the delivery of safe and high quality care to patients and to the continuous improvement of NHS services including those who do so through their contribution to academic medicine

Additional Programme Activity

Applicable to Medical Directors only

The remuneration for this is covered by Schedules 13 and 14 of the Terms and Conditions – Consultants (England) 2003.

Clinical Director Responsibility

Applicable to all Medical Directors

Recognises the increased responsibilities associated with the role of Medical Director.

Medical On Call Applicable to Medical Directors only

The on-call availability supplement recognises the time spent being available while on call. It does not recognise the work actually done while on call.

UCLH’s strategy and business planning process sets key business objectives, which in turn inform individual objectives for senior managers. Performance is closely monitored and discussed through both an annual and ongoing appraisal process. This approach will continue to be applied in the forthcoming year. Senior managers, other than directors, have pay progression linked to performance in line with the nationally implemented Agenda for Change system.

Senior managers are employed on contracts of employment, with a standard six month notice period, and are substantive employees of UCLH. UCLH’s disciplinary policies apply to senior managers, including the sanction of dismissal for gross misconduct. UCLH’s redundancy policy is consistent with NHS redundancy terms for all staff.

Details of the Remuneration Committees which determine the remuneration of board members can be found on page 68 and 78. Details of the appointments committees can be found on page 69 (non-executive panel) and page 78 (Remuneration Committee). No compensation for early termination was paid during this financial year. No early terminations are expected and no provisions are required accordingly. No awards have been made to any past senior managers or directors. There were no benefits in kind or non-cash elements of remuneration paid to directors in the year.

The salaries and pension entitlements of the directors for 2014/15 and 2013/14 are shown on the following pages. Accounting policies for pensions and other retirement benefits are set out in note 7 of the accounts.


36,490job applications this year


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Table 19a: Senior manager remuneration Note: all salary paid in the year is reflected in the first column. The table also shows the notional increase / (decrease) in pension-related benefits (see note below). Therefore the final column should not be interpreted as the total salary paid in the year.

Year ended 31 March 2015

Name and title

TOTAL Salary and Fees

(bands of £5000)£000

Taxable Benefits and Bonuses

(bands of £5000)£000

Notional Increase / (Decrease) in

Pension-Related Benefits (see note

below)

(bands of £2500)£000

Total Including Notional

Increase in Pension-Related

Benefits

(bands of £5000)£000

R MurleyChairman

60-65 - - 60-65

Sir A BreckenridgeNon-Executive Director

10-15 - - 10-15

H BushNon-Executive Director

10-15 - - 10-15

R Makarem Non-Executive Director

15-20 - - 15-20

K MurphyNon-Executive DirectorFrom 1 January 2014

10-15 - - 10-15

C WoolleyNon-Executive DirectorFrom 1 January 2015

0-5 - - 0-5

Sir J TookeNon-Executive Director

10-15 - - 10-15

D WalfordNon-Executive Director

10-15 - - 10-15

Sir R NaylorChief Executive

265-270 - (10-7.5) 255-260

N GriffithsDeputy Chief ExecutiveFrom 2 June 2014

155-160 - 2.5-5 160-165

R AlexanderDirector of Finance

185-190 - 17.5-20 205-210

G BellinganMedical Director

250-255 - (10-7.5) 245-250

J FieldenMedical Director

220-225 - (62.5-60) 160-165

G GaskinMedical Director

200-205 - 17.5-20 220-225

A MundyMedical Director

150-155 - - 150-155

K FentonChief Nurse

95-100 - - 95-100


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Table 19b: Senior manager remuneration

Year ended 31 March 2014

Name and title

TOTAL Salary and Fees

(bands of £5000)£000

Taxable Benefits and Bonuses

(bands of £5000)£000

Notional Increase / (Decrease) in

Pension-Related Benefits (see note

below)

(bands of £2500)£000

Total Including Notional

Increase in Pension-Related

Benefits

(bands of £5000)£000

R MurleyChairman

60-65 - - 60-65

Sir A BreckenridgeNon-Executive Director

10-15 - - 10-15

H BushNon-Executive Director

10-15 - - 10-15

R Makarem Non-Executive Director

10-15 - - 10-15

K MurphyNon-Executive DirectorFrom 1 January 2014

0-5 - - 0-5

Sir J TookeNon-Executive Director

10-15 - - 10-15

D WalfordNon-Executive Director

10-15 - - 10-15

S AtkinsonNon-Executive DirectorTo 30 June 2013

0-5 - - 0-5

R DelbridgeNon-Executive DirectorTo 31 December 2013

10-15 - - 10-15


260-265 - 2.5-5 260-265


185-190 - 25-27.5 210-215


250-255 - (12.5-10) 240-245


225-230 - 117.5-120 340-345


200-205 - 25-27.5 225-230

A MundyMedical Director

150-155 - - 150-155

K FentonChief Nurse

140-145 - (20-17.5) 120-125

M FosterDeputy Chief ExecutiveTo 31 March 2014

190-195 - 2.5-5 195-200

90+commissioners that UCLH works with


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Pension-related benefits are intended to show the notional increase or decrease in the value of directors’ pensions, assuming the pension is drawn for 20 years after retirement. It is calculated as 20 x annual pension increase + lump sum increase, less any employees’ pension contributions paid in the year. These increases are then adjusted for inflation to show the “real” increase in pension-related benefits – this may be negative where the inflation adjustment is greater than the underlying increase. Medical Director salaries include payment for both their Director role and NHS clinical work.

Senior managers are not paid any taxable benefits, annual performance-related bonuses or long-term performance-related bonuses. Where a director is released to serve as a non-executive director elsewhere, the director does not retain any earnings from that role.

Table 20: Senior Manager Total Pension Entitlement

Real increase/ (decrease) in pension and related lump sum at age 60

(bands of £2500)

Total accrued lump sum at age 60 at 31 March 2015

(bands of £5000)

Total accrued pension at 31 March 2015

(bands of £5000)

Cash equivalent transfer value (CETV) at 31 March 2014

Cash equivalent transfer value (CETV) at 31 March 2015

Real increase/ (decrease) in cash equivalent value

Name and title £000 £000 £000 £000 £000 £000


1-2.5 430-435 140-145 0 0 0


1-2.5 50-55 15-20 282 325 35


(2.5-0) 185-190 60-65 1,260 1,563 269

N GriffithsDeputy Chief ExecutiveFrom 2 June 2014

1-2.5 60-65 20-25 357 400 27


1-2.5 65-70 20-25 386 435 39


(2.5-0) 190-195 60-65 1,149 1,187 7

The information above is based on that provided by the NHS Pension Agency. CETVs are stated as actual values, with the increase / (decrease) figure adjusted for inflation. CETVs are shown as zero for directors aged over 60 at the end of the year, as these directors are not permitted to transfer their pensions.

Real increase / (decrease) in pension and related lump sum is the increase / (decrease) in annual pension compared to 31 March 2014, adjusted for inflation.

Total accrued pension at 31 March 2015 is the annual pension that each director has accrued, including any purchase of added years and transferred-in benefits from other employments. No additional benefit is payable in the event that a director retires early and no director is a member of a separate pension scheme in relation to this employment.


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Table 21: Lord Hutton Report – Fair Pay MultipleReporting bodies are required to disclose the relationship between the remuneration of the highest-paid director in their organisation and the median remuneration of the organisation’s workforce.

2014-15 2013-14

Band of the Highest Paid Director’s Total Remuneration (£000)

265-270 260-265

Median Pay Remuneration (£)

37,408 37,694

7.2 7.0

The banded remuneration of the highest-paid director in The Trust in the financial year 2014/15 was in the band £265k-£270k (2013/14, £260k-£265k). This was 7.2 times (2013/14, 7.0) the median remuneration of the workforce, which was £37,408 (2013/14, £37,694).

In 2014/15, no employee (2013/14, 1) received remuneration in excess of the highest-paid director.

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

High Paid Off-Payroll Arrangements

Table 22: For all off-payroll engagements as of 31 March 2015, for more than £220 per day and that last for longer than six months

No. of existing engagements as of 31 March 2015

3

of which

Number that have existed for less than one year at the time of reporting

2

Number that have existed for between one and two years at the time of reporting

0

Number that have existed for between two and three years at the time of reporting

0

Number that have existed for between three and four years at the time of reporting

0

Number that have existed for four or more years at the time of reporting*

1

* This individual had left the Trust at the time of publication. All existing off-payroll engagements, outlined above, have at some point been subject to a risk based assessment as to whether assurance is required that the individual is paying the right amount of tax and, where necessary, that assurance has been sought.

Table 23: For all new off-payroll engagements, or those that reached six months in duration, between 1 April 2014 and 31 March 2015, for more than £220 per day and that last for longer than six months

Number of new engagements, or those that reached six months in duration between 01 April 2014 and 31 March 2015

5

Number of the above which include contractual clauses giving the trust the right to request assurance in relation to income tax and national insurance obligations

5

Number for whom assurance has been requested

5

of which

Number for whom assurance has been received

5

Number for whom assurance has not been received

0

Number that have been terminated as a result of assurance not being received

0

47,323patient experience surveys collected





Heart Hospital


Appendix 1

UCLH staff survey results


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Table 24: UCLH staff survey results – top and bottom scores for 2014/15 compared with 2013/14

2014/15 2013/14

UCLH National average

UCLH National average

UCLH improvement/ deterioration

Response rate 40% 42% 48% 48% Deterioration

Top five scores

1. KF29 percentage of staff agreeing that feedback from patients is used to make informed decisions in their directorate/ department.

68% 56% n/a n/a New key finding

2. KF8 percentage of staff having well-structured appraisals in the last 12 months.

47% 38% 51% 38% Deterioration

3. KF15 percentage of staff agreeing that they would feel secure raising concerns about unsafe clinical practice.

76% 67% n/a n/a New key finding

4. KF24 staff recommendation of UCLH as a place to work or receive treatment (score out of 5).

3.97 3.67 4.05 3.68 Deterioration

5. KF21 percentage of staff reporting good communication between senior management and staff.


Bottom five scores

1. KF5 percentage of staff working extra hours. 77% 71% 75% 70% No change

2. KF27 percentage of staff believing UCLH provides equal opportunities for career progression or promotion.


3. KF28 percentage of staff experiencing discrimination at work in the last 12 months.

18% 11% 17% 11% No change

4. KF19 percentage of staff experiencing harassment, bullying or abuse from staff in the last 12 months.

30% 23% 29% 24% No change

5. KF26 percentage of staff having equality and diversity training in last 12 months.






Heart Hospital


Appendix 2

Quality report 2014/15


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Contents

1. Statement on Quality from the Chief Executive 93

2. Introduction 94 � Current view of University College London Hospitals NHS Foundation

Trust’s position on quality 94

� ►Quality highlights of 2014/15 and where we need to improve 94

� Our Quality Improvements over the years 96

3. Progress against 2014/15 priorities 984. Priorities for improvement and statement of assurance from the

Board 118

� Deciding our quality priorities for 2015/16 118

� Priority 1: Patient Experience 118

� Priority 2: Patient Safety 122

� Priority 3: Clinical Outcomes 125

� Statements of assurance from the Board 126

� Participation in clinical audits 126

� Participation in clinical research 132

� CQUIN payment framework 134

� Care Quality Commission (CQC) registration and compliance 135

� Data quality 135

� NHS number and General Medical Practice Code Validity 135

� Information Governance Toolkit attainment levels 135

� Clinical coding error rate 135

5. Review of Quality Performance 136Annex 1: Statements from commissioners, Healthwatch and Overview and

Scrutiny Committee 144

Annex 2: Statement of directors’ responsibilities 146

Annex 3: External audit limited assurance report 147

Annex 4: Glossary of terms and abbreviations 149


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1 Statement on quality from the chief executive

This is reflected in our top 10 objectives and is a constant focus in everything that we do.

This year has been demanding – we have had challenges in achieving the 18 week referral to treatment waiting times targets and the 62 day cancer target. Through investment and huge commitment from all staff, we have made excellent progress but this remains a challenge for next year. We are very pleased that we have maintained our high standards of quality despite these pressures. For example, we have improved the care of patients with dementia and made good progress on reducing falls with harm and pressure ulcers and have improved ways to share learning from incidents and complaints. Along with most other trusts nationally, we have had difficulty in meeting the operational standard that 95 per cent of our patients are seen in our emergency department within four hours. However in the most challenging winter period we did achieve the 95% target and were the third best performer in London – a great achievement

despite considerable pressures.These are exciting times

as we continue to work on our ‘UCLH Future’ plans, our strategy for the move of cardiac services to Barts Health NHS Trust and the development of our cancer services.

Pressures will continue next year as we continue to face very high demand for our services but I am confident that we will maintain our unrelenting focus on the three strands of quality: safety, effectiveness (clinical outcomes) and patient experience.

This quality report contains data on our performance in relation to quality which by its nature is less precise than financial information and there are acceptable differences in the way in which this type of information is measured.

With this in mind UCLH has done its best to ensure that, 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 indicator as described in section 5).

Excellent quality patient care remains the top priority at UCLH (University College London Hospitals NHS Foundation Trust).

Sir Robert Naylor Chief executive


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2 Introduction

We have been very focused on responding to the significant financial pressures in the NHS. However, this is also an opportunity to improve quality, particularly in patient experience.

We have developed a programme of change – ‘UCLH Future’ – that centres around four key areas:

Care delivery system – about how we deliver care; iCare – about use of technology and information to improve the patient experience;

UCLH Institute – about learning through improvement; and

Organisational Development – about leadership culture and change.

With these key areas we aim to take UCLH from being one of the best trusts in the NHS to one of the best worldwide.

Current view of UCLH’s position on quality

Quality highlights of 2014/15

Nurse staffing levels and systems of patient safetyUCLH consists of University College Hospital, the Royal National Throat Nose and Ear Hospital, the Royal London Hospital for Integrated Medicine, the National Hospital for Neurology and Neurosurgery, the Heart Hospital and the Eastman Dental Hospital.

In July 2014, University College Hospital was noted to be the safest hospital in England after NHS England published new data on nurse staffing levels and systems of patient safety.

The hospital achieved a 114% score in safe staffing levels and was the only hospital in the NHS to perform above expectations in all six categories:

Patient safety reporting Infection control and cleanliness Patients assessed for blood clots NHS England patient safety notices Care Quality Commission national standards Recommended by staff

All the other hospitals in UCLH performed excellently.

Security of patient recordsA number of developments were initiated as a result of the Care Quality Commission’s (CQC) inspection in November 2013. The inspectors said that improvements were needed in relation to the security of patient records on the acute medical

wards. We have modernised our casenote storage and the importance of keeping information safe has been extensively communicated and we have included casenote compliance in our Mandatory Training. Monitoring and assurance is undertaken at our weekly Matrons Quality Rounds (see glossary), and larger multi-professional ‘Improving Care Rounds’ (see glossary). We also have developed a casenote audit app which we use in some areas. These changes show that we continue to demonstrate improvement.

Nursing documentationThe CQC inspection also identified the need to improve nursing documentation. As a result we have implemented the new SOAPIER (see glossary) documentation tool Trust wide. This provides a consistent patient centred approach to nursing documentation in relation to plans of care, and these are regularly checked for quality of documentation. To monitor progress, notes are reviewed with the nurse caring for the patient on that shift, they are checked daily by the ward sister, weekly by the matron, fortnightly on the quality rounds and monthly during the unannounced visits by the Chief Nurse Team.Ongoing monitoring has shown that whilst great improvements have been made with plans of care, improvements are still required with accurate dating and signing.


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Productive Outpatient ProgrammeLast year we highlighted that we needed to improve our outpatient experience. In response, this year we have run an ambitious outpatient improvement programme with actions focused on patient experience and the movement of patients, involving all our outpatient sites. The most intensive of these programmes was the ‘Productive Outpatient Programme’ which was run on a much broader scale than in previous years. Since its inception in 2011, 105 clinical teams have participated in the programme. 955 individual clinics have benefited, improving the experience for 258,710 patients per year.

As a result 93 per cent of clinics have improved the ability to see more patients for first consultation sooner (i.e. the time from their referral from the GP to a first appointment has reduced)

64 per cent of clinics have improved patient attendance levels (by reducing the number of patients who do not attend on the day) and can therefore see more patients per clinic

Services seeking to reduce waiting times for either a new or follow up appointment have achieved this with the degree of reduction ranging from 87 per cent to 30 per cent.

Every clinic at the Royal National Throat Nose and Ear Hospital (RNTNEH) participated in the programme between July 2014 and February 2015. During the programme the number of wasted appointments through patients not attending was reduced from

15 per cent to 11 per cent meaning that 736 more patients attended their appointments during the project period. In addition to improving the way specific clinics are run, and thus waiting times for patients, we have also tackled issues which affect the whole site including the waiting area, signage, and queuing for reception. The programme has also enabled patients to be seen by the most appropriate clinician on their day of attendance, reducing the number of journeys patients make to the RNTNEH for their care. Feedback from staff and patients has been extremely positive.

Where we need to improve

Staff SurveyStaff continue to recommend UCLH as a place to work and to be treated, and our overall staff engagement scores remain in the top 20 per cent of acute hospitals. However, most NHS staff survey results are generally less positive than last year and there were less favourable responses from UCLH staff in respect of working longer hours, work related stress, discrimination and harassment and bullying and abuse by other staff. Work is being undertaken to help the areas that had the most challenging results.

WHO safe surgery checklist We wish to improve further the use of the WHO safe surgery checklist (see glossary) and associated theatre behaviour and so we have included it as one of our safety priorities for 2015/16 – reducing surgical harm (see Section 4, Priority 2).


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OutpatientsDespite the progress we have made (described above) there is still work to be done and this continues to be one of our priorities (see Section 4, Priority 1.2).

Referral to treatment waitsThe Trust started 2014/15 with long referral to treatment (RTT) waits across a range of specialties and being non-compliant with the three national RTT standards (these are 90 per cent of patients treated via admission and 95 per cent of patients treated in out-patients to be within 18 weeks, and 92 per cent of patients waiting for treatment to be under 18 weeks).

This was due to increasing referrals, with a 30 per cent increase in elective (planned) referrals seen over the last 5 years, in particular in our specialist areas such as neurosurgery. In 2014/15 we made improvements by undertaking more surgery and improving access to diagnostic tests and investigations. We also improved our waiting list management and reporting. We are now achieving

two out of the three RTT standards, and plan to be fully compliant from June 2015. For further information on this indicator see section 5 (Access targets and outcome indicators).

We are aware of the impact that waiting to be seen has on patients’ experience and the anxiety this must cause and it is a priority for us to improve our waiting times. To reduce the risk of harm to patients we inform GPs of those who have waited 26 weeks or more, and ask them to inform us of any clinical concerns that might result from delay. For some conditions, it is difficult to assess the extent to which delays have an impact; however, we have not detected any harm to date.

Our quality improvements over the yearsThe table below charts our Quality Report priorities over the last few years and demonstrates the continuity of some priorities alongside newly emerging priorities.

2012/13 2013/14 2014/15 2015/16

Improve patient experience in five CQUIN areas.

Improve patient experience CQUIN areas.

National inpatient survey question- how would you rate your overall experience.

National inpatient survey question – how would you rate your overall experience.

National inpatient survey question – involved in decisions about care and treatment.

National inpatient survey question – Care: more than 5 minutes to answer call button.

National inpatient survey questions – explanation about how you could expect to feel after your operation.

National inpatient survey question: Staff contradict each other.

Ensure availability of hand gel.

Improve nursing communication with patients.

Improve overall care rating in outpatients.

Improve overall care rating in outpatients.

Continue to improve overall care ratings and waiting times in outpatients as measured by our local survey.

Continue to improve overall care ratings and waiting times in outpatients as measured by our local survey.

Improve cancer patient experience.

Improve cancer patient experience.

Continue to improve cancer patient experience.

Continue to improve cancer patient experience overall and in selected areas as measured by our local survey.


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2012/13 2013/14 2014/15 2015/16

Improve our end of life care.

Continue to improve end of life care.

Improve the management of pain relief.

Improve care of patients with dementia.

Reduce number of falls resulting in harm.

Reduce harm from falls, VTE (see glossary), HAPU & infection.

Continue to reduce harm from falls and infection.

Reduce surgery related harm.

Increase VTE risk assess. Eliminate grade 4 Hospital Acquired Pressure Ulcers (HAPU).

Achieve CQUIN* targets for reducing harm from pressure ulcers.

Reduce harm from unrecognised deterioration.

Reduce medication omissions.

Use Ward Safety Checklist on daily ward rounds.

Improve Trust wide learning from Serious Incidents.

Reduce patient harm from sepsis.

Continue Trust wide learning from Serious Incidents.

Review our unplanned readmissions.

Develop clinical outcome measures specific to each specialty.

Continue to develop specialty clinical outcomes.

To publish 10 specialty specific clinical outcome measures per quarter.

Improve our hospital mortality ratio.

Continue to improve mortality ratio.

Continue to improve mortality ratio with focus on weekend mortality.

Maintain our position in the top 10% of trusts nationally for SHMI.

*CQUIN – see glossaryFor further information on progress with 2014/15 objectives see Section 3. For further information on priorities for 2015/16 see Section 4.


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3 Progress against 2014/15 priorities

Priority 1: Patient Experience1. Increasing overall patient satisfaction as measured by local and national surveys

1.1 Inpatient surveys In this section we describe three survey results we have used to measure patient experience – the National Inpatient Survey (CQC) results (how we compare to every NHS trust), Picker survey results (comparing to trusts using this survey provider) and our internal real time patient feedback system, Meridian. Our aims were to improve our patient rating of overall experience and in specific areas which required improvement – explanations given to patients prior to surgery and involvement in decisions about care.

The targets we set and the results were as follows:

Table 1

National inpatient survey results (CQC) – higher scores are better

2014 target* 2014 Result*

Overall experience rating (higher is better)

8.4/10 8.1/10

Were you told how you could expect to feel after your operation?

7.4/10 7.3/10

Involvement in decisions about your care and treatment

7.5/10 7.5/10

* Individual responses are converted into scores on a scale from 0-10, with 10 representing the best possible score and 0 the worst (see glossary for further information).

However, the results from the National Inpatient Survey were not available until 21 May 2015 and we therefore used the Picker survey results and Meridian to assess our performance. The Picker Institute carries out the patient survey programmes on behalf of the Care Quality Commission for some trusts.

Action plans and measures were developed for each of the priorities last year and performance has been monitored through the year by clinical teams and UCLH committees.


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The results from the Picker survey for the questions we agreed to focus on are as follows:

Table 2

National survey results (Picker) – lower scores are better

2013 result (Picker)*

2014 result (Picker)*

Overall experience rating 12% 13%


40% 39%


39% 36%

* The Picker report uses problem scores which show the percentage of patients for each question who have indicated that a particular aspect could have been improved (see glossary for further information). Lower scores are better. 765 patients of the total of 1700 patients who were asked to participate completed the survey – 46 per cent. According to the Picker results improvements have been made in the two targeted questions but not in the overall experience rating.

As the National Inpatient Survey and the Picker survey are carried out yearly, we used Meridian to monitor our performance against these questions throughout the year. Our experience is that by including these questions in the survey and reporting on the results directly to the wards, the performance improves. We find that local surveys tend to produce better results than the national survey and so we set higher internal targets.

A total of 11488 adult inpatients completed the Meridian questionnaire between April 2014 and March 2015, a total of 35.8 per cent of eligible patients. The majority of patients are surveyed in hospital at the point of discharge although there is the opportunity to complete the survey online once the patient gets home. Data shows that 92% of patients completing the survey did so while still in hospital. The results are as follows:

Table 3

Meridian survey results – higher scores are betterQuestion

2013 target (Meridan)*

2014 result (Meridian)*

Overall experience rating 95% 91%


86% 86%


80% 87%

* Meridian scores measure the answer as a percentage of the maximum score (see glossary for further information).


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Results over the year are as follows:

Figure 1: Inpatient – Overall experience rating

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Meridian performance target

Meridian scores measure the answers as a percentage of the maximum score (see glossary for further information).

The target of 95 per cent was not achieved.

Figure 2: Inpatient – were you told how you could expect to feel after your operation?

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Meridian performance Target



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The target of 86 per cent was met throughout most of the year.

Figure 3: Inpatient – involvement in decisions about your care and treatment

70.00%

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Performance Target


The target of 80% was met or exceeded throughout most of the year. This question was only added to the Meridian Survey questionnaire in September 2014.

Whilst the results on Meridian are often more favourable and we did well on the specific questions against our target (fig 2 and 3) the trend for overall patient experience as illustrated in fig 1 showed little improvement during the year and so we need to have a greater focus on actions that will improve our overall patient experience, using all our local data to drive improvements.

Looking at the Picker results and Meridian results together, we have not met our target to improve the overall experience rating but we have improved our survey results on the other two questions. The National Inpatient results published in May 2015 confirm that we did not meet the overall target for overall experience and that we narrowly missed our target for being told what to expect after the operation. We did meet our target for involvement in decisions about care and treatment. This suggests that we need to continue to focus on overall experience in 2015/16. This is described in section 4.

This is the best NHS hospital I have been in. The staff were so friendly, were informed, made you feel very welcome. The ward was nice and spotless a relaxed environment.

I felt I was not fully involved in my care from the medical point of view e.g. when medication is changed I am not informed and given a chance to ask questions.

Excellent care. Found it extremely helpful that my consultant arranged for me to meet another patient who had same operation, it relieved my anxieties and prepared me for what was to come.

My operation wasn’t explained to me beforehand. I was told it was very simple and I’d be out in two days. This isn’t the case. I’ve been here six days and I have to come back for two more.


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1.2 Outpatient survey Our progress against the targets we set comes from our local Meridian outpatient surveys as there is no recent outpatient survey, and is detailed in the table below – we focused on overall experience and waiting times.

To help with waiting times we introduced kiosks to make it quicker to check in and this also gives information to the team on how many patients are waiting. Other initiatives to improve outpatients include the Out Patient Improvement Project described in the introduction. A total of 4772 adult patients completed the Outpatient Survey Meridian questionnaire between April 2014 and March 2015, approximately 0.6 per cent of total appointments. We recognised that this is a low response rate and we piloted a new way to gather feedback using a simpler paper-based form. This saw the average responses increase by 150 per cent in the area it was tested (from 65 to 165 per month). The results are as follows:

Table 4


2014Target

2014Results

Overall how would you rate the care you received (1) 86% 89%

How long after the stated appointment time did the appointment start? (2)

70% 69%

(1) Percentage of patients who rated the care as good or better(2) Percentage patients who waited less than 30 minutes for their appointment to startMeridian scores measure the answers as a percentage of the maximum score (see glossary for further information).

The results over the year are as follows:

Figure 4: Outpatients – overall how would you rate the care you received

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*Meridian scores measure the answers as a percentage of the maximum score (see glossary for further information).

We did meet our target of 86 per cent over the year.

Figure 5: Outpatient – How long after the stated appointment time did the appointment start?*

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*Meridian scores measure the answers as a percentage of the maximum score (see glossary for further information). We did not consistently meet this target throughout the year.

We have improved on the overall rating of care but did not achieve our target for waiting time which continues to be variable between clinics and we will continue to focus on this for 2015/16.

Very efficient. Excellent staff manner. Hardly any waiting. Well organised.

Very professional and prompt. Courteous, explained everything very fully. Gave me confidence that they would be ‘on the case’ of my issue. I feel very looked after.

Kind staff, good medical care, waiting time too long.

I waited almost two hours to be seen.


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1.3 Cancer survey Our performance in the 2014 National Cancer Experience Survey (NCPES) is detailed in the table below. 879 adult patients responded – this is a 51 per cent response rate – the national response rate was 64%.

Table 5

NCPES Question – higher scores are better

2014 National survey target*

2014 National survey result*

Overall how would you rate the care you received 90% 88%

Were you given enough information about your condition 90% 85%

Were you given the name and contact number of your Clinical Nurse Specialist 92% 92%

Hospital staff definitely gave patient enough emotional support 71% 64%

*The NCPES is administered by Quality Health. In that survey the questions have been summarised as the percentage of patients who reported a positive experience. For example, the percentage of patients who said they were given enough information about their condition. Higher scores are better.

Overall, the results from the NCPES were better this year; there were more responses to questions where we were in the top 20 per cent and fewer responses to questions where we were in the bottom 10 per cent. We were pleased that we did better in patients knowing who their Clinical Nurse Specialist (CNS) was, the provision of information and confidence in ward staff. We were disappointed however that we did not improve in the specific questions above.

As the national survey is yearly or less we monitor internally using our real-time patient feedback system Meridian and the results are as follows:

Table 6


Local Survey results (Meridian)2013/14*

Local Survey targets (Meridian)2013/14*

Local Survey results (Meridian)2014/15*

Overall how would you rate the care you received 90% 91% 90%

Were you given enough information about your condition 88% 90% 93%

Were you given the name and contact number of your CNS 72% 82% 65%

Hospital staff definitely gave patient enough emotional support 79% 85% 85%

*Meridian scores measure the answers as a percentage of the maximum score (see glossary for further information).

Cancer patients are asked these questions when in outpatients or day care. A total of 1209 adult patients completed the Meridian Cancer Survey questionnaire between April 2014 and March 2015, a total of 2.3 per cent of eligible patients.


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The graphs below show the results over the year.

Figure 6: Cancer – overall how would you rate the care you received?

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We did not consistently meet the target throughout the year.

Figure 7: Cancer – were you given enough information about your condition

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We met the target throughout most of the year.


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Figure 8: Cancer – were you given the name and contact number of your CNS

50.00%55.00%60.00%65.00%70.00%75.00%80.00%85.00%90.00%95.00%

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We did not meet the target throughout the year.

Figure 9: Cancer – hospital staff definitely gave patient enough emotional support

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We did not consistently meet the target throughout the year.


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We did not meet the target rating for overall care in either survey. We met the target for the question relating to enough information in the Meridian survey but not in the national survey. Although we met the target for the question regarding the name and contact number of the CNS in the national survey this result was not supported in the Meridian survey. The target for the question about enough emotional support was not met according to the national survey.

We therefore agreed to continue to focus on the overall experience and the question relating to the name and contact number of the CNS as this showed the poorest results in the local survey.

My CNS is excellent, always helpful and supportive.

Medical treatment we are very happy with, it is very good. But waiting times need to be improved and it would be nice to have some more information and emotional support from staff.

Patient has not been given a name for her CNS only a number and when they tried to call the number it was very hard to get through to anyone.

Staff very helpful, lots of useful information given, the consultant is first rate.


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1.4 Complaints In 2014/15 UCLH received 835 formal written complaints, compared to 791 in the previous year, this represents an increase of 5.6 per cent. However, caution should be used in only looking at the actual number of complaints as we actively encourage the reporting of complaints and concerns so that we can learn and improve. New leaflets were circulated across the Trust and information on raising concerns and complaints was included in the new ‘welcome pack’ (see glossary).

We recognise that it can be very difficult for patients to raise concerns and we use our Trust induction training to tell staff the importance of giving patients time to raise concerns and to respond to them before they become complaints. In the past year we have met with Voiceability (see glossary) and Healthwatch and have also signposted patients to their services.

In addition to the formal complaints received between 1st April 2014 and 31st March 2015 there have been 69 reinvestigations; this represents approximately a reinvestigation rate of <10%which we are planning to benchmark against the Shelford group of hospitals when the data is available.

During 2014/5 there has been a significant increase in the number of complaints investigated nationally by the Parliamentary Health Service Ombudsman (PHSO) (see glossary). At UCLH there were 67 contacts from the PHSO. Most of these were considered premature e.g. the complaint had not been received at UCLH or was still being investigated. In 2014/15 the PHSO requested 18 complaints to investigate compared to 23 for the previous year. In 2014/15, one complaint relating to care in 2011 was partially upheld due to the length of time it had taken to offer a meeting (2013). The reason for this was multifactorial and the approach to logging requests for meetings has been strengthened to avoid similar delays in future. 12 cases for 14/15 are still under review by the PHSO.

National reporting of complaints data is expected to be revised next year, with the introduction of quarterly reports which it is hoped will offer timelier benchmarking and allow us to target areas of improvement more quickly.

The Trust is committed to learning from complaints and is continuing to explore how best to use complaints to improve care including sharing patient stories at the board.

Below are examples of improvements made as a result of patient complaints.

Menu choicesAll complaints about nutrition, menu choice or assistance with meals are shared with the Trust’s Nutritional Steering Group. Women’s Health post-natal ward have introduced a hotel style folder for patients to see meal and beverage choices after this featured in a wider complaint about post-natal care. The issue of halal and vegetarian menu choices being very limited was raised in recent complaints. This was discussed at the Nutritional Steering Group and work is now going on at a contractual level to improve the scope of these options for patients, with facilities, dieticians and nursing staff working together.

Miscarriage and bereavement supportFollowing a small number of complaints a working group has been set up within Women’s Health, including representatives from midwifery, obstetrics, gynaecology, psychology and bereavement support to review and improve the experience for access to scans, care, advice and support during and after miscarriage. The group have identified the need to update patient information and additional scanning capacity has been established for weekends. A staff educational programme has been developed and use of stickers allows easier identification so staff do not have to repeat distressing questions.

Outpatient and phlebotomy movesWhilst the move itself was well coordinated, complaints and feedback were received, particularly about the phlebotomy services moving to outpatients. A number of immediate actions were taken

A floor walker was introduced into main outpatients to signpost patients to different phlebotomy areas

a numbering system was introduced patients are offered blood tests at a number of local GP practices

extra space for phlebotomy was found at a neighbouring site and

a multidisciplinary group has been setup in conjunction with estates and facilities and patients have been invited to input into this.


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Issues from complaints are shared across the organisation to ensure we learn lessons and make improvements. Analysis of clinical themes from complaints has fed into many areas of work e.g. end of life, medication safety, discharge, pain management, disability and equality issues, nutrition and hydration, falls and pressure ulcers. This sharing ensures that any areas of concern are identified and that the experts within the committees can add to action plans or monitoring after complaints are received.

The chairman and complaints manager have held joint presentations for staff about themes from complaints, and have visited the Heart Hospital, the National Hospital and the Eastman Dental Hospital in the past year.Presentations on themes have also been given to the Nursing and Midwifery Committee and the clinical boards by the complaints manager.

2. Continue to improve our end of life care (EOLC)Last year we said we would train staff on end of life care and introduce the AMBER care bundle (see glossary) on six wards. This consists of four elements: talking to the patient and family to let them know the healthcare team has concerns about their condition and to establish their preferences and wishes, deciding together how the patient will be cared for should their condition worsen, documenting a medical plan and agreeing these plans with all the clinical team looking after the patient.

We also said that we would monitor the number of patients who have the Preferred Place of Care (PPC) recorded and we would develop and use a survey.

We have set up an EOLC Board which oversees the work of the Transforming EOLC team. We have trained 253 staff on 5 wards in the use of important aspects of EOLC including AMBER care bundle, Advance Care Planning, Rapid Discharge guidelines, Co-ordinate My Care and Care in the last days of life. We have been unable to identify a robust way to ensure that the preferred place of care of patients within UCLH is recorded. However, the Electronic Palliative Care Coordination System, Co-ordinate My Care (CMC), is being introduced to the Trust, and we will continue to work on this.

We have developed a survey that will be given to all relatives when they attend the hospital to collect the death certificate of a loved one, to obtain an

assessment of the care of patients who die at UCLH. We are also developing a survey to assess how ward staff feel about the care of patients who die at UCLH.

This priority is now well established in the Trust and has a board and a reporting structure up to and including the Executive Board. Priorities for 2015/16 have been agreed – these include training staff on a further 13 wards in the important aspects of EOLC (see above), reducing the 30 day readmission rate of those patients discharged from UCLH, and improving the experience of bereaved relatives. It was therefore decided that sufficient processes have been put in place to ensure that this remains a key area within the Trust and that it no longer needs to be included as a quality report priority.

3. Improve the care of patients with dementiaLast year we said that we would ensure that specified wards will provide a dementia friendly environment and we would look at further environmental changes. We said that staff on the Acute Medical Unit (AMU), Elderly Care Ward (T7) and A&E will have received dementia management training and the future training plan will be in progress.

This year a number of environmental changes have taken place on the wards on the UCH site. These include:

Changing a bathroom on T7 (Elderly Care ward) into a reminiscence room providing a place to rest and relax away from the busy ward areas

all toilet doors on wards most frequently used by people with dementia are now pale blue with a red toilet sign to enable people to find their way to the toilet independently

the bays on T7 have been colour co-ordinated; the curtains in each bay are a different colour to assist patients to find their bed area

there are digital radios in all side rooms and ward bays on AMU, T7, Hyper-Acute Stroke Unit (HASU) and T8 (Infection ward) for entertainment. Digital radios provide access to foreign language stations reducing the feelings of isolation for non-English speaking patients. It also has helped patients feel less isolated with some background music

large clocks displaying time, AM/PM and date have been placed on the walls in all bays and side rooms in AMU, T7, HASU and T8 and in the cubicles in the emergency department to help with the patient’s orientation

on T7 there are wall mounted games and reminiscence photos on the walls to provide points of interest and help patients find their way

AMU, T7, HASU and T8 have been furnished with


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an array of appropriate books, playing cards, flash cards, pens and paper, letter writing equipment, shoes and polish etc. to provide stimulation and a sense of purpose.

These improvements, except the reminiscence room, are now being rolled out across the relevant wards at the National Hospital for Neurology and Neurosurgery. The Emergency Department rebuild will also be dementia friendly.

Dementia trainingIn August, mandatory e-learning (see glossary) was launched for all nursing staff, allied health professionals and patient facing staff. Over 3500 staff members have completed the course. The interactive content dispels common myths about dementia, explains the different types of dementia and describes the signs and symptoms. As part of the session ‘Barbara’s story’ is shown. ‘Barbara’s story’ was made by Guys and St Thomas’ Hospital to raise awareness on how it feels to be a patient with dementia. The story follows Barbara through an outpatient appointment and admission to a ward. The emphasis is on the importance of kindness and good communication.

As well as e-learning, advanced face-to-face training will continue. This consists of one and two-day courses for front-line staff, including medical and therapy staff. The number of courses will increase next year to meet the increasing demand. Bespoke training will continue for departments – for example theatres, outpatients, transport and pre-assessment. Dementia training is part of medical and nursing students’ education programme as well as preceptor nurses and these will continue too.

In areas identified as most likely to look after patients with dementia, 800 staff have undertaken either the one day or in most cases, 3 day face-to-face training in addition to staff who have undertaken the e-learning package.

We are pleased with the progress on the care of patients with dementia and this will continue to be a high priority in the organisation. Our processes are well established and we did not consider that it needed to be highlighted in the quality report for a further year.

Reminiscence room T7

New toilet doors

Wall mounted game


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Priority 2: Patient Safety: Continue our focus on reducing avoidable harm1. Reducing harm from falls, pressure ulcers and infectionIn 2014/15 we continued our focus on three areas of avoidable harm – falls with harm, hospital acquired pressure ulcers and infections.

Falls with harmOur aim was to reduce the number of falls with harm by 10 per cent by the end of the year. We based our target on the first quarter. This was because we changed how we report falls with harm in line with recent guidance (we added in ‘unwitnessed’ and ‘medical collapse’ related falls) from April 2014. Overall falls numbers reported have decreased from an average of 23 per month in the first quarter to an average of 20 per month in the last quarter, so achieving a 14 per cent reduction.

However, this remains a high priority in the organisation. Our falls group, chaired by a consultant specialising in care of the elderly, with physiotherapy and nursing members, has introduced a number of falls prevention initiatives, including a new way to help with assessment of patients and planning care, and guidance on how to care for patients after a fall. Technology, such as seat cushions with noise alerts if a patient gets up, is being tested.

All falls are being reviewed weekly by our

expert ‘Falls Group’ to monitor the level of harm patients have experienced and prompt changes and investigations as necessary. Falls will remain a key focus for us – the falls group is now well established and we are continuing to train staff to become ‘falls champions’ and are continuing to raise falls prevention awareness.

We will continue to report monthly on progress at meetings with our commissioners (see glossary) and at the Board. Our processes are well established and we did not consider that it needed to be highlighted in the quality report for a further year.

The Trust Board takes falls very seriously – and, as part of a ‘Board Safety Series’, the topic will be the subject to a Board of Directors review and presentation on progress and next steps in May 2015.

UCLH compares favourably against our peer English teaching hospitals for rates of falls (falls per 1000 bed days, compared with top-ten English teaching hospitals); however – our ambition is clear – to reduce falls to the absolute minimum and to have the lowest level of harm events (related to falls) amongst our peer hospitals. For 2015/16 we have set ourselves a further stretch target of reducing harm events related to falls by a further 15 per cent this financial year (building on the 14 per cent reduction last year).


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Figure 10: Falls with harm 2014/15

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Pressure UlcersWe said we would meet our CQUIN target of a reduction of grade 3, 4 and 5 hospital acquired pressure ulcers (HAPUs) by 50 per cent. During 2014/15 we have achieved a further reduction from last year and met the CQUIN target for quarter 1 and 2 and 80 per cent of the CQUIN target for quarter 3 and quarter 4. We have had no grade 4 pressure ulcers.

A key aim of this year’s plan is to further enhance our collaboration with community colleagues, recognising that successful pressure ulcer reduction requires an entire health economy approach.

Our sustained reductions in HAPUs represents the effort and commitment to high quality care shown by all clinical teams across the Trust. Our pressure ulcer prevention team continues to work with matrons, sisters and ward staff to raise awareness and improve the preventative care of patients at risk of pressure damage.

Like falls, this remains a high priority in the organisation. Our processes are well established and we did not consider that it needed to be highlighted in the quality report for a further year.

Figure 11: All pressure ulcers acquired at UCLH

April May June July August September October November December January February MarchCategory4 2014/15 0 0 0 0 0 0 0 0 0 0 0 0Category3 2014/15 0 3 0 2 0 0 0 1 0 2 2 2Category2 2014/15 6 4 6 9 3 4 2 11 8 3 3 5Target for Category 2 and above 9 9 9 9 9 9 8 8 8 7 7 7All Pressure Ulcers 2013/14 17 24 20 13 13 16 14 7 11 9 14 6

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Infection – Clostridium difficile and MRSAClostridium difficileClostridium difficile is an infection of the large bowel which causes diarrhoea and inflammation of the gut. It is often associated with antibiotic use which disrupts the normal bacteria in the gut.

The Clostridium difficile micro-organisms may contaminate the environment, can be spread by hands and consumed on food. It is possible to prevent the development and transmission of Clostridium difficile by careful antibiotic prescribing, scrupulous cleaning, isolation of patients with Clostridium difficile and hand hygiene with soap and water.

It is not possible to prevent all cases of Clostridium difficile. An increasing proportion of our patients are admitted with Clostridium difficile (carriers). In some cases the use of antibiotics is essential such as patients being treated for cancer with an infection or to treat significant infections. These patients are at risk of developing Clostridium difficile infections when they are given antibiotics.

At UCLH we screen all patients with diarrhoea for Clostridium difficile unless another cause is known. We screen 20 per cent more patients for Clostridium difficile than trusts generally. This is because early identification and treatment improves patient outcome.

UCLH reported 109 cases of Clostridium difficile in 2014/15. 80 of these cases have been successfully appealed as not being lapses in care. 20 cases are still under review. Nine cases of Clostridium difficile have been found to be a lapse in care by the Trust. Therefore we have stayed within our threshold set of 71.

In common with most UK hospitals and in line with national guidance the key interventions used to prevent and control Clostridium difficile by UCLH include antibiotic stewardship and careful review of the continuing requirement for antibiotics; monitoring of stools using the Bristol stool chart for early identification of diarrhoea; rapid stool sampling and testing in the presence of diarrhoea and isolation in a single room until a cause is found or the infection risk has ceased and the use of personal protective equipment and hand-washing.

We also ensure appropriate and timely treatment and support including new treatments such as faecal transplants (see glossary) in persistent infections. We also review the use of Proton pump inhibitors (see glossary) and other drugs which may contribute to the development of Clostridium difficile; use including hydrogen peroxide vaporization and deep cleaning for the enviromment. Information and education of staff, patients and visitors, feedback of learning from

the RCAs (see glossary) and Board level awareness and support of Clostridium difficile reduction efforts are also very important.

MRSA bacteraemia MRSA bacteraemia is an infection of the blood. The target was zero and UCLH has had three cases this year which is a reduction on last year‘s total of six cases.

This year’s cases were due to poor intravenous (IV) line insertion and care. UCLH now has a nurse specialising in intravenous lines, who trains staff in inserting and caring for lines and who investigates the causes of bacteraemia.

A new tool to improve documentation has recently been introduced and a pack has also been introduced which ensures the samples are taken properly. However, we recognise that still more needs to be done.

Current plans are to recruit and train “champions” from each specialty so that they can monitor and support good IV line care.

2. Improve UCLH wide learning from Serious IncidentsWe aimed to provide monthly safety reports to all clinical areas which include overall incident data and summaries of serious incidents including case studies, and learning to prevent recurrence. We also wanted to encourage serious incident discussions at all quality and safety (governance) meetings.

Regular incident analysis reports have been circulated to staff in the UCLH. The reports include overall incident data and a focus on the areas of highest reporting such as pressure ulcers and medicines. Case studies have been included. The internal Quality and Safety bulletin which is circulated to staff has been used to share learning, from serious incidents in particular. Discussions have taken place with the web team to develop a specific site on Insight, the internal website, for access to information on serious incidents and learning.

A ‘Quality Forum’ in February 2015 was focused on serious incident case studies and the importance of understanding how policies and procedures which affect patient safety are followed in practice.

We reviewed the guidance for staff on what to include in the local quality and safety meetings, ensuring a greater focus on learning from incidents, complaints and claims and this is being implemented.

We undertake multidisciplinary ‘Improving Care walk rounds’ to help staff and management teams to improve their services. The purpose of the walk rounds is not to criticise, but to promote improvement


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in care, environment and services by coming into the area with ‘fresh eyes’. Questions we always ask staff on the walk rounds are: ‘What was the last serious incident in the division?’ and ‘What did you learn from it?’.

Any immediate concerns and areas of excellence identified by the walk round team are fed back to the divisional management team at a debrief meeting after the walk round. A detailed report of all findings and observations is prepared for the management team and the medical director. The divisions draw up an action plan to address any identified concerns and this plan is monitored by the relevant clinical board.

We promote After Action Reviews (AAR). These were introduced to UCLH in 2008 as a universal approach to improving patient safety and the quality and effectiveness of our services. AAR is a group

discussion which is structured around four simple questions:

What was expected? (there is sometimes no plan but there is always some form of expectation)

What actually happened? Why was there a difference? What can we learn as a result?

These are underpinned by a set of ground rules and specifically focused on seeking to learn after an event rather than blame.

AARs can take many forms, from a very formal three hour meeting to a 10 minute debrief and are being widely used in clinical and non-clinical areas of UCLH and other NHS organisations.

AAR is now established as widespread practice with front line teams as a learning and debrief tool.


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Priority 3: Clinical outcomes1. Improve our performance on hospital mortalityThe SHMI (Summary hospital-level mortality indicator) is the ratio between the actual number of patients who die following hospitalisation at the Trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated here. It includes deaths which occur in hospital and deaths which occur outside of hospital within 30 days (inclusive) of discharge – ‘external SHMI.’

The Health and Social Care Information Centre (HSCIC) release the external SHMI every quarter but there is a six month time lag. The latest external SHMI released in April 2015 was for the period October 2013 to September 2014. A review of the SHMI analysis for the period covering July 2011 September 2014 is shown below.

In addition to the above, we also monitor an ‘internal SHMI’ which only includes deaths in hospital. This data is available to us on a monthly basis and does not have a time lag.

Since 2013, we have seen an increase in the Trust’s external SHMI whilst the internal SHMI has remained relatively steady.

The chart below shows the trend of the external SHMI over time (a lower number is better):

Figure 12: External SHMI

Jul 11to Jun

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14SHMI 0.71 0.68 0.71 0.71 0.74 0.75 0.76 0.80 0.78 0.79Na�onal average 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0

00.10.20.30.40.50.60.70.80.9

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When looking at our internal SHMI there is less change; it has remained steady at an average of 0.50 for the past 20 months. This suggests that deaths outside of hospital within 30 days of discharge may be increasing. Deaths within 30 days of discharge for elective admissions have increased slightly since the publication of the October 2012 to September 2013 external SHMI.

We know from the Care Quality Commission Intelligent Monitoring Reports that our weekend mortality ratio is within the expected range and that weekday mortality is less than expected.


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Figure 13: Local SHMI – relative risk – (1 yr rolling data)

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National Average 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00

As the HSCIC release the external SHMI data by diagnosis group, we are able to identify which diagnosis groups have had the most increase above the expected rate. The relevant divisions will continue to review the deaths in these diagnosis groups and we have decided to keep this as one of our priorities – see Section 4, Priority 3

2. Develop specialty specific clinical outcomes measuresWe said that we would aim for all specialties to have three identified clinical outcome measures, that data will be available against each indicator and that benchmarking data will be provided for at least one indicator.

Specialties have begun to do this and are completing a template of information explaining outcome description and rationale and including performance graphs. The challenges have been in finding robust benchmarking data. We will continue to work on this and have started to publish the data on our external website – go to www.uclh.nhs.uk/cci


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4 Priorities for improvement and statement of assurancefrom the Board

Deciding our quality priorities for 2015/16In order to determine our priorities we have consulted with a number of stakeholders including our Trust Quality and Safety Committee (QSC), clinical boards, our commissioners and GP representatives through our Clinical Quality Review Group and our governors (see glossary). The QSC on behalf of the board approved the priorities and there will be regular reports on progress to the QSC throughout the year.

We have ensured that our quality priorities are aligned with this year’s UCLH top ten objectives for patient safety, experience and clinical outcomes and we have taken into account our progress throughout the year against last year’s priorities to help decide which priorities need an ongoing focus within this year’s quality report. The following have been agreed:

Patient ExperienceThere are a number of national patient experience surveys and we have chosen to continue to focus on three areas as part of our quality priorities – inpatients and outpatients as these patients are seen across UCLH and cancer patients as cancer services is an area of development for us and where we see the need for most improvement. We wish to improve the overall ratings experience ratings as well as in selected areas as measured by national and local surveys.

Patient SafetyWe will focus on the following ‘Sign up to Safety’ pledges: (see glossary)

To reduce surgery related harm To reduce harm from unrecognised deterioration

To reduce patient harm from sepsis Continually learn – continue to focus on improving UCLH wide learning from serious incidents.

Clinical OutcomesWe will continue to improve clinical outcomes. We will:

publish 10 specialty specific clinical outcome measures per quarter

maintain our position in the top 10 per cent of trusts nationally for the mortality indicator SHMI (Summary Hospital-level Mortality Indicator)

Priority 1: Patient Experience1. Improving overall patient experience as measured by local and national surveys

Why we have chosen this priorityWe know that good patient experience has a positive effect on recovery and clinical outcomes. To improve that experience we need to listen to patients and respond to their feedback and in our view this is central to caring for our patients. To this end we run continuous real-time surveys which provide valuable feedback to clinical teams about the care in their area. This is supplemented by national patient surveys which allow us to benchmark ourselves nationally and within London.


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What we are trying to improveOur aim is to drive continuous improvement in patient experience to become one of the best in the country. In addition to work by individual wards and departments, we target particular aspects of care each year based on national and local survey results. We want to improve our patient rating in overall experience in the national inpatient survey and continue our improvement programmes for cancer and outpatient experience.

How we will monitor progressAs national surveys are published yearly or less we measure our performance using our real time patient feedback system (Meridian). This provides monthly feedback which is shared with all the clinical teams. At a UCLH level this data is reviewed at the Cancer Clinical Steering Group and the Patient Experience Committee as well as the Quality and Safety Committee. We will also be linking this to our ‘Future UCLH’ programme of improvement in the coming years.

1.1 Inpatient Survey

What success will look likeA national Inpatient survey is conducted each year and published on the CQC website. The survey results are benchmarked against all NHS trusts and therefore allow national comparison. Our aim is to achieve year on year improvement on the question which asks patients to rate their overall experience on a scale of 0 – 10 with 10 being “a very good experience”.

In addition each year we target specific areas where patients have told us that experience could be improved. The national inpatient survey results were published too late for us to consider the areas to focus on for next year through our internal and external consultation process so we selected two questions based on the Picker survey – areas where we have worsened significantly compared with last year. Since we agreed these questions the national inpatient survey results have been published. We reviewed the results and confirmed that the areas we had chosen were areas we needed to focus on but we also decided to add a further question where we had not done well – ‘did not always get enough help from staff to eat meals’

In summary the areas we agreed are as follows with targets:

Table 7

National survey results (Picker) – lower scores are better

2014 result*

2015 target*

Overall experience rating ( scored less than 7/10)

13% 12%

Care: Staff contradict each other

37% 30%

Care: More than 5 mins to answer call button

20% 14%

Hospital: did not always get enough help from staff to eat meals

41% 37%

* problem scores – lower scores are better. See glossary for more information on how these are calculated.

The targets chosen are based on previous best performance over the last four years (in the same survey)

As overall experience is already above average compared with other trusts in the Picker survey we want to maintain this performance.

The results from the national inpatient survey and the targets are as follows:

Table 8

National inpatient survey results (CQC) – higher scores are better

2014 result*

2015 target*

Overall experience rating (1) 8.1 8.4

Care: Staff contradict each other (2)

7.7 8.2

Care: More than 5 mins to answer call button (2)

6.0 6.2

Hospital: did not always get enough help from staff to eat meals (2)

6.5 7.9

* Individual responses are converted into scores on a scale from 0-10, with 10 representing the best possible score and 0 the worst (see glossary for further information).1 Maintain the target from last year2 Target is last year’s score


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We know from experience that by including these questions in our real time patient experience survey, performance will improve as ward teams are able to try ways to improve patients’ experience in specific areas and see quickly whether there is an impact.

We also believe that our ‘Home for Lunch’ initiative will help with staff not contradicting each other. This is a system of ‘planning for tomorrow’, where ward staff meet as a multi-disciplinary team (MDT) to review all patients on their ward, establish their progress and ensure that all plans for discharge are in place. Ensuring everyone is clear about patients’ plans and progress also makes for more consistent information being provided to patients and relatives by the members of the MDT.

We have started to look at best practice in other trusts for helping patients with meals and have areas of good practice within the trust that we can learn from. We will use this experience to agree a plan to implement improvement in all areas.

1.2 Outpatient Survey

What success will look likeLast year patients attended 940,000 outpatient appointments and it is important to us that this should be a positive experience. We have been working with clinical teams in a structured programme called the ‘Productive Outpatient Programme’ (POP). POP works to improve the quality, efficiency and smooth running of clinics and improve the experience of patients who visit us.

We are continuing to work on initiatives that will make the waiting time shorter and each waiting area is being reviewed to ensure that when waits are unavoidable, patients are made as comfortable as possible and kept informed. We have introduced pagers in most outpatient areas to call patients who have impaired hearing, and to allow patients to leave the waiting areas if waits are long.

We have been working with clinic teams to give them tools to understand what patients want and supporting them to develop and test solutions to improve the experience in their services. We have made some improvement in the overall rating of care that patients received but we did not meet the target for the time patients waited. However, we want to do better and have therefore set a higher target. There is no national survey planned this year, and the last data is from 2011 so local surveys are being used to measure how we are doing.

We also want to increase the number of patients that respond to the survey so that we get a better

idea of how we are doing. At present, very small numbers of patients respond to our feedback survey offered on tablets or online. We have trialled alternative ways of providing feedback (e.g. a paper form) and initially want to increase responses to at least 1 per cent while we agree the right system to use. We are also asking patients more frequently about our service so that we can take prompt action.

We have also undertaken further UCLH wide work to improve the booking/contact processes including administration, management on the day, and staff attitudes, all of which are aimed at improving our outpatient experience and efficiency.

Our performance and targets are as follows:

Table 9


2014 result(Meridian)

2015 Target (Meridian)

Overall how would you rate the care you received (1)

89% 91%

How long after the stated appointment time did the appointment start? (2)

69% 74%

(1) Percentage of patients who rated the care as good or better(2) Percentage of patients who waited less than 30 minutes for appointment to start.

1.3 Cancer Survey

What success will look like The Trust continues to work to improve the cancer patient experience and we are pleased to note a number of improvements in key areas. We continue to work with our staff and patients to address issues raised by the survey and we have set targets that reflect areas which we feel are particularly important to patients.

We have set our targets based on the results of the National Cancer Patient Experience Survey (NCPES) as follows:


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Table 10

NCPES Question – higher scores are better

NCPES 2014 result*

2015 target*

Overall how would you rate the care you received (1)

89% 91%

How easy is it for you to contact your Clinical Nurse Specialist (CNS)? (2)

69% 74%

While you were in hospital did the doctors and nurses ask you what name you prefer to be called by? (3)

54% 60%

If your family or someone else close to you wanted to talk to a doctor, did they have enough opportunity to do so? (4)

65% 68%

*The National cancer experience survey is administered by Quality Health. In that survey the questions have been summarised as the percentage of patients who reported a positive experience. For example, the percentage of patients who said they were given enough information about their condition. (1) We have chosen a target based on the top 20 per cent trusts.(2) Contact with a CNS: we have demonstrated that patients now know who their CNS is but we still have a problem with patients being able to contact them. We have based our target on the national average of 73 per cent. (3) Preferred name: this is still only 54 per cent in the National Cancer Patient Experience Survey (NCPES) and we believe we should be able to improve this number. We have based our target on the national average of 60 per cent.(4) Family able to talk to a doctor: this is an important component of quality care, and scored 65 per cent in NCPES in 2014. We have based our target on being higher than the national average of 67 per cent.

There will be no NCPES in 2015 and so we will monitor our performance against our real time patient survey system Meridian.

To help us improve the overall experience and how we do against the specific questions we will:

Continue to train Clinical Nurse Specialists (CNS) in ‘Holistic Needs Assessment’ (HNA) – a process in which there is general discussion with patients to ensure that their needs are met and their worries and fears are discussed

continue with ‘Sage and Thyme’ (see glossary) training in particular for front line and administrative staff. This training helps staff to be more able to deal with patients’ anxieties

provide training for ward staff in caring for cancer patients and for senior doctors and nurses in communication skills

provide dedicated administrative support to help CNSs to manage telephone calls so that they can be contacted more easily by patients and more time can be spent with patients and their families.

encourage CNS teams to develop generic email addresses for patients to use e.g. [email protected]

continue with the ‘Cancer CNS Community of Practice’, a meeting of Cancer CNSs, used to share ideas and solutions.

We would like to improve our response rate as we have had less than 100 patients surveyed per month since October. However this is challenging and we are looking at other ways of getting feedback such as focus groups.

Responsible directors for priority 1: patient experience

Flo Panel-Coates, Chief Nurse Gill Gaskin, Medical Director, Specialist Hospitals Board


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Priority 2: Patient Safety1. Reduce surgery related harm

Why we have chosen this prioritySometimes during surgical procedures things go wrong and we encourage our staff to report when this happens so that we can learn and prevent recurrence. We also ask them to tell us about near misses – something which if it had may have caused harm. Looking at near misses is seen as a good way of preventing harm. We also call these ‘good catches’. A review of data already reported shows 14 incidents per month which may have caused harm, for example surgical instruments unavailable or delays due to bed availability, and 48 per month which cause no harm of which 8 are near misses.

We also know from our staff that improvements could be made in the way people work together and tackle problems to improve safety in theatres.

What we are trying to improveWe would like to increase our overall incident reporting rate and in particular the reporting of near misses. This will give us more information to help us learn how to make surgery even safer. We will focus on the use of the WHO Surgical Safety Checklist (see glossary) in operating theatres making sure that it is routinely used in all operations. In particular, we aim to encourage a team brief at the start of the day, and also a debrief to discuss issues (good or bad) when the surgical list is complete. We want to help develop a good safety culture in operating theatres and help theatre staff deal with issues as a team so that, for example, even junior members of theatre teams are confident to speak up and raise concerns.

What success will look likeSuccess will see an increase in the number of incidents and near misses reported. Whilst we want to see this increased reporting, we want to see a reduction in incidents which lead to harm.

We will introduce a process in each theatre where trained observers will look at what goes well and what could be done better when observing the use of the WHO Surgical Safety Checklist. The results will be fed back to the teams. We will look at measuring improvement in the number of briefings and debriefings that are carried out, collaborative cross checking in theatre teams (i.e. where one team member intervenes when there is a safety problem),

and team behaviours relating to eliminating distractions and interruptions during safety critical checks.

We will be able to measure improvement in the use of the Checklist from observational audit.

Our targets over three years as part of our safety plan are:

10 per cent increase in reporting incidents of surgical harm

10 per cent increase in near misses being reported (within the 10 per cent increase)

50 per cent reduction in incidents leading to harm observational audits of checklist use which over time identify improvement in the use of the checklist and associated behaviour in all our theatres.

How we will monitor progressPerformance will be measured and monitored by the WHO Surgical Safety Steering Group and reported to the Quality and Safety Committee.

2. Reduce the harm from unrecognised deterioration

Why we have chosen this priorityThrough our quality improvement work we have achieved a 50 per cent reduction in the number of patients who suffer a cardiac arrest. We want to sustain this improvement.

We recognise that areas to focus on now are improving the reliability with which vital signs, i.e. heart rate, blood pressure, temperature and breathing rate (respiratory rate) are recorded and the communication between teams when a patient’s condition deteriorates.

A systematic review of our harm data identified 1.3 incidents with harm per month caused by unrecognised patient deterioration.

What we are trying to improveWe want to reduce patient harm caused by failure to recognise patient deterioration by improving early recognition of at risk patients – making sure that vital signs are being reliably recorded – and improving the communication to medical and senior nursing staff when a patient is at risk of deteriorating so that urgent action can be taken.

What success will look likeWe want to see an overall reduction in the frequency of incidents leading to harm from unrecognised


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patient deterioration and we want to maintain our reduction in the number of patients suffering a cardiac arrest at UCLH. We also want to measure that the vital signs charts are being completed.

Our targets over three years as part of our safety plan are:

96 per cent vital signs completed per patient / per ward, based on a sample of 10 per ward per month

90 per cent patients escalated to the Patient Emergency Response and Resuscitation Team (PERRT) using an agreed communication tool

20 per cent reduction in the mean number of incidents reported per month leading to harm.

How we will monitor progressPerformance will be measured and monitored by clinical boards and the Deteriorating Patient Group and reported to the Quality and Safety Committee.

3. Reducing harm from sepsis

Why we have chosen this prioritySepsis is a common and potentially life-threatening condition triggered by infection. If not treated quickly, sepsis can lead to multiple organ failure and death. Successful management of sepsis requires early recognition and treatment. We have chosen to focus on this as we have data that suggests that it is a cause of harm at UCLH.

What we are trying to improveLike many other trusts, we do not have a clear understanding of the number of patients harmed by sepsis. We do know from an audit carried out at one UCLH site in a two week period in May 2014 that 34 patients with sepsis were referred to the Patient Emergency Response & Resuscitation Team (PERRT) or directly to critical care. Extrapolated up, this would mean 884 sepsis-related PERRT/critical care referrals at University College Hospital in a year.

We therefore know we need to address the harm caused by sepsis, but we will need to start by understanding our baseline level of harm. We recognise that some trusts have got good data and good approaches to managing sepsis and we will seek to learn from them and develop a plan based on their experiences. This will identify what we can hope to achieve by the end of year one and subsequently as part of our three year plan.

What success will look likeWe will have established a baseline of the number of patients with sepsis and the number of deaths relating to sepsis from which to measure progress. Using the experience of other trusts, we will agree a target for training staff and how and what to measure during the patient’s pathway of care to ensure reliable, effective management and improved outcomes.

We will initially focus training and education on the recognition and treatment of sepsis by staff in areas where the majority of patients with sepsis will be seen (such as the emergency department).

We will continue to focus on the recording of vital signs as described in priority 2; and work to ensure that there is a reliable, early identification of patients with sepsis, and that 95 per cent of appropriate patients receive all elements of an agreed bundle of interventions within the designated time. We will undertake this work over three years as part of our safety plan. This will be aligned with the national CQUIN.

How we will monitor progressPerformance will be measured and monitored via clinical boards and by the Sepsis Steering Committee and reported to the Quality and Safety Committee.

4. Continue UCLH wide learning from serious incidents

Why we have chosen this priorityWe chose this as a priority last year due to the value and importance of learning from serious incidents


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and in particular ‘never events’ (see glossary). We also knew from our CQC inspection in December 2013 that staff did not always know about recent serious incidents or the actions that had been proposed if they worked in areas not directly affected. This means that staff cannot use this information to learn from and make changes to improve patient safety. Although we made progress last year there is still more work to be done.

What we are trying to improveWe are trying to improve the learning and subsequent changes in practice from serious incident investigations, in particular across UCLH and not just in one area. For example this year a group of doctors, dieticians and nurses considered the problem of the misplacement of nasogastric (NG) tubes. These are tubes used for feeding being put in the lungs instead of the stomach by mistake. This is a ‘never event’. The learning from several serious incidents at UCLH led to a revision of the nasogastric tube feeding policy which included the adoption of good practice from one area – using a chart for checking that the NG tube was in the correct place. We would like to see more examples of UCLH wide learning occurring. We will also focus on timeliness of serious incident reports following an incident investigation to ensure that learning can be shared as soon as possible.

What success will look like Monthly quality and safety bulletins to continue and to include a ‘good catch’ story every month to encourage learning from near misses. We will

also add a more in-depth focus on a learning topic every quarter.

Publication of learning from serious incidents on our website.

At least two quality forums per year focusing on safety.

Each Medical Board to identify cross UCLH learning from at least one serious incident and through the medical directors ensure UCLH wide implementation of changes to practice. Assurance to be built into the audit plans.

Education services will support teams in sharing their learning from After Action Reviews more widely. It will create a store of AAR summary reports that will be available to users of the UCLH intranet. After Action Review training will be offered both as a standalone programme, and integrated into a wider quality improvement curriculum

Achieve the national guidelines for investigation reports being completed following a serious incident (60 working days)

Have no ‘never events’ reported Continue with improving care rounds and the focus on learning.

How we will monitor progressPerformance will be measured and monitored by the Quality and Safety Committee.

Responsible director for priority 2: Patient Safety Sandra Hallett, director of quality & safety


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Priority 3: Clinical Outcomes1. To publish 10 specialty specific clinical outcome measures per quarter

Why we have chosen this priorityLast year we worked with specialties to develop three clinical outcome measures for each specialty. Clinicians were asked to outline the objectives they are measuring for that clinical outcome, the rationale for that objective, the results at UCLH and a commentary which includes any comparison with national benchmark data.

We want to continue our work in developing these and to publish them.

What we are trying to improveWe want to be transparent with patients about how we are doing. We also believe this data will encourage specialties to set objectives to improve their performance and work towards the best performance compared with any external benchmark.

What success will look likeWe will aim to publish on our public website 10 specialty specific clinical outcome measures per quarter. Please see the UCLH website for the latest indicators – www.uclh.nhs.uk/cci

How we will monitor progressWe will monitor this via the Clinical Outcomes Group and report to the Quality and Safety Committee.

Responsible DirectorTony Mundy, Medical Director, Corporate Services

2. Maintain our position in the top 10 per cent of hospitals nationally for mortality rates as measured by the Summary Hospital Level Mortality Rate Indicator (SHMI)

Why we have chosen this priority and what are we trying to improveHospital mortality ratios compare the actual number of patients who died following treatment at a Trust with a number who would be expected to die, based on the national average death rates in England and the particular characteristics of the patients treated. We are proud of our record of consistently having one

of the lowest mortality ratios nationally and wish to continue this focus in line with the Secretary of State’s ambition to have no avoidable deaths.

Our other quality priorities will help with our aim to maintain a low mortality rate by focusing on deterioration and sepsis.

What success will look likeWe will monitor our performance against the national data – SHMI is produced and published quarterly as an official statistic by the Health and Social Care Information Centre (HSCIC). Success will be measured by our continued low mortality. We will continue to undertake a review of deaths in those specialities that show a death rate that is higher than expected to identify those which might have been avoidable, to enable learning.

How we will monitor progressWe will monitor this via the UCLH performance scorecards and clinical board reviews and report to the Quality and Safety Committee.

Responsible directorSandra Hallett, director of quality and safety


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Statements of assurance from the BoardAll providers of NHS services are required to produce an annual quality account (report) and certain elements within it are mandatory. This section contains the mandatory information along with an explanation of our quality governance arrangements.

The quality governance arrangements within UCLH ensure that key quality indicators and reports are regularly reviewed by clinical teams and by committees up to and including the Board of Directors. There are a number of committees and executive groups with specific responsibilities for aspects of the quality agenda, which report to the UCLH Quality and Safety Committee. The Executive Board Performance Board reviews quality performance monthly. In addition, the Performance Committee, consisting of Non-Executive Directors and Executive Directors, monitors in detail performance against UCLH Top 10 Objectives. The committee selects those with poor performance and requests an in depth review – a recent example being Referral To Treatment targets. The Audit Committee is responsible on behalf of the Board for independently reviewing the systems of governance, control, risk management and assurance. The Board of Directors receives a monthly corporate performance report (available on the UCLH website as part of the published Board papers) that includes a range of quality indicators across the three domains of patient safety, experience and clinical effectiveness (outcomes). In addition the Board receives quarterly reports in areas such as serious incidents, and quarterly and annual reports in areas such as child safeguarding and complaints. The Board is further assured by reviews undertaken by internal audit which this year has included CQC governance – looking at how the Trust ensures compliance with the CQC standards.

In addition, board members including the chairman and chief executive, medical directors, chief nurse, and non-executive directors, regularly undertake walkabouts around the Trust talking to staff and patients. They focus on the CQC essential standards of safe, effective, caring, responsive and well led. These visits and what is learnt provides additional assurances on services. There are other visits – matrons undertake ‘quality rounds’ and the governors visit clinical areas.

A review of our servicesDuring 2014/15 University College London Hospitals NHS Foundation Trust provided and/or subcontracted 60 relevant health services. University College London Hospitals NHS Foundation Trust has reviewed all the data available to them on the quality of care in all of these relevant health services. The income generated by the relevant health services reviewed in 2014/15 represents 100% of the total income generated from the provision of relevant health services by University College London Hospitals NHS Foundation Trust for 2014/15.

Participation in clinical auditClinical audit is an evaluation of the quality of care provided against agreed standards and is a key component of quality improvement. Its aim is to provide assurance and to identify improvement opportunities. UCLH NHS Foundation Trust has a yearly programme of clinical audits which includes 3 types of audit:1. National clinical audit, where the Trust aims to

participate in all applicable audits. The full list of these and University College London Hospital NHS Foundation Trust participation is shown in the table below.

2. Corporate clinical audit, where we set a list of clinical audits that all specialties should carry out based on Trust priorities.

3. Local clinical audit, that is determined by clinical teams and specialties and which reflect their local priorities and interests.

Audit findings are reviewed by clinical teams in their quality and safety (Governance) meetings, as a basis for peer review and for targeting or tracking improvements. A Clinical Audit and Quality Improvement Committee oversees the corporate clinical audit programme and activity, and reports directly to the Quality and Safety Committee.

National Clinical AuditDuring 2014/15, 40 national clinical audits (NCA) and 2 national confidential enquiries (NCE) (four studies) covered relevant services that University College London Hospitals NHS Foundation Trust provides. During that period, that University College London Hospitals NHS Foundation Trust participated in 100% of the national clinical audits and 100% of national confidential enquiries which it was eligible to participate in.

The national clinical audits and national confidential enquiries that University College London Hospitals NHS Foundation Trust was eligible


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to participate in during 2014/2015 and the national clinical audits and national confidential enquiries that University College London Hospitals NHS Foundation Trust participated in, and for which data collection was completed during 2014/15 are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.

Table 11

AuditUCLH eligible

UCLH participation

Cases submittedPercentage of cases required

1 National Prostate Cancer Audit Yes 1st round of data collection in progress

Not applicable

2 Lung Cancer (NLCA) Yes Cardio-thoracic: 19Invasive Lung: 184

100%

3 National bowel cancer audit programme (NBOCAP)

Yes 139 100%

4 Oesophago-gastric cancer audit Yes 60 100%

5 Inflammatory bowel disease (IBD)Includes: Paediatric Inflammatory Bowel Disease Services

Yes 124 92%

6 PROMs Hernia Yes 126 (April & December 2014)

74%

7 National Emergency Laparotomy audit (NELA)

Yes 110 90%

8 National Vascular Registry (elements include NCIA, peripheral vascular surgery, VSGBI Vascular Surgery Database, NVD)

Yes 107 100%

9 PROMs, varicose veins Yes 134 (April & December 2014)

61%

10 National head & neck cancer comparative audit (DAHNO)

Yes 100 75%

11 National joint registry (NJR) Yes 451 (April to December 2014)

94%

12 National Hip Fracture Database (part of Falls and Fragility Fractures Audit Programme (FFFAP)

Yes 123 >90%

13 PROMs, knee replacements Yes 164 (April & December 2014)

90%

14 PROMs, hip replacements Yes 189 (April & December 2014)

90%

15 Adult cardiac surgery audit (CABG & valvular surgery)

Yes 683 100%


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AuditUCLH eligible

UCLH participation


16 Congenital heart disease Yes 99 100%

17 Coronary angioplasty / PCI audit Yes 604 100%

18 Heart failure audit Yes 200 100%

19 Cardiac Rhythm Management (previously: Cardiac arrhythmia audit (HRM))

Yes 1159 100%

20 Acute coronary syndrome or Acute myocardial infarction (MINAP)

Yes 394 100%

-- Pulmonary Hypertension No N/A

21 Sentinel Stroke National Audit Project (SSNAP) including SINAP

Yes 570 (April to December 2014)

58%

-- Prescribing for mental health (POMH) No N/A

22 Adherence to British Society for Clinical Neurophysiology (BSCN) and Association of Neurophysiological Scientists (ANS) Standards for Ulnar Neuropathy at Elbow (UNE) testing

Yes 20 100%

23 National neonatal audit programme (NNAP)


100%

24 National Paediatric Diabetes audit (NPDA)

Yes 425 100%

25 Childhood epilepsy (Epilepsy 12) Yes 27 (In conjunction with The Royal Free London NHS Foundation Trust)

100%

-- Paediatric Intensive Care (PICANet) No N/A

26 ICNARC Case Mix Programme (Critical Care)


100%

27 Severe Trauma (TARN) Yes 180 81%

28 Mental Health in Emergency Departments

Yes 44 100%

29 Older People (Care in Emergency Departments)

Yes 91 100%

30 Fitting Child (Care in Emergency Departments)

Yes 19 100%

31 Diabetes (Adult) ND(A), includes National Diabetes Inpatient Audit (NaDIA)

Yes No data collection in 2014-15

Not applicable


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AuditUCLH eligible

UCLH participation


32 National Audit of Dementia Yes Pilot site, data collection due approx. Aug-Nov 2015

Not applicable

33 Rheumatoid & early inflammatory arthritis

Yes 50 70%

-- National Chronic Kidney Disease audit No N/A

-- Renal Replacement Therapy No N/A

34 Adult Community Acquired Pneumonia

Yes Data collection in progress (December 2014 – May 2015)

Not applicable

35 Non-invasive Ventilation Yes No data collection in 2014-15

Not applicable

36 COPD Yes 60 100%

37 Pleural procedures Yes 14 100%

38 National Audit of Intermediate Care Yes 50 100%

39 National Comparative Audit of Blood Transfusion

Yes 1158 86%

40 National Cardiac Arrest Audit Yes 90 (April 2014 – February 2015)

100%

Table 12

NCEUCLH eligible

UCLH participation

Cases submitted Cases required

National confidential enquiry into patient outcome and death (NCEPOD)

Yes Sepsis – 5 cases (study still open)Gastrointestinal haemorrhage – 4 cases

Sepsis: 8 casesGI – 9 cases

Maternal infant and newborn programme (MBRRACE-UK)

Yes Perinatal death – 23 neonatal deaths and 32 pregnancy losses submitted1 maternal death

100%

The reports of five national clinical audits and 11 local clinical audits were reviewed by the Trust at corporate level in 2014/15. Examples of actions University College London Hospitals NHS Foundation Trust intends to take to improve the quality of healthcare provided are shown below.


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National Clinical Audit examples of improvement resulting from audit of :

1) Paediatrics and Medical SpecialtiesNational Paediatric Diabetes Audit (NPDA) – The primary aim of the NPDA is to examine the quality of care in children and young people with diabetes and their outcomes. UCLH is a high performing Trust and ranks third in England and Wales. A way of monitoring blood sugar levels long term is to check how many red blood cells are carrying oxygen and glucose (these cells are called glycated).The National Institute for Health and Care Excellence (NICE) have set a national target for the number of these cells and the NPDA monitors this. UCLH is working directly with our families to set achievable individual blood glucose targets with them to do even better than the national target which leads to better outcomes for our patients.

2) Respiratory MedicinePleural Procedures – This audit reviews the procedures used to drain built up fluid in the space between the lung and the chest wall (pleural space) due to various causes such as heart failure or cancer. UCLH has introduced care plans, to ensure consistent care for patients who require drainage of fluid on the lungs (pleural effusions) and for collapsed lungs (pneumothoraces). In addition UCLH has introduced an audit of chest drainage equipment across the Trust to examine different practices, and seek opportunities to standardise and improve safety.

3) Epilepsy and PaediatricsPaediatric Epilepsy 12 point audit – This audit was established in 2009, with the aim of helping epilepsy services to measure and improve the quality of care for children and young people with seizures and epilepsies. Key results found that only 79 per cent of children diagnosed with epilepsy had seizure classification by one year – classification improves care because it ensures the most appropriate drugs can be given. This finding of 79 per cent was not considered a problem because in some children it was difficult to classify seizures. Nevertheless it was agreed to continue to work on classification to increase the number of children with a classification. In addition UCLH has introduced a template to be used for follow up patients in clinic to improve follow up appointments.

4) Cancer and Thoracic National Lung Cancer Audit (NLCA) – The National Lung Cancer Audit looks at the care delivered

during referral, diagnosis, treatment and outcomes for people diagnosed with lung cancer and mesothelioma. The Trust has nationally leading rates on diagnosis and survival, but this audit highlighted that Lung Clinical Nurse Specialists (CNS) were not always present when the patient’s diagnosis was being given. The National Institute for Health and Care Excellence (NICE) have set a national target of a CNS being present at diagnosis to improve patient experience. As a result the Trust has appointed a new Lung CNS and reviewed how clinics run so the nurse can be present more often.

5) Critical Care National Cardiac Arrest Audit – The aims of this national audit include improving patient outcomes as well as promoting adoption and compliance with evidence-based practice. Actions as a result of this audit include an increase in junior medical staff covering surgical wards at the weekends, as well as a weekly review of cardiac arrest investigations with the specialist team and the Risk Department. Learning has been shared through UCLH’s monthly Quality and Safety Bulletin.

Corporate Clinical Audit The aim of the corporate clinical audit programme is to support UCLH’s top ten objectives, provide assurance to commissioners, demonstrate compliance with recommendations from the National Institute for Health and Care Excellence (NICE) and help manage risk. A summary of the programme is below. Although they are not clinical audits per se, patient surveys are included because they are an important part of quality improvement and the best indicator of patient experience.


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Table 13

Objective Quality Priorities Supporting Corporate Audit Activity

Improve Patient Safety Reduce hospital acquired infections, pressure ulcers, falls and missed medications

Develop plans to move to 24 hour /7 day working where appropriate

Improve how we share learning across UCLH from safety incidents and patient feedback.

Hand Hygiene Surgical wound infection surveillance MRSA Bacteraemia Adherence to surgical prophylaxis guidance

Antimicrobial Prescribing Saving Lives Care Bundle Clostridium Difficile Infections NHS Safety Thermometer (pressure ulcers, falls & urinary tract infection in patients with a catheter)

VTE Risk Assessments VTE Administrations of prophylaxis Medication Safety Dose Omissions Acute Kidney Injury Quality and timeliness of GP communications following appointments

Standards of Record Keeping Nutrition Screening Vital Signs Resuscitation trolley and equipment Cardiac arrest & PERT team calls audit World Health Organisation (WHO) Safe Surgery Checklist

Deliver Excellent Clinical Outcomes

Improve outcomes against Trust-wide and specialty-specific measures

Reduce avoidable emergency admissions

Achieve access standards and the right clinical staff across emergency pathways

Outcome and safety of new interventional procedures

Readmissions reported monthly via the Performance Pack

We have taken Quality Improvement approach to the urgent care pathway enabling us to maintain and improve performance as documented monthly in our performance reports and weekly at the urgent care transformation program.

Deliver high quality patient experience and customer service excellence

Develop standards for patient experience (as customers)

Develop the Making a Difference Together programme to improve patient experience

Make it easy for patients to give us timely feedback and act on it

Patient Surveys: � Inpatients � Outpatients � Cancer � Maternity

Pre and post-operative patient reported outcomes

Trustwide snapshot pain audit Pain assessment and management End of Life Care – AMBER care bundle


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Local Clinical Audit Local clinical audits are developed by teams and specialties in response to issues identified at a local level. They may be related to a specific procedure or equipment, patient pathway, or service. The Board attaches importance to clinical audit as a tool for improving patient care. Although there has been some improvement in audit, further progress is required. Some examples are given below.

Examples of improvement resulting from local clinical audit

1) Emergency ServicesAdherence to antibiotic guidelines in the Emergency Department – The Emergency Department re-audited their antibiotic prescribing in line with UCLH guidelines. There was 100% compliance to basic prescribing principles but where no specific guidelines exist for treatment in the emergency setting, 10 per cent of antibiotics prescribed were inappropriate. The emergency department have expanded their local guidelines to include conditions increasingly presenting to the department requiring antibiotics.

2) Orthopaedics Fragility fractures and referral for osteoporosis management – The aim of this audit was to assess the compliance of University College Hospital’s fracture clinic with NICE guidance on the assessment of osteoporosis risk factors in patients presenting with a fracture. Patients attending the Fracture Clinic, aged 50 and above, with fractures of the wrist, ankle or hip could potentially have osteoporosis (brittle bones). In accordance with national guidance they will now be given a self-assessment form to complete with a patient information leaflet. If they are identified as at risk they will be referred to the Osteoporosis clinic, and their GP informed, enabling swift diagnosis and treatment before further fractures occur.

3) Dietetics Nutrition Screening Compliance at UCLH – A snapshot audit was undertaken to ascertain if 85 per cent of patients or more are nutrition screened, ensuring patients at risk of malnutrition are identified. Key results show nutrition screening is at the 85 per cent compliance rate target. To further increase compliance a new nutrition screening tool has been introduced. This remains evidence based but is more streamlined for staff to complete, improving patient outcomes.

4) Neurology Epilepsy surgery evaluations – The aim of this audit

was to compare current clinical practice in regard to Epilepsy Surgery at the Telemetry Unit with previous studies and available guidelines. 613 patients were admitted for pre-surgical evaluation over the last 5 years. As a result of the audit the Telemetry Unit at the National Hospital for Neurology and Neurosurgery (NHNN) have begun pre-surgery counselling to advise patients of their personal risk versus the benefits and of their realistic outcomes of epilepsy surgery at the start of their surgical pathway. It is hoped that this will reduce the number of patients who decide not to go ahead with surgery in the final stages of pre-assessment following many hospital appointments and tests.

5) Cancer Audit to see whether UCLH/ NHNN brain tumour patients are following DVLA (Driver and Vehicle Licensing Agency) guidelines – Following patients’ confusion regarding driving guidelines, patients will be given a patient information leaflet when they attend the radiotherapy department informing them of the DVLA regulations. In addition, neurosurgeons are advised to incorporate discussions about driving into the clinic letter.

Our participation in clinical researchA key focus for the National Institute for Health Research is the development and delivery of quality, relevant, patient focused research within the NHS. UCLH continues to embrace this aim, remaining at the forefront of research activity, creating and supporting research infrastructures, providing expert and prompt support in research and regulatory approvals, and promoting key academic and commercial collaborations.

UCLH continues to develop the active involvement of patients and the public in research design and process through training and other resources, to ensure those studies which take place at UCLH are relevant and inclusive of patients. UCLH will also be focusing its efforts on improving patient and public access to information about research to improve patient choice and experience.

Between April 2014 and March 2015 a total of 284 new research studies were approved to begin recruitment at UCLH. These range from Clinical Trials of Medicinal Products and Device studies, through to service and patient satisfaction studies. There are currently 1523 studies involving UCLH patients that are open to recruitment or follow-up. Of these, around 50 per cent of studies are adopted onto the National Institute of Health Research Clinical Research


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Network (NIHR CRN) portfolio of research.The number of patients receiving relevant health

services provided or sub-contracted by University College London Hospitals NHS Foundation Trust in 2014/15 that were recruited during that period to participate in research approved by a research ethics committee was 21363.

UCLH is recognised as one of 11 leading centres for experimental medicine in England. In partnership with University College London UCLH has secured National Institute of Health Research Biomedical Research Centre status for another five years (2012-17). The Biomedical Research Centre has a focus on our four

broad areas of world class strength for innovative, early phase research in cancer, neuroscience, cardiometabolic diseases and Infection, immunity and inflammation.

UCLH’s commitment to research is further evidenced by the fact it is part of UCL Partners, one of five Academic Health Science Partnerships. UCLP itself has a director of quality committed to sharing best practice across the partnership. UCLH is one of four centres pioneering a UCLP initiative to streamline the approval and successful recruitment to commercially contract clinical trials across North Thames.


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CQUIN payment frameworkCommissioning for Quality and Innovation (CQUIN) is a payment framework that allows commissioners to agree payments to hospitals based on agreed quality improvement and innovation work.

A proportion of University College Hospitals NHS Foundation Trust’s income in 2014/15 was conditional on achieving quality improvement and innovation goals agreed between University College Hospitals NHS Foundation Trust and any person or body they entered into a contract, agreement or arrangement with for the provision of relevant health services, through the Commissioning for Quality and Innovation payment framework.

Through discussions with our commissioners we agreed a number of improvement goals for 2014/15 that reflect areas of improvement interest nationally, within London and locally. The total of income conditional upon achieving quality improvement and innovation goals for 2014/15 is £14,560,023*.

The associated payment in 2013/14 was £16,025,891. A high level summary of the CQUIN measures for 2014/15 is shown in the following table:

Table 14

CQUIN CQUIN Categories Actual Value

National CQUIN Friends & Family Test £830,690

NHS Thermometer- Pressure ulcers £936,070

Dementia and delirium £991,862

Local CQUIN Smoking prevention £1,732,323.58

Alcohol misuse £1,645,707.40

Domestic violence £1,732,323.58

Value based commissioning £906,444.74

NHS England CQUIN Specialised workshops £543,620

Endocrine out-patient coding £557,559

Cardiac surgery £557,559

Specialised orthopaedics £418,170

Perinatal pathology £557,559

Retinopathy of permaturity £418,170

Clinical utilisation (Neuro rehab) £418,170

Fetal Medicine – tertiary opinion £418,170

Dashboards £599,376

QIPP scheme – PAO / JHS waiting times £362,414

QIPP scheme – MS admissions avoidance £362,414

QIPP scheme – Reducing LoS Brain Tumour surgery £362,414

Bowel cancer Screening £27,025

Smoking cessation £9,799

Further details of the agreed goals for 2014/15 and for the following 12 month period are available on request from:

Performance Department2nd Floor Central Email: [email protected] Euston Road Phone: 020 3447 9974London, NW1 2PG

* This figure is still provisional. A final figure will not be available until all activity has been billed through at the beginning of June.


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Care Quality Commission (CQC) registration and complianceUniversity College Hospitals NHS Foundation Trusts is required to register with the Care Quality Commission (CQC) and its current registration status is that all Trust locations are fully registered with the CQC, without conditions.

The Care Quality Commission has not taken enforcement action against University College Hospitals NHS Foundation Trust during the reporting period ending on 31st March 2015.

University College Hospitals NHS Foundation Trust has not participated in any special reviews or investigations by the CQC during the reporting period.

Data qualityClinicians and managers need ready access to accurate and comprehensive data to support the delivery of high quality care. Improving the quality and reliability of information is therefore a fundamental component of quality improvement. At University College Hospitals NHS Foundation Trust we monitor the accuracy of data in a number of ways including a monthly data quality review group, coding improvement and medical records improvement groups.

NHS number and General Medical Practice Code ValidityUniversity College Hospitals NHS Foundation Trusts submitted records during 2014/15 to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data.

The percentage of records in the published data*: which included the patient’s valid NHS number was:

� ●97.30percentforadmittedpatientcare � ●98.40percentforoutpatientcare � ●81.03percentforaccidentandemergencycare

which included the patient’s valid General Medical Practice Code was:

� ●96.98percentforadmittedpatientcare � ●95.93percentforoutpatientcare � ●90.22percentforaccidentandemergencycare

*12 months’ worth of data is not available until 3 June 2015. The figures above are based on Months 1-11 i.e. April 2014 to February 2015 inclusive.

Information Governance Toolkit attainment levels The Information Governance Toolkit (IGT) provides

an overall measure of the quality of data systems, standards and processes. The score a trust achieves is therefore indicative of how well they have followed guidance and good practice.

The University College London Hospitals NHS Foundation Trust Information Governance Assessment Report overall score for 2014/15 was 71 per cent and was graded green.

Clinical coding error rateUniversity College Hospitals NHS Foundation Trust was subject to the Payment by Results clinical coding audit during 2014/15 by the Audit Commission and the error rates reported in the latest published audit for that period for diagnoses and treatment coding (clinical coding) were:

Primary Diagnoses Incorrect = 5.5 per cent Secondary Diagnoses Incorrect = 4.5 per cent Primary Procedures Incorrect = 4.5 per cent Secondary Procedures Incorrect = 3.9 per cent

Clinical coding is the process by which patient diagnosis and treatment is translated into standard, recognised codes that reflect the activity that happens to patients. The accuracy of this coding is a fundamental indicator of the accuracy of patient records. The results should not be extrapolated further than the actual sample audited.

The following services were audited: HRG Subchapter: AA –Nervous System Procedures & Disorders

HRG Subchapter : PA – Paediatric Medicine

University College Hospitals NHS Foundation Trust will be taking the following actions to improve data quality:

the continuation of a systematic training and audit cycle that underpins high quality coding within the Coding Department

ongoing engagement with clinicians and clinical divisions in the validation of coded activity ensuring accuracy between coding classifications and clinical care provided

an e-learning module has been introduced which has enhanced awareness of coding amongst clinicians. It covers all aspects surrounding the importance of coding and has an assessment at the end to gauge the level of understanding. This module has been incorporated within the mandatory training profile for all doctors to ensure that it is competed by all and general managers have been driving this in their areas.


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Table of progress against locally chosen prioritiesThe following table provides information against a number of national priorities and measures from the UCLH Quality & Safety scorecard we have chosen to focus on and which forms part of our continuous UCLH review and reporting. These measures cover patient safety, experience and clinical outcomes and are metrics nationally known to be important indicators in their respective areas. Where possible we have included historical performance and where available we have included national benchmarks so that progress over time can be seen as well as performance compared to other providers.+ These indicators use nationally agreed definitions in their construction. Otherwise indicators are necessarily locally defined.

We have chosen to measure our performance against the following metrics:

2012/13 2013/14 2014/15 2014/15 benchmark

What this means

Safety measures reported1 Patients with MRSA infection/10,000 bed days+

0.23 0.22 0.11 0.1 Lower scores are better

2 Patients with Clostridium difficile infection/10,000 bed days+

2.05 3.71~ 4.04 1.3 Lower scores are better. **

3 Medication incidents 1112 1435 1366 No local target

Higher numbers may indicate a more open reporting culture

4 Inpatient falls with harm * ¯ 145 136 297 187 Lower scores are better5 CVC (see glossary) line care 93.50% 95.13% 89.49% No local

targetHigher scores are better

6 Safe surgery intervention (time out using WHO safety checklist)

91.00% 89% 95% No local target

Higher scores are better

7 Vital signs audit (Harm from deterioration) ¨

91.40% 92.43%^ 95.68% 95% Higher scores are better

8 Surgical site infections + 7.10% 8.30% 6.88% 0.00% Lower scores are better.Clinical outcome measures reported9 External Summary Hospital-level Mortality Indicator (SHMI) – Rolling one year period, six months in arrears+

68 75 79.5 100 NHS Choices website. Summary Hospital-level Mortality Indicator (SHMI), Lower scores are better

10 Stroke mortality rates (Based on diagnoses 161x, 164x, P101, P524)

8.93% 9.29% 7.87% No local target

Lower scores are better.

11 Deaths in hospital 822 924 892 No local target

Lower numbers are better.

12 Last minute cancelled operations *+

0.94% 0.71% 0.52% 0.80% Lower scores are better.

13 28 day Emergency Readmission rate + (readmissions to UCLH)

3.00% 2.80% 2.90% 6% (chks peer Apr 13to Mar 14)

Lower numbers are better

14 Complication following surgery *

127 136 158 144 Lower numbers are better

Patient Experience Measures Reported15 Overall satisfaction rating + 8.3 8.3 8.1 Higher numbers are better16 Respect and dignity + 9.1 9.1 8.8 Higher numbers are better17 Involvement in decisions + 7.1 7.2 7.5 Higher numbers are better18 Worries and fears + 5.9 5.9 5.8 Higher numbers are betterStaff Experience Measures Reported19 Staff job satisfaction + 3.62 3.64 3.61 3.6 Higher numbers are better

5 Review of quality performance


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We have chosen to measure our performance against the following metrics:

2012/13 2013/14 2014/15 2014/15 benchmark

What this means

20 Appraisal & re-validation rates + 86% 93% 91% 85% Higher numbers are better21 Care of patients is my Trust’s top priority +

79% 84% 81% 70% Higher numbers are better

22 Staff would recommend the Trust as a place to work +

3.99 4.05 3.98 3.67 Higher numbers are better

23 If a friend or relative needed treatment, I would be happy with the standard of care provided by this Trust +

83% 83% 83% 65% Higher numbers are better

**The C difficile figure is the total number of trust attributable cases which includes successful appeals, cases under review and lapses in care+ These indicators use nationally agreed definitions in their construction. Otherwise indicators are necessarily locally defined.~This was reported as 3.66 in last year’s Quality Report as the data had not been finalised*14/15 Local targets used as 14/15 benchmark figure ^ This was reported as 91.87 in last year’s account but the figure has since been updated. ¯Falls reporting has been replaced with inpatient falls with harm since 2011-12. The methodology for counting falls has changed in 2014-15, with unwitnessed falls now being included.¨ The value stated uses the reporting of 8 vital signs using the Meridian App which commenced in mid-May therefore the data only represents the time period from May-March. Prior to this measurements were against only 6 vital signs.

Three indicators that are no longer measured have been removed – percentage of all inpatients screened for MRSA, nurses and doctors working together, patient would recommend hospital to family/friends.

Table of progress against Monitor’s Risk Assessment Framework

Access targets and Outcome indicators Monitor uses a limited set of national measures of access and outcome objectives as part of the assessment of governance at NHS foundation trusts. It is a Monitor requirement to include these in the UCLH Quality Report. The table below sets out the measures, thresholds and quarterly performance.

Indicator Threshold Q1 Q2 Q3 Q42014-15 actual

Access

Referral to treatment time, 18 weeks in aggregate, admitted patients*

90% 83.7% 83.0% 80.8% 83.1% 82.7%

Referral to treatment time, 18 weeks in aggregate, non-admitted patients*

95% 93.2% 92.8% 88.8% 95.1% 92.6%

Referral to treatment time, 18 weeks in aggregate, incomplete pathways*

92% 87.2% 87.9% 90.9% 93.3% 89.7%

A&E Clinical Quality- Total Time in A&E under 4 hours

95% 95.0% 94.2% 94.1% 95.1% 94.6%

Cancer 62 Day Waits for first treatment (from urgent GP referral)

85% 75.2% 67.1% 66.9% 69.5% 69.7%


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Indicator Threshold Q1 Q2 Q3 Q42014-15 actual

Cancer 62 Day Waits for first treatment (from NHS Cancer Screening Service referral)

90% 100.0% 100.0% 71.4% 80.0% 82.3%

Cancer 31 day wait for second or subsequent treatment – surgery

94% 97.3% 96.7% 96.0% 92.2% 95.8%

Cancer 31 day wait for second or subsequent treatment – drug treatments

98% 99.7% 100.0% 99.6% 99.7% 99.7%

Cancer 31 day wait for second or subsequent treatment – radiotherapy

94% 99.0% 100.0% 100.0% 98.0% 99.6%

Cancer 31 day wait from diagnosis to first treatment

96% 97.2% 95.4% 95.6% 91.4% 94.6%

Cancer 2 week (all cancers) 93% 94.3% 93.1% 93.2% 94.2% 93.7%

Cancer 2 week (breast symptoms) 93% 97.1% 93.7% 84.6% 95.0% 92.6%

Outcomes

C.difficile due to lapses in care (ytd) 71 3 3 5 8 8

Total C.difficile YTD (including: cases deemed not to be due to lapse in care and cases under review)

21 57 77 80 80

C.difficile cases under review (YTD) 3 0 2 21 21

Total C.difficile 109

* As a result of extensive validation carried out during 2014/15, the Trust is aware that its historic RTT performance figures did not contain all pathways that at the time fell under the scope of the RTT. The performance figures also included patient pathways where the patient was no longer waiting for treatment.

An internal audit in 2014 on RTT data quality, together with a range of other RTT data quality assessments, found clinical and administrative data entry errors and processing weaknesses in the management of RTT pathways. To address these points we have introduced and continue to develop:

improved operational reports that help clinical teams closely manage waiting lists operational meetings at all levels of the organisation to ensure that waiting lists are scrutinised at least weekly

a more comprehensive suite of data quality reports, including identification of where errors occurred, to help operational teams pinpoint issues and provide training for staff in how to avoid the data quality issues in the future

more support for clinicians in filling out the clinic outcome forms that are key in moving patients accurately along RTT pathways

higher quality training courses, including on RTT rules and how to manage patient waiting times records on our patient administration system

more rigorous chasing of referring hospitals for the date that patients started waiting prior to being referred on to us for treatment

technical adjustments to how we process RTT pathways through our IT systems


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Core indicators for 2014/15Amended regulations from the Department of Health require trusts to report performance against a core set of indicators using data made available to the trust by the Health and Social Care Information Centre (HSCIC). These mandated indicators are set out below and are as at the time of this report and may not reflect the current position. Where the required data is made available by the HSCIC, a comparison has been made with the national average results and the highest and lowest trusts’ results.

Summary hospital-level mortality indicator and patient deaths with palliative careUCLH NHS Foundation Trust considers that this data is as described for the following reasons: UCLH has a robust process for clinical coding and review of mortality data so is confident that the data is accurate.

UCLH

Perfor-

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Jul12 to

Jun13

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Sept 14

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Lowest

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Oct 13 to

Sept 14

a) The value and banding of the summary hospital-level mortality indicator (‘SHMI’) for the trust for the reporting period

73.5 (Band 3)

78.8 (Band 3)

79.5 (Band 3)

100 59.7 (Band 3)

119.8 (Band 1)

(b) The percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the trust for the reporting period.

29.7% 31.3% 31.5% 25.4% 0.0% 49.4%

UCLH NHS Foundation Trust has taken the following action to improve this number and so the quality of its services:

Monthly review of specialty level mortality at local and UCLH level patient level clinical and coding review of any specialty or conditions which show as mortality outliers when compared with national data

presenting a monthly report to the Quality and Safety Committee detailing the percentage of patient deaths with palliative care coding. UCLH has also set a local target to monitor its rate of palliative care coding and any large variances are investigated by the clinical coding team.


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Patient Reported Outcome MeasuresUCLH NHS Foundation Trust considers that this data is as described for the following reasons: UCLH has processes in place to ensure that relevant patients are given questionnaires to complete. However, it has no control over their completion and return.

The trust’s patient reported outcome measures scores for:

UCLH Performance 2011/12



National Average 2013/14

Lowest Performing Trust 2013/14

Highest Performing Trust 2013/14

(i) groin hernia surgery

0.07 0.04 0.05 0.08 0.04 0.13

(ii) varicose vein surgery

0.08 0.07 0.09 0.09 0.02 0.15

(iii) hip replacement surgery and

0.40 0.44 0.44 0.43 0.33 0.49

(iv) knee replacement surgery

0.24 0.31 0.24 0.32 0.21 0.40

UCLH NHS Foundation Trust has taken the following actions to improve this rate and so the quality of its services:

The PROMs Steering Group, chaired by a consultant lead and with consultant representatives from all relevant specialties, continues to monitor performance and agree actions with appropriate specialties.

Developed practice in knee replacement to include better pre-operative information, improved peri-operative analgesia and post discharge telephone call / advice from clinical nurse practitioners.

28 Day Emergency Readmission RateUCLH NHS Foundation Trust considers that this data is as described for the following reasons: UCLH has a robust process for clinical coding so is confident that the data is accurate.

The percentage of patients aged:




National Average Amongst our Peers 2011/12*



(i) 0 to 15 6.69 8.12 6.32 9.49 14.94 3.75

(ii) 16 or over 10.65 10.73 11.72 11.31 17.15 6.48

Readmitted to a hospital which forms part of the trust within 28 days of being discharged from a hospital which forms part of the trust during the reporting period.*National Average taken against all acute trusts. Trusts with zero readmissions have been excluded from the table.


Collaborative working with primary care and other secondary care providers across patient pathways providing physicians for community clinics increasing specialist nurse discharge support to 7 day working admissions avoidance – providing a team in the Emergency Department and Acute Medical Unit for the avoidance of preventable or inappropriate admission of patients to hospital


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enhanced social work provision strengthening joined up care Improved information management – It is envisaged that better information across community, social, primary and secondary care will support the prevention of unnecessary re admissions

specialist nurse discharge support – UCLH will continue to enhance the skills of its established discharge and admission avoidance team to optimise patient care across organisational boundaries.

Responsiveness to Personal Needs of Patients*UCLH NHS Foundation Trust considers that this data is as described for the following reasons: undertaken independently as part of the annual national inpatient survey.

UCLH Perfor-mance 2012/13



Lowest Perfor-ming Trust 2013/14

Highest Perfor-ming Trust 2013/14

The trust’s responsiveness to the personal needs of its patients during the reporting period.

71.9 68.9 68.7 54.5 84.2


Monitoring performance on Meridian in real-time through regular discussion at quality huddles and agreeing local action plans

Trialled new patient information card explaining other staff that patients could talk to Added another field to Meridian ‘did the nurse in charge introduce herself every shift?’

* Responsiveness to personal needs of patients is a composite score from five CQC National Inpatient Survey questions. The five questions are:

Were you as involved as you wanted to be in decisions about your care and treatment? Did you find someone on the hospital staff to talk to about worries and fears? Were you given enough privacy when discussing your condition or treatment? Did a member of staff tell you about medication side effects to watch for when you went home? Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital?

Staff recommendation of the trust as a provider of care to their family or friends UCLH NHS Foundation Trust considers that this data is as described for the following reasons: undertaken independently as part of the annual national staff survey.



National Average of Acute Trusts 2014/15

Lowest Perfor-ming Acute Trust 2014/15

Highest Perfor-ming Acute Trust 2014/15

The percentage of staff employed by, or undercontract to, the trust during the reporting period who would recommend the trust as a provider of care to their family or friends.

83.4% 83.5% 64.7% 38.2% 89.3%


Staff suggestion scheme launched in Sept 2014 which includes suggestions to improve both staff and


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patient experience Further actions that will be taken include: New focus on staff experience will be launched in April 2015 Further work to look at common themes arising from both patient and staff issues and identify actions to address

Other areas are as described in the patient experience priority

Rate of admissions assessed for VTEUCLH NHS Foundation Trust considers that this data is as described for the following reasons: the Trust has a robust process for measuring VTE risk assessment of patients and this is also part of the monthly Safety Thermometer audit.

UCLH Perfor-mance July 2014 to Sep 2014

UCLH Perfor-mance Oct 2014 to Dec 2014

National Average Oct 2014 to Dec 2014

Lowest Performing Trust Oct 2014 to Dec 2014

Highest Performing Trust Oct 2014 to Dec 2014

The percentage of patients who were admitted to hospital and who were risk assessed for venous thromboembolism during the reporting period.

94.4% 93.3% 95.9 81.2 100


Monitoring as part of the Key Performance Indicators from ward up to Board level Identifying and taking action in low performing areas

Clostridium difficile RateUCLH NHS Foundation Trust considers that this data is as described for the following reasons: the data has been sourced from the Health and Social Care Information Centre and compared to internal UCLH data and data hosted by the Health Protection Agency.






The rate per 100,000 bed days of cases of C.difficile infection reported within the trust amongst patients aged 2 or over during the reporting period.

20.50 37.1 14.7 37.1 0

This refers to all UCLH attributable c difficile infections including those subsequently appealed and under review.


Comprehensive action plan focusing on standardising cleaning practice across our sites, improving hand hygiene for everyone entering the hospital, and improving our learning from any Clostridium difficile cases.

Implemented an upgraded deep-clean regime and the use of hydrogen peroxide vapour cleaning. Continue to monitor antibiotic prescribing


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Incident ReportingUCLH NHS Foundation Trust considers that this data is as described for the following reasons: data has been submitted to the National Reporting and Learning System (NRLS) in accordance with national reporting requirements.

UCLH Perfor-mance October 2012 – March 2013

UCLH Perfor-mance October 2013 – March 2014

National Average October 2013 – March 2014

Lowest Performing Trust October 2013 – March 2014

Highest Performing Trust October 2013 – March 2014

The number of patient safety incidents reported within the trust during the reporting period.

3660 3785 6184 2422 12152

The rate of patient safety incidents reported within the trust during the reporting period.

5.7 4.7 8.7 4.6 14.9

The number of such patient safety incidents that resulted in severe harm or death.

21 14 22.8 69 1

The percentage of such patient safety incidents that resulted in severe harm or death.

0.6% 0.4% 0.4% 1.00% 0.00%


Encourage incident reporting through the monthly Quality and Safety bulletin which shares learning on reporting from incidents, and encourages the reporting of near misses.

Introduced a quarterly report on incident trends and learning

Correction:With apologies to Central Manchester University Hospitals, in last year’s Quality Report we reported that they had the worst incident reporting rate. They actually had the best incident reporting rate as a higher rate is better.


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Annex 1: Statement fromCommissioners and Healthwatch

NHS Camden Clinical Commissioning Group (CCG) is responsible for the commissioning of health services from University College London Hospitals (UCLH) NHS Foundation Trust on behalf of the population of Camden and surrounding boroughs. NHS Camden CCG have worked closely with UCLH to ensure we have the right level of assurance in relation to these commissioned services and we have undertaken commissioner walk rounds in UCLH and formally review service quality at the Clinical Quality Review Groups.

NHS Camden Clinical Commissioning Group welcomes the opportunity to provide this statement on UCLH’s Trust’s Quality Accounts. We confirm that we have reviewed the information contained within the Account and checked this against data sources where this is available to us as part of existing contract/performance monitoring discussions and is accurate in relation to the services provided. We have taken particular account of the identified priorities for improvement for UCLH Trust and how this work will enable real focus on improving the quality and safety of health services for the population they serve.

We have reviewed the content of the Account and confirm that this complies with the prescribed information, form and content as set out by the Department of Health. We believe that the Account represents a fair, representative and balanced overview of the quality of care at UCLH. We have discussed the development of this Quality Account with UCLH over the year and have been able to contribute our views on consultation and content.

This Account has been shared with NHS Islington, NHS Central London CCGs, NHS Haringey, NHS Enfield and NHS Barnet Clinical Commissioning Groups, NHS England and by colleagues in NHS North and East London Commissioning Support Unit for their review and input.

We are pleased to see the UCLH’s chosen priority areas for improvement and ambition to focus on quality and safety to be further embedded in 2015/16. The emphasis for improvement in the use of the World Health Organization (WHO) Surgical Safety Checklist and the focus on improving Cancer patient experience is welcomed.

UCLH is extending the focus on prioritising Trust wide learning from Serious Incidents in 2015/16 and it is pleasing to see that this area continues to be a priority for the Trust. In particular the approach to learning from Never Events and achieving the national guidelines for investigation reports being completed following a serious incident (60 working days) will further embed the patient safety culture within the Trust. As a CCG we will continue to monitor

this area moving forward and acknowledge the improvements they have achieved to date.

Within this Account UCLH acknowledges challenges faced in reducing patient treatment waiting times. In 2015/16 we would like to see further improvements made in reducing patient treatment waiting times, with a focus on improving patient safety, experience and clinical effectiveness. We would also envisage improvements in other areas of patient experience in relation to maternity services, and privacy and dignity of inpatients.

Overall this is a very positive Quality Account and we welcome the vision described and agree on the priority areas. There are still areas for improvements to be made and as commissioners NHS Camden CCG will continue to work with UCLH continuously and monitor these areas to improve the quality of services provided to patients.

NHS Camden Clinical Commissioning Group

Joint Statement from Camden Healthwatch and the Camden Health and Adult Social Care Scrutiny CommitteeCamden Healthwatch and the Camden Health and Adult Social Care Scrutiny welcome the opportunity to jointly comment on University College London Hospitals NHS Foundation Trusts’ (UCLH) Quality Account for 2014/15 and their priorities for quality improvements in 2015/16.

It is clear from the report that the Trust has performed well this year in what has been a challenging climate for the NHS and for this it is to be congratulated. There is evidence of progress being made on waiting time targets for both cancer and referral to treatment waits and the Trust also met the A&E target of 95% of patients seen within 4 hours during the difficult winter period which is a considerable achievement. There is still room for improvement however in meeting waiting time targets for A&E and we would like the Trust to say more about how it is working with partners locally to reduce attendances at A&E.

We are pleased with the way the Trust has responded to the findings of the CQC inspection in November 2013 although recognising there is work still to be done. We are pleased that outpatient experience will continue to be a priority for the Trust in the coming year.

We believe that there is still room for improvement with the quality report in terms of tailoring the content and style of the report for a public readership and we would like the Trust to do


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more to explain in future reports how it has engaged with the public, patients and governors in setting its priorities. We would also like to see the Trust say more about what it offers to the community in its immediate environment.

Overall, this is a very encouraging report, representing a huge amount of work and effort by the staff. As always there is a lot left to do but the people of Camden who use this hospital should feel reassured.


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Annex 2: Statement of Directors’ Responsibilities

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 April 2014 to 21/05/2015;

� Papers relating to Quality reported to the Board over the period April 2014 to 21/05/2015

� Feedback from the commissioners dated 30/04/2015

� Feedback from the governors between 01/01/2015 and 31/04/2015

� Feedback from Local Healthwatch organisations dated 11/05/2015

� Feedback from Overview and Scrutiny Committee dated 11/05/2015

� The trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated 01/04/2013 to 31/03/2014 and quarterly reports during the year

� National patient survey 21/05/2015 � National staff survey 24/02/2015 � The head of internal audit’s opinion over the trust’s control environment dated 11/05/2015

� Care Quality Commission intelligent monitoring reports between 01/04/2014 and 31/12/2014

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 at www.monitor.go.uk/annualreportingmanual) as well as the standards to support data quality for the preparation of the Quality Report (available at www.monitor.gov.uk/annualreportingmanual).

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

NB: sign and date in any colour ink except black

Chairman27 May 2015

Chief Executive27 May 2015


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Annex 3: 2014/15 limited assurance report on the content of the quality reports and mandated performance indicators

Independent auditor’s report to the council of governors of University College London Hospitals NHS Foundation Trust on the quality report

We have been engaged by the council of governors of University College London Hospitals NHS Foundation Trust to perform an independent assurance engagement in respect of University College London Hospitals 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 University College London Hospitals NHS Foundation Trust as a body, to assist the council of governors in reporting University College London Hospitals NHS Foundation Trust’s quality agenda, performance and activities. We permit the disclosure of this report within the Annual Report for the year ended 31 March 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 University College London Hospitals NHS Foundation Trust for our work or this report, except where terms are expressly agreed and with our prior consent in writing.

Scope and subject matterThe indicators for the year ended 31 March 2015

subject to limited assurance consist of the national priority indicators as mandated by Monitor:

Cancer 62 day waits for first treatment (from urgent GP referral); and

Referral to treatment time, 18 weeks in aggregate, incomplete pathways.

We refer to these national priority indicators collectively as the ‘indicators’.

Respective responsibilities of the directors and auditorsThe 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 Detailed guidance for external assurance on quality reports, issued by Monitor; 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:

board minutes for the period April 2014 to 27 May 2015;

papers relating to quality reported to the board over the period April 2014 to 27 May 2015;

feedback from Camden Clinical Commissioning Group, dated 30/04/2015;

feedback from governors, dated between 01/01/2015 and 30/04/2015;

feedback from local Healthwatch organisations, dated 11/05/2015;

feedback from Overview and Scrutiny Committee, dated 11/05/2015;

the trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated 01/04/2013 to 31/03/2014;

the national patient survey, dated 21/05/2015; the national staff survey, dated 24/02/2015; Care Quality Commission Intelligent Monitoring

Report dated 01/12/2014 and 01/07/2014; the Head of Internal Audit’s annual opinion over

the trust’s control environment dated 13/05/2015; and

any other information included in our review.

We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with those documents (collectively the ‘documents’). Our responsibilities do not extend to any other information.

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


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assurance practitioners and relevant subject matter experts.

Assurance work performedWe 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 to include re-performance of

calculations; 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.

LimitationsNon-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 conclusionAs set out in the Review of Quality Performance

section on page 138 of the Trust’s Quality Report, the Trust identified a number of issues in its 18 week Referral-to-Treatment reporting during the year that was supported by our testing, including:

The published indicator incorrectly includes records which should be excluded from the calculation;

The underlying data includes records where end dates of treatment were not captured, per the national guidelines and the Trust’s access policy, affecting the calculation of the published indicator; and

The calculation of the published indicator has been applied on an incorrect date.

With support from NHS England’s Intensive Support Team, the Trust has taken actions to resolve the issues identified in its processes and is due to complete its planned responses in June 2015. As the Trust notes, the data prior to this date has not been revised and the resulting metrics have not been recalculated as it is not practical to do so.

As a result of the issues identified by the Trust in the data we have concluded that there are errors in the calculation of the 18 week Referral-to-Treatment incomplete pathway indicator for the year ended 31 March 2015.

We are unable to quantify the effect of these errors on the reported indicator for the year ended 31 March 2015.

Qualified conclusionBased on the results of our procedures, except

for the effect of the matters set out in the basis for qualified conclusion paragraph, 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 Monitor’s Detailed Guidance for External Assurance on Quality Reports 2014/15; 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, Chartered Accountants, St Albans27 May 2015


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Annex 4: Glossary of terms and abbreviations

AMBER Care Bundle – AMBER Care Bundle provides a systematic approach to improve the care of hospital patients who are facing an uncertain recovery with limited reversibility and who are at risk of dying in the next one to two months. It consists of four elements:

� talking to the person and their family to let them know that the healthcare team has concerns about their condition, and to establish their preferences and wishes

� deciding together how the person will be cared for should their condition get worse

� documenting a medical plan � agreeing these plans with all of the clinical team looking after the person.

Cancer survey – calculation of responses – the questions are summarised as the percentage of patients who reported a positive experience. Neutral responses, such as “Don’t Know” and ‘I did not need an explanation’ are not included in the denominator when computing the score. The higher the score the better the UCLH’s performance.

Care bundles – consist of a group of precautionary steps which, when combined and executed reliably for a specific treatment, have proven to significantly reduce untoward outcomes.

Care Quality Commission (CQC) – the independent regulator of all health and social care services in England

CNS – clinical nurse specialist Commissioners – the organisation, NHS North Central London, that commissions care for UCLH patients

CQC Inpatient Survey – Scoring – For each question in the survey, the individual (standardised) responses are converted into scores on a scale from 0 to 10. A score of 10 represents the best possible response and a score of zero the worst. The higher the score for each question, the better the trust is performing.

CQUIN – Commissioning for Quality and Innovation – is a payment framework which allows commissioners to agree payments to hospitals based on agreed improvement work In addition to contributing to the UCLH wide programmes, local teams routinely identify their own quality improvement topics in areas that they want to enhance the safety, experience or clinical outcomes of their specific patient community. In this way the ethos of continuous improvement is embedded within UCLH and is personal and proactive.

CVC – central venous catheters. A catheter placed into a large vein in the neck, chest or groin.

E- learning – the use of electronic educational technology in teaching and learning.

Faecal transplant – the process of transplantation of feacal bacteria from a healthy individual into a recipient. It involves restoration of the colonic microflora by introducing healthy bacterial flora through infusion of stool, e.g. by enema, orogastric tube or orally in the form of a capsule containing freeze-dried material, obtained from a healthy donor. A limited number of studies have shown it to be an effective treatment for patients suffering from Clostridium difficile infection.

Governors – staff representatives on the Council of Governors (previously Governing Body), which helps to shape the services UCLH provides and reflects the needs and priorities of patients, staff and local communities.

Improving Care Rounds – At UCLH we undertake ‘Improving Care walk rounds’ to help staff and management teams to prepare for regulatory inspections by the Care Quality Commission (CQC). According to the model recommended by Sir Bruce Keogh, the Medical Director of the National Health Service in England, the walk rounds are multidisciplinary. Our walk round team includes junior and senior medical staff, student nurses, senior nurses, managers, AHPs, patients by experience and specialists in medication safety, infection control and safeguarding. The purpose of the walk rounds is not to criticise, but to promote improvement in care, environment and services by coming into the area with ‘fresh eyes’.

Matron quality rounds – UCLH Matrons perform weekly ‘Matrons Rounds’ – these are quality, environmental & patient/staff experience reviews by groups of UCLH Matrons, outside of their own clinical areas. The Rounds provide peer review, challenge and support to clinical areas across UCLH. Feedback is instant, via a ‘huddle’. The Rounds have been well received by staff throughout UCLH and will continue to evolve in 2015/16.

Meridian Survey – calculation of scores Meridian starts scoring at question level and builds up an overall score from each response received from patients. Meridian calculates the score based on the following steps:

� What is the MAXIMUM POSSIBLE score for this question?

� What is the ACTUAL score for this question? The OVERALL score is ACTUAL / MAXIMUM.


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Never Event – ‘Never events’ are largely preventable patient safety incidents that have the potential for, or cause severe harm, and should not occur if relevant preventative measures have been put in place.

NHSLA – National Health Service Litigation Authority. Organisation responsible for assessing how effectively trusts manage risk.

Ombudsman – the Parliamentary and Health Services Ombudsman consider complaints that government departments, a range of other public bodies in the UK, and the NHS in England, have not acted properly or fairly or have provided a poor service.

Picker survey – calculation of response rates and explanation of problem scores.The problem score shows the percentage of patients for each question who, by their response, indicated that a particular aspect of their care could have been improved. Problem scores are calculated by combining response categories. Lower scores are better.

Proton-pump inhibitors – a group of drugs whose main action is a pronounced and long-lasting reduction of gastric acid production. They are the most potent inhibitors of acid secretion available.

Root Cause Analysis (RCA) – Root Cause Analysis investigation is a well recognised way of identifying how and why patient safety incidents happen. Analysis is used to identify areas for change and to develop recommendations which deliver safer care for patients.

Sage and Thyme Training – a 3hr training session that teaches: a memorable structured approach for getting into and out of a conversation, how to empower patients and carers who are worried or distressed and communication skills that are evidence based

Sign up to Safety – Sign up to Safety is a new national patient safety campaign that was announced in March by the Secretary of State for Health. It launched on 24 June 2014 with the mission to strengthen patient safety in the NHS and make it the safest healthcare system in the world. Organisations who Sign up to Safety commit to strengthen patient safety by:

� Setting out the actions they will undertake in response to the five Sign up to Safety pledges and agree to publish this on their website for staff, patients and the public to see.

� Committing to turn their actions into a safety improvement plan (including a driver diagram) which will show how organisations intend to save lives and reduce harm for patients over

the next 3 years. SOAPIER – documentation tool:

� SUBJECTIVE- What does the patient (and family) report as their main problems or concerns?

� OBJECTIVE – Observations – Record of relevant factual measurable data (e.g. vital signs, fluid balance charts, test results…)

� ANALYSIS – Conclusions or diagnosis based on subjective and objective data including risk factors.

� PLAN – What are the key care requirements or outstanding issues to be addressed? To be agreed with patient and/or relatives. Details to be taken from the care plan if required.

� INTERVENTION/EVALUATION – What have you done for your patient? What was the outcome of your plan?

� RE-PLAN – What are the key care requirements to hand over to the next shift?

SSI – surgical site infections VoiceAbility – VoiceAbility offer services across the advocacy and involvement spectrum. They work in many local authorities, offering statutory and informal advocacy, as well as nationwide for their consultancy, training and easyread services. VoiceAbility runs NHS Complaints Advocacy services in several areas across England.

VTE – venous thromboembolism (blood clots) Welcome Pack – all inpatients admitted to UCLH are given a welcome pack when they arrive on the ward. The contents of the pack and the welcome booklet have been developed to respond to patient feedback about what would make a hospital stay that bit better.

WHO Surgical Safety Checklist – The checklist identifies three phases of an operation, each corresponding to a specific period in the normal flow of work: Before the induction of anaesthesia (“sign in”), before the incision of the skin (“time out”) and before the patient leaves the operating room (“sign out”). In each phase, a checklist coordinator must confirm that the surgery team has completed the listed tasks before it proceeds with the operation.





Heart Hospital


Appendix 3

Annual Governance Statement 2014/15


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Annual Governance Statement 2014/15

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 Board of Directors (Board) is accountable for internal control. I have overall accountability for risk management in the Trust. The control of risk is embedded into the management roles of the Executive Directors, particularly the Corporate Medical Director who leads on Clinical Risk and the Medical Directors of the Medicine, Surgery & Cancer, and Specialist Hospitals Boards, given their prime responsibility for the delivery of operational services. Levels of accountability and responsibility are detailed in the Trust Risk Management Strategy. The risk register and risk process is overseen by the Risk Coordination Board (RCB), an executive sub-committee chaired by the Deputy Chief Executive, reporting to the Executive Board.

In order to ensure that risk management is not seen only as an issue that needs to be addressed within the Trust, there are arrangements in place for working with stakeholders and partner organisations, including close working with Clinical Commissioning Groups (CCGs) and NHS England (our commissioners), University College London and key partner organisations with whom we work to provide a comprehensive range of clinical and non-clinical support services. These cover both operational and strategic issues such as service planning and commissioning, performance management, research, education and clinical governance. The Risk Management Strategy and Risk Management policy / procedure define the process for capturing risks both locally and strategically. The Trust’s risk appetite is determined through this process.

The Trust continues to build upon the Board Assurance Framework (BAF). The central purpose is to set out the objectives of the Trust for the year, identify

principal risks against them, the controls and any gaps in control, the assurances and gaps in assurances, and the action plans to remedy such gaps. The assurance framework is subject to an Executive Director-led peer review process which is considered quarterly by the RCB, Executive Board and the Board.

Processes for auditing and monitoring clinical activity are in place in all the clinical divisions. Clinical processes are updated when national guidance is published or in response to adverse events and national safety notices, the latter via the Central Alerting System (CAS), which is monitored via the Patient Safety and Risk Steering Group. Sub committees of the Quality and Safety Committee (QSC) monitor implementation of NICE guidance and recommendations by NCEPOD and the corporate audit programme. Standard clinical data sets have now been established, including areas of performance such as readmissions and returns to theatre - these are assessed on a monthly basis by the QSC to provide assurance on clinical outcomes and to identify any emerging risks for further investigation and action. The Corporate Medical Director receives ongoing notification of unexpected complications and all deaths.

The Audit Committee terms of reference require it to review all risk and control-related disclosure statements prior to endorsement by the Board, and the effectiveness of the management of principal risks including risk review procedures and reports.

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 University College London Hospitals NHS Foundation Trust (UCLH), 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 UCLH for the year ended 31 March 2015 and up to the date of approval of the annual report and accounts.


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The system of internal control is based upon a number of individual controls – for example, policies and procedures covering important business activities, how staff are appointed and managed, the Standing Orders, Standing Financial Instructions and Scheme of Delegation that are used to govern the Trust. In addition there are checks and balances inherent in internal and external audit reviews, Executive Board and Board oversight.

Capacity to Handle RiskThe Executive Board brings together the corporate, financial, workforce, clinical, information and research governance risk agendas. The BAF ensures that there is clarity over the risks that may impact the Trust’s ability to deliver its objectives together with any gaps in control or assurance.

There are internal processes to ensure that incidents which fit the national criteria for serious incidents are reported on the Department of Health Strategic Executive Information System (STEIS) The QSC has an oversight role for serious incidents. A quarterly report on Serious Incidents is provided to the Board & a monthly update to commissioners.

The operational responsibility for the Trust’s risk management work is vested in the Corporate Medical Director and is overseen by the RCB. The RCB enables clinical risk management and corporate risk issues to be brought together to be considered and reported as a whole. The process of identification, assessment, analysis and management of risks and incidents is the responsibility of all staff across the Trust and particularly of all managers. The process for the identification, assessment, reporting, action planning, review, and monitoring of risks is detailed in the Trust Risk Management Policy and Procedure.

Board members receive training in risk management and an overview of the risk systems. Staff receive training in risk at induction – face to face and online training. The Risk Manager also provides one to one and group training as required. Guidance for risk management is available on the Trusts’ intranet. Good practice is shared through the RCB.

The Risk and Control FrameworkThe Trust has recently revised its Risk Management Strategy. The document is available to all staff on the Trust’s intranet site.

The Trust uses Datix Risk Management software to log and maintain a repository of Trust risks. The software is used to assist in the production of the risk report and to help staff manage local risk registers. Risk reports, including the top risks, are reviewed quarterly by the RCB and EB with an oversight from

the Audit Committee.This means that risks are captured from within the

Trust and are supplemented with an assessment of risks by all Board members. The Trust is developing the breadth and scope of its risk work, for example by focusing on strategic risk, and this will become embedded in the BAF in the year to come.

The Trust reviews the most significant risk and the associated risk management plans every three months. The Trust Risk Manager collates the risk register submissions from Divisions, assesses the risks and produces a summary report for consideration by the RCB. The RCB reports to the Executive Board quarterly. The Audit Committee consider the risk report also on a quarterly basis. The Board considers the Risk and Assurance Framework report on a quarterly basis.

The Audit Committee oversees and monitors the performance of the risk management system. Internal Audit (Baker Tilly) and External Audit (Deloitte) work closely with this committee and undertake reviews and provide assurances on the systems of control operating within the Trust. Internal Audit has confirmed that the Trust has had a well-functioning Assurance Framework in place throughout 2014/15. During the course of the year the Trust has sought to further develop the framework and this process has involved consultation with Internal Audit and a joint presentation between Internal Audit and the Deputy Director of Quality and Safety to the Board. Internal Audit has confirmed it is satisfied with the developments to the Assurance Framework and the improved links to the operational risk registers and is satisfied that there has been suitable management and committee scrutiny of the Assurance Framework and the risks, controls and assurances contained within it.

The risk procedures define what risks need to be escalated to the next management level as well as defining the level of risk which must be referred to the RCB and the Board.

The QSC is responsible for ensuring that effective arrangements are in place for the oversight and monitoring of all aspects of clinical quality and safety, UCLH’s top priorities, including identifying potential risks to the quality of clinical care. The Board relies on the QSC to provide advice on all aspects of clinical quality and risk and for assurance on areas of clinical governance and audit. The QSC focuses on promoting a culture of openness and organisational learning from incidents, complaints and patient feedback, and ensures that feedback from patients and other stakeholders is used to inform policy and practice. On behalf of the Board, the QSC reviews compliance and


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receives assurance in meeting regulatory standards set by the Care Quality Commission.

In compliance with the regulations of the Health and Social Care Act the Trust has registered ten locations and nine registerable activities. The Trust has implemented a new system of ‘improving care walkarounds’ for assessing CQC compliance based on the new inspection model used by the CQC. Reports are generated following the visits for the divisions and they are required to produce action plans which are monitored by the clinical boards.

Internal Audit and Counter Fraud ActivitiesThe results of Internal Audit reviews are reported to the Audit Committee which takes a close interest in ensuring system weaknesses are addressed. Improved procedures are in place to monitor the implementation of control improvements and to undertake follow up reviews where systems were deemed less than adequate. An internal audit action recommendation tracking system is in place which records progress in implementing the recommendations by management.

Management’s progress in implementing corrective action following Internal Audit recommendations is reported to the Audit Committee, and the Executive Board also receives regular reports on outstanding high and medium issues. The counter fraud programme is led by the Finance Director and monitored by the Audit Committee.

Information GovernanceThe Trust has an Information Governance Group (IGG) which is chaired by the Caldicott Guardian. This Group reports to the Information and Communications Technology Strategy Board (ICT SB). The ICT SB reports to the Executive Board and is chaired by the Deputy Chief Executive who is the Senior Information Risk Officer (SIRO) for the Trust. The IGG and ICT SB oversee the Trust’s Information Governance Toolkit annual assessment and action plan. Through this governance structure the Trust’s Information Governance Statement of Compliance (IGSoC) is assessed on an ongoing and annual basis to ensure connection to the NHS National Network (N3) and the use of the NHS Care Records Service applications. The controls exercised by the Trust are compliant with the IGSoC control requirements.

The toolkit includes a requirement to undertake an annual “data mapping” exercise to assess all routine data flows within the Trust and between the Trust and any third party. The output of this exercise was fed into the Trust’s Risk Management Framework.

The Trust is making good progress in determining its IG Toolkit attainment levels and collating the relevant documentation and evidence to support its attainment levels. Version 12 is broadly similar to the previous version. The IG Toolkit overall assessment score for version 12 is 71 per cent(compliant).

Data security risks are managed via an Information Governance Framework, which comprises an Information Governance Policy, related policies and guidance and the Information Governance Group (IGG). In particular, the Information Risk Policy sets out a structured approach to information risk management which is integrated with the Trust’s broader risk management arrangements. This includes the appointment of the Senior Information Risk Officer (SIRO), Information Asset Owners and Information Asset Administrators. The Information Governance Group and the Trust’s external auditor have approved a draft Information Risk Management Strategy. This sets out specific pieces of work that the Trust will complete over the next two financial years, including; implementing secure email, eliminating the use of traditional faxes and replacing them with secure electronic faxing, developing a mechanism for capturing patients consent/decisions electronically and implementing a robust patient engagement communications campaign

Information risk identification is supported by the maintenance of an Information Asset Register and regular information mapping exercises. Any significant risks identified from these processes are included in the Trust’s Risk Register and will therefore be subject to the formal management attention commensurate with the assessed risk.

The Trust operates in a complex environment and exchanges data with a number of organisations. The Trust therefore continues to prioritise activities to reduce the risk of data loss or accidental disclosure of personal data. Information Governance Policy and guidance is continually reviewed and training and awareness raising programmes target all Trust staff. Information Governance Training includes an assessment of understanding of key aspects of policy and assessment scores will indicate the success of awareness raising activities. Strengthened technical controls will result in a reduction of risk of specific types of data loss, for example preventing the use of unencrypted memory sticks.

There have been no Level 2 serious incidents reported on to the Information Governance Incident Reporting Tool 2014/15. There were no serious incidents involving personal data reported to the Information Commissioner’s office in 2014/15.


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Major RisksThe Trust has described the principal strategic and

operational risks that it faces in the Annual Report.The principal current strategic risks are identified

as follows: Financial - financial pressures in the NHS affecting our ability to meet our key financial targets and our financing strategy for future capital developments. Due to the failure to agree the position with the tariff for specialist services and the continuing financial pressures nationally these risks will continue into 2015.

Development of the cancer strategy - risks around commissioning, capacity (in particular bed capacity) and staffing continue into 2015.

Development of neuroscience services - risks associated with the complexity of the relationships with partners and uncertain funding continue.

Mitigation and the current status for each of these risks are described in more detail in the Annual Report. Our service development risks relating to the move of cardiac services to Barts Health NHS Trust were addressed in year as the move was completed in early May 2015.

With regard to operational risks the principal current risks are identified as follows:

Emergency Department flow - risk of insufficient capacity (in terms of beds, theatres, outpatient and diagnostic resources) to meet the 4 hour Accident and Emergency target. Despite the pressures the Trust has performed well but this will continue to be an area that is closely monitored.

Referral to treatment time – following a challenging year, this is expected to be fully mitigated by June 2015. Within this cancer waiting times are a particular issue due to increasing numbers of referrals.

Staff shortages - in the context of a national shortage of nurses and high levels of staff turnover, the Trust is experiencing difficulty in recruiting, and service expansion is compounding nurse shortages at ward level which may, if unmitigated, impact on the quality of care. There are a number of initiatives in place to mitigate this and quality of care is closely monitored.

All risks above are current risks to the Trust, but are also expected to continue into the future. The risks associated with financial pressures in the NHS are expected to increase, and in particular there is a risk that the Trust’s planned developments, including new

hospital buildings and investment in a new electronic health records system to support the Trust’s plan to improve efficiency, are not able to deliver benefits as planned.

Foundation Trust Governance RequirementsThe Board sets the strategic direction of the UCLH and is responsible for overseeing the Trust’s performance It has governance structures and procedures in place to manage the organisation including oversight committees and an Executive Board. The UCLH Constitution, Standing Orders, Scheme of Delegation and Standing Financial Instructions set out the arrangements and responsibilities of directors, Trust officers and the Council of Governors (Council). The Board agrees its strategy and objectives annually, which are set out in the Annual Report. The Council has received a regular update on clinical and financial performance and reports relating to service delivery. Governors also input to the annual plan and met with the non-executive directors before Council meetings. This has enabled the governors to discharge their duties.

The Board is a unitary body collectively responsible for the performance of UCLH. Its focus is on patient safety, outcomes and experience, operational performance and financial probity, strategic direction, corporate and clinical governance and internal control. The Board has six oversight committees: audit, finance and contracting, investment, performance, quality and safety and remuneration, each of which is chaired by non-executive directors, and it receives reports from each of these committees. More detailed information on the coverage of these oversight committees and the attendance records of members of each can be found on page x of the annual report. In addition, the Board reviews the risk register and BAF (previously described above). It also receives a report from an Executive Board attended by all executive directors. This oversees delivery of the operational service and reviews performance against financial, workforce and clinical indicators monthly.

UCLH has clinical leadership model, which through four medical directors and its chief nurse, bring a clinical focus to the Board. Three of the medical directors manage the operational service through three clinical boards and 18 divisions supported by corporate functions such as finance and workforce.

An annual assessment of compliance with the Trust’s Licence (including its compliance with the FT condition) is undertaken and an audit of assurances in relation to five of the Licence conditions was carried out by Baker Tilly in March 2015. There were no


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recommendations or exceptions raised as part of this review.

The Trust has a well-established performance management framework that ensures that key indicators across a range of the business are scrutinised on a monthly basis, with key exceptions analysed further at clinical team, clinical board and Trust Board level as appropriate.

Each of the key issues (governance measures, quality, activity levels and efficiency) are discussed at specific sub-board meetings and form sections within the board performance report. Quality, waiting times and data quality are all reviewed at the performance board, membership of which includes senior leaders from all clinical boards, nursing and midwifery, workforce, quality and safety and performance.

The role of the performance board is to challenge performance issues and action plans, and to provide support and analysis to help management teams deliver against the targets. It synthesises issues for the Executive Board, agreeing the key messages to be included when presenting the CEO performance pack and preparing the final board performance report for publication.

The Board receives the monthly performance pack at its meetings. The Quality and Safety Committee also receives a monthly performance report focussed on quality issues.

Performance metrics are reviewed on an annual basis to ensure that all national and local priority indicators are included.

The Board will self-certify the validity of its Corporate Governance Statement. A number of compliance self-assessments support the adequacy of the governance arrangements. These include the finance director who provides assurance on financial performance and the QSC which has reviewed compliance against the CQC standards. Also Internal Audit has provided assurances in relation to aspects of the Trust’s Licence and External Audit provide comment on corporate governance in their annual report.

Stakeholder Involvement in Risk ManagementStakeholders attend meetings and are involved in the Trust which gives them opportunities to raise issues relating to risks that impact upon them. In addition, the Trust actively works with external stakeholders and partner organisations – for example with UCLPartners, other health providers (such as Barts Health in relation to the planned transfer of cardiac services from UCLH to Barts Health), and our joint

venture partners. Risk management is a key part of these partnerships, and the Trust actively engages in the identification and management of risks in relation to each.

UCLH also engages with a wide a diverse public and stakeholder community in a number of ways including

Governors receive Board minutes, the BAF and Board performance report and each of the following Trust committees (Patient Experience Committee, Nursing and Midwifery Board and QSC) has a governor representative. They also participate in governor walkrounds.

Public/Patients: Council and Annual Members’ Meetings; MembersMeets; community events; local Overview and Scrutiny Committees; national and local patient surveys; patient forums and patient focus groups; exhibitions and mail outs; patient advisory liaison service and UCLH News (members’ magazine)

Staff: annual staff survey; CEO roadshow; joint staff forum; team brief; executive walkrounds; and Inside Story (staff magazine)

- Health Partners: Clinical quality review group; integrated care board; GP liaison committee and newsletter; quarterly stakeholder bulletin; joint strategic planning meetings; and cancer service planning groups.

Other Control MeasuresAs 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 the Trust’s obligations under equality, diversity and human rights legislation are complied with. Equality Impact Assessments are carried out for all new service developments and when reviewing policies.

Risk assessments are undertaken 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.


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Economy, Efficiency and Effectiveness of the Use of ResourcesMonthly finance and performance reports are presented to the Finance and Contracting Committee, Executive Board and to the Board. The Trust has reported a financial position slightly better than plan in 2014/15, as a result of higher than the budgeted level of support from the Department of Health in relation to specialist services.

Internal Audit reports consider value for money and Deloitte are required as part of their annual audit to satisfy themselves the Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources and report by exception if in their opinion the Trust has not.

Quality ReportThe 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.

There are a number of controls in place to ensure the quality of the Quality Report, the key controls are:

Corporate objectives for data quality are defined; Data quality priorities are monitored; Comprehensive guidance on data quality in the data capture policy;

Data quality reports are provided to divisions; Performance is monitored at Executive Board and QSC;

Clinical Boards monitor and manage performance; and

Clinical and quality data is reported to the Board and scrutinised and challenged at Board subcommittees.

External assurance statements on the Quality Report are provided by our local commissioners, OSC and our local Healthwatch as required by Quality Account Regulations. External audit is undertaken as required by Monitor and Deloitte’s report and findings on the 2014/15 Quality Report, which focussed on the areas of Referral to Treatment (RTT) incomplete pathways and 62 day cancer waits, have been considered by the Board. Internal audit and Deloitte have been commissioned to conduct audit of the data quality and specific quality indicators as part of the production of the Quality Report for 2014/15. Internal Audit and Deloitte’s audit of the data quality and

specific quality indicators as part of the production of the Quality Report for 2013/14 have been implemented.

The Trust has had a challenging year in relation to achieving a number of access targets. A key area of focus in the year has been on improving the recording of, and performance against, RTT targets. RTT performance reports are routinely provided to divisions, the RTT Steering Group and the Board. Data quality reports are also provided to divisions, together with a validations database to report patient pathways and track data quality tasks and corrections. In addition, RTT guidance and training materials are available for staff to help improve controls in this highly complex area. RTT administrative leads are identified in each divisional area as subject matter experts, and validators are located centrally and in clinical divisions to pick up and correct RTT data quality errors.

A number of core functionality changes were introduced to the Trust’s patient administration system (Carecast) in an upgrade in July 2014. These changes focussed on improving the user experience and embedding RTT rules and logic into Carecast. There were defects in the upgrade which have been actively resolved since go-live. These defects have impacted on user experience and reporting of KPI Referral to treatment indicators.

An internal audit in 2014 on RTT data quality, together with a range of other RTT data quality assessments, found clinical and administrative data entry errors and processing weaknesses in the management of RTT pathways. To address these points we have introduced and continue to develop:

enhanced patient target list report and functionality

more standardised patient target list operational meetings

a more comprehensive suite of RTT data quality reports, including identification of where errors occurred,,to support more helpful end-user feedback and inform re-training.

stronger training courses.

Internal audit will be asked to audit RTT again in 2015/16, and the Trust remains committed to improving performance in this area (see separate section below)

The foundation trust is fully compliant with the registration requirements of the Care Quality Commission.

Review of EffectivenessAs Accounting Officer, I have responsibility for


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reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed primarily by those managers and clinical leads within the NHS foundation trust who have responsibility for the development and maintenance of the internal control framework, supplemented by the work of the internal auditors and clinical audit. 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. The Board, the Audit Committee and the Quality and Safety Committee review plans to address weaknesses and ensure continuous improvement of the system is in place.

The Trust reviews its effectiveness of the system of internal control through Executive Directors and managers within the organisation, who have responsibility for the development and maintenance of the system of internal control and the Board Assurance Framework. The responsibility for compliance with the Care Quality Commission standards is allocated to lead Executive Directors who are responsible for maintaining evidence of compliance. The assessment of compliance and the work of Internal Audit through the year, including advice and support on the development of the Board Assurance Framework, have assisted the Trust in gaining assurance on its system of internal control. The results of External Audit’s work on the Trust’s annual accounts and quality account are a key assurance together with the results of patient and staff surveys. I have been advised on effectiveness of the system of internal control through reports produced for the Quality and Safety Committee, Corporate Medical Director and the Audit Committee, and plans to address weaknesses and ensure continuous improvement of the system are in place.

The Trust, in common with most providers across the NHS, faces an unprecedented financial challenge over the coming years, particularly in relation to the level of reimbursement for specialist services in the light of growing demand for healthcare. The Trust is commencing a major transformation project to help us meet these financial challenges whilst improving the patient care we provide.

The Board has played a key role in reviewing risks to the delivery of the Trust’s performance objectives through monthly monitoring and discussion of the performance dashboard which reports performance in the key areas of finance, activity, national targets, patient safety and quality and workforce. This enables the Executive Board and the Board to focus on key

issues as they arise and address them.The Audit Committee has overseen the

effectiveness of the Trust’s risk management arrangements and has taken part in a review of its role and responsibilities.

The Audit Committee is supported in this oversight role by the work of the Quality and Safety Committee and the Clinical Audit and Quality Improvement committee which reports to the QSC.

The Head of Internal Audit Opinion has given a significant assurance there is a generally sound system of internal control.

Some specific concerns were raised by Internal Audit in 2014/15 in relation to control failures.

Timeliness of completion of job plans and clarity over the numbers of programme activities within the job plans together with a lack of visibility to the Board of these issues. An action plan was put in place which is in the process of being implemented.

Data quality on the Trust’s patient administration system (see also the section on referral to treatment times in the quality report section above)

Policy and process in relation to completion of the Pre-operative and Surgical Safety checklists

Processes in relation to preparation for inquests where these relate to out of Trust patients

Contract management processes in relation to the Trust’s provision of ICT services

Documentation and process in relation to obtaining patient consent

Action plans have been agreed for each of these reviews and the recommendations are included within the action tracker which is regularly updated and reported back to each meeting of the Audit Committee.

Emergency Department (ED) four hour waitsThe Trust narrowly missed the ED waiting time target for the year (95 per cent of patients treated within 4 hours) for 2014/15. Despite this, the Trust did achieve the 95 per cent in quarter 4 and was one of the top 5 performers nationally in the months of December, January, February and March.

Performance was challenged due to ongoing high attendances through 2014/15; the department consistently saw over 400 attendances per day, against an average of 350 in 2011/12. Delay reasons were mainly due to bed capacity and access to specialist opinions.

There were a number of successful measures


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put in place in late November that reduced delays from that point. These included measures to reduce departmental delays such as a second rapid assessment and treatment team (RAT) at busy times, GPs based in the department and the introduction of the navigator role to direct patients to primary care where appropriate. There were also schemes to reduce bed delays by improving flow or building additional capacity, including introduction of UCLH@home which provides care to patients from home and increased therapies support to facilitate discharge and roll out of the ‘home for lunch’ programme. We had also planned to open an additional step down ward in St Pancras hospital, however, nursing recruitment issues meant that this could not be safely staffed.

Acute bed capacity in the University College Hospital tower remains pressured and we are reviewing other mitigating schemes for 2015/16 including length of stay reductions in line with peer benchmarks, expanded use of UCLH@home, better use of bed capacity at our other sites and increased outsourcing of elective work. The full effect of the Heart Hospital strategic moves will be felt by November 2015, and these will realise further capacity benefits. Building work will also start in 2015/16 to expand the emergency department, providing much needed additional space to see and treat emergency patients. The new facility will also allow for implementation of improved ambulatory care pathways therefore reducing admissions.

Clostridum DifficileThere were 109 C.difficile toxin positive cases at UCLH in 2014/15, which were reported to Public Health England - to date only nine of these cases were attributed to ‘lapses in care’ though 20 are awaiting appeal or for a completion of the root cause analysis. The target for this period was < 71 avoidable cases of C.difficile toxin positive cases.

The C.difficile task force oversaw the successful implementation of a comprehensive action plan to reduce C.difficile. Actions included improvements in cleaning standards, improved monitoring of ward compliance with cleaning standards and improved isolation protocols.

18 week Referral to Treatment (RTT) targetsThe Trust is assessed against three separate targets in relation to referral to treatment times:

92 per cent of patients still awaiting treatment should be within 18 weeks of referral

90 per cent of admitted patients should have commenced treatment within 18 weeks of referral

95 per cent of non-admitted patients should have commenced treatment within 18 weeks of referral

We missed all three targets in quarters 1 and 2, and achieved the 92 per cent standard for incomplete pathways from November onwards. We achieved the target for non-admitted in February and March, and did not achieve the target for admitted at any point in the year.

We have undergone a Trust-wide RTT turnaround programme through the year, supported by an RTT turn-around director and turn-around team. This programme of work has involved a comprehensive review of all elements of RTT management and reporting. It has included implementation of a robust RTT governance and delivery structure at all levels in the Trust, development of an RTT training package for all staff involved in RTT pathways, upgrade to our PAS to better support pathway management and complete review of all RTT reporting. There has been a focused programme of work to increase activity in order to shorten waiting lists, delivered through improved scheduling, increased weekend and evening capacity and outsourcing activity where clinically appropriate.

Looking forward, we expect to continue to achieve the non-admitted and incomplete targets consistently through 2015/16, and we expect to achieve the admitted target from June 2015/16 onwards.

62 day cancer waitThe Trust did not achieve the 62 day wait for cancer treatment following GP referral in any quarter in 2014/15, including a slippage in performance in Q4 as a result of an overall increase in cancer activity and increasing numbers of referrals received late in the pathway, particularly in urology. Across the year, breaches resulted mainly from issues that are outside of the Trust’s direct control: late referrals from other Trusts, patient choice and pathway complexity issues. There are, however, some breaches due to capacity or administrative delays. As a result of our performance on this measure, and in the context of failures against RTT and A&E standards, Monitor changed our governance rating to “under review” following our quarter 2 performance.

In response we agreed a full recovery plan with our commissioners and Monitor which tackles all issues that are having an impact on our performance, whether or not they are directly or only indirectly under our control. The action plan


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includes a trajectory to compliance in July, and we have remained on track with that trajectory to date. A key risk remains our relative dependence on the performance of other providers in sending us referrals in a timescale that enables us to treat patients within the 62 day standard.Actions in the improvement plan include:

Introduction of a Trust-wide meeting to review all potential breaches – this has been in place since November.

Introduction of timed pathways in all tumour sites to provide early escalation when a pathway starts to veer from agreed timescales.

Use of a new breach root cause analysis process that provides much fuller analysis of breaches, allowing us to understand all delaying factors on the pathway, not just the primary breach reason. The learning from this is crucial to improving the position.

Feeding back to commissioners and referring trusts all details of late referrals, and working with referring trusts to understand the reasons for late referrals and developing streamlined tertiary pathways in response.

In response to our provision of evidence of progress in delivering improvements and planned changes to address cancer waiting times, A&E and RTT performance Monitor informed us in mid-May that they were returning our risk rating to “green – no evident concerns”. Monitor expects us to continue to move back into compliance against all key indicators based on successful implementation of the actions in our improvement plans

Never EventsDuring the year the Trust reported five serious incidents under the definition set in the Never event policy framework (2012) by the Department of Health. Two of these incidents involved a retained foreign object post-surgery: one was a throat swab and the other was a bag used to collect tissue. Both objects were immediately removed and the patients were not harmed. Two incidents involved the wrong tooth in children – one in which the wrong tooth was drilled and the other in which the wrong tooth was removed. One incident was the administration of an incompatible blood transfusion in which the patient subsequently died. Immediate actions have been put in place for all never events to reduce the risk of recurrence and comprehensive investigations have been undertaken.

The Trust takes all such serious incidents extremely seriously. Each serious incident is individually and carefully reviewed to establish what has happened and if/how controls failed to prevent them occurring. Immediate actions are taken where needed and lessons to be learnt are established and circulated to strengthen controls in future. Each is individually reported to clinical teams and to the Board of Directors.

No significant internal control issues other than those mentioned above were identified in the year.



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Heart Hospital


Appendix 4

Annual accounts 2014/15


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Statement of the Chief Executive’s Responsibilities as the Accounting Officer of University College London Hospitals NHS Foundation TrustThe 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 the Independent Regulator of NHS Foundation Trusts (“Monitor”).

Under the NHS Act 2006, Monitor has directed the University College London Hospitals 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 University College London Hospitals 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:

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;

prepare the financial statements on a going concern basis; and

ensure that the use of public funds complies with the relevant legislation, delegated authorities and guidance

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.

Sir Robert NaylorChief Executive 27 May 2015


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University College London Hospitals NHS Foundation Trust

Foreword to the accounts

These accounts, for the 12 months ended 31 March 2015, have been prepared by the University College London Hospitals NHS Foundation Trust in accordance with paragraphs 24 and 25 of Schedule 7 to the National Health Service Act 2006.

Presented to Parliament pursuant to Schedule 7, paragraph 25(4) of the National Health Service Act 2006.

Sir Robert NaylorChief Executive 27 May 2015


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Independent Auditor’s Report to the Board of Governors and Board Of Directors of University College London Hospitals NHS Foundation Trust

Opinion on financial statements of University College London Hospitals NHS Foundation Trust

In our opinion the financial statements: give a true and fair view of the state of the Trust’s affairs as at 31 March 2015 and of its 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 Statement of Comprehensive Income, the Statement of Financial Position, the Statement of Changes in Taxpayers’ Equity, the Statement of Cash Flows and the related notes 172 to 214. 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.

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.

Going concern We have reviewed the Accounting Officer’s statement on page 31 of the Annual Report that the Trust is a going concern. We confirm that:

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; and

we have not identified any material uncertainties that may cast significant doubt on the Trust’s ability to continue as a going concern.

However, because not all future events or conditions can be predicted, this statement is not a guarantee as to the Trust’s ability to continue as a going concern.

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.


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Risk How the scope of our audit responded to the risk

NHS revenue and provisionsIn 2014/15, income from activities amounted to £775m, with NHS debt of £99.5m, of this debt £26m 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; and

the judgemental nature of provisions for disputes, including in respect of outstanding overperformance income for quarters 3 and 4.

The settlement of income with Clinical Commissioning Groups continues to present challenges, leading to disputes and delays in the agreement of year-end positions.

We evaluated, with the assistance of IT specialists, the design and implementation of controls over recognition of Payment by Results income.

We performed detailed substantive testing of the recoverability of overperformance income through the year, and evaluated the results of the agreement of balances exercise.

We reviewed the significant commissioner contracts for potential penalties and performance related income, tested recognition of these balances and agreed baseline activities to signed contracts.

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.

We tested NHS debtor and revenue balances included in the Intra NHS agreement of balances exercise and investigated significant areas of difference.

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 valuationsAt the beginning of 2014/15 the Trust held property assets of £386m within buildings at a modern equivalent use valuation and £140m of land. 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 year the Trust had a net revaluation gain of £10.3m to land and £14.2m 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 Trust to the valuer.

We used internal valuation specialists to review and challenge the appropriateness of the key assumptions used in the valuation of the Trust’s properties, including through benchmarking against revaluations performed by other Trusts at 31 March 2015.

We assessed whether the valuation and the accounting treatment of the impairment were compliant with the relevant accounting standards and in particular whether impairments should be recognised in the Income Statement or in Other Comprehensive Income.


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Risk How the scope of our audit responded to the risk

Accounting for capital expenditure The Trust plans to significantly increase its capital spend over the next 2 years and there is judgement in the accounting treatment of capital additions.

Where existing properties are being modernised, the “modern equivalent use” valuation rules can lead to a “day one” impairment where the accumulated cost of the asset exceeds the cost of a newly built facility.

We have evaluated the design and implementation of controls around the capitalisation of costs.

We performed detailed substantive testing of additions in the year to test whether they have been appropriately capitalised in accordance with the accounting requirements.

We challenged management’s assessment of whether any impairment arose in respect of capitalised expenditure

The description of risks above should be read in conjunction with the significant issues considered by the Audit Committee discussed on page 76.

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.

We determined materiality for the Trust to be £7.5m, which is below 1% of revenue.

We agreed with the Audit Committee that we would report to the Committee all audit differences in excess of £149,000, 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.


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An overview of the scope of our audit

Our audit was scoped by obtaining an understanding of the entity and its environment, including internal control. Audit work was performed at the Trust’s head offices in London directly by the audit engagement team, led by the audit partner.

The audit team included integrated Deloitte specialists bringing specific skills and experience in property valuations and Information Technology systems.

Data analytic techniques were used as part of audit testing, in particular to support profiling of populations to identify items of audit interest

Opinion on other matters prescribed by the National Health Service Act 2006

We determined materiality for the Trust to be £7.5m, which is below 1% of revenue.

Our assessment of risks of material misstatement

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.

We agreed with the Audit Committee that we would report to the Committee all audit differences in excess of £149,000, 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.

Matters on which we are required to report by exception

Annual Governance Statement, use of resources, 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;

the NHS foundation trust has not made proper arrangements for securing economy, efficiency and effectiveness in its use of resources; 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.


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Our duty to read other information in the Annual Report

Under International Standards on Auditing (UK and Ireland), we are required to report to you if, in our opinion, information in the annual report is:

materially inconsistent with the information in the audited financial statements;

apparently materially incorrect based on, or materially inconsistent with, our knowledge of the Trust acquired in the course of performing our audit; or

otherwise misleading.In particular, we 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 University College London Hospitals NHS Foundation Trust, as a body, in accordance with paragraph 4 of Schedule 10 of the National Health Service Act 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.


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Scope of the audit of the financial statements

An audit involves obtaining evidence about the amounts and disclosures in the financial statements sufficient to give reasonable assurance that the financial statements are free from material misstatement, whether caused by fraud or error. This includes an assessment of: whether the accounting policies are appropriate to the Trust’s circumstances and have been consistently applied and adequately disclosed; the reasonableness of significant accounting estimates made by the Accounting Officer; and the overall presentation of the financial statements. In addition, we read all the financial and non-financial information in the annual report to identify material inconsistencies with the audited financial statements and to identify any information that is apparently materially incorrect based on, or materially inconsistent with, the knowledge acquired by us in the course of performing the audit. If we become aware of any apparent material misstatements or inconsistencies we consider the implications for our report.

Heather Bygrave FCA(Senior Statutory Auditor)for and on behalf of Deloitte LLPChartered Accountants and Statutory Auditor St Albans, United Kingdom27 May 2015


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Statement of comprehensive income for the year ended 31 March 20152014/15

Year Ended31 March 2015

2013/14Year Ended

31 March 2014

Note £000 £000

Operating Income from continuing operations 3 945,944 912,630

Operating Expenses of continuing operations 4 (895,756) (855,804)

Operating surplus 50,188 56,826

Finance costs:

Investment Revenue 9 269 317

Finance costs – financial liabilities 10 (33,441) (32,860)

Public dividend capital dividends payable (9,669) (8,213)

SURPLUS FOR THE YEAR 7,347 16,070

Other comprehensive income(Not reclassified to income and expenditure)

Impairments 14 (2,791) (10,511)

Revaluations 14 18,921 16,262

TOTAL COMPREHENSIVE INCOME/(EXPENDITURE) FOR THE YEAR

23,477 21,821

Note to Statement of Comprehensive Income £000 £000

Total comprehensive income/(expense) as above 23,477 21,821

Plus reserve movements in other comprehensive income a (16,130) (5,751)

Total comprehensive income before reserve movements 7,347 16,070

Add back impairments and reversal of impairments included in surplus above

b(4,874) (12,010)

Donated asset impact c (97) 496

Loss/(Profit) on disposal of fixed assets d 0 43

NET SURPLUS EXCLUDING ITEMS ABOVE 2 2,376 4,599

This is the primary view which is used by the Board of Directors to monitor UCLH’s financial performance.a This is the total of the two items shown in Other Comprehensive Income b This is the total of impairments and impairment reversals charged to expenditure or credited to

income as in Note 14c This is the total impact on the surplus / deficit for the financial year as a result of change in

accounting policy for donated assets as adopted in 2011/12


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Statement of financial position as at 31 March 2015

31 March 2015 31 March 2014

Note £000 £000

Non-current assets

Property, plant and equipment 11 660,596 623,314Intangible assets 12 438 337Investments in associates/joint ventures 13 2,590 394Trade and other receivables 18 28,443 25,290Total non-current assets 692,067 649,335

Current assetsInventories 17 20,760 19,660Trade and other receivables 18 128,261 87,204Cash and cash equivalents 19 92,816 129,937Total current assets 241,837 236,801Total assets 933,904 886,136Current liabilitiesTrade and other payables 21 (131,648) (123,042)Borrowings 22 (7,053) (6,789)Provisions 27 (7,777) (4,094)Other liabilities 23 (13,622) (13,336)Net current assets 81,737 89,540Total assets less current liabilities 773,804 738,875Non-current liabilitiesBorrowings 22 (316,750) (312,303)Provisions 27 (1,710) (1,944)Other liabilities 23 (5,726) (6,126)Total assets employed 449,618 418,502

Financed by taxpayers' equity:Public dividend capital SOCITE 208,091 200,452Retained earnings SOCITE 106,342 98,995Revaluation reserve SOCITE 131,112 114,982Other reserves SOCITE 4,073 4,073Total Taxpayers' Equity 449,618 418,502

The financial statements on pages 172 to 175 were approved by the Board on 27 May 2015 and signed on its behalf by:

Richard AlexanderFinance Director27 May 2015



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Statement of changes in taxpayers’ equity

Public dividend

capital (PDC)

Revaluation reserve

Other reserves

Retained earnings

Total

£000 £000 £000 £000 £000

Taxpayers' Equity as at 1 April 2014 200,452 114,982 4,073 98,995 418,502

Changes in taxpayers’ equity for 2014/15Surplus for the year 0 0 0 7,347 7,347Impairments 0 (2,791) 0 0 (2,791)Revaluations 0 18,921 0 0 18,921

Public Dividend Capital received 7,639 0 0 0 7,639

Balance at 31 March 2015 208,091 131,112 4,073 106,342 449,618

Public

dividend capital (PDC)

Revaluation reserve

Other reserves

Retained earnings

Total

£000 £000 £000 £000 £000

Taxpayers' Equity as at 1 April 2013 197,677 114,875 4,073 77,281 393,906

Changes in taxpayers’ equity for 2013/14Surplus for the year 0 0 0 16,070 16,070Impairments 0 (10,511) 0 0 (10,511)Revaluations 0 16,262 0 0 16,262Asset disposals 0 (5,103) 0 5,103 0Public Dividend Capital received 2,775 0 0 0 2,775Other Reserve Movements 0 (541) 0 541 0Balance at 31 March 2014 200,452 114,982 4,073 98,995 418,502


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Statement of cash flows for the year ended 31 March 2015

2014/1531 March

2013/1431 March

Note £000 £000

Cash flows from operating activitiesOperating surplus from continuing operations 50,188 56,826Operating surplus 50,188 56,826

Non-cash income and expenses:

Depreciation and amortisation 23,750 25,877Impairments 14 7,114 12,497Reversals of impairments 14 (11,988) (24,507)Loss/(Gain) on disposals of Property, Plant and Equipment 0 43Non-cash donations credited to income 0 (1,983)(Increase)/Decrease in Trade and Other Receivables 18 (43,730) (34,192)(Increase) in Inventories 17 (1,100) (528)Increase/(Decrease) in Trade and Other Payables 21 5,851 6,896Increase/(Decrease) in Other Liabilities 23 (115) 6,460Increase/(Decrease) in Provisions 27 3,413 (1,368)Tax (paid) / received 0 914Other movements in operating cash flows (20) (556)NET CASH GENERATED FROM OPERATIONS 33,363 46,379

Cash flows from investing activitiesInterest received 269 317Purchase of intangible assets (185) 0Purchase of Property, Plant and Equipment (37,309) (31,748)Sales of Property, Plant and Equipment 0 8,250Net cash (used in) investing activities (37,225) (23,181)

Cash flows from financing activitiesPublic dividend capital received 7,639 2,775Loans received from Independent Trust Financing Facility 11,500 0Loans repaid to the Independent Trust Financing Facility (2,801) (2,801)Capital element of Private Finance Initiative Obligations (4,451) (4,096)Interest paid on Independent Trust Financing Facility (2,334) (2,445)Interest element of Private Finance Initiative obligations (31,067) (30,380)PDC Dividend paid (9,492) (6,702)Cash flows from (used in) other financing activities (2,253) 0Net cash (used in) financing activities (33,259) (43,649)(Decrease)/Increase in cash and cash equivalents (37,121) (20,451)Cash and Cash equivalents at 1 April 129,937 150,388Cash and Cash equivalents at 31 March 92,816 129,937


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Notes to the accounts

1. Accounting Policies and Other InformationMonitor has directed that the financial statements of NHS Foundation Trusts shall meet the accounting requirements of the NHS 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 2014/15 NHS FT ARM issued by Monitor. The accounting policies contained in that manual follow International Financial Reporting Standards (IFRS) and HM Treasury’s Financial Reporting Manual to the extent that they are meaningful and appropriate to NHS foundation trusts. The accounting policies have been applied consistently in dealing with items considered material in relation to the accounts.

Going ConcernThe directors have given serious consideration to the application of the going concern concept to UCLH given the deteriorating financial context within the trust and the wider NHS. They have assessed the trust’s ability to continue operating on a going concern basis in two ways:a. Monitor, the sector regulator for health services in

England, states that anticipated continuation of the provision of a service in the future is sufficient evidence of going concern, on the assumption that upon any dissolution of a foundation trust the services will continue to be provided. The directors consider that there will be no material closure of NHS services currently run by UCLH (with the exception of the agreed transfer of cardiac services to Barts health in April 2015) in the next business period (considered to be 12 months) following publication of this report and accounts.

b. In relation to UCLH as an entity, the directors have a reasonable expectation that UCLH has adequate resources to continue to service its debts and run operational activities for at least the next business period (considered to be 12 months) following publication of this report and accounts, despite currently planning on the basis of a significant deficit in 2015/16. UCLH has sufficient cash to ensure its obligations are met over this time period. There remains significant uncertainty about the trust’s financial sustainability over a longer time period than the 12 months considered here, particularly as a result of underfunding of specialist services. This and other funding issues will need resolution in order for the trust to be confident of remaining a going concern beyond

the time period assessed here.For these reasons, the directors continue to adopt the going concern basis in preparing the accounts.

1.1 Accounting ConventionThese 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 Consolidation

Joint ControlJoint control is a contractually agreed sharing of control such that the strategic operational and financial decisions require the unanimous consent of all parties.

Other SubsidiariesSubsidiary entities are those over which the 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 minority interests are included as a separate item in the Statement of Financial Position.

The amounts consolidated are drawn from the published financial statements of the subsidiaries for the year.

Where subsidiaries’ accounting policies are not aligned with those of the trust (including where they report under UK GAAP) then amounts are adjusted during consolidation where the differences are material. Inter-entity balances, transactions and gains/losses are eliminated in full on consolidation.

AssociatesAssociate entities are those over which University College Hospitals NHS Foundation Trust (UCLH) has the power to exercise a significant influence. Associate entities are recognised in UCLH’s financial statement using the equity method. The investment is initially recognised at cost. It is increased or decreased subsequently to reflect UCLH’s share of the entity’s profit or loss or other gains and losses (e.g. revaluation gains on the entity’s property, plant and equipment) following acquisition. It is also reduced when any distribution e.g. share dividends are received by UCLH from the associate. However, where UCLH’s proportion of an Associates cumulative


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profits or losses at year end are less than £50,000, no adjustment is made to the cost of the investment on the basis of immateriality.

Associates which are classified as held for sale are measured at the lower of their carrying amount and ‘fair value less costs to sell’.

Joint VenturesJoint ventures are separate entities over which UCLH has joint control with one or more other parties, and where it has the rights to the net assets of the arrangement. The meaning of control is the same as that for subsidiaries.

Joint ventures are accounted for using the equity method with any investment originally recognised at cost.

Joint ventures which are classified as held for sale are measured at the lower of their carrying amount and ‘fair value less costs to sell’.

Joint OperationsJoint 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 trust includes within its financial statements its share of the assets, liabilities, income and expenses.

1.3 IncomeIncome 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 UCLH is contracts with commissioners in respect of healthcare services. Revenue relating to patient care spells which are part-completed at the year-end is apportioned across the financial years on the basis of 50% of the expected spell price.

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 sum due under the sale contract.

1.4 Expenditure on Employee Benefits

Short-Term Employee BenefitsSalaries, wages and employment-related payments are recognised in the period in which the service is received from employees. The cost of annual leave entitlement earned but not taken by employees at the end of the period is recognised in the financial

statements to the extent that employees are permitted to carry forward leave into the following period.

Pension CostsThe NHS Pension scheme is an unfunded, defined benefit scheme that covers multiple NHS employers, 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.

Employers pension cost contributions are charged to operating expenses as and when they become due.

Additional pension liabilities arising from early retirements are not funded by the scheme except where the retirement is due to ill-health. The full amount of the liability for the additional costs is charged to the operating expenses at the time the trust commits itself to the retirement, regardless of method of payment.

1.5 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.

1.6 Property, Plant and Equipment

RecognitionProperty, plant and equipment is capitalised if:

●itisheldforuseindeliveringservicesorforadministrative purposes;

it is probable that future economic benefits will flow to, or service potential will be supplied to, UCLH;

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


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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 e.g. plant and equipment, then these components are treated as separate assets and depreciated over their own useful economic lives. Assets classified as in use are depreciated from the beginning of the next month.

ValuationAll property, plant and equipment are 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.Fair value is defined in IAS16 as ‘the amount

for which an asset could be exchanged between knowledgeable, willing parties in an arm’s length transaction’. The valuation of each property is therefore on the basis of market value, on the assumption that the property is sold as part of the continuing enterprise in operation.

Specialised assets are valued using the Modern Equivalent Asset (MEA) approach. Both physical and functional obsolescence is applied to buildings, to reflect their actual characteristics and value.

Properties in the course of construction for service or administration purposes are carried at cost, less any impairment loss. Assets are revalued and depreciation commences when they are brought into use. Borrowing costs are not capitalised.

Non specialised assets are held at market value which is measured on an existing use basis.

Surplus land and buildings are valued on the basis of fair value, taking into account alternative uses.

Subsequent ExpenditureExpenditure incurred after items of property, plant and equipment have been put into operation, such as repairs and maintenance, is normally charged to the income statement in the period in which it is incurred. In situations where it can be clearly demonstrated that the expenditure has resulted in an increase in the future economic benefits expected to be obtained from the use of an item of property, plant and equipment, and where the cost of the item can be measured reliably, the expenditure is capitalised as an

additional cost of that asset or as a replacement.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 de-recognised.

DepreciationItems of Property, Plant and Equipment are depreciated on a straight line basis 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 be depreciated upon 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 UCLH.

Revaluation Gains & LossesRevaluation 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 in 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 are 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’

ImpairmentsIn accordance with the FT ARM, impairments that are due to 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.

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

An impairment arising from a loss 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


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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.

De-recognitionAssets 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;

the sale must be highly probable i.e.: � management are committed to a plan to sell the asset;

� an active programme has begun to find a buyer and complete the sale;

� the asset is being actively marketed at a reasonable price;

� the sale is expected to be completed within 12 months of the date of classification as ‘Held for Sale’ ; and

� the actions needed to complete the plan indicate it is unlikely that the plan will be dropped or significant changes made to it.

Following reclassification, the assets are measured at the lower of their existing carrying amount and their ‘fair value less costs to sell’. Depreciation ceases to be charged and the assets are not revalued, except where the ‘fair value less costs to sell’ falls below the carrying amount. Assets are de-recognised when all material sale contract conditions have been met.

Property, plant and equipment which is to be scrapped or demolished does not qualify for recognition as ‘Held for Sale’ and instead is retained as an operational asset and the asset’s economic life is adjusted. The asset is de-recognised when scrapping or demolition occurs.

Donated, Government Grant and other Grant-Funded AssetsDonated property, plant and equipment assets are capitalised at their fair value on receipt. The donation is credited to income at the same time, unless the donor imposes a condition that the future economic benefits embodied in the donation are to be consumed in a manner specified by the donor, in which case, the donation 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 assets are subsequently accounted for in the same manner as other items of property, plant and equipment.

1.7 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 UCLH. 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 finance cost is calculated using the implicit interest rate for the scheme.

The service charge is recognised in operating expenses and the finance cost is charged to Finance Costs in the Statement of Comprehensive Income.

Lifecycle ReplacementAn amount is set aside from the unitary payment each year into a Lifecycle Replacement Prepayment to reflect the fact that UCLH is effectively pre-funding some elements of future lifecycle replacement by the operator.

When the operator replaces a capital asset, the fair value of this replacement item is recognised as property, plant and equipment.

Where the item was planned for replacement and therefore its value is being funded through the unitary payment, the lifecycle prepayment is reduced by the amount of the fair value.

The prepayment is reviewed annually to ensure that its carrying amount will be realised through future lifecycle components to be provided by the operator. Any unrecoverable balance is written out of the prepayment and charged to operating expenses.

Where the lifecycle item was not planned for replacement during the contract it is effectively being provided free of charge to UCLH. A deferred income balance is therefore recognised instead and this is released to operating income over the remaining life of the contract.

Assets contributed by UCLH to the operator for use in the schemeAssets contributed for use in the scheme continue


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to be recognised as items of property, plant and equipment in UCLH’s Statement of Financial Position.

Other Assets contributed by UCLH to the OperatorAssets contributed (e.g. cash payments, surplus property) by UCLH to the operator before the asset is brought into use, which are intended to defray the operator’s capital costs, are recognised initially as prepayments during the construction phase of the contract. Subsequently, when the asset is made available to UCLH, the prepayment is treated as an initial payment towards the finance lease liability and is set against the carrying value of the liability.

1.8 Intangible Assets

RecognitionIntangible assets are non-monetary assets without physical substance which are capable of being sold separately from the rest of UCLH’s business or which arise from contractual or other legal rights. They are recognised only where it is probable that future economic benefits will flow to, or service potential be provided to, UCLH and where the cost of the asset can be measured reliably.

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

Expenditure on research is not capitalised.Expenditure on development is capitalised only

where all of the following can be demonstrated: the project is technically feasible to the point of completion and will result in an intangible asset for sale or use;

UCLH intends to complete the asset and sell or use it;

UCLH has the ability to sell or use the asset; how the intangible asset will generate probable future economic or service delivery benefits e.g. the presence of a market for it or its output, or where it is to be used for internal use, the usefulness of the asset;

adequate financial, technical and other resources are available to UCLH to complete the development and sell or use the asset; and

UCLH can measure reliably the expenses attributable to the asset during development.

SoftwareSoftware which is integral to the operation of

hardware e.g. an operating system is capitalised as part of the relevant item of property, plant and equipment. Software which is not integral to the operation of hardware e.g. application software, is capitalised as an intangible asset.

MeasurementIntangible 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. Increases in asset values arising from revaluations are recognised in the revaluation reserve, except where, and to the extent that, they reverse an impairment previously recognised in operating expenses, in which case they are recognised in operating income. Decreases in asset values and impairments are charged to the revaluation reserve to the extent that there is an available balance for the asset concerned, and thereafter are 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’.

Intangible assets held for sale are measured at the lower of their carrying amount or ‘fair value less costs to sell’.

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

1.9 Revenue Grants – Government and Other

Government grants are grants from Government bodies other than income from commissioners or NHS trusts for the provision of services. Grants from the Department of Health, are accounted for as Government grants as are grants from the Big Lottery Fund. Where the grant is used to fund revenue expenditure it is taken to the Statement of Comprehensive Income to match that expenditure.

Where the grant is used to fund capital expenditure the grant is credited to income at the same time, unless the grantor imposes a condition that the future economic benefits embodied in the grant are to be consumed in a manner specified by the grantor, in which case, the 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 grant funded assets are


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subsequently accounted for in the same manner as other items of property, plant and equipment.

1.10 InventoriesInventories are valued at the lower of cost and net realisable value.

The cost of inventories is measured using a weighted average cost basis recalculated monthly for Pharmacy stocks and annually for other consumables.

1.11 Cash and Cash EquivalentsCash 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.

In the Statement of Cash Flows, cash and cash equivalents are shown net of bank overdrafts that are repayable on demand.

1.12 Financial Instruments and Financial Liabilities

RecognitionFinancial 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 UCLH’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 UCLH becomes a party to the contractual provisions of the instrument.

De-recognitionAll financial assets are de-recognised when the rights to receive cash flows from the assets have expired or UCLH 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 and MeasurementFinancial assets are classified into the following categories: financial assets at fair value through Statement of Comprehensive Income; held to maturity

investments; available for sale financial assets, and loans and receivables. The classification depends on the nature and purpose of the financial assets and is determined at the time of initial recognition.

Financial liabilities are classified as ‘Fair value through Income and Expenditure’ or as ‘Other Financial liabilities’. Otherwise, financial liabilities are initially recognised at fair value.

Financial Assets and Financial Liabilities at ‘Fair Value through Income and Expenditure’Financial assets and financial liabilities at ‘fair value through income and expenditure’ are financial assets or financial liabilities held for trading. A financial asset or financial liability is classified in this category if acquired principally for the purpose of selling in the short-term. Derivatives are also categorised as held for trading unless they are designated as hedges. Derivatives which are embedded in other contracts but which are not ‘closely-related’ to those contracts are separated-out from those contracts and measured in this category. Assets and liabilities in this category are classified as current assets and current liabilities.

These financial assets and financial liabilities are recognised initially at fair value, with transaction costs expensed in the income and expenditure account. Subsequent movements in the fair value are recognised as gains or losses in the Statement of Comprehensive Income.

Loans and ReceivablesLoans 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. UCLH’s loans and receivables comprise: cash and cash equivalents, NHS receivables, accrued income and ‘other receivables’.

Loans and receivables are recognised initially at fair value, net of transactions costs, and are measured subsequently at amortised cost, using the effective interest method. The effective interest rate is the rate that discounts exactly estimated future cash receipts through the expected life of the financial asset or, when appropriate, a shorter period, to the net carrying amount of the financial asset.

Interest on loans and receivables is calculated using the effective interest method and credited to the Statement of Comprehensive Income.

Available-for-sale Financial AssetsAvailable-for-sale financial assets are non-derivative financial assets which are either designated in this category or not classified in any of the other


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categories. They are included in long-term assets unless UCLH 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.

Other Financial LiabilitiesAll other financial liabilities are recognised initially at fair value, net of transaction costs incurred, and measured subsequently at amortised cost using the effective interest method. The effective interest rate is the rate that discounts exactly estimated future cash payments through the expected life of the financial liability or, when appropriate, a shorter period, to the net carrying amount of the financial liability.

They are included in current liabilities except for amounts payable more than 12 months after the Statement of Financial Position date, which are classified as 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.

Impairment of Financial AssetsAt the Statement of Financial Position date, UCLH assesses whether any financial assets, other than those held at ‘fair value through income and expenditure’ are impaired. Financial assets are impaired and impairment losses are recognised if, and only if, there is objective evidence of impairment as a result of one or more events which occurred after the initial recognition of the asset and which has an impact on the estimated future cash flows of the asset.

For financial assets carried at amortised cost, the amount of the impairment loss is measured as the difference between the asset’s carrying amount and the present value of the revised future cash flows discounted at the asset’s original effective interest rate. The loss is recognised in the Statement of Comprehensive Income and the carrying amount of the asset is reduced directly.

1.13 Leases

UCLH as LesseeFinance LeasesWhere substantially all risks and rewards of ownership of a leased asset are borne by UCLH, 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 implicit interest rate is that which produces a constant periodic rate of interest on the outstanding liability.

The asset and liability are recognised at the inception of the lease, and are de-recognised when the liability is discharged, cancelled or expires. The annual rental is split between the repayment of the liability and a finance cost. The annual finance cost is calculated by applying the implicit interest rate to the outstanding liability and is charged to Finance Costs in the Statement of Comprehensive Income.

Contingent rentals are recognised as an expense in the period in which they are incurred.

Operating LeasesOther 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 BuildingsWhere a lease is for land and buildings, the land component is separated from the building component and the classification for each is assessed separately. Leased land is treated as an operating lease. When a lease includes both land and building elements, the Trust assesses the classification of each element as a finance or operating lease separately. In determining whether the land element is an operating or a finance lease, an important consideration is that land normally has an indefinite economic life.

UCLH as LessorAmounts due from lessees under finance leases are recorded as receivables at the amount of UCLH’s net investment in the leases. Finance lease income is allocated to accounting periods so as to reflect a constant periodic rate of return on UCLH’s net investment outstanding in respect of the leases.


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Rental income from operating leases is recognised on a straight-line basis over the term of the lease. Initial direct costs incurred in negotiating and arranging an operating lease are added to the carrying amount of the leased asset and recognised on a straight-line basis over the lease term.

1.14 ProvisionsUCLH 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.

When some or all of the economic benefits required to settle a provision are expected to be recovered from a third party, the receivable is recognised as an asset if it is virtually certain that reimbursements will be received and the amount of the receivable can be measured reliably.

Present obligations arising under onerous contracts are recognised and measured as a provision. An onerous contract is considered to exist where UCLH has a contract under which the unavoidable costs of meeting the obligations under the contract exceed the economic benefits expected to be received under it.

A restructuring provision is recognised when UCLH has developed a detailed formal plan for the restructuring and has raised a valid expectation in those affected that it will carry out the restructuring by starting to implement the plan or announcing its main features to those affected by it. The measurement of a restructuring provision includes only the direct expenditures arsing from the restructuring, which are those amounts that are both necessarily entailed by the restructuring and not associated with ongoing activities of the entity.

Clinical Negligence CostsThe NHS Litigation Authority (NHSLA) operates a risk pooling scheme under which UCLH pays an annual contribution to the NHSLA, which, in return, settles all clinical negligence claims. Although the NHSLA is administratively responsible for all clinical negligence cases, the legal liability remains with UCLH. The total value of clinical negligence provisions carried by the NHSLA on behalf of UCLH is disclosed at Note 27.

Non-Clinical Risk PoolingUCLH participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which UCLH 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 when the liability arises.

1.15 ContingenciesContingent assets (that is, assets arising from past events whose existence will only be confirmed by one or more future events not wholly within the entity’s control) are not recognised as assets, but are disclosed in Note 28 where an inflow of economic benefits is probable.

Contingent liabilities are not recognised, but are disclosed in Note 28, 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.

1.16 Public Dividend CapitalPublic 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 IAS 32.

A charge, reflecting the cost of capital utilised by UCLH, is payable as PDC dividend. The charge is calculated at the rate set by HM Treasury (currently 3.5%) on the average relevant net assets of UCLH during the financial year. Relevant net assets are calculated as the value of all assets less the value of all liabilities, except for (i) donated assets and (ii) average daily cash balance held with the Government Banking Service and (iii) any PDC dividend balance receivable or payable. In accordance with the requirements laid down by the Department of Health (as issuer of PDC), the dividend for the year is calculated on the actual average relevant net assets as set out in the ‘pre-


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audit’ version of the annual accounts. The dividend thus calculated is not revised should any adjustment to net assets occur as a result of the audit of the annual accounts.

1.17 Value Added TaxMost of the activities of UCLH are outside the scope of VAT and, in general, output tax does not apply and input tax on purchases is not recoverable.

Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT.

1.18 Corporation TaxNHS Foundation Trusts can be subject to corporation tax in respect of certain commercial non-core health care activities they undertake in relation to the Income Tax Act 2007 and Corporation Tax Act 2010.

UCLH does not undertake any non-core health activities which are subject to corporation tax, therefore does not have a corporation tax liability.

1.19 Foreign ExchangeThe functional and presentational currencies of UCLH 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.

Where UCLH has assets or liabilities denominated in a foreign currency at the Statement

of Financial Position date: monetary items (other than financial instruments measured at ‘fair value through income and expenditure’) are translated at the spot exchange rate on 31 March;

non-monetary assets and liabilities measured at historical cost are translated using the spot exchange rate at the date of the transaction; and

non-monetary assets and liabilities measured at fair value are translated using the spot exchange rate at the date the fair value was determined.

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.

UCLH has a loan from ITFF with fixed repayments and fixed interest rate. Therefore UCLH’s exposure to

interest rate fluctuations is minimal.

1.20 Third Party AssetsAssets 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, they are disclosed in a separate note to the accounts in accordance with the requirements of HM Treasury’s Financial Reporting Manual. Details of third party assets are given in Note 32 to the accounts.

1.21 Losses and Special PaymentsLosses 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 Trusts not been bearing their own risks (with insurance premiums then being included as normal revenue expenditure). However, the note on losses and special payments is compiled directly from the losses and compensations register which reports amounts on an accruals basis with the exception of provisions for future losses.

1.22 Critical Estimates and JudgementsIn 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 and the estimates and underlying assumptions are continually reviewed. 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.

The critical accounting judgements and key sources of estimation uncertainty that have a significant effect on the amounts recognised in the financial


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statements are detailed below:

Valuation of Land and BuildingsUCLH’s land and building assets are valued on the basis explained in Note 1.6 and Note 11 to the accounts.

The District Valuer (DV) provided UCLH with a valuation of land and building assets (estimated fair value and remaining useful life.)

The valuation, based on estimates provided by a suitably qualified professional in accordance with HM Treasury Guidance, leads to revaluation adjustments as described in Note 14 to the accounts. Future revaluations of UCLH’s property may result in further changes to the carrying values of non-current assets.

ProvisionsProvisions have been made for legal and constructive obligations of uncertain timing or amount as at the reporting date. These are based on estimates using relevant and reliable information as is available at the time the financial statements are prepared. These provisions are estimates of the actual costs of future cash flows and are dependent on future events. Any difference between expectations and the actual future liability will be accounted for in the period when such determination is made.

The carrying amounts and basis of UCLH’s provisions are detailed in Note 27 to the accounts.

Impairment of ReceivablesUCLH impairs all receivables older than 3 months at rates determined by the age of the debt. Additionally specific receivables are impaired where UCLH deems it will not be able to collect the amounts due. Amounts impaired are disclosed in Note 18.2 to the accounts.

1.23 Transfers of Functions from other NHS BodiesFor functions that have been transferred to UCLH from another NHS body, the assets and liabilities transferred are recognised in the accounts as at the date of transfer. The assets and liabilities are not adjusted to fair value prior to recognition. The net gain or loss corresponding to the net assets or liabilities transferred is recognised within income or expenses, but not within operating activities.

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

1.24 Standards Issued but not yet adopted for Foundation Trusts

Change published Published by IASBFinancial year for which the change first applies

IFRS 13 Fair Value Measurement May 2011 Adoption delayed by HM Treasury. To be adopted from 2015/16.

IFRS 15 Revenue from contracts with customers

May 2014 Not yet EU adopted. Expected to be effective from 2017/18.

IFRS 9 Financial Instruments July 2014 Not yet EU adopted. Expected to be effective from 2018/19.

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


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Change published Published by IASBFinancial year for which the change first applies

IAS 19 (amendment) – employer contributions to defined benefit pension schemes

November 2013 Effective from 2015/16 but not yet EU adopted

Amendments to IFRS 10, IFRS 12 and IAS 28 (Dec 2015)

For accounting periods starting on or after 1st Jan 2016

Amendments to IAS 1(Dec 2015)


Annual Improvements to IFRSs: 2012-2014 Cycle(Sept 2014)


Amendments to IFRS 10 and IAS 28 (Sept 2014)


Amendments to IAS 27(Aug 2014)


Amendments to IAS 16 and IAS 38 (May 2014)


Amendments to IFRS 11 (May 2014) For accounting periods starting on or after 1st Jan 2016

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.

2. Operating segments The NHS foundation trust operates solely in the UK. Patients who do not live in the UK are treated via reciprocal arrangements or are required to pay for their own treatment. £1.6m (2013/14 £2.2m) came from overseas patients without reciprocal arrangements.

UCLH’s activity is organised into three clinical boards, each of which provide healthcare services, R&D and Education segments and one corporate segment.

The Board of Directors receive financial reports that analyse the financial performance of UCLH in several ways. However, income and expenditure is reported against budget for each of three Clinical Boards, Research and Development, Education and Corporate segments.

These segments are run on a day to day basis by a separate clinical or executive board. The clinical segments are Medicine, Surgery & Cancer and

Specialist Hospitals. The latter encompasses the Eastman Dental Hospital, Paediatrics and Adolescents, Women’s Health, The National Hospital for Neurology and Neurosurgery, the Heart Hospital (Cardiology and Cardiothoracic Surgery), the Royal Hospital for Integrated Medicine and the Royal National Throat, Nose and Ear Hospital.

Income for the clinical boards is received via the contracts with commissioners (CCGs and NHS England). The contracts follow the requirements of the DH’s payment by results guidance, and services are paid for on the basis of a national or local tariff for each treatment. The number of treatments is agreed with our main commissioners.

All of UCLH’s major customers are commissioners and transactions with them are summarised in Note 31.

The Chief Operating Decision Maker (CODM) of this Trust is the UCLH Board. It has been determined


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that this is the CODM as under our scheme of delegation the Board is required to approve the budget and all major operational decisions.

The monthly performance report to the CODM reports financial summary information in the format of the table below.

This financial information is the information reported to the May 2015 Board meeting for the year ended 31st March 2015.

.

MedicineSpecialist Hospitals

Surgery & Cancer

Research & Development

Education Corporate TOTAL

14-15 13-14 14-15 13-14 14-15 13-14 14-15 13-14 14-15 13-14 14-15 13-14 14-15 13-14

£m £m £m £m £m £m £m £m £m £m £m £m £m £m

Direct Income 148.9 142.2 423.0 405.7 242.2 221.7 39.3 35.7 35.3 40.3 44.9 39.2 933.6 884.7

Direct Costs -156.4 -148.6 -312.1 -298.7 -205.7 -189.7 -31.8 -26.0 -43.0 -43.2 -117.8 -111.2 -866.8 -817.4

Internal Trading &

Indirect Costs

6.4 4.7 -62.9 -63.4 -30.4 -31.5 -8.0 -7.8 - - 94.8 97.9 - -

CONTRIBUTION /EBITDA

(at Trust level)

-1.1 -1.7 48.0 43.6 6.1 0.5 -0.5 1.9 -7.7 -2.9 21.9 25.9 66.8 67.3

ITDA (before donation

adjustments &

exceptional items)

- - - - - - - - - - -64.4 -62.7 -64.4 -62.7

I&E (before donation

adjustments &

exceptional items)

-1.1 -1.7 48.0 43.6 6.1 0.5 -0.5 1.9 -7.7 -2.9 -42.5 -36.8 2.4 4.6

Donation adjustments - - - - - - - - - - 0.1 -0.5 0.1 -0.5

I&E (after donation

adjustments, pre-

exceptionals)

-1.1 -1.7 48.0 43.6 6.1 0.5 -0.5 1.9 -7.7 -2.9 -42.4 -37.3 2.5 4.1

Exceptional Items - - - - - - - - - - 4.8 12.0 4.8 12.0

Net Surplus/(Deficit) -1.1 -1.7 48.0 43.6 6.1 0.5 -0.5 1.9 -7.7 -2.9 -37.6 -25.3 7.3 16.1

Notes 1) At segmental level, positions are reported at the level of “Contribution”. At Trust level this equates to “EBITDA”.2) “Donation adjustments” represent the accounting for donations in the year of receipt rather than matching with depreciation over the life of the donated asset3) The I&E position before donation adjustments reflects the old (pre-2012/13) NHS accounting rules. The Trust reports under both the old accounting regime (as the best measure of underlying financial performance as it is unaffected by the timing of charitable donations) and the new accounting regime, which accounts for charitable donations as income in the period in which they are received. 4) ITDA is the total of interest, taxation, depreciation and amortisation. EBITDA is earnings before interest, taxation, depreciation and amortisation. 5) Total assets and liabilities are not reported to the CODM by reportable segment.6) Exceptional items consist of impairments and reversals of impairments before the effect of accounting policy adjustments7) Specialist Hospitals position excludes any Project Diamond funding, which is reported corporately. PFI costs including interest are allocated to and reported within the relevant segments, predominantly Medicine and Surgery & Cancer who occupy the majority of the PFI buildings.


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3. Operating Income by Classification 2014/15


2013/14Year Ended

31 March 2014£000 £000

Acute TrustsElective income 182,619 169,661Non elective income 102,229 97,378Outpatient income 139,342 134,386A & E income 16,923 16,529Other NHS clinical income 310,611 277,249Paying patient income (private and overseas chargeable to patient)

18,040 23,895

Other clinical income 4,877 4,404

Total income from activities 774,641 723,502

Total other operating income (see note 3A) 171,303 189,128

Total Operating Income 945,944 912,630


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3A: Operating Income by Type2014/15


2013/14Year Ended

31 March 2014£000 £000

Income From ActivitiesNHS Foundation Trusts 0 691NHS Trusts 0 11Clinical Commissioning Groups (CCG) and NHS England 727,363 682,639Department of Health – other 23,306 11,000Non-NHS: Private Patients 16,393 21,645Non-NHS: Overseas patients (chargeable to patient) 1,647 2,249NHS Injury scheme (previously RTA) 1,055 863Non-NHS: Other 4,877 4,404

Total Income From Activities 774,641 723,502Other Operating IncomeResearch and development 44,300 39,033Education and training 46,128 49,586Charitable and other contributions to expenditure 4,402 4,572Non-patient care services to other bodies 17,888 17,417Reversal of impairments of property, plant and equipment 11,923 24,488Reversal of impairments of financial assets 65 19Rental revenue from operating leases – minimum lease receipts

3,685 5,653

Staff costs recharged to other organisations 2,687 5,504Pharmacy sales 28,353 29,050Clinical Excellence Awards 7,204 6,473Other 4,668 7,333 **

Total Other Operating Income 171,303 189,128

Total Operating Income 945,944 912,630

*Non-NHS: Private Patients income includes contributions of £9.4m from HCA in respect of lease income and other services(£11.32m in 2013-14) ** £5,563k of income has been reclassified from Property Rental to Other for 2013-14

3B: Overseas Visitors (relating to patients charged directly by the Foundation Trust)

2014/15Year Ended

31 March 2015

2013/14Year Ended

31 March 2014

£000 £000Income recognised this year 1,647 2,249Cash payments received in-year (relating to invoices raised in current and previous years)

1,429 1,007

Amounts added to provision for impairment of receivables (relating to invoices raised in current and prior years)

218 170

Amounts written off in-year (relating to invoices raised in current and previous years)

0 964


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4. Operating Expenses

2014/15Year Ended

31 March 2015

2013/14Year Ended

31 March 2014£000 £000

Services from NHS Foundation Trusts 4,595 0

Services from NHS Trusts 239 4,134

Purchase of healthcare from non NHS bodies 11,986 7,147

Employee Expenses – Executive directors 1,827 1,533

Employee Expenses – Non-executive directors 165 161

Employee Expenses – Staff 475,468 449,350

Drug costs 124,027 117,750

Supplies and services – clinical (excluding drug costs) 86,142 85,914

Supplies and services – general 10,246 8,227

Establishment 8,294 6,828

Research and development 17,237 10,185

Transport 8,178 7,099

Premises 64,474 70,280

Increase in provision for impairment of receivables 3,708 4,379

Rentals under operating leases – minimum lease payments 22,377 16,196

Depreciation on property, plant and equipment 23,666 25,800 **

Amortisation on intangible assets 84 77

Impairments of property, plant and equipment 6,992 12,497

Impairment of Financial Assets 122 0

Audit fees- statutory audit * 134 136

Other auditors remuneration – further assurance services 59 25

Clinical negligence 8,075 7,376

Clinical negligence – excesses payable and premiums due to alternative insurers

109 0

Loss on disposal of other property, plant and equipment 0 43

Legal fees 249 638

Consultancy costs 6,663 6,562

Training, courses and conferences 3,156 2,293

Patient Travel 1,963 1,670

Other services, eg external payroll 225 217

Losses, ex gratia & special payments 26 10

Other 5,270 9,277

Total operating Expenses 895,756 855,804

* The audit fee for the 2014-15 statutory audit was £194,000 (2013/14 £161,000), comprising £110,000 Regulatory reporting fee (2013/14: £107,000), £29,500 Quality Assurance reporting fee (2013/14: £18,000), £2,000 for WGA work,£20,000 for ad-hoc work (2013/14 £7,000) and irrecoverable VAT of £32,500 (2013/14: £26,800). ** Includes £3.1m additional cumulative depreciation from a review carried out in 2013/14 of asset categories and asset lives.“The following realignments have been made to 2013-14 expenditure: Premises reduced by £398k and now reported against Training; Other expenditure adjusted by £236k and also reported against Training; New category of patients travel of £1,670k was previously included within Establishment in 2013/14; Costs moved from Services from CCGs to other – £6.5m


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5. Operating leases

5.1 As lesseeUCLH has a number of property leases for both clinical and administrative buildings. These leases are of varying length of term between 1 and 77 years, with the average being 10 years. In addition, UCLH has a portfolio of equipment leases, typically with lease terms of between 5 to 7 years.

UCLH’s operating lease contracts do not allow for the renewal of leases for a secondary period at substantially lower than market rates nor do they allow for UCLH to exercise beneficial purchase clauses allowing UCLH to acquire assets at other than market value.

Contingent rentalsThe majority of UCLH rentals are fixed for any particular accounting period. Some of these leases include clauses that allow for an uplift of future rentals, typically on a five year basis, to prevailing market rates. Given the uncertainty of future rent reviews UCLH does not estimate such future uplifts.

Accordingly lease payments under operating leases exclude contingent rental amounts.Equipment leases are fixed for the period of the concession and accordingly contain no contingent rents.

All of the above leases have been assessed in accordance with IAS 17 and deemed to be classified as operating leases.

2014/1531 March

2013/1431 March

£000 £000

Minimum lease payments 22,377 16,196Minimum lease payments 22,377 16,196

The aggregate future minimum lease payments under non-cancellable operating leases are as follows :

2014/1531 March

2013/1431 March

£000 £000

Not later than 1 year 11,367 12,073

Later than 1 year and no later than 5 years 31,601 32,013

Later than 5 years 30,890 43,847

Total 73,858 87,933

The operating lease expenditure shown is included under the headings of Transport, Premises and also Supplies and services – clinical within Note 4 Operating Expenses.


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5.2 As lessor UCLH is the lessor in a number of arrangements with other entities. The income by entity is listed below. UCLH includes this income within income derived from rental revenue from operating leases – minimum lease receipts (as reported in Note 3).

2014/15 2013/14£000 £000

Great Ormond Street Hospital for Children NHS Foundation Trust

141 1,033

Hays Specialist Recruitment Limited 203 496

The Doctors Laboratory Ltd 172 519

University College London 1,075 1,200

The Centre for Reproductive & Genetic Health Ltd 215 291

UCLH Charity 43 220

Other 1,836 1,894

Total 3,685 5,653

6. Employee costs and numbers6.1 Employee costs

2014/15Year Ended

31 March

2013/14Year Ended

31 March£000 £000

Salaries and wages 391,732 367,184 *

Social Security Costs 30,606 29,285

Employer contributions to NHS Pension scheme 38,962 37,301

Pension Cost – other contributions 5 4

Total excluding Agency staff 461,305 433,774

Agency staff 17,608 17,736 *

Employee benefits expense 478,913 451,510

Less: Employee Costs Charged to Capital 1,618 627 *Employee Costs as per Note 4 477,295 450,883

*Restated to show capital costs separately for the prior year

6.2 Average number of people employed (whole time equivalents)Average in year

ended 31 March 2015

Average in year ended

31 March 2014Number Number

Medical and dental 1,222 1,216

Administration and estates 1,622 1,558

Healthcare assistants and other support staff 688 626

Nursing, midwifery and health visiting staff 2,533 2,475

Scientific, therapeutic and technical staff 1,383 1,306

Social care staff 0 2

Agency and contract staff 202 246

Bank staff 755 646

Total 8,405 8,075


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6.3 Staff Exit Packages During the year UCLH agreed non-compulsory redundancies and other exit packages within the cost bands shown below:

2014/15 2013/14

Other agreed packages:

Other agreed packages:

Under £10,000 5 0

£10,000-£25,000 28 2

£25,001-£50,000 0 2

Total number 33 4

Total cost £000 716 83

Other agreed packages relates to non-contractual payments that required HMT approval and MARS agreements. There were no compulsory or voluntary redundancies or early retirements during 2014/15 (2013/14: Nil).


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7 Pension CostsPast 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 ValuationA valuation of the scheme liability is carried out annually by the scheme actuary as at the end of the reporting period. Actuarial assessments are undertaken in intervening years between formal valuations using updated membership data 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 the valuation data as 31 March 2015, updated to 31 March 2015 with summary global member and accounting data. In undertaking this actuarial assessment, the methodology prescribed in IAS 19, relevant FReM interpretations, and the discount rate prescribed by HM Treasury have also been used.

The latest assessment of the liabilities of the scheme is contained in the scheme actuary report, which forms part of the annual NHS Pension Scheme (England and Wales) Pension Accounts, 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) ValuationThe 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 were changed to 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 ProvisionsThe 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).

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.


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Employer Contribution 2015/16The employer contribution to the NHS Scheme for 2015/16 is forecast to be £39.7m based on the Trust pay budget for the financial year.

8. Retirements due to ill-healthThis note discloses the number and additional pension costs for individuals who retired early on ill-health grounds during the year.

During 2014/15 there were 10 retirements (2013/14: 4), at an additional cost of £635,000 (2013/14: £47,000). This information has been supplied by NHS Pensions.

This cost is not reported within the Trust’s accounts.

9. Investment revenue2014/15

Year Ended31 March

2013/14Year Ended

31 March£000 £000

Interest revenue:Bank accounts 269 317Total 269 317

10. Finance Costs

2014/15Year Ended

31 March

2013/14Year Ended

31 March£000 £000

Interest on loans from Independent Trust Financing Facility* 2,338 2,445

Interest on obligations under PFI contracts:

– main finance cost 31,067 30,380

Unwinding of discount 36 35

Total 33,441 32,860

* Previously known as Foundation Trust Financing Facility


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11. Property, plant and equipment

Land

Buildings

excluding

dwellings

Assets under

construct

and poa

Plant and

machinery

Transport

Equipment

Information

TechnologyFurniture

& fittings Total

2014/15: £000 £000 £000 £000 £000 £000 £000 £000

Valuation/Gross cost at

1 April 2014

140,354 385,982 27,749 75,934 0 22,935 29,828 682,782

Additions purchased 0 3,011 35,686 0 0 0 0 38,697

Additions – assets

purchased from cash

donations / grants

0 0 0 1,090 100 0 0 1,190

Impairments charged to

revaluation reserve

(2,000) (791) 0 0 0 0 0 (2,791)

Impairments recognised

in operating expenses

(0) (3,515) (3,477) 0 0 0 0 (6,992)

Reversal of impairments

recognised in operating

income

619 11,304 0 0 0 0 0 11,923

Reclassifications 0 11,610 (32,804) 8,263 69 12,451 412 (0)

Revaluations 11,723 7,197 0 0 0 0 0 18,921

Valuation/ Gross cost at

31 March 2015

150,696 414,798 27,154 85,287 169 35,386 30,240 743,730

Accumulated

depreciation at 1 April

2014

0 (0) (0) 36,169 0 8,545 14,754 59,468

Provided during the

year **

0 9,922 0 7,918 8 3,490 2,328 23,666

Disposals 0 0 0 0 0 0 0 0

Depreciation at 31

March 2015

0 9,922 (0) 44,087 8 12,035 17,082 83,134

Net book value at 31

March 2015

Owned 150,696 127,701 27,154 31,855 64 23,087 12,409 372,966

PFI 0 238,715 0 0 0 0 0 238,715

Donated 0 38,460 0 9,345 97 264 749 48,914

Total at 31 March 2015 150,696 404,876 27,154 41,200 161 23,351 13,158 660,596

Analysis of property,

plant and equipment

Protected Property 150,696 403,823 0 0 0 0 0 554,519

Unprotected Property 0 1,053 27,154 41,200 161 23,351 13,158 106,077

Total at 31 March 2015 150,696 404,876 27,154 41,200 161 23,351 13,158 660,596

** Buildings depreciation was eliminated on revaluation at 31 March 2015 through the entries in “Impairments charged to revaluation reserve”, “Impairments recognised in operating expenses” and “Revaluation surpluses”. The 1 April 2014 Buildings opening value is as per the net book value as advised by the District Valuer at 31 March 2014.


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Prior year:

Land

Buildings

excluding

dwellings

Assets under

construct

and poa

Plant and

machinery

Transport

Equipment

Information

technology Furniture

& fittings Total

2013/14: £000 £000 £000 £000 £000 £000 £000 £000

Cost or valuation at 1

April 2013

141,181 376,851 11,669 71,464 0 20,798 30,913 652,876

Additions purchased 0 692 28,014 0 0 0 0 28,706

Additions donated 0 1,931 0 0 0 52 0 1,983

Impairments charged to

revaluation reserve

(4,400) (6,111) 0 0 0 0 0 (10,511)

Impairments recognised

in operating expenses

0 (10,750) 0 (425) 0 0 (1,322) (12,497)

Reversal of impairments

recognised in operating

income

594 23,894 0 0 0 0 0 24,488

Reclassifications 0 4,563 (11,934) 4,939 0 2,111 321 0

Revaluation surpluses 5,454 10,808 0 0 0 0 0 16,262

Transferred to disposal

group as asset held for

sale

(2,475) (5,775) 0 0 0 0 0 (8,250)

Disposals* 0 0 0 (44) 0 (26) (83) (153)

At 31 March 2014 140,354 396,103 27,749 75,934 0 22,935 29,829 692,904

Depreciation at 1 April

2013

0 (0) (0) 27,433 0 5,592 10,788 43,813

Provided during the

year **

0 10,120 0 8,736 0 2,953 3,992 25,800

Disposals* 0 0 0 0 0 0 (26) (26)

Depreciation at 31 March

2014

0 10,120 (0) 36,169 0 8,546 14,755 69,590

Net book value at 31

March 2014

Owned 140,354 120,525 27,749 29,587 0 14,062 14,100 346,378

PFI 0 227,270 0 0 0 0 0 227,270

Donated 0 38,188 0 10,178 0 327 974 49,667

Total at 31 March 2014 140,354 385,983 27,749 39,765 0 14,389 15,074 623,314

Analysis of property,

plant and equipment

Protected Property 140,354 385,983 0 0 0 0 0 526,336

Unprotected Property 0 0 27,749 39,765 0 14,389 15,074 96,977

Total at 31 March 2014 140,354 385,983 27,749 39,765 0 14,389 15,074 623,314

* UCLH disposed of Arthur Stanley House, a surplus property, in March 2014. The property’s carrying value at 31 March 2013 was £5.2m. Prior

to disposal, the district valuer revalued the property at £8.25m, the value at which the property was dispo

** Buildings depreciation was eliminated on revaluation at 31 March 2014 through the entries in “Impairments charged to revaluation

reserve”, “Impairments recognised in operating expenses” and “Revaluation surpluses”. The 1 April 2013 Buildings opening value is as per the

net book value as advised by the District Valuer at 31 March 2013.


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End of Year ValuationIn the year ending 31st March 2015 a full valuation exercise was carried out on UCLH’s properties by the District Valuer (DV). The purpose of this exercise was to determine a fair value for Trust land and buildings as at 31st March 2015. A detailed physical inspection was carried out for this valuation.

The exercise was carried out in February 2015 with the prospective valuation date of 31st March 2015. It resulted in a number of revaluation adjustments, both upwards and downwards, some of which related to assets with existing revaluation reserve balances and some of which related to assets with no revaluation reserve balance. See note 14 for further details.

The valuations were undertaken having regard to International Financial Reporting Standards (IFRS) as applied to the United Kingdom public sector and in accordance with HM Treasury guidance, International Valuation Standards and the requirements of the Royal Institution of Chartered Surveyors (RICS) Valuation Standards 6th Edition.

Basis of ValuationThe valuation was conducted in accordance with the terms of the Royal Institution of Chartered Surveyors’ Valuation Standards, 6th Edition, insofar as these terms are consistent with the requirements of HM Treasury, the National Health Service and the Department of Health.

Fair value is defined as the amount for which an asset could be exchanged between knowledgeable, willing parties in an arm’s length transaction. The fair value of land and buildings is usually determined from market-based evidence by appraisal undertaken by professionally qualified valuers.

The valuation of each property is on the basis of Market Value. The Market Value used in arriving at fair value for UCLH’s operational assets is subject to the assumption that the property is sold as part of the continuing enterprise in occupation.

In the case of non-specialised operational assets, this equates in practice to Existing Use Value (EUV).

In the case of specialised operational assets, if there is no market-based evidence of fair value because of the specialised nature of the property and the item is rarely sold, except as part of a continuing business; fair value is estimated using a depreciated replacement cost approach subject to the assumption of continuing use.

Where depreciated replacement cost (DRC) has been used, it is confirmed that the valuer has had regard to the RICS Valuation Information Paper No. 10, “The Depreciated Replacement Cost (DRC)

Method of Valuation for Financial Reporting”, as supplemented by Treasury guidance.

Non-operational assets, including surplus land, are valued on the basis of Market Value, on the assumption that the property is no longer required for existing operations, which have ceased.

There is an assumption that properties valued will continue to be in the occupation of the NHS for the foreseeable future having regard to the prospect and viability of the continuance of that occupation.

a) Depreciated Replacement CostThe basis used for the valuation of specialised operational property for financial accounting purposes is Depreciated Replacement Cost (DRC). The RICS Standards at Appendix 4.1, restating International Valuation Application 1 (IVA 1) provides the following definition:

“The current cost of replacing an asset with its modern equivalent asset less deductions for physical deterioration and all relevant forms of obsolescence and optimisation.”

Those buildings which qualify as specialised operational assets, and therefore fall to be assessed using the Depreciated Replacement Cost approach, have been valued on a modern equivalent asset basis.

b) Existing Use Value (EUV)The basis used for the valuation of non-specialised operational owner-occupied property for financial accounting purposes under IAS 16 is fair value, which is the market value subject to the assumption that the property is sold as part of the continuing enterprise in occupation. This can be equated with EUV, which is defined in the RICS Standards at UK PS1.3 as:

“The estimated amount for which a property should exchange on the date of valuation between a willing buyer and a willing seller in an arm’s-length transaction, after proper marketing wherein the parties had acted knowledgeably, prudently and without compulsion, assuming that the buyer is granted vacant possession of all parts of the property required by the business and disregarding potential alternative uses and any other characteristics of the property that would cause its Market Value to differ from that needed to replace the remaining service potential at least cost.”

c) Market ValueMarket Value is the basis of valuation adopted for the reporting of non-operational properties, including surplus land, for financial accounting purposes. The RICS Standards at PS3.2 define MV as:


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“The estimated amount for which a property should exchange on the date of valuation between a willing buyer and a willing seller in an arm’s-length transaction after proper marketing wherein the parties had each acted knowledgeably, prudently and without compulsion.”

Variations to RICS Valuation StandardsIn order to meet the underlying objectives established by HM Treasury and the Department of Health for capital accounting and the capital charges system, the following variations from the RICS Valuation Standards were required and agreed between UCLH and the DV. For assets valued using depreciated replacement cost, the replacement cost figures include VAT and professional fees but exclude finance charges, with an “instant building” being assumed.The valuation figures reflect physical obsolescence and have been reduced to reflect functional obsolescence. Assets in the course of construction at the valuation date are included at the cost incurred to the valuation date in accordance with current capital charging arrangements. When stating the certified cost of work carried out (as at the valuation date), no deduction has been made for the risk of failure to complete the project.As regards alternative use values, it is confirmed that unless otherwise indicated operational assets have been valued to Fair Value on the assumption that their market value reflects the property being sold as part of the continuing enterprise in occupation.

The value ascribed to the operational assets does not reflect any potential alternative use value, which could be higher or lower than the stated Fair Value.

Assumptions Arising from use of a Prospective Valuation DateThe following assumptions were made in respect of giving a prospective valuation as at 31st March 2015, on valuations carried out in February 2015:The age and remaining lives of buildings and their elements have been assessed as at the valuation date. The assumption is that building elements will continue to be maintained normally over the period from the date of inspection to the valuation date and that there will be no untoward changes.With respect to non-specialised operational property valued to fair value assuming the continuance of occupation for the existing use, non-operational properties valued to Market Value and the land element of DRC properties, their valuations have been prepared having regard both to the market evidence available at the date of the report and to likely and foreseeable local and national market trends between the date of carrying out the valuation and the valuation date.

Interaction with Private Finance Initiative (PFI) ContractsUCLH’s PFI asset (the new hospital building) has been valued to fair value on the market value, subject to the assumption of continuance of the existing use, with the DRC approach being adopted where the asset is specialised.


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12. Intangible assets

2014/15:Computersoftware -purchased

Total

£000 £000

Gross cost at 1 April 2014 590 590

Additions purchased 185 185

Gross cost at 31 March 2015 775 775

Amortisation at 1 April 2014 253 253

Provided during the year 84 84

Amortisation at 31 March 2015 337 337

Net book value at 31 March 2015

Purchased 438 438

Total at 31 March 2015 438 438

Prior year:

2013/14:Computersoftware -purchased

Total

£000 £000

Gross cost at 1 April 2013 590 590

Additions purchased 0 0

Gross cost at 31 March 2014 590 590

Amortisation at 1 April 2013 176 176

Provided during the year 77 77

Amortisation at 31 March 2014 253 253

Net book value at 31 March 2014

Purchased 337 337

Total at 31 March 2014 337 337

Intangible fixed assets represents application software identified in IT projects..


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13. Investment in Joint Venture Note 2014/15 2013/14

£000 £000

Opening investment in joint venture 394 375

Acquisitions in Year 2,253 0

Reversal of Impairment 65 19

Impairment 14 (122) 0

Carrying value at 31st March 2,590 394

In April 2011 UCLH acquired a 50% stake in an arrangement with Imaging Partners Online Limited to operate a joint venture (Radiology Reporting Online (RRO)) delivering both an enhanced on-site and off-site imaging reporting service. UCLH has impaired its investment in the joint venture by 50% of the RRO’s operating loss for the first two financial years, 2011/12 and 2012/13, which has been partially reversed in 2013/14 and 2014/15 by 50% of the value of the surplus (or projected surplus) for the year (a gain of £65k including an adjustment to reflect the finalised 2013/14 position).

UCLH has engaged in a second joint venture, Health Services Laboratories LLP (HSL LLP) with partners The Doctors Laboratory (TDL) and the Royal Free London NHS Foundation Trust (RFL). UCLH has a 24.5% stake in this operation (TDL 51%, RFL 24.5%), with joint venture status agreed as a result of a series of significant decisions requiring unanimous agreement.

Although the go-live date for operational services provided by this JV is 1st April 2015, UCLH (and other members) have made payment of agreed start-up capital in March 2015 in readiness for go-live. UCLH’s contribution was £2,253k. This has been recorded as an investment under the equity method. UCLH has impaired this initial investment by 24.5% of pre go-live trading losses incurred by the JV in advance of go-live (£122k), in relation to development of business opportunities.

14. Impairments and Revaluations

Land and buildings were valued independently by the District Valuer as at 31 March 2015 in line with accounting policies. The valuation included positive and negative valuation movements. Revaluation gains were taken to the revaluation reserve, unless they related to a property which has previously been impaired through operating expenses, in which case the revaluation gain was taken to operating income. Revaluation losses were taken to the revaluation reserve to the extent that there was a revaluation surplus for that property. Any losses over and above the revaluation surplus were charged to operating expenses. The movement arising from the professional valuation can be summarised as follows: Summary of 2014-15 impairments and revaluations:

2014/15 2013/14

Income and expenditure

Reserves TotalIncome and expenditure

Reserves Total

£000 £000 £000 £000 £000 £000

a) Impairments and reversals

Impairment reversals credited to operating income

11,988 – 11,988 24,507 – 24,507

Impairments charged to operating expenses

(7,114) (7,114) (12,497) – (12,497)

Impairments charged to revaluation reserve

– (2,791) (2,791) – (10,511) (10,511)

Total impairment reversal/(charge)

4,874 (2,791) 2,083 12,010 (10,511) 1,499


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2014/15 2013/14

Income and expenditure

Reserves TotalIncome and expenditure

Reserves Total

£000 £000 £000 £000 £000 £000

b) RevaluationsCredited to revaluation reserve as above

– 18,921 18,921 – 16,262 16,262

Total revaluations – 18,921 18,921 – 16,262 16,262

NotesThere was a net increase in the carrying value of UCLH’s property as a result of the valuation exercise described in note 11. Land and

building values increased significantly, partially offset by downward revaluations in respect of specific properties. Impairments charged to Income & Expenditure include £122k in respect of Joint Ventures (HSL).Impairment reversals in Income & Expenditure include £65k in respect of Joint Ventures (RRO).

15. Property, Plant & Equipment Economic Lives Property, plant and equipment is depreciated on current valuation over estimated useful life as follows:

Minimum Maximum

Buildings excluding dwellings 1 50

Plant & Machinery 5 15

Information Technology 5 8

Furniture & Fittings 5 10

16. Capital commitmentsContracted capital commitments at 31 March not otherwise included in these financial statements:

31 March 2015 31 March 2014

£000 £000

Property, plant and equipment 8,727 8,067

Total 8,727 8,067

17. Inventories

17.1 Inventories

31 March 2015 31 March 2014

£000 £000

Drugs 8,171 8,188

Consumables 12,448 11,276

Energy 141 196

Total 20,760 19,660

Of which held at net realisable value: 3,237 * 0

* Stock held at net realisable value is Cardiac specific stock being sold to Barts as part of the transfer of cardiac services


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17.2 Inventories recognised in expenses

31 March 2015 31 March 2014

£000 £000

Inventories recognised as an expense in the period

196,233 193,419

Total 196,233 193,419

18. Trade and other receivables

18.1 Trade and other receivables

Current Non-current

31 March 2015 31 March 2014 31 March 2015 31 March 2014

£000 £000 £000 £000

NHS invoiced receivables 73,464 64,867 0 0

Provision for the impairment of receivables

(43,007) (33,050) 0 0

VAT 3,060 1,914 0 0

Accrued income 59,955 28,862 0 0

Prepayments – PFI lifecycle replacements

0 0 28,443 25,290

Prepayments other 7,211 4,030 0 0

Other receivables 26,061 19,544 0 0

Other receivables capital* 1,517 1,037 0 0

Total 128,261 87,204 28,443 25,290

* These items are considered non-operational and are excluded from the movement in receivables shown in the cash flow statement

18.2 Analysis of impaired receivables

Ageing of impaired receivables 31 March 2015 31 March 2014

£000 £000

0 – 30 days 629 0

30 – 90 days 1,258 2,915

90 – 180 days 8,979 4,969

over 180 days 32,141 25,166

Total 43,007 33,050

The above analyses the ‘Provision for impairment of receivables’ by reference to the age of the underlying debt.

18.3 Analysis of non-impaired receivables


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Ageing of non-impaired receivables 31 March 2015 31 March 2014

£000 £000

0 – 30 days 71,346 46,875

30 – 90 days 38,474 36,339

90 – 180 days 9,528 1,229

over 180 days 1,702 28,051

Total 121,050 112,494

All receivables over 3 months old are impaired at rates determined by the age of the debt. In addition to the impairment of all receivables over 3 months old, specific provisions are made in respect of certain categories of debt which are less than 3 months old.

18.4 Provision for impairment of receivables

31 March 2015 31 March 2014

£000 £000

Balance at 1 April 33,050 21,577

Increase in provision 11,918 12,535

Amounts utilised (1,961) (1,062)

Unused amounts reversed 0 0

Balance at 31 March 43,007 33,050

UCLH has impaired receivables based on age and any specific details known. Figures above include impairment of NHS receivables which are accounted for as a reduction of income rather than as a charge to operating expenses.

19. Cash and cash equivalents

31 March 2015 31 March 2014

£000 £000

Balance at 1 April 129,937 150,388

Net change in year (37,121) (20,451)

Balance at 31 March 92,816 129,937

Made up of

Cash with the Government Banking Service 92,574 129,830

Commercial banks and cash in hand 242 107

Cash and cash equivalents as in statement of financial position 92,816 129,937

Cash and cash equivalents as in statement of cash flows 92,816 129,937


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20. Non-current assets held for sale

31 March 2015 31 March 2014

£000 £000

Balance brought forward 1st April 0 0

Plus assets classified as held for sale in the year 0 8,250

Less assets sold in year 0 (8,250)

Balance carried forward at 31 March 2015 0 0

21. Trade and other payables

Current Non-current


£000 £000 £000 £000

Receipts in advance 0 0 * 0 0

NHS payables 8,077 1,234 0 0

Trade payables – capital* 3,159 581 0 0

Other trade payables – revenue 778 0 0 0

Taxes payable 14,682 14,507 0 0

Other payables 45,521 61,096 0 0

Accruals 58,807 45,177 * 0 0

PDC dividend payable* 624 447 0 0

Total 131,648 123,043 0 0

* these items are considered non-operational and are excluded from the movement in payables shown in the cash flow statement

22. Borrowings

Current Non-current


£000 £000 £000 £000

Loans from Independent Trust Financing Facility

2,801 2,801 66,188 57,489

Obligations under Private Finance Initiative contracts

4,252 3,988 250,562 254,813

Total 7,053 6,789 316,750 312,303

The outstanding balance on the Trust’s Independent Trust Financing Facility (previously known as Foundation Trust Financing Facility) loan at 31st March 2015 was £69.0m (31st March 2014 £60.3m). The total loan facility has been used to part-fund the UCH Macmillan Cancer Centre, which opened in April 2012, and to fund work on the Phase 4 (Proton Beam Therapy) facility. The Trust has signed agreements for £357.3m of loan financing in place with the Independent Trust Financing Facility (ITFF). This relates to the Emergency Department, Phase 4, Phase 5 and Proton Beam Therapy projects. To date drawdowns of £11.5m have been made to fund the start of capital works on the ED and Phase 4 projects. This leaves £345.8m remaining to drawdown.


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23. Other liabilities

Current Non-current


£000 £000 £000 £000

Deferred Income 13,622 13,336 5,726 6,126

Total 13,622 13,336 5,726 6,126

24. Finance lease receivables (i.e. as lessor) UCLH has an arrangement with PCHA (Paddington Church Housing Association), an organisation which rents four Trust properties. This arrangement falls under a finance lease arrangement, however UCLH receives no rent for these properties.

25. Finance lease commitments UCLH has no finance lease commitments other than those included as Private Finance Initiative contracts (2014: £nil).

26. Private Finance Initiative contracts

26.1 PFI schemes OFF-STATEMENT OF FINANCIAL POSITION Integrated Care Record ServiceIn September 2003, UCLH NHS FT signed a 10 year contract with IDX Systems UK Limited for the provision of an Integrated Care Record Service (ICRS), including delivery of a Managed Service, along with the implementation of a network infrastructure to the new hospital. The total value of the contract is £87m (including Value Added Tax) and has been funded through the Private Finance Initiative.

During 2006/07 UCLH NHS FT was approached by the ICRS partner who wished to transfer their obligations under the 10 year PFI contract. An agreement was reached whereby the main contractual aspects of the ICRS PFI contract were novated to Logica CMG, previously the main subcontractor under the original PFI contract.

In totality, the scheme was proposed to consume assets over its 10 year life of £17.4m. This contract has been assessed under IFRIC 4 to identify whether the arrangement contains a lease. Due to complexities with implementing the solution and the transfer of the contract in 2006/07 it has not been possible to accurately identify and estimate the capital value of any sole use assets. Accordingly, UCLH has not recognised any capital assets in UCLH Statement of Financial Position.

In order to facilitate the implementation of an improved data centre facility UCLH signed a variation to the ICRS agreement during the year to extend the contract by 30 months. The contract will now end in March 2016.

Total Future Off-SOFP PFI payment commitments:

31 March 2015 31 March 2014

£000 £000

Not later than one year 6,056 6,056

Later than one year, not later than five years 0 6,056

Total 6,056 12,112


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26.2 PFI schemes ON-STATEMENT OF FINANCIAL POSITIONUniversity College Hospital – Private Finance InitiativeA contract for the development of the hospital was signed on 12th July 2000, to build and run the hospital. The scheme is in conjunction with Health Management (UCLH) Plc (HMU), a consortium entity. The HMU consortium now consists of Semperian (part of Trillium group), Credit Suisse, Interserve PFI Holdings Ltd and Dalmore Capital.

The scheme is contracted to end on 1 June 2040, at which time the building will revert to the ownership of UCLH NHS FT.

The St Martin site, upon which the hospital has been constructed, was purchased in 2000/01 to provide the site for the hospital. A 40 year lease has been granted to the PFI partners, who contracted to build the hospital.

The new building was handed over in two phases, phase 1 on 19th April 2005 and phase 2 on 5th August 2008. Over the period, we, and our partners HMU Plc, invested £422m in building and equipping the new hospital. A number of existing UCLH NHS FT properties were sold and most of the income invested in the scheme.

UCLH NHS FT is committed to pay quarterly PFI unitary charge payments in advance which commenced with the opening of phase 1 of the development in 2005. This was initially at a reduced rate until phase 2 opened in 2008. After phase 2 was handed over to UCLH, UCLH NHS FT is committed to annual unitary charge building availability payments to the end of the contract in 2040, with the original per annum figure of £27.9m uplifted by the Retail Price Index each year since the opening of the PFI. The total availability fee payable in 2014/15 was £38.8m, of which £31.1m was charged as interest, £3.9m allocated to repayment of capital, and £3.8m payment into the lifecycle replacement fund, which at 31 March 2015 totals £28.4m and which is included in non-current trade and other receivables (2013/14: £25.3m). These costs will be transferred to Property, Plant and Equipment as and when the operator undertakes lifecycle modifications to the asset.

The PFI agreement has been assessed under IFRIC 12 and the asset is deemed to be on Statement of Financial Position. The substance of the contract is that UCLH has a finance lease and payments comprise three elements – imputed finance lease charges, lifecycle fund and service charge.

Total obligations for on-statement of financial position PFI contracts due:

31 March 2015 31 March 2014£000 £000

Not later than one year 20,296 20,296Later than one year, not later than five years 81,186 81,186Later than five years 405,929 426,225Gross PFI liabilities 507,411 527,707

Less: interest element (252,597) (268,906)Net PFI obligation 254,814 258,801

– not later than one year 4,252 3,988 – later than one year and not later than five 25,874 24,266 – later than five years 224,688 230,547

254,814 258,801


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Service commitments

31 March 2015 31 March 2014£000 £000

Within one year 20,058 19,3572nd to 5th years (inclusive) 80,232 77,428Later than five years 404,952 410,156

Total 505,242 506,941

26.3 Charges to expenditure UCLH is committed to the following future annual payments in respect of the on-SoFP and off-SoFP PFI contracts (including estimated energy costs):

31 March 2015 31 March 2014£000 £000

PFI scheme expiry date:Not later than one year 26,114 25,413Later than one year, not later than five years 80,232 83,484

Later than five years 404,952 410,156Total 511,298 519,053

27. Provisions

Current Non-current


£000 £000 £000 £000

Pensions relating to other staff 305 313 1,710 1,725

Legal claims 337 366 0 33

Restructurings 1,095 0 0 0

Other 6,039 3,416 (0) 186

Total 7,777 4,095 1,710 1,944


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Pensions relating to other staff

Legal claims

Restructrings Other Total

£000 £000 £000 £000 £000

At 1 April 2014 2,038 398 0 3,602 6,038

Arising during the year 253 218 1,095 2,422 3,988

Utilised during the year (309) (244) 0 (37) (590)

Reversed unused (3) (35) 0 54 16

Unwinding of discount 36 0 0 (1) 35

At 31 March 2015 2,015 337 1,095 6,040 9,487

Expected timing of cash flows:

- not later than one year; 305 337 1,095 6,040 7,777

- later than one year and not later than five years;

1,221 0 0 0 1,221

- later than five years. 489 0 (0) (0) 489

Total 2,015 337 1,095 6,040 9,487

Staff pensions are calculated using a formula supplied by the NHS Pensions Agency. These pensions are the costs of early retirement of staff resulting from reorganisation. Legal claims are estimates from UCLH legal advisors on employer and public liability claims. The risks are limited to the excess of the policy excesses with the NHS Litigation Authority. Other provisions include provisions for S106 Obligations (£5.4m), HMRC (£0.3m) and FSD Network (£0.1m) The restructuring provision in respect of costs associated with the Cardiac-Cancer realignment £49.4m is included in the provisions of the NHS Litigation Authority at 31 Mar 2015 in respect of clinical negligence liabilities of UCLH (31 March 2014: £51m).

28. Contingencies

In order to obtain planning permission for the new hospital, UCLH NHS FT was contractually bound to deliver several obligations under the Town and Country Planning Act 1990 to provide facilities for the London Borough of Camden. Several obligations have been discharged. UCLH continues to work with the London Borough of Camden to satisfy its remaining Section 106 obligations. One such obligation relates to the provision of affordable housing on the Middlesex Annex site – this obligation contains a clause that under certain circumstances allows the London Borough of Camden to obtain the site for £1. As discussions are progressing, UCLH has assessed the risk of this clause being exercised as possible and as such is disclosing here as a contingent liability.


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29. Financial Instruments

29.1 Financial assetsAt fair value

through Income and Expenditure

Loans and receivables

Total

£000 £000 £000

NHS Trade and other receivables excluding non financial assets (at 31 March 2015)

0 121,050 121,050

Other Investments (at 31 March 2015) 0 2,589 2,589

Cash and cash equivalents at bank and in hand (at 31 March 2015)

0 92,816 92,816

Total at 31 March 2015 0 216,455 216,455

NHS Trade and other receivables excluding non financial assets (at 31 March 2014)

0 83,174 83,174

Other Investments (at 31 March 2014) 0 394 394

Cash and cash equivalents at bank and in hand (at 31 March 2014)

0 129,937 129,937

Total at 31 March 2014 0 213,505 213,505

29.2 Financial liabilitiesAt fair value

through Income and Expenditure

Other Total

£000 £000 £000

Borrowings excluding Finance lease and PFI liabilities (at 31 March 2015)

0 68,989 68,989

Obligations under Private Finance Initiative contracts (at 31 March 2015)

0 254,814 254,814

NHS Trade and other payables excluding non financial assets (at 31 March 2015)

0 131,648 131,648

Provisions under Contract 9,487 9,487

Total at 31 March 2015 0 464,938 464,938


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At fair value through

Income and Expenditure

Other Total

£000 £000 £000

Borrowings excluding Finance lease and PFI liabilities (at 31 March 2014)

0 60,291 60,291

Obligations under Private Finance Initiative contracts (at 31 March 2014)

0 258,801 258,801

NHS Trade and other payables excluding non financial assets (at 31 March 2014)

0 1,234 1,234

Other financial liabilities 0 121,362 121,362

Provisions under Contract 0 6,038 6,038

Total at 31 March 2014 0 447,726 447,726

The fair value of financial assets and financial liabilities does not differ from carrying amount.

29.3 Financial risk managementUCLH’s financial risk management operations are carried out by the Trust’s treasury function, within parameters defined formally within the policies and procedures manual agreed by the Board of Directors. This activity is routinely reported and is subject to review by internal and external auditors.

UCLH’s financial instruments, comprise cash and liquid resources, borrowings and various items such as trade debtors and creditors that arise directly from its operations. UCLH does not undertake speculative treasury transactions.

Currency risk and interest rate risk UCLH is principally a domestic organisation with the majority of transactions, assets and liabilities being in the UK and sterling based. As such, UCLH undertakes very few transactions in currencies other than sterling and is therefore not exposed to movements in exchange rates over time.

UCLH has no significant overseas operations. UCLH has a loan from the Independent Trust Financing Facility (previously known as the Foundation Trust

Financing Facility) with fixed repayments and fixed interest rate. Therefore UCLH’s exposure to interest rate fluctuations is minimal.

Market price risk of financial assets UCLH has no investments in overseas banks. Surplus cash is invested in the Office of the Government Banking Service.

Credit risk Due to the fact that the majority of UCLH’s income comes from legally binding contracts with other government departments and other NHS Bodies UCLH is not exposed to major concentrations of credit risk. UCLH investments in money market funds and money market deposits does expose UCLH to credit risk. This is managed by Treasury Policies limiting the investments to highly rated institutions and spreading the investments to restrict exposure. In 2013/14 no significant deposits were placed outside of the Trust’s Government Banking Service account.

Liquidity risk UCLH has only utilised external borrowings in year associated with its PFI investment and Independent Trust Financing Facility Loan.

UCLH currently has substantial cash balances and is not currently exposed to any liquidity risk associated


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with inability to pay creditors.

30. Financial performance targetsMonitor has revised its financial performance regime and the Prudential Borrowing Code and Financial Risk Rating have been replaced with a simpler Continuity of Services Risk Rating.

31. Related party transactions

University College London Hospitals NHS Foundation Trust is a body corporate established by the Secretary of State. The Independent Regulator of NHS Foundation Trusts (“Monitor”) and other Foundation Trusts are considered related parties.

The Department of Health is regarded as a related party as it exerts influence over the number of transaction and operating policies of UCLH. During the year ended 31 March 2015 UCLH had a significant number of material transactions with the Department, and with other entities for which the Department is regarded as the parent Department of those entities.

During the year none of the Department of Health Ministers, trust board members or members of the key management staff, or parties related to any of them, has undertaken any material transactions with UCLH, where material is defined to be transactions above £2m. UCLH had material transactions with the following entities:

2014/15

OrganisationIncome £000

Expenditure £000

Receivables £000

Payables £000

NHS England 406,000 - 31,000 -NHS Camden CCG 69,000 - 11,000 -NHS Islington CCG 61,000 - 7,000 -Health Education England 45,000 - - -Department of Health 55,000 - 23,000 -Central and North West London NHS Foundation Trust 26,000 3,000 9,000 -NHS Barnet CCG 22,000 - 3,000 -

NHS Haringey CCG 18,000 - 2,000 -NHS Central London (Westminster) CCG 16,000 - - -NHS Enfield CCG 15,000 - 4,000 -NHS City And Hackney CCG 13,000 - 3,000 -NHS Herts Valleys CCG 8,000 - - -NHS East And North Hertfordshire CCG 7,000 - - -NHS Slough CCG 7,000 - - -Barts Health NHS Trust 5,000 - - 3,000 NHS Brent CCG 5,000 - - -NHS Waltham Forest CCG 5,000 - - -NHS West London (K&C & Qpp) CCG 4,000 - - -NHS West Essex CCG 4,000 - 3,000 -NHS Newham CCG 4,000 - - -NHS Redbridge CCG 4,000 - - -NHS Tower Hamlets CCG 3,000 - - -NHS Harrow CCG 3,000 - - -NHS Ealing CCG 3,000 - - -Royal Free London NHS Foundation Trust 3,000 5,000 4,000 3,000 Great Ormond Street Hospital for Children NHS Foundation Trust

- - - 7,000

NHS Hillingdon CCG 2,000 - - -The Whittington Hospital NHS Trust 2,000 - - -NHS Havering CCG 2,000 - - -


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2014/15


Expenditure £000

Receivables £000

Payables £000

NHS Lambeth CCG 2,000 - - -NHS Litigation Authority - 8,000 - -

2013/14


Expenditure £000

Receivables £000

Payables £000

NHS England – Core 420,000 - 22,000 -NHS Camden CCG 66,000 - 10,000 -NHS Islington CCG 58,000 - 5,000 -Health Education England 49,000 - - -Department of Health 43,000 19,000 - -Central And North West London MH NHS Foundation Trust 28,000 2,000 6,000 -NHS Barnet CCG 19,000 - 6,000 -

NHS Haringey CCG 18,000 - 2,000 -NHS Central London (Westminster) CCG 15,000 - 2,000 -NHS Enfield CCG 13,000 - 4,000 -NHS City And Hackney CCG 11,000 - 2,000 -NHS Herts Valleys CCG 6,000 - - -NHS East And North Hertfordshire CCG 6,000 - - -NHS Slough CCG 5,000 - - -NHS Brent CCG 5,000 - - -NHS West London (K&C & Qpp) CCG 5,000 - 1,000 -NHS Waltham Forest CCG 5,000 - 1,000 -NHS West Essex CCG 4,000 - 1,000 -NHS Redbridge CCG 3,000 - 1,000 -NHS Newham CCG 3,000 - 1,000 -NHS Tower Hamlets CCG 3,000 - - -NHS Harrow CCG 2,000 - - -Whittington Hospital NHS Trust 2,000 1,000 1,000 1,000Royal Free London NHS Foundation Trust 2,000 5,000 3,000 3,000Hertfordshire and the South Midlands Area Team 2,000 - - -NHS Lambeth CCG 2,000 - - -NHS Ealing CCG 2,000 - - -NHS Business Services Authority - 9,000 - 3,000NHS Litigation Authority - 8,000 - -Great Ormond Street Hospital for Children NHS Foundation Trust

- 7,000 1,000 -

UCLH is a member of UCL Partners Limited (a company limited by guarantee) acquired by a guarantee of £1. The company’s costs are funded by its partners who contribute to its running costs on an annual basis. During the year UCLH made a payment to UCLP of £0.314m (2013/14: £0.170m) which was expensed to operating expenses.As identified in Investment note 13, UCLH has a 50% share in Radiology Reporting Online LLP (RRO LLP), a limited liability partnership.During the year UCLH received services from RRO LLP of £1.546m (2013/14: £1.702m), which are recorded in operating expenses. Additionally, UCLH provided services to RRO of £0.422m (2013/14: £0.693m) which are recorded in other income.Included within other creditors is the sum of £0.124m (2013/14: £0.139m) representing sums due to RRO LLP.Included within other debtors is the sum of £0.356m (2013/14: £0.127m) representing sums due from RRO LLP.During the year UCLH made payments to HMRC in relation to the Income Tax deducted at source and Social Security costs as per Note 6, and relating to Value Added Tax payments / refunds.Included within Trade and Other Debtors is a VAT debtor of £3.060m (2013/14: £1.914m)Included within tax payable in Trade and Other Creditors is £9.028m owed to HMRC (2013/14: £8.970m)During the year UCLH made payments to the NHS Pension Agency as per Note 6.Included within tax payable in Trade and Other Creditors is £5.655m owed to NHS Pension Agency (2013/14: £5.524m.) Related party transactions were made on terms equivalent to those that prevail in arm’s length transactions


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32. Third Party Assets UCLH held £18,348 cash and cash equivalents at 31 March 2015 (£18,399 at 31 March 2014) in relation to monies held on behalf of patients. This has been excluded from the cash and cash equivalents figure reported in the accounts.

33. Losses and Special Payments NHS Foundation Trusts are required to report to the Department of Health any losses or special payments, as the Department still retains responsibility for reporting on these to Parliament. By their very nature such payments ideally should not arise, and they are therefore subject to special control procedures compared to payments made in the normal course of business.

In the twelve months to 31 March 2015 the value of losses and special payments was £71,000 (2013/14: £1,339,000) relating to 67 cases (2013/14: 354 cases).

Losses and special payments are reported on an accruals basis, and exclude provisions for future losses. Details are shown in the table below

2014/15 2014/15 2013/14 2013/14Total

number of cases

Total value of cases

Total number of

cases

Total value of cases

Number £000 Number £000Fruitless payments 28 6 36 4Bad debts and claims abandoned 0 0 287 1,175Special payments – extra statutory 14 31 14 155Special payments – ex gratia 25 34 17 5

Total 67 71 354 1,339

34. Transfer by AbsorptionThere were no Transfers by Absorption during 2014/15 (2013/14: Nil).

annual report and accounts 2014/15

Documents