1

East of England Ambulance Service NHS Trust

Annual Report 2013/14

East of England Ambulance Service NHS Trust

1

ANNUAL REPORT 2013/14 Welcome by Interim Chair I joined the Trust in March 2014 and my primary aim is to work with the Board to make sure we deliver improved services to patients and better support our staff. Getting to where we need to be is going to take time but we have a plan in place with six very clear priorities which cut to the root of the challenges we face - not enough front line staff and not enough ambulances. The progress we have made in just three months under Dr Marsh's leadership is impressive and it is especially heartening to see the time patients are waiting for an ambulance reducing, but there is still much to be done. When we consider national targets and performance, we will not start to see the rewards of this work until later in the year but it will happen through the Trust pulling together and working towards our common goals. The Board understands the scale of the challenge it faces and is determined to take this Trust forward for the benefits of the public, patients, staff and volunteers. I‟m really pleased to lead the service with Dr Marsh and start to see the fruition of everybody‟s hard work. Sarah Boulton Interim Chair

2

Foreword by Chief Executive, Dr Anthony Marsh Last Spring I was asked to carry out a governance review of the Trust which highlighted the key issues that staff, patients and stakeholders were concerned about: long ambulance responses and back-up delays, sub-standard performance and response times, poor staff morale and a shortage of paramedics. Following that review, I became Chief Executive on 1st January and set the immediate priority for the service to reduce the long ambulance waits some of our patients experience. We are starting to see these delays come down and once we make further progress we will then focus on improving our performance against national standards. To improve our services to all, I have been very clear that we need more paramedics and ambulances on the road and have put in place a number of actions. These have included: Student paramedic recruitment We are recruiting 400 student paramedics and have had a fantastic response with more than 3,500 applications in just over the first three weeks of the advert being published. The first cohort of students started their training in April and will be operational by the end of June. We will also be recruiting qualified and graduate paramedics throughout the year, but it is the student paramedic programme which will significantly boost our front line staff numbers. Upskilling our staff Developing, and investing in, our own staff is extremely important. Therefore we are offering all our emergency care assistants (ECAs) the opportunity to train to become emergency medical technicians (EMTs) and all our EMTs the opportunity to train to become paramedics. Courses for ECAs and EMTs have been underway since February and March respectively, and will continue until complete. Modernising and increasing the ambulance fleet We have launched a massive ambulance replacement programme – 120 new emergency ambulances to replace old ambulances and we have ordered and received another 27 emergency ambulances to boost our ambulance fleet. My aim is to have no ambulance or response car that is over five-years-old and so in 2014/15 we will be ordering another 120 new ambulances to replace old ones. Maximising clinical frontline staffing and ambulances The number of paramedics on secondment has been reduced by approximately 80% so they can return to front line duties. We will continue to reduce secondments and ensure our paramedics are being used to deliver patient care. We have also decreased the number of rapid response cars we use and switched those staff hours into hours spent on ambulances. There is still much work to do which will also take time but we have already taken great strides in moving the Trust forward. I have been hugely impressed with how hard our staff are working to do their best for patients. I am very proud of all our staff. I am also grateful and very appreciative of the support given to me by our staff, managers and stakeholders since I came to the Trust and for the energy that‟s going into making improvements. Please be assured of my continued full support and my determination to do everything I can to support our staff to improve the service. Dr Anthony Marsh Chief Executive

3

Introducing the East of England Ambulance Service NHS Trust About us The East of England Ambulance Service NHS Trust (EEAST) has provided emergency, urgent and primary care services throughout Bedfordshire, Cambridgeshire, Hertfordshire, Essex, Norfolk and Suffolk since July 1st, 2006. Our dedicated and skilled staff work 365 days a year, 24 hours a day to make sure patients receive the best possible care. We have more than 4,000 staff operating from 140 sites and a fleet of 1,000 vehicles. We are supported by more than 1,500 volunteers who provide community first responder and volunteer ambulance car services. The eastern region is made up of both urban and rural areas and we deliver our services to nearly six million people as well as several thousand more tourists who enjoy coming to the area in peak seasons. The emergency 999 service More than 2,000 emergency 999 calls come into the ambulance service every day and are answered and managed in one of our emergency operations centres at Bedford, Chelmsford or Norwich. During each call the staff record information about the nature of the patient‟s illness or injury to make sure that the right kind of medical help is sent to them. Our call handlers use sophisticated software to put the call into a particular category, depending on how urgent the problem is. This allows us to make sure the most seriously ill patients can be prioritised and get the fastest response. Once the category and priority of the patients‟ condition is established, the response will be either an emergency ambulance dispatched on blue lights through to further clinical assessment over the phone for patients with minor conditions which could be advice over the phone from a paramedic or a referral to their GP, pharmacist or local walk-in centre. Not just an emergency service As well as providing the 999 emergency ambulance service, EEAST also provides a range of other services including: Patient transport services and primary care We provide non-emergency patient transport services around the region to take patients who need assistance because of their medical condition or age, from home to outpatient appointments at hospitals or other care centres. This service also provides specialist neonatal transfers between hospitals for babies in need of special care. The Trust also runs the 111 non-emergency health service number in Norfolk and the out-of-hours GP service. Special and partnership operations The Trust operates two hazardous area response teams and has a resilience and emergency planning department who work closely with charities, air ambulance services and community volunteers to respond to a variety of emergency situations. Commercial services The Trust operates a number of services which generate income for the Trust. These include training for blue-light drivers and first aid at work. In addition there is a contact centre and a medical service which cover events, festivals and medical repatriation.

4

Review of the year….and the year ahead Emergency operations When someone calls 999 they are put through to one of the Trust‟s control rooms located in Bedford, Chelmsford and Norwich. They speak to a call handler who records information about the patient‟s illness or injury to make sure the right kind of medical help is sent to them. Given the high volume of 999 calls, the Trust has to prioritise each patient. This is to ensure those with the greatest need get help first. This is done through a sophisticated software system which categorises the severity of each patient‟s condition; there are six nationally agreed categories each with an agreed response target as detailed in the table below.

Category Description Response time and target

Red 1 Patients with potentially life threatening conditions; for example a cardiac arrest

An eight minute response 75% of the time

Red 2 Patients with potentially life threatening conditions; for example a suspected stroke

An eight minute response 75% of the time

Green 1 Patients with serious, but not life threatening, conditions; for example a diabetic condition

An emergency response within 20 minutes, 75% of the time

Green 2 Patients with serious, but not life threatening, conditions; for example a suspected fractured arm

An emergency response within 30 minutes, 75% of the time

Green 3 Patients with non-emergency conditions; for example an overdose with no symptoms

A response within 50 minutes or a phone assessment from a clinician within 20 minutes, 75% of the time

Green 4 Patients with non-emergency conditions; for example someone who has fallen with no apparent injuries

A response within 90 minutes or a phone assessment from a clinician within 60 minutes, 75% of the time

The vast majority of patients do not have life-threatening conditions – more than 60% are non-life-threatening based on the proportion of calls that are categorized as Green. Therefore, for some patients with minor conditions, a paramedic or nurse may treat them over the phone, completing a more in depth assessment to understand what the patient really needs. This may be seeing their GP, visiting their local pharmacy and so on. This means that those patients get the right care for their needs locally, rather than taking them to a potentially busy A&E department when they could be treated closer to home. Crucially it also frees up ambulances for those in the greatest need, giving them a faster response. Performance The most significant challenge the Trust faced during the year were levels of frontline staffing and ambulance cover. Taken together, it simply resulted in the Trust not having enough paramedics or ambulances – we had relied too much on rapid response cars, private ambulance services and holding too many frontline vacancies. As a result, a number of patients have had to wait too long for an ambulance. Since joining in January, Chief Executive Dr Anthony Marsh has made reducing long ambulance delays his number one priority. The Trust did put in place a recruitment programme over the year, but due to the national shortage of paramedics it couldn‟t fill most of the vacancies. As a result, Dr Marsh launched a student paramedic drive in January which received more than 3,500 applications in just over three weeks. In addition, Dr Marsh has put actions in place which have increased ambulance cover, including: returning those front line staff on secondments back to front line duties and reducing the amount of rapid response cars in favour of ambulances.

5

As a result of these actions, the average time it takes to get an emergency ambulance to a patient has fallen, which is shown in figure 1. However, the Trust has not met its national performance targets for response times to red calls as shown in table 1. Figure 1: average ambulance response times for January – March 2014

Table 1: ambulance response time performance

Category/Measure 2012/13 Activity 2012/13 Performance

2013/14 Activity

2013/14 Performance

999 Calls 929,134 912,474

R1 11,634 74.30% 13,093 73.57%

R2 230,295 73.14% 250,695 69.42%

R19 240,537 93.53% 262,270 92.92%

G1 55,356 78.49% 46,954 79.12%

G2 208,229 82.88% 218,592 82.97%

G3 36,992 N/A 31,372 90.72%

G4 105,979 N/A 95,628 92.99%

URG 58,027 66.24% 60,242 75.14%

To improve standards and patient care, a series of interim minimum floor standards have been set. Every occasion were there has been a breach in the floor standard, the incident is reviewed by the clinical directorate and declared a Serious Incident if patient harm has been caused by the delayed response. A report monitoring the number of breaches alongside operational performance is regularly produced and shared with commissioners.

6

The floor targets are:-

Red 1: maximum response time of 30 minutes

Red 2: maximum response time of 40 minutes

Red Transport (the time it takes to get an ambulance to a red call): maximum response time for an ambulance of 60 minutes

Green 1: maximum response time of 60 minutes

Green 2: maximum response time of 90 minutes

Green 3: maximum response time of 120 minutes

Green 4: maximum response time of 120 minutes Performance improvement action plan When Dr Marsh joined the Trust he set six priorities, which form the heart of the performance improvement action plan. These priorities are:

1. Recruit 400 student paramedics in 2014/15 2. Up-skill emergency care assistants to emergency medical technicians (EMT) and

EMTs to paramedics 3. Maximise clinical staff on frontline vehicles 4. Reduce rapid response cars and increase ambulances 5. Accelerate fleet and equipment replacement programmes 6. Reinvest corporate spend in frontline delivery

The full plan can be found at http://www.eastamb.nhs.uk/Performance/performance-improvement-action-plan.htm and is updated regularly. Significant progress has already been made against all the priorities, with nearly 20% of actions complete within the first three months. A summary of the progress made and further work in 2014/15 is detailed below. Priority 1: Recruit 400 student paramedics in 2014/15 The Trust received a massive response to its student paramedic recruitment campaign, with more than 3,500 applications in the first few weeks of the jobs being advertised. The first course began in April and more courses are scheduled to run throughout the year at Trust training centres. The Trust is running more adverts targeted at specific geographical areas to ensure it recruits more staff in the right locations. Students go through an initial eight-week training programme, followed by three weeks of driver and blue light training. It takes between two and two-and-a-half years to complete the training and qualify as a registered paramedic, but in that time they will develop their skills from working at an emergency care assistant level, to an emergency medical technician level through to final registration as a paramedic. Students do a mix of classroom training and learning on the role, overseen by a mentor. All of this feeds into the ongoing assessment programme. Priority 2: Up-skill emergency care assistants to emergency medical technicians (EMT) and EMTs to paramedics Giving frontline staff more skills and career progression is a vital component of the plan to both give better care to patients and improve staff learning and morale. The first 15 emergency care assistants (ECA) have already completed their training to become emergency medical technicians (EMT) and 200 ECAs have passed the assessment to get onto future training courses. In 2014/15 another 60 will be trained to be EMTs with further numbers trained in 2015/16.

7

The first cohort of 25 EMTs are already registered with the University of Northampton and started their paramedic course in March which has been positively received by staff. Priority 3: Maximise clinical staff on frontline vehicles There has been a review of all staff who were seconded in non-patient facing roles. Whilst many were undertaking useful roles, the priority has to be on front-line staffing and so of the 137 originally on secondments, 83 have returned to frontline duties with plans made to return the others as soon as possible. It is not possible to return all secondees as some are undertaking vital roles such as working on the air ambulances as critical care paramedics Priority 4: Reduce rapid response cars and increase ambulances A review was done to identify areas which absolutely need a rapid response car and where the deployment model can be altered so staff can be put on ambulances instead. Locations that need cars are often more rural, where it is important to have an ambulance response in the community to get to patients quickly to start treatment and care whilst an ambulance is on its way. As a result of this work 36 cars remain as “priority cars” with others, which have permanent staff assigned to them on rota lines, only covered when that member of staff is on duty. The remaining staff are all now dynamically deployed on ambulances as priority. Priority 5: Accelerate fleet and equipment replacement programmes The ambulance replacement programme has seen 147 new ambulances coming into service by the end of June. Of these, 120 are replacement vehicles and 27 are an increase in the fleet. An order has been placed for another 120 ambulances which will arrive in the first half of 2015 meaning no ambulance in the fleet is over five-years-old. The vehicle replacement programme timeline is detailed below

The Trust has also bought 68 new rapid response cars which have all-wheel drive, which will all have been delivered by June this year. These cars give the Trust greater resilience when bad weather hits as they will be better able to drive through challenging conditions.

8

Priority 6: Reinvest corporate spend in frontline delivery Having reviewed all the agency and interim staff roles, the Trust has ended a number of interim contracts saving nearly £1 million – money which will be put into frontline services. The structure of the Trust has been reviewed to ensure it is fit for purpose and that support services are efficient and streamlined as possible. This will result in savings in support services and this money will be put into frontline services. The target is to complete the majority of the restructure over the summer. Community first responders (CFR) A community first responder is a volunteer who is trained by the ambulance service to attend emergency calls in the area where they live or work. Their aim is to reach a potentially life threatening emergency in the first vital minutes before the ambulance crew arrives. We have nearly 1,400 CFRs and they play a vital role in saving lives in their community. They are an addition to the ambulance service response. Often CFRs can get to the scene of a patient with a life threatening condition, such as a cardiac arrest, in minutes and start life-saving treatment whilst the ambulance is on its way. Over the past year our CFRs have attended 21,800 emergency calls between them, supporting patients and their relatives and providing life-saving treatment. During the year CFRs have successfully helped resuscitate 75 patients across the east of England. Led by the community partnership team, the volunteers have also been busy promoting the role of the CFR and have attended many events in their communities, to inform and educate people on the importance of basic life support and defibrillation, and also the role of CFRs in the community. We have launched 10 new groups in the region and welcomed them to the family of nearly 280 CFR groups, along with our third RAF co-responder group in partnership with RAF Henlow in Bedfordshire. We have also been working with partners to support the placement of defibrillators across the region as part of a network of defibrillators that can be used by the public at their time of need. This has included working with the East of England Co-operative Society, Bedfordshire Fire and Rescue Service and Bedfordshire Borough Council, Eastgate Shopping Centre‟s Valentine appeal for the schools of Basildon, along with many parish councils and local groups interested in placing the defibrillators within their communities. In the last quarter we gave CFR groups the tools to book on and off duty via text messaging. This will support the control room in knowing where the on duty CFRs are located and enable them to be contacted quicker to mobilise to patients. We have also trained all our CFRs in the administration of Epipens, for patients suffering an anaphylactic reaction, prior to the arrival of the ambulance service. We are extremely proud of our CFRs and would like to thank them for their dedication and commitment to the ambulance service and saving lives. Patient transport services The Trust‟s patient transport services (PTS) are used by people who have scheduled appointments at hospitals or clinics but are unable to make their own way there. The criteria for eligibility to use this service is set by the clinical commissioning groups, not the ambulance service. In 2013/14 the Trust carried out 774,121 contracted journeys, equivalent to more than 2,100 journeys every day across Cambridgeshire, mid and north Essex, Great Yarmouth and Waveney, Norfolk and Suffolk.

9

We use special vehicles to convey patients who are elderly, disabled and frail or with mobility or medical needs. Those who are mobile and able to sit comfortably in a standard saloon car may be taken to hospital by one of our volunteer drivers, known as the Ambulance Car Service (ACS). The ACS plays an essential role in helping us to provide better patient care. Each journey can be stressful for the patient, irrespective of the number of times they visit hospital, so a friendly face and understanding attitude will always put them at their ease. Drivers can become a regular part of someone‟s life, especially for patients who have frequent hospital appointments. For some, the journey to hospital may be the patients‟ only trip out of their house for many weeks, so it is a big responsibility for our volunteers. Contracts for patient transport services are tendered by the local clinical commissioning group. PTS operate in a very competitive market with many private companies bidding aggressively for the business. The Trust believes it is best placed to deliver these services, with dedicated, committed and passionate staff, and it also complements our 999 emergency service. In addition it provides greater resilience to the ambulance service and healthcare response during peak periods (such as winter time), or if a major incident occurs as our PTS staff often provide transport for the walking wounded, ensuring they get to a place of safety and care quickly. Unfortunately, private companies do not provide this resilience as it is often not part of the contracts and the value of this added benefit is not realised until a major incident occurs. During the year, the Trust bid for five contracts in mid Essex, north Essex (for mental health patients), west Essex, Great Yarmouth and Waveney and Norfolk. Three of these contracts were for services already provided by the Trust. The Trust won the Great Yarmouth and Waveney contract but unfortunately lost the other four which went to private companies. The Trust has, and is, providing support to those staff who are transferred across to new providers. The Trust measures what patients think of the service through patient satisfaction surveys. Satisfaction with our patient transport service is extremely high, ranging between 87% and 98% as shown in figure 2.

10

Figure 2: patient satisfaction; % of patients rating the service either satisfactory or very satisfactory

0102030405060708090

100

Patient Satisfaction (%)

Patient Satisfaction (%)

The Trust also uses a number of indicators to measure and monitor the quality of service being given to patients. A number of these are highlighted in the table below.

Area % of patients who were collected within 60 minutes of their booked ready time

% of patients whose GP practice details were recorded

% of patients whose NHS number was recorded

% of vehicles meeting infection, prevention and control standards

Cambridgeshire 95.0% 99.9% 100% 97.3%

Mid Essex 87.1% 100% 100% 99.8%

North Essex 88.0% 100% 100% 99.8%

Great Yarmouth & Waveney

80.9% 100% 99.7% 98.7%

Norfolk 88.1% 100% 99.9% 98.8%

Suffolk 89.4% 100% 100% 98.7%

Notes to the table:

All figures in this table are rounded to the nearest 0.1%.

The „booked ready‟ time is the time hospital wards inform the Trust that patients will be ready to be picked up for their return journey home

The infection, prevention and control target is set nationally at 85% and these figures show how well the Trust performs against such national standards. In 2013/14, the patient transport service maintained its ISO 9001 standards in all areas. This is an auditable quality management system and is very valuable as a demonstration of the quality standards that the Trust set for itself. During the year all frontline PTS staff in Cambridgeshire, Norfolk and Suffolk received training in „first person on scene‟ response. This is designed to prepare staff if they ever find themselves first on scene at a serious incident, as the actions taken early on in an incident will determine the effectiveness of the ambulance and healthcare response.

11

Personal Digital Assistants (PDAs) were issued to all staff in April 2013 to cut down on paper usage, and to give operational crews the most up to date and current information regarding patient journeys. From October, PTS in Essex started managing around four to five patient journeys to hospital a day on behalf of the 999 service. These are not emergency calls but calls made by GPs to request that a patient is taken to hospital in a specific time frame (usually within four hours of the call). Supporting the 999 service by transporting these lower acuity patients means that it frees up ambulances to respond to those in greatest need. Looking ahead, the Trust will bid for PTS contracts which are tendered. The Trust recently bid for the Bedfordshire and Hertfordshire contract and is waiting to hear the outcome of this. To develop PTS and services to patients, some of the highlights of our innovative plans for 2014/15 include:

rolling out new bariatric vehicles

improving our communications with patient by trialing text alerts, so they know what time they will be picked up, and an on-line system so that patients can book themselves ready for collection once their hospital appointment is finished. This will help cut down on wasted journeys and waiting at patient‟s houses when they are not ready

developing inbound screens at hospitals, showing departments and hospital staff the estimated time of arrival of their patients

care bundles developed around the conditions of those patients most frequently transported, so we provide the best possible care for patients as well as giving staff increased skills and training.

Primary care EEAST run the Norfolk 111 non-emergency service and the GP out of hours care. NHS 111 is a telephone service that makes it easier for the public to access health care and information 24/7. It is designed for those people who need medical help, but it is not an emergency. They can get health advice over the phone or be directed to the right local service for their needs - that could be an out-of-hours doctor, walk-in centre or urgent care centre, community nurse, emergency dentist or late opening chemist. The GP out of hours care in Norfolk operates when GP surgeries are closed and provides access to a GP in convenient local bases and clinical telephone triage. Callers are assessed on the telephone by a doctor, and then receive one of the following:

Telephone advice

An invitation to attend a primary care centre

A visit from an Emergency Care Practitioner or nurse

A visit from a GP The Norfolk 111 service was launched in late 2012 and suffered initial challenges around public demand and staffing levels. To address this more staff were brought in and the Trust saw a significant improvement in performance levels. In June the service began to achieve target expectations for the first time and has maintained performance above target since, as shown in the graph below.

12

The high point of the year came during the Christmas period when performance targets were exceeded, thus providing evidence that NHS 111 is of real benefit to the public in Norfolk. Subsequently we are now one of the highest performing 111 sites in the country. By working closely with 999 and GP out of hour colleagues, the patient‟s journey is improved and the local community benefits from this unified approach. One of the main benefits is the added resilience and patient focus by having the 111 centre sitting alongside the 999 control room. This allows the 111 service to support the 999 service in periods of very high demand, ensuring patients receive the correct care at the right time. Our aspiration for Norfolk 111 is to maintain our current position as one of the best 111 services in the country. By continuing to work closely and proactively with our 999 and GP out of hour colleagues the patient‟s journey will become more seamless. The Norfolk GP out of hours service has continued to operate successfully, with a reduction in the number of upheld complaints and a continuing improvement in sickness absence rates. Performance against all standards remained strong throughout the year. Training has been a focus through the year, with drivers getting skid pan and dispatch training. A number of office staff have started NVQs to develop their skills and communications between the teams has been improved. The focus for 2014/15 is to maintain performance and standards, increase the number of doctors working for the service and deliver personal development reviews for all staff. Commercial services The Trust runs a number of services that generate income for the Trust and the 999 emergency service. These services are managed by the Trust as they are extensions of existing activity, such as running call centres. Medical Care Service (MCS) Since its beginnings as a pilot programme two years ago to provide dedicated medical event cover across Norfolk and Suffolk, the scope of MCS has grown rapidly and it now effectively operates as an internal private ambulance service, providing considerable support to the Trust‟s own patient transport and 999 services in Norfolk.

13

The MCS has developed an excellent relationship with commissioners and has won several contracts providing a range of patient transport services that would otherwise have gone to private companies. It also recently won the contract to provide critical care transport for patients from the James Paget Hospital in Great Yarmouth. The MCS business model has proven to be a success within Norfolk. It is financially viable and supports other functions in the Trust which directly results in decreased spend on external private ambulance service providers. The ambition is to replicate this model, where viable, across the region and the MCS team are also looking at how support for the 999 emergency service can be extended and enhanced. For example, MCS is looking at how it can help respond to those patients who have fallen – the largest category of 999 calls. In terms of revenue and financial contribution in 2013/14, MCS significantly exceeded expectations due to a combination of consolidating existing contracts and adding new business from critical care transfers for the James Paget Hospital and event medical cover for Fakenham Racecourse in Norfolk. Commercial Contact Centre This Norwich-based centre offers 24/7/365 call centre services to a large number of NHS and private sector customers. The management team are focused on exceeding customer expectations and this has contributed to the very high level of customer retention and new business development in 2013/14. The team have developed excellent working relationships with customers and especially local commissioners who recognise the high quality service provided. In 2014/15 the first major contract won from outside the region will be delivered. This contract will provide call message handling and referral services on behalf of the Birmingham Community Health Care NHS Trust. This contract demonstrates our ability to offer contact centre services anywhere in the UK, widening opportunities in order to meet ambitious growth plans. In addition to acquiring new business, the focus in 2014/15 is to develop and empower staff. To deliver a very high quality service, there will be an investment in training and the development of a formal Quality Management System. The department will also be rebranded to „CallEAST‟ and will develop a standalone website as part of a wider marketing programme. National Performance Advisory Group (NPAG) The group offers a range of management services to the NHS and the public sector and delivered several major conferences in 2013/14, including the Trust‟s inaugural community first responder conference at Newmarket Racecourse. It also delivered its largest ever conference on behalf of HM Treasury, catering for more than 800 delegates over three days in Brighton. Formal feedback from delegates indicated it was the best conference they‟d ever attended and as a direct result NPAG won the contract to deliver the 2014 conference. This year NPAG continues to grow its training workshop portfolio which includes a suite of occupational health workshops. The „Putting the Patient First‟ workshop, developed in light of the Francis Report, proved to be extremely popular with acute trusts nationwide and NPAG has been developing a new bariatric patient care workshop which is already stimulating considerable interest and will be launched in 2014/15. Additionally, NPAG facilitates more than 20 „best value groups‟ (BVGs) covering a broad spectrum of interest areas to NHS managers, ranging from sterile services to telecoms. Each BVG provides a national forum for managers and their peers to meet, network, critically compare and review services, and seek continuous improvement in terms of quality, fitness-for-purpose, performance and value for money. Membership increased in 2013/14 and the focus for 2014/15 is to start new groups and increase membership subscription revenues.

14

Driver Training Unit For the fourth year running, the Driver Training Unit (DTU) has been awarded an A* rating from accreditation awarding body Edexcel for both the D1 Ambulance Driving and D2 Ambulance Emergency Driving qualifications. In 2013/14 the DTU trained 71 new Patient Transport Service staff to the D1 Ambulance Driving standard as well as 215 candidates for the D2 Ambulance Emergency Driving standard. This included 188 emergency care assistants, two direct-entrant and 23 graduate paramedics, and two external candidates. All of the DTU instructional team are now qualified 4x4 off road instructors and have successfully attained the Driving Standards Agency Approved Driving Instructor qualification. Commercial First Aid Training team This offers a full range of Ofqual-regulated first aid training courses for businesses and individuals, specialising in tailoring courses to specific industry requirements and are members of the National Ambulance Service First Aid Training consortium In 2013/14 more than 3,500 pupils and more than 500 university students were taught by the unit, plus almost 3,000 commercial clients. Feedback from clients has been outstanding and reflects their experiences in learning valuable life-saving skills. Resilience and special operations The Civil Contingencies Act (2004) has been in place for 10 years and has had a significant impact on the UK‟s resilience arrangements, including NHS ambulance services. The key duties that the Trust has to comply with under the legislation are:

• assess and evaluate the risks • compile plans to deal with risks • work with our partner agencies • warn, inform and advise the public • share information between agencies • jointly exercise multi agency plans • promote business continuity.

The Trust‟s compliance is discharged as a Statuary Ambulance Service. This happens through multi-agency work (national, supra-regional and local resilience fora), and a clear audit trail of appropriate decisions and actions is held and regularly updated. The Trust also complies with the legislation through its resilience arrangements which manages these processes and are internally scrutinised by the Executive Team. The major incident, business continuity and pandemic influenza plans are revised, scrutinised and tested and are reviewed and approved by the Trust Board every year. The Board also receive an update on the Trust‟s compliance with the CCA and NHS England Framework for Emergency Preparedness Resilience and Response (EPRR) (2013). Under the CCA and NHS EPRR Framework, the Trust completes a three-yearly multi-agency live exercise. This was held last April with a large scale exercise focused on a rail crash and involved a range of partners including fire, police, local authorities, RAF and the voluntary sector. The Trust also takes part in local multi-agency exercises and regularly test its communication processes. This, together with the National Ambulance Resilience Unit (NARU), in creating standard national ambulance documentation ensures that EEAST fulfils its requirements under the CCA and NHS England Framework.

15

Major incidents The Trust has managed and coordinated the response to a number of major and significant incidents in 2013/14:

• Adverse weather and flooding in January and February 2014 • M11 coach crash in Cambridgeshire in July 2013 • East coast tidal surge in December 2013 • USAF helicopter crash in Norfolk in January 2014 • Gas explosion in Clacton in February 2014

The Trust response to chemical, biological, radiological and nuclear (CBRNE) The UK faces a sustained period of significant terrorist threat and the Trust actively ensures that it can respond to any such emergency. Our specialist vehicles enable the Trust to provide national mutual aid support if required whilst maintaining a response within the region. Air operations and charity partners The Trust uses five air ambulances thanks to its charity partners – the East Anglian Air Ambulance, the Essex and Herts Air Ambulance and Magpas Helimedic. The East Anglian Air Ambulance has one helicopter flying into the early hours of the morning, the first time the region has had an air ambulance operating at night time. Three volunteer doctor-led support teams provide expert care and treatment to patients who are suffering extreme trauma or have challenging conditions to manage before stabilisation and transporting to hospital. These include the Suffolk Accident Rescue Service, Norfolk Accident Rescue Service and Basics Essex Accident Rescue Scheme. The Trust has a 24/7 critical care desk which manages the deployment of specialist response units such as air ambulances and the air operations team work with all these charity partners to promote the value of immediate and specialist care support at incidents within the region. Hazardous area response teams (HART) HART was launched in 2007 to enable ambulance staff to treat patients in the most difficult circumstances, such as a collapsed building or major incidents. Historically, treating such patients did not start until after the fire and rescue service had brought them out of the inner cordon to the ambulance staff. Specialist training and equipment has given HART staff the ability to work alongside fire and police colleagues and reach patients who are in hazardous environments, confined spaces or trapped at height to give life-saving treatment and care at the point of harm. The Trust now has two HART teams, located in Cambridgeshire and Essex, which are sent to specialist incidents allowing regular ambulance crews to be released from protracted calls, as well as ensuring medical care can be delivered to those in need within a hazardous environment. In October, the second HART base in Great Notley was officially opened by local MP Brooks Newmark. The HART teams have attended a wide range of incidents in the last year, including providing dedicated teams to support the delivery of care to patients in and around water during and following the east coast surge flood in December, and a building explosion and collapse in Clacton where the team worked with Essex Fire and Rescue Service to ensure there were no patients trapped and injured in the building. Business continuity During 2013/14 the Trust started aligning its Business Continuity Management System to the new international standard the ISO 22301:2012 Business Continuity Management Systems Requirements. This work will be completed in 2014/15, and in October a review by other ambulance service business continuity leads confirmed the Trust is well placed to achieve this objective.

16

All departments are focussed on supporting the four prioritised Trust activities of call handling, triage, treatment and transport. The Business Continuity Policy and Process is reviewed and agreed annually by the Board. During 2013/14 the Trust suffered a significant software failure; however its business continuity processes ensured that the Trust could function at an acceptable level which ensured patient safety was not affected. Engaging with partner agencies The Resilience and Special Operations Unit works closely with a range of stakeholders to ensure a joined up approach to emergency planning and resilience. Last May, the team hosted its fourth multi-agency resilience awareness day, with guests attending from local authorities, NHS England, clinical commissioning groups, hospitals, emergency services and other partner agencies. This gave them the opportunity to understand the type and extent of equipment and specialist medical provision provided by the Trust for major incidents. The Trust also works closely with voluntary aid agencies and holds an annual networking event for them, hosted by the Trust. We also completed an innovative project with the British Red Cross which will provide additional support to our Specialist Operations Response Team. Training and exercising The Trust has a Specialist Operations Response Team (SORT), made up of volunteer staff. This team provides a specialised emergency response to major incidents involving hazardous materials. To ensure the team is prepared for any eventuality, the Trust has monthly training in place. The Resilience and Special Operations teams provide a range of training in command and control, major incidents and continuing professional development (CPD). All competency-based training courses align with the national occupational standards and have been accredited by both the Emergency Planning Society and Institute of Civil Protection and Emergency Management. The Trust is currently working towards achieving academic accreditation with Loughborough University. The loggist courses have proved extremely successful and have been provided to a range of other agencies including St John Ambulance, Chief Fire Officers Association and NHS Trusts. This course is now seen as essential for all managers and support staff who may be called upon to act in this role. The CPD training for all operational staff has included elements of CBRNE and a personal workbook looking at all aspects of resilience. We pioneered the use of video for the CPD session ensuring consistency of delivery and have also launched e-learning via the Trust intranet. Debriefing The Trust has fully integrated its system of debriefing following major incidents and exercises which produce a report and a subsequent action plan from any learning points. This is tabled at both the Resilience and Special Operations monthly meetings and is posted on the Intranet for staff to see. Fleet, estates and equipment The operations support team ensure that frontline staff have the ambulances, equipment and premises to deliver the best possible care to patients.

17

Fleet It was a busy year for the fleet team as they started an ambitious programme to modernise the fleet to get to a point were no ambulance or rapid response car is older than 5 years by end of March 2015. This saw the team procuring 147 new ambulances, which will all be delivered by June 2014. 120 of these are replacement ambulances, to replace old ambulances and the remaining 27 are additional to the fleet to help improve ambulance cover and availability. Another 120 new ambulances have been ordered to complete the ambulance replacement programme and these will be on the road by the end of March 2015. The Trust also ordered 110 new rapid response vehicles. This will help improve our service to patients, especially when we experience ice and snow as these cars are all wheel drive. By the end of the financial year 42 had already been delivered and were on the road, with the remaining cars due to be on the road by June. The Trust also introduced 12 4x4 Landrover Freelanders to the fleet, again to build resilience for adverse weather conditions. All new vehicles are being fitted with vehicle telemetrics. This will allow the fleet department to monitor the performance of vehicles and identify earlier issues that may need to be resolved. As part of the team‟s carbon reduction work, a Hybrid vehicle was introduced to stores, which uses the same energy recovery systems as Formula 1 cars. The team are assessing the benefit of this type of vehicle especially in terms of suitability, fuel consumption and carbon reduction. Estates Over the past 2 years we have invested £1.5M in new UPS and standby generation systems to ensure that the power supply at each control room site is resilient. We have also invested in ambulance stations to ensure clinical spaces comply with infection, prevention and control requirements. In 2013/14 the Trust invested more than £250,000 in energy conservation schemes, ranging from low energy lighting and high efficiency boilers to photo-voltaic electricity generation schemes to help in the Trust‟s carbon reduction plans. The Trust now has over 230kW of installed renewable generation, providing almost 200,000 kWh of energy per annum. The Trust is currently looking to relocate its ambulance station at Chelmsford, giving staff a better facility to work in and a more optimum point to deploy ambulances from. It is anticipated this will be operational in 2015. We have also accepted an offer from Hertfordshire County Council for its leasehold interest in the St Albans ambulance station and work has started to identify a replacement site, which will provide a significantly better ambulance station. Based on a 2013 conditional appraisal, we estimate that 40% of our estate is below an acceptable condition. To address this, we are continuing to develop our backlog maintenance programme which will run over the next five years. This will increase the functional suitability of the existing retained estate in line with the following milestones:

75% of the estate to be in category B or above by 2015

90% of the estate to be in category B or above by 2017 Going forward, we will continue to strive for further estates efficiency by:

continuing our ongoing review of space utilisation within our current estate with the objective of achieving a suitable balance between the size of the estate, operational efficiency and encouraging modern working practices

investing in energy conservation technologies and a programme of staff awareness to support our wider carbon reduction programme

working to reduce the current level of building related energy consumption (48GJ/100M³) over the next five years, in line with the following milestones:

o <42GJ/100M³ heated volume of the estate by 2015 o <35GJ/100M³ heated volume of the estate by 2017

18

Medical equipment A major project was undertaken to select the next generation of 12 lead cardiac monitor defibrillators, a vital piece of equipment in helping to save lives. As a result, 160 units have been procured at a cost of nearly £3 million with a further 250 units due to be bought in 2014/15. This gives the Trust state of the art, modular and lightweight defibrillators which will enable our staff to give even better care for their patients. Clinical Engineering, as the Trust‟s new in-house provider of support to medical devices, completed its first year of operation. It has made significant improvements in ensuring our equipment is serviced to time and promptly repaired when any medical device goes wrong. During the inspection by the Care Quality Commission (CQC) in December a number of ambulance stations, vehicles and items of equipment were audited. The CQC found that the equipment was fit for purpose and within service date. The CQC also received positive feedback from staff on the system for getting equipment repaired through Clinical Engineering. Research and development Research helps the NHS to improve the current and future health of the people it serves. It is essential in successfully promoting health and plays a major part in continuing to improve the services and supporting safe and effective care. It identifies new ways of preventing, diagnosing and treating conditions. Twenty patients and 16 staff were recruited in 2013/14 by EEAST to participate in research approved by a research ethics committee. Accruals to research during 2013/14 arose partly from Trust participation in four projects on the National Institute for Health Research (NIHR) portfolio in different medical specialties. These were:

ATLANTIC: a 30-day study to evaluate efficacy and safety of pre-hospital versus in-hospital initiation of ticagrelor therapy in STEMI patients planned for percutaneous coronary intervention

a study of major system reconfiguration in stroke services

identification of emergency and urgent care system characteristics affecting preventable emergency admission rates

evaluation of the implementation and health-related impacts of the national cold weather plan for England

The Trust also participated in two Collaborations for Leadership in Applied Health Research and Care (CLAHRC) projects. One was a staff-related study focusing on hospital admission close to the end of life. The other looked at the use of the ambulance service by people with dementia. In addition, Research Support Services (RSS) supported a number of smaller-scale student level projects being undertaken by staff. Continued participation in such clinical research activity has demonstrated the Trust‟s on-going commitment to improving the quality of care offered and making a contribution to wider health improvement. Indeed, research findings are regularly used to inform clinical service developments where such evidence is available. An awareness raising event was organised in response to the NIHR „OK to Ask‟ campaign and literature and emerging research evidence are made available to staff through the Trust‟s intranet. Two managers are being supported by RSS to undertake on-line research skills modules, and one manager has won a CLAHRC Fellowship.

19

The RSS activity was supported by funding from the three Comprehensive Local Research Networks in the region and through recruitment of subjects to portfolio studies where applicable. Looking ahead, the Trust will continue to submit research bids for external funding, which if successful will entail the Trust sponsoring research for the first time. Financial performance The Trust had an annual turnover of £238m in 2013/14, which has increased from the previous year by £2m. Although we provide a range of services to non-NHS organisations, the majority of our income comes from within the NHS. The Trust delivered its financial performance targets meeting all its statutory financial duties: Breakeven, External Financial Limit and Capital Resource Limit. Plans submitted to NHS Trust Development Authority were used for monitoring the Trust‟s financial performance during the year. The Trust reported a retained deficit after impairments of £2,525,000; the adjusted surplus was £379,000 after excluding the impairment of £2,904,000 for the year ending 31 March 2014, compared to a reported surplus in 2012/13 of £4,175,000. The Trust also ended the year with a strong cash position of £18,048,000 as demonstrated in the Statement of Cash Flows.

20

Sustainability report

During 2013/14 the Trust has been working through year two of its Sustainable Development Management Plan (SDMP). The SDMP is focused on six action plans: Travel, Procurement, Facilities Management, Workforce, Community Involvement and New Buildings. By implementing these plans we are committed to become more sustainable over a five year time frame.

Sustainable care models Our Trust strategy aims to provide a service which is more tailored to individual patients‟ clinical needs by providing an alternative to an emergency ambulance response. This may be in the form of telephone advice, a visit from a specialist falls car service or being directed to a different service based closer to a patients home.

This strategy is not only making us more sustainable in delivering our services, but it is more sustainable for the wider health economy, patients and staff. It gives patients more focused and appropriate care, reduces inappropriate transportations to hospital (which in turn reduces the pressure on hospital resources) ensuring more care is provided closer to patients‟ homes, and frees up emergency ambulances to respond to those with the greatest needs.

The Commissioning for Quality and Innovation (CQuIN) scheme promotes sustainable initiatives. In 2013/14 eight of the Trusts CQuINs could be directly linked to sustainability:

CQuIN Scheme Contribution to Sustainability

Dementia Pathway Improve care for patients with dementia through referral

to dementia care pathways

Reduced resource deployment Reduced hospital conveyances Reduced hospital admissions Improved patient experience

Improved access to Alternative Care Pathways We will work with the CCGs to set up and implement a

maximum of three new pathways per CCG cluster

Reduced resource deployment Reduced hospital conveyances Reduced hospital admissions

Wound Care Introduction of basic wound closure skills (use of Steri strips and glue) for Paramedics with six months post

qualification experience

Reduced resource deployment Reduced hospital conveyances

Improved patient experience through treatment at scene

GP Urgents Improved management of GP urgent patients by

identifying alternative appropriate transport

More appropriate and efficient use of transport

Schools and University Education Implement a scheme in selected education institutes to

raise awareness of the ambulance service

Improved public education and health promotion, resulting in potential

reduction in demand

Mental Health (MH) Partnership working with local mental health

organisations and the development of MH referral pathways

More efficient use of resources across the health economy

Reduced hospital conveyances Reduced hospital admissions

Frequent Caller Unit To improve the management of those patients who are

deemed as “frequent callers”

Reduced hospital conveyances Reduction in number of times a patient

might fall = improved lifestyle

Specialist Paramedics To provide additional training to support paramedics

with tools and increased confidence in decision making to increase the number of clinically appropriate non

conveyed patients

Reduced hospital conveyances Improvement to Paramedic job quality

and satisfaction

21

Communicating with Staff and our communities Over the last year the Trust has developed and integrated digital communications to enhance how it engages with staff, volunteers, the public and stakeholders. This has included the establishment of „virtual crew rooms‟ on Facebook for operational staff in each county, the launch of a „Flickr‟ account and better integration of messaging across channels. The Trust has also been promoting the valuable role its volunteers play through promoting their activity and opportunities to become a community first responder in the media, through social media channels and at the annual public meeting. Those volunteers who had served for more than 10 years were also invited to attend the Trust‟s long service awards to recognise their dedication and achievement. The Trust has been promoting its work around sustainability and how staff can make small changes, both in and out of work, that have a big positive impact on local communities. As the Trust develops its internal communications it will embed sustainability messages even further. Investing in our staff Our Occupational Health Department have been working towards the Department of Health‟s

Responsibility Deal pledges, which encourage organisations to commit to playing their part in

improving public health. In 2012/13 the Trust signed up to three health at work pledges and

have continued through 2013/14 to build on its commitment to encourage our workforce to be

as healthy as possible.

The three pledges we are working towards are listed below, with a brief description on how they

support sustainability.

Health at Work 2: We will use only occupational health services which meet the new

occupational health standards and which aim to be accredited by 2012/13.

The health and wellbeing of our workforce is crucial to the delivery of the improvements in

patient care. By raising the standard of our occupational health provision and continuing our

commitment to health and wellbeing internally, staff will be fitter, healthier and more engaged.

The Trust carried out a formal tender process to find an accredited provider who has

successfully achieved the required standards. This exercise was completed in June 2013 and

the new provider commenced work with the Trust in August 2013.

Health at Work 3: We will include a section on the health and wellbeing of employees within our

annual reports and on our staff intranet site.

Monitoring trends in causes of staff sickness provides a means for identifying areas of concern

and taking proactive action to prevent staff from becoming unwell. Over the past year there has

been a dedicated sickness „taskforce‟ who have been working within operations to establish

and sustain a reduction in sickness absence. Health and wellbeing forms a section within our

Annual Report and the staff intranet contains a specific section on health and wellbeing.

Health at Work 5: We will encourage staff to stop smoking, by facilitating onsite stop smoking

support services. We will also take action to reduce other risks to respiratory health arising in

the workplace.

All Trust sites are declared as non-smoking areas and our No Smoking Policy informs staff that

non-smoking is the expected standard for employees on Trust premises.

In January 2014 our Occupational Health provider began their proactive wellness programme,

holding a number of health fairs at stations around the Trust. These will continue throughout

2014 and include carbon monoxide testing and smoking cessation support.

22

Annual carbon (CO2) emissions report

The NHS aims to reduce its carbon footprint by 10% by 2015. The Trust has set a challenging target of a 30% reduction on 2010 emissions by 2015. Our Carbon Management Plan (CMP) sets out five annual savings targets, of which 2013/14 is year three, with a planned in year saving of 3,668 tonnes of carbon dioxide (tCO2).

In 2013/14 our carbon footprint increased by 595 tCO2.

Carbon Emissions Summary Actual Change on 2012/13

Actual

Report 2013/14 2013/14 2012/13* 2011/12 2010/11

tCO2 tCO2 % tCO2 tCO2 tCO2

Stationary Energy 5,216 -7 -0.1% 5,223 4,909 5,249

Further Sources

Waste (Landfill) 52 11 26.8% 41 38 119

Water 15 0 0.6% 15 13 12

Vehicles

Fleet 15,786 552 3.6% 15,233 15,122 13,546

Staff Business 1,089 -6 -0.6% 1,095 887 960

Outsourced (PAS/VAS) 1,104 45 4.2% 1,060 877 502

Total 23,262 595 2.6% 22,667 21,845 20,389

* The 2012/13 figures have been restated in 2013/14. This is due to a small number of stations where gas usage is estimated being excluded from the original figures.

Although our footprint increased, we did implement and complete projects during the year

which are calculated to save 1,068 tCO2. This was 29% of our planned target. The reasons why

the footprint still increased include: increased staff numbers and kilometres travelled, estate

growth and staff utilisation of the estate.

Within the CMP are three significant projects which were planned to deliver over 80% of the

annual savings. These are in two areas:

- Advanced Clinical Triage (ACT) which delivered 25% of its target. When initially set up this

project was forecast to be working at a much higher capacity. It has now been scaled down

and will not achieve the future planned savings leaving 4,610 tCO2 of savings at risk over

the next two years.

- Through driver awareness training and monitoring and vehicle speed limiters 1,907 tCO2

were forecast to be saved. All new drivers receive Eco driver training and the facility to limit

vehicle speeds (when not travelling on blue lights) and monitor driver behaviour is installed.

The plans originally were considered ambitions and the Trust has so far not been able give

all drivers Eco training. It is expected that savings will be made in future years as this is

rolled out and implemented fully.

Stationary and estate, utilities, waste & Information Technology On the positive side, our stationary emissions have decreased by 7 tCO2, and water usage

remained constant, despite an increase in estate floor area of 1% and staff numbers by 2.9%.

Our Estates team undertook carbon reduction work during the year which should save almost

£38,000 and avoid release of over 180 tCO2 into the atmosphere each year. This work included:

- Significant lighting improvements on two of our largest sites;

- Implementing energy usage controls at our Melbourn site (this alone is forecast to save

£12,400 annual energy spend with only a 2.74 year payback, and 58.8 tCO2 annual

saving).

23

- Increased numbers of boiler replacements across the estate.

- Installation of a 30kW Photo Voltaic array at Cromer.

The Information Technology department are continuing to roll out new virtualised servers which

run at a reduced energy rate. They are also installing the Lync system on computers which will

enable staff to call and host meetings virtually, rather than travelling around the region, saving

fuel emissions and staff time.

Vehicles Although total vehicle emissions continue to rise, it is encouraging to see that staff business travel is reducing. This means that not only are staff reducing emissions, but as a result of spending less time in their vehicles, they are more productive for the Trust.

Carbon Management Plan Key Performance Indicators (KPIs):

Ref KPI Title Unit 2013/14 2012/13* 2011/12

CMP1 Absolute carbon tonnes tCO2 23,262 22,667 21,845

CMP2 CO2 footprint against baseline year +/- % 14% 11% 7%

CMP3 Distance from CO2 annual target** +/- % -16% -38% -421%

CMP4 CO2 footprint per whole time equivalent tCO2 6.2 6.2 6.0

CMP5 Stationary emissions per estate floor area tCO2 m2 0.11 0.11 0.10

CMP6 Vehicle Emissions per km travelled kgCO2 km 0.4 0.4 0.4

CMP7 Total Vehicle Emissions per EO vehicle tCO2 32.5 32.6 40.1

* The 2012/13 figures have been restated in 2013/14. This is due to a small number of stations where gas usage is estimated being excluded from the original figures. ** 100% = all savings made, 0% = no savings made, -% = increase in emissions.

The set of KPI‟s allows us to measure our emissions against our statutory baseline requirements and our changing resource levels. In CMP2 we have increased emissions against the baseline year by 14%. This is mainly due to our front line fleet increasing the number of kilometres travelled by 2.3 million on the prior year. CMP7 is reporting that emissions per vehicle have actually decreased marginally, as a result of an increase in newer vehicles which are more CO2 efficient. It should be noted that CMPs 4 and 5 have remained constant even with a growth in estate and staff numbers. This is testament to our estate team improving the efficiency of our buildings‟ lighting and heating, and implementing green energy sources. These elements keep emissions down despite the increase in size and use of the whole estate.

For 2014/15 and beyond the Trust is increasing front line staff and vehicle numbers. This will have a direct impact on the CO2 footprint. Without the implementation of those projects mentioned earlier, the Trust will not meet its challenging 30% reduction target. The statutory 10% target is also considered at risk.

Carbon Reduction Commitment The Carbon Reduction Commitment Energy Efficiency Scheme is a mandatory scheme aimed at improving energy efficiency and cutting emissions in large public and private sector organisations. The Trust does not qualify for the scheme; therefore our gross expenditure during 2013/14 was £0.

24

Adaptation The preparation of an adaptation plan for the Trust is documented in the SDMP. We are working closely with other ambulance trusts to develop a consistent approach, as well as other local adaptation networks to ensure local issues are considered. A final adaptation plan is forecast to be in place by the end of March 2015.

25

Caring for patients 2013/14 Quality Priorities Summary Review The Quality Account reflects on the progress made during the previous year and identifies EEAST‟s priorities for the coming year. The Trust‟s priorities for 2014/15 have been set to ensure that its standard of clinical quality is high, that patients are seen promptly, treated effectively and are satisfied with the service that they receive from staff. Core priorities for 2013/14 In 2013/14, 22 priorities were identified for the service; the Trust is pleased to report that it has seen improvement across a wide range of these. In particular it has made some significant clinical improvements which have had a positive impact on both patients and staff; including the introduction of wound closure skills to paramedics, the development of the clinical record viewer to support Hear and Treat clinicians, and recognition of the Trust‟s dementia pathways as best practice. EEAST has made strides in its drive to recruit more paramedics and put more ambulances on the road; with 27 additional emergency ambulances delivered and in use, having shortlisted over 1,000 student paramedic applications, and successfully training the first cohort of emergency care assistants on their six week conversion course to emergency medical technician. However there are areas in which the service failed to make the improvements it wanted, most notably in meeting time performance standards. This year, the Trust‟s core priorities will reflect this and focus on meeting these targets, and improving both the quality of care and speed of response to patients. Core priorities for 2014/15 The Trust has seen significant changes within the last year and acknowledges that the ambitious 22 quality priorities set have been challenging to meet. To reflect the work the Trust needs to do in the coming year to stabilise and meet the needs of patients we will be focussing on a reduced number of core priorities which match the mandatory indicators for ambulance Trusts set by the Department of Health. The areas covered will include:

Category „A‟ ambulance response times: preventing people from dying prematurely (domain 1)

Patients with a pre-hospital diagnosis of suspected ST elevation myocardial infarction who received an appropriate care bundle: preventing people from dying prematurely (domain 1), helping people to recover from episodes of ill health or following injury (domain 3)

Suspected stroke patients assessed face to face who received the appropriate care bundle: preventing people from dying prematurely (domain 1), helping people to recover from episodes of ill health or following injury (domain 3)

Percentage of staff who would recommend the provider to friends or family needing care: ensuring people have a positive experience of care (domain 4)

Rate of patient safety incidents and percentage resulting in severe harm or death: treating and caring for people in a safe environment and protecting them from avoidable harm (domain 5)

26

These map to seven priorities that the Trust will set for 2014/15, which include the treatment of sepsis patients for which the Trust is involved in national improvement work, as follows:

Timely Response

Stroke Care

Friends and Family

Frequent Callers

Cardiac Arrest Care

Sepsis Care

Heart Attack Care

2013/14 Quality account summary Timely Response Rationale: Ambulances services are required to meet response time standards for 999 calls coded as life threatening. Faster response times improve health outcomes and experience for patients with immediately life-threatening conditions. The Trust failed to meet this target in both 2012/13 and 2013/14. We are aware through feedback and complaints that patients who are non life-threatening have had increased waiting times for an ambulance also. Improvement: The Trust aims to see a specific improvement in the longest waiting time for these indicators, hence the introduction of maximum response times. This means that less patients will have long delays for an ambulance response than in the previous year. This will improve the time taken to get patients with life threatening conditions to hospital. Benefits for non-life threatening patients are expected to include a decreased amount of time spent on the floor for those patients that have fallen and therefore reducing the potential for avoidable pressure ulcers occurring.

27

Baseline: 2013/14 end of year performance for Red 1 is 73.6% and for Red 2 is 69.4%. Based on provisional data for 2013/14, of the nine performance (time based) indicators for green and urgent calls, the Trust has met eight of the required standards. All of the Green indicators have been met and these include emergency responses within 20 or 30 minutes and also telephone based assessment for those calls not requiring an ambulance response. 2013/14 has proved a challenging year for the Trust. In the last quarter, six key objectives were set out by new Chief Executive Anthony Marsh. One of these objectives implemented in January was the reduction in rapid response vehicles and an increase in the number of ambulances. Whilst performance has not been achieved against the national standards, this action has resulted in reduced waiting time for ambulances and therefore is a key element of patient safety. In 2014/15 the focus will be in a sustained reduction in ambulance waiting times alongside a continual improvement against the national standards from the last quarter 2013/14 baseline. This is reflected in the revised indicators for 2014/15 as described below. Goal: To improve the response times to patients for the most life-threatening call categories. The Trust is committed to improving performance against national targets and has also committed to meeting local quality indicators for non life threatening calls. As part of its commitment to improving performance against national standards, the Trust has agreed a series of maximum response standards for 2014/15. These will be monitored from April with a target applied from October. In effect, these replace the percentile measures for 2013/14. Sepsis Care Rationale: Sepsis claims the lives of over 37,000 people in the UK, which is more than lung cancer and more than breast and bowel cancer combined. The estimated cost to the NHS for sepsis is around £2 billion annually for treatment. During 2013/14 The Trust worked in partnership with other health care providers to improve outcomes for septic patients. It is shown in recent research that early recognition of the signs and symptoms of sepsis will save lives, possibly as many as 12,500 per year in the UK. Neutropenic sepsis is a significant cause of death for cancer patients receiving chemotherapy and causes delays and changes to planned treatments. In England and Wales, relative to the increasing number of cancer diagnoses, the proportion of deaths due to neutropenic sepsis continued to rise for all age groups between 2001 and 2010. Recent NICE guidance recognises neutropenic sepsis is a medical emergency that requires immediate hospital investigation and treatment and recommends improving the clinical care pathways of cancer patients undergoing chemotherapy, immediate access to antibiotics and appropriate healthcare staff training. Baseline: We are currently seeing approximately 70-90 cases across the region per month where our clinicians have recognised sepsis and the patient‟s condition has warranted hospital admission, equating to a recognition rate of approximately 75%. Goal: The Trust intends to increase the number of sepsis cases our clinicians recognise and record to 85%. Improvement: We will continue to increase the awareness and delivery of the sepsis 6 care bundle and neutropenic sepsis thus giving our patients the very highest standards of pre hospital care.

28

Frequent Callers Rationale: A frequent caller is defined as someone who calls 999 regularly and contact with the ambulance service can range from daily calls to multiple calls within a month. A frequent caller should not necessarily be considered a nuisance caller, many suffer from long term conditions which may necessitate more regular contact with the service. These calls only represent a small number of the Trust‟s overall call volume but can make it more challenging to deal with those patients who have serious, life-threatening emergencies. An alternative way to manage these patients, who will invariably have complex health and social care Needs, is required which will necessitate us working closely with other health care partners. Baseline: Currently Ambulance Quality Indicator (AQI) measures the number of frequent callers as a percentage of all calls received. Each ambulance service has its own definition of a frequent caller and can manage them locally as they see fit. This leads to huge variations between ambulance trusts and the data cannot be compared fairly. The Frequent Caller AQI guidance is currently under review and it is expected it will recommend and introduce improved and comparable frequent caller national reporting parameters. The baseline will be defined during the year when these new reporting processes are in place. Goal: To increase the number of patients with a locally agreed frequent callers procedure in place by working in partnership with the patient‟s other health and social care providers. Improvement: If patients are identified, the patient‟s GP details will be obtained and call volume details recorded via an established format and made available to the patient‟s GP. If the patient is not registered with a GP, the local commissioning group or other relevant agency will be approached. The Trust should provide quarterly analysis relating to management plans in place for patients identified as frequent callers. Heart Attack Care Rationale: Most deaths from heart disease are caused by a heart attack in the UK and someone dies every seven minutes from a heart attack. Around 103,000 heart attacks occur each year, with some people having more than one. Approximately 50,000 of those heart attacks are suffered by men and around 32,000 by women. The British Heart Foundation also estimates that one in three people die of a heart attack in the UK. This is why the care in the pre-hospital arena is vital. Most heart attacks are caused by coronary heart disease which is when the coronary arteries narrow due to a gradual build up of atheroma (fatty material) within their walls and a piece breaks off leading to a blood clot. A heart attack is life threatening and by providing patients with a pre-hospital assessment for a STEMI and administering an appropriate care bundle a significant improvement on patient outcomes will result, thereby supporting the NHS to reduce the number of patients dying prematurely and to help people to recover from episodes of ill health or following injury. In particular working together for patients as the patient care pathway crosses organisational boundaries and requires robust systems in place to ensure patient handovers are safe. Baseline: The Trust already measures the AQI‟s for the percentage of patients suffering a STEMI who are directly transferred to a centre capable of delivering PPCI and angioplasty within 150 minutes of call and the percentage of patients suffering a STEMI who receive an appropriate care bundle. The baseline figure for STEMI 150 in February 2014 is 88.6% and the care bundle is 85.4%. Goal: The Trust intends to achieve 95% PPCI within 150minutes and 87% STEMI care bundle compliance.

29

Improvement: To reduce the on scene times for those patients who are having confirmed STEMI and to continue to give high standards of care to those patients experiencing cardiac chest pain. Cardiac Arrest Care Rationale: Around 30,000 people each year in the UK have cardiac arrests in the pre-hospital environment – less than 10 per cent of these people will survive to be discharged from hospital according to data from the Resuscitation Council UK. Evidence shows that around two thirds of cardiac arrests that occur outside of hospital occur in the home, and that nearly half that occur in public are witnessed by bystanders. With each minute that passes in cardiac arrest before defibrillation, chances of survival are reduced by about 10 per cent. Immediate CPR in a shockable pre-hospital cardiac arrest can improve the chances of survival by up to a factor of three. The British Heart Foundation has a campaign to train members of the public in emergency life support in an attempt to train young people to deal with cardiac arrests and to get it as part of the National Curriculum in England and for Government to include skills training as part of the National Citizen Service Baseline: Previous years‟ figures for return of spontaneous circulation (ROSC) and „survival to discharge‟. Goal: To improve our outcomes from cardiac arrest and work towards an increase in our ROSC and Survival To Discharge figures. Improvement: The trust will aim to see improvements in both the ROSC (Overall and Utstein) and the Survival to Discharge (Overall and Utstein) figures on a consistent basis. Baseline: The baseline figures for 2014/15 will be taken from the latest year to date available at time of printing. Stroke Care Rationale: Stroke is the third biggest cause of death in the UK and the largest single cause of severe disability. Each year more than 110,000 people in England will have a stroke. FAST, which stands for Face-Arm-Speech-Time, is a simple test to help people recognise the signs of stroke and understand the importance of emergency treatment. The faster a stroke patient receives treatment (care bundle) the better their chances are of surviving and reducing long-term disability. Baseline: The Trust already measures the percentage of Face Arms Speech Test (FAST) positive Stroke patients (assessed face-to-face) potentially eligible for Stroke thrombolysis who arrive at a hyper-acute Stroke centre within 60 minutes. The baseline figure for year to date February 2014 is 52.7% for Stroke 60 and 96% for the care bundle. Goal: The Trust aims to achieve continuous improvement in stroke 60. We will aim to see continually high care bundle compliance. Improvement: To reduce on scene times for these patients who are having a Stroke and continue to give high quality care.

30

Friends and Family Rationale: The NHS has introduced that patients and staff should be asked whether they would want a friend or relative to be treated there in their hour of need. The Prime Minister says the results will be made public so ‟everyone will have a really clear idea of where to get the best care‟ which will drive continuous improvement. The Trust supports this model and has been capturing this data for the last year. It has found that, whilst not a sophisticated measure of quality, it captures what patients think of our services and encourages the Trust to focus on what matters to patients. This is a relatively simple measure that can easily be applied. Baseline: (friends and family test) during the previous year friends and family (net promoter) scores ranged as follows (year to date January 2014): Emergency Services: +79 Primary care services: +51 Patient transport services: +68 Goal: Once the national average is known, the Trust will aim to maintain the friends and family score at the national level for those patients who agree or strongly agree that they would recommend the East of England Ambulance Service to a friend or relative across all service lines which will capture the experience of the patients served by the Trust. Improvement: To see a rise in the Friends and Family Score for those patients who are surveyed which will give a simple indication of how our patients view our Trust and the service it provides. Baseline (Staff) During the previous year the Trust had a score of 40 when staff responded to the statement “if a friend or relative needed treatment, I would be happy with the standard of care provided by the organisation”. This is lower than the average median score (50) for other ambulance services. Goal: To increase the number of positive responses received to Question 12d in the annual staff survey to meet the average median for ambulance Trusts recorded in 2013. Improvement: To see a rise in the score for Question 12d of the annual staff survey which will provide an indication of how our staff view the Trust and the care that we provide. Public and patient engagement The public and patient involvement and engagement team (PPI) are responsible for getting feedback from the public and patients and taking these views back into the Trust to help aid service developments. Last year, the team attended 22 public events to speak with the public and patients about the ambulance service, promote the service‟s messages, provide health care advice - particularly around stroke awareness - and carry out blood pressure checks. The team focussed on reaching the widest possible audience and so activity was focussed around visiting shopping centres and specific events such as Ely Aquafest, the Indian mela in Suffolk, older peoples warm home events, gay pride events and the Essex Young Farmers Show.

31

Trust User Group This group of volunteers are the organisations‟ critical friend. Their work is supported by the PPI team and together they carried out more than 50 discovery interviews with patients. These interviews give the Trust an opportunity to learn from their experiences - the feedback and actions identified are reported internally, shared with operational managers and staff, used for training, and videos of interviews are shown at every Trust Board meeting. The group also help assist with station cleanliness audits, undertake patient handover audits at hospitals, review trust documents and surveys and have taken on the role of ambassadors. Improving engagement and communication with the public helps the Trust to understand and manage public expectations of the service. Last year, we launched the role of ambulance service ambassador. Ambassadors are volunteers or staff who are willing and able to go into their community and spread information and news from the ambulance service and bring information on patient experiences and views back to the Trust. Our first ambassadors are now going out in their communities and have delivered talks with various groups and distributed leaflets and posters. Serious Incidents A serious incident can be defined as an event which resulted in one or more of the following:

• Unexpected or avoidable death or severe harm • A „never‟ event • A scenario that prevents, or threatens to prevent, the ability to continue to deliver

healthcare • Allegations or incidents of physical abuse and sexual assault or abuse • Loss of confidence in the service, adverse media coverage or public concern.

In 2013/14, the Trust reported 54 serious incidents, an increase of two compared to the previous financial year. Of the 54 reported, two incidents occurred in 2012/13 but were not identified until 2013/14. The chart below shows the number of serious incidents reported each month and compares this to the total number of incidents reported by staff.

Delays in ambulance attendance and clinical assessment continue to be the most common themes as shown in the table below.

32

Several themes have been identified which are being worked on in order to improve safety and reduce the number of serious incidents occurring in the future: 1. Escalation within the emergency operations centres

Investigations have shown that there is variation in application of procedures between the control rooms. A lack of escalation and request for help in a number of incidents have prevented senior and clinical staff within the control rooms from helping avoid a serious incident from occurring. As a result, the processes within the control rooms are being reviewed to improve the safety of procedures.

2. Crew resource management There have been instances where staff have worked beyond their scope of practice and there has been a lack of challenge by others on scene to prevent errors. This shows a cultural issue and the Trust has put in a bid for the Shine award to be able to work with an external partner to resolve this issue.

3. Vehicle daily inspection There have been four serious incidents that have highlighted a lack of robust vehicle inspection. As a result a new vehicle daily inspection has been piloted and will be rolled out in 2014/15. This will help staff and ensure that every vehicle is sufficiently stocked and checked before starting a shift.

4. Non-conveyance There have been several instances where following a clinical assessment, patients have been incorrectly left at home, when they should have been taken to hospital. As a result, patient assessment forms will be part of the mandatory training for all emergency operations staff for 2014/15. In addition, a non-conveyance checklist has been developed and will be rolled out, which must be completed whenever a patient is left at home, in order to ensure that an appropriate level of assessment has been completed.

Significant work in relation to the serious incident process has been undertaken to ensure that investigations are robust and completed in a timely manner, so that learning can occur. Last May, 20 staff completed a two-day root cause analysis course giving the Trust sufficiently trained investigators. Work has also been done with the lead commissioners to ensure that appropriate quality and monitoring occurred. Finally, the serious incident policy has been rewritten and the process revised.

33

Compliments and complaints The patient services team coordinate all complaints, patient advice and liaison service (PALS) and compliments, as well as legal claims against the Trust, inquests involving Trust staff and requests for information, for example under the Data Protection Act 1998 and Freedom of Information Act 2000. The feedback, both positive and negative, is managed by the department. Complainants, enquirers and staff are kept informed throughout the process and informed of the outcome. In 2013, the Trust updated the information on its website to explain how the public can give feedback, including compliments and complaints, about the service they had received. A section is included on the information we need from people about seeking consent when someone is raising an issue on behalf of someone else. Compliments In 2013/14 more than 1,350 compliments were made about the service, an average of 115 a month. The Trust also received 221 donations, totalling more than £105,000, with most donations being for community first responder schemes. Compliments are reported to the Trust Board and the staff names are published internally. Local management teams are informed of all compliments so they can be passed onto the staff. In future, personal letters will be sent by the Chief Executive to members of staff directly to recognise their excellent work. Complaints The Trust has a dedicated department for responding to complaints and concerns raised by patients and members of the public to ensure their concerns are heard, investigated and action is taken to put things right. People who wish to provide feedback about the Trust can do so through a dedicated complaints email address, by phone or in writing. The feedback provided by the public helps improve services. An „easy read‟ poster about how to provide feedback to the Trust was sent to community centres such as libraries and religious centres, across the region to help improve accessibility. The department logs complaints on a risk management system and liaises with the complainant to ensure the correct information has been captured and all issues have been identified. They then work with the investigating manager to ensure a thorough and objective investigation has been completed. In 2013/14, the Trust received 798 complaints, which is a 32% decrease compared to 2012/13. Of those 77% related to emergency care, 16% related to patient transport services and 7% related to primary care services. This averages to about seven complaints per 10,000 emergency calls.

34

Complaints are acknowledged as quickly as possible. Of the complaints received in the year, 98.75% were acknowledged within three working days in line with the Local Authority Social Services and National Health Service Complaints Regulations (2009). This is an improvement on 2012/13, when 96% were acknowledged within three working days. Working with other NHS organisations is also embedded within the department and the Trust worked on 92 joint complaints this year. The main theme from the complaints was around delays in ambulance response. The Trust also received a formal „Preventing Future Deaths‟ report from a coroner regarding the delay in attending to a patient who had fallen in the street and sustained a head injury. The immediate priority of the Trusts‟ new Chief Executive is to reduce long waits for ambulances, as set out earlier. This will help reduce complaints and provide patients with a better service. The other two main themes were attitude of staff and clinical care. A „customer care‟ process has been developed for staff who are involved in a complaint about their attitude, and customer care is now on the Professional Update programme for all operational staff. With respect to clinical care, the Trust regularly updates paramedics of their professional responsibilities via the monthly Clinical Quality Matters staff newsletter. Although most complaints are resolved through the Trust‟s complaints process, complainants are able to refer their complaint to the Parliamentary and Health Services Ombudsman (PHSO) if they feel it has not been resolved. In 2013/14, the Trust received 21 referrals, compared to 13 in 2012/13 as a result of a change in PHSO procedures, which has resulted in an increase across the NHS in the amount of cases referred by the PHSO for formal investigation. Where complaints were upheld, appropriate action was taken by the Trust in response to recommendations made by the Ombudsman. For example, the guidance for emergency operation centre staff around the escalation of calls to duty managers has been revised and re-issued.

35

The graph shows the number of referrals the Trust has received from the PHSO per quarter,

to April 2014. Of those that have been closed by the PHSO during 2013-14, three cases

were partially upheld (i.e. some aspects of the complaint were upheld by the PHSO).

Patient Advice and Liaison Service (PALS) The Trust‟s PALS service is integrated into the patient services team. This simplifies the procedure for the public to either log a PALS enquiry or to escalate their issues to a complaint, if appropriate. PALS also enables the Trust to signpost people to the correct services, answer queries, deal with lost property and advise on the complaints process. A total of 1,231 contacts were in relation to negative concerns or feedback and a further 380 contacts included enquiries about lost property or comments about the Trust, for example about driving. This makes a total of 1,611 PALS concerns received, an increase of 49% on 2012/13.

36

Learning into Action The team is committed to using the feedback we receive through complaints and PALS to help improve the service. The themes and trends identified are linked with learning from other sources; such as clinical audits, staff reported incidents, claims made by staff and patients and health and safety issues. Examples include:

receiving claims from staff regarding injuries from the use of responder bags. This has led to a review of the bags and canvassing staff views. A review group is working on ideas and recommendations for new systems of bags

a module of abdominal assessment and symptoms on the mandatory professional development programme

training to ensure staff are aware they can take guide dogs in an ambulance with patients. Ambulances that are specially adapted to convey guide dogs have been introduced.

Looking forward Feedback from staff and anyone who uses the service is actively encouraged. An Equality Analysis identified that people with learning disabilities were under-represented amongst those providing feedback which led to the „easy read‟ poster mentioned earlier being developed. Information is captured about the lessons learned and action taken as a result of complaints and PALS concerns on our database, in order to identify themes in particular service areas. And the Trust is sending out a survey in 2014/15 to ask people about their experience of the complaints process to help drive further improvements.

37

Safeguarding There is a high focus on safeguarding and the Trust strives to improve the referral process. A recent review of the questions set for referrals and update training for Single Point of Contact (SPOC) call handlers led to an increase in the quality of information being sent to partner agencies. After a recent peer review the Trust received excellent feedback regarding its systems and the SPOC process. There has been a steady increase in the use of SPOC to relay concerns to social care and patient‟s GPs – 625 referrals in April 2013 rising to 1,055 in March 2014. In the last year 34% of referrals made through SPOC received feedback, which is an increase on the previous year of 27.1%. The amount of feedback received and obtained has increased by 113%. The Trust aims to provide staff with an understanding of their referrals and the impact on their patients. The Trust will endeavour to ensure they remain supported and engaged in the protection of the most vulnerable members of communities and to ensure information gets to the right agency for the most appropriate support. There is a continued focus on the quality assurance of the referrals through evolution of the referral form and review of the quality assurance process which is in place in the Safeguarding Team and at SPOC level. The Trust will support operational staff with a greater understanding of the Mental Health and Mental Capacity acts and ensure compliance to legislation requirements, particularly with the introduction of the Mental Health Crisis Care Concordat published earlier this year. The safeguarding team will evaluate pathway options for domestic abuse cases and scope partnership working with the six police forces to send information directly to them.

38

Our people The Trust employs more than 4,000 staff and has around 1,500 volunteers. It is thanks to the hard work, dedication and commitment of staff and volunteers that services are improving. The table below shows the breakdown of staff at the end of 2013/14.

TRUST STAFFING As at 31st March 2014 Headcount

Emergency Operations 2,849

Patient transport and non-emergency services 550

Primary care 140

Air operations, special operations & operations support 230

Support services e.g.HR and finance 343

TOTAL WHOLE TRUST 4112

The Trust takes an inclusive approach to employee relations and benefits from effective partnership working with its recognised trade union, UNISON. Consultative mechanisms were developed in partnership and exist at local, regional and Trust-wide level and we have embedded within the organisation proactive consultation and engagement on all matters, either through our trade union partners or directly with staff. Staff engagement Improving how we engage with staff and lifting morale has been a priority over the past year. At the start of the year the internal communications team launched a review of all staff communications. The review, which involved more than 500 staff, included a staff survey and qualitative research which formed the foundations from which improvements have been made. As a result, and based on staff feedback, the following happened:

- A reduction in internal communication channels - Enhancements to the staff weekly e-zine, developing it as the one stop shop for all

Trust news and information - Launch of county „virtual crew rooms‟ on Facebook for operational staff - Reduction in email bulletins being sent to staff

More than 80% of staff who responded to the survey said they would use a rolling news site that could be accessed at any time internally or externally. As a result the internal communications team have developed a web based staff news site which will be launched in 2014/15. This will allow staff to access the latest Trust news and information from any computer, smartphone or tablet. It will be backed up by both a printed copy and email version to ensure staff can access this information in the format they want. New Chief Executive Anthony Marsh has spent much time meeting and talking to staff across the region since he joined in January. He has also held two manager events to set out the challenges and actions being taken to improve services that received very positive feedback. Health & wellbeing and investing in staff The Department of Health‟s responsibility deal initiative encourages organisations to play their part in improving public health. Organisations agree to support the deal‟s ambitions and make collective pledges on alcohol, food, health at work and physical activity. In 2012/13 the

39

Trust signed up to three health at work pledges and continued this through 2013/14 to build on its commitment to encourage our workforce to be as healthy as possible. Health at Work 2: We will use only occupational health services which meet the new occupational health standards and which aim to be accredited by 2012/13 The health of the workforce is crucial to the delivery of the improvements in patient care. By raising the standard of our occupational health provision and continuing our commitment to health and wellbeing internally, staff will be fitter, healthier and more engaged. The Trust put in place a new occupational health provider in August, People Asset Management (PAM) to ensure it meets the standards required by the Safe Effective Quality Occupational Health Service (SEQOHS) accreditation. PAM‟s utilisation of electronic administration processes aims to provide a more efficient service from pre-employment stages through to management referrals on which managers can access reports on the same day as the employee has been seen and „live track‟ referrals to see when appointments have been made. Health at Work 3: We will include a section on the health and wellbeing of employees within our annual reports and on our staff intranet site Monitoring trends in causes of staff sickness is a high priority for the Trust. It helps identify areas of concern and informs what proactive action is needed to prevent staff from becoming unwell. A dedicated sickness „taskforce‟ has been working to offer coaching and training to managers in their day to day management of sickness absence, in tandem with providing guidance and support to build their skills. This has resulted in a reduction in sickness absence. Health and wellbeing forms a section within our annual report and plan. The Trust‟s Employee Assistance Programme (EAP) provider gives monthly reports indicating the type of support staff and volunteers are accessing. The Trust‟s intranet has a section on health and wellbeing which includes useful information relating to EAP, occupational health, work/life balance and provides encouragement to staff to improve their health and well-being by promoting the benefits of sport and social activities. Health at Work 5: We will encourage staff to stop smoking, by facilitating on-site ‘stop smoking’ support services. We will also take action to reduce other risks to respiratory health arising in the workplace. All Trust sites are non-smoking areas. It is the team‟s aim to support staff to stop smoking, set a good example to the public, demonstrate adherence to the NHS-wide no smoking principle and to national no smoking in line with the Health Act 2006. In January PAM began its proactive wellness programme, holding a number of health fairs at ambulance stations. These were hosted by a physiotherapist and nutritionist to offer staff the opportunity to access a health assessment and receive a personalised rehabilitation plan. These will continue throughout 2014/15 and evolve to include, amongst other things, osteoporosis testing, carbon monoxide testing and smoking cessation support. Staff sickness absence The sickness absence management policy and procedure was been reviewed and amended. The new Occupational Health provider has given the Trust an additional service to staff which gives immediate clinical advice, support, welfare and physiotherapy services to them on day one of their absence from work.

40

There was an overall decrease in sickness absence in 2013/14, resulting in a lower year-end position than the previous year by 1.27%. During the year absence levels followed seasonal trends culminating in a peak of 7.88% in December. Staff survey The 2013 NHS Staff Survey saw a response rate of 34% for the Trust down from 48% in 2012, but the Trust took the decision not to survey all staff, only the Care Quality Commission recommended sample size. The results showed that the Trust has improved in three areas, stayed the same in 24 and got worse in one area. Overall EEAST improved on results compared to all of the ambulance trusts in England with eight lowest scores, compared to 13 in 2012/13. It is encouraging that the overall staff engagement score has increased from 2.96 to 3.09 in 2013/14. In addition EEAST scored 2.72 on staff recommendation of the Trust as a place of work or to receive treatment which is an increase on the previous result of 2.64. The biggest areas of improvement were in staff appraisal, health and safety training and equality and diversity training. To ensure staff engagement improves the Trust Board will be reviewing an action plan and locality Directors have been asked to develop local plans focussing on two to three key areas for improvement. Recruitment The recruitment team is currently working towards the priority to recruit 400 student paramedics in 2014/15. The adverts for the student paramedic programme have received thousands of applications and at the end of April more than 100 offers were been made for the programme to applicants – a quarter of the target achieved already. The paramedic programme is essentially a 30-month programme in which students complete their qualification via a partner higher education institution that leads to eligibility to apply for registration with the Health and Care Professions Council. Those who successfully complete the course and obtain registration will be offered substantive paramedic contracts. Student paramedics work in the Trust for periods during their training, thereby potentially improving the delivery of services to patients and the overall performance of the Trust. The first element of the programme requires attendance on an eight week clinical course and three weeks of driver training. At that point, successful candidates are able to work as part of crews, although not as a paramedic. The first cohort of students started their training in April and further courses are planned throughout the year. The Trust is also looking to recruit graduate and qualified paramedics and qualified emergency medical technicians. The following targets have been set for the year ahead:

50 direct-entry and graduate paramedics

24 direct-entry technicians Training and development Professional Update (PU) The PU programme provides clinical staff with training and updates on a range of subjects. Successful completion of this training enhances their skills to deliver patient care. During 2013/14, 95% of staff attended the training, an increase of 35% on 2012/13.

41

Personal Development Review Delivery of personal development reviews (PDR) was a priority for the development of staff in 2013/14, with 86% of staff having a PDR meeting with a local manager, 33% more than in 2012/13. From this review, an agreed Personal Development Plan is set up.

Operations

PU completion

Training workbook completion

PDR completion

2012/13 59.7% 59.8% 52.6%

2013/14 94.7% 78.0% 85.7%

Trust

2012/13 61.0% 60.0% 49.0%

2013/14 93.9% 61.6% 77.4%

Major programmes of training carried out in 2013/14 Voluntary Continuous Professional Development (CPD) The Trust secured funding that allowed 1,700 staff to benefit from CPD activities. A wide range of subjects were offered including telephone triage, clinical assessment, minor injuries and illnesses, assessment of the older person, assessment of the child in primary care and wound care. A range of accredited university modules were also offered covering hear and treat, mental health awareness, and practice placement educator (mentorship). New higher education pathways allow many of pre-registration clinical staff to progress to registration as paramedics, and individual applications for study in clinical higher education modules have been supported. Apprenticeships The year saw the first of many new apprenticeships, a development that will have an increasing impact across the Trust in supporting the development and training of new staff, as well as being an avenue of training and personal progression for many existing staff. LEAN A LEAN training package has been provided to offer a high degree of staff involvement and ownership of service improvement. The programme will have an increasing profile during 2014/15 as LEAN projects are initiated. Training and development plans for 2014/15 The major priority in the forthcoming year is the development and implementation of the student paramedic programme and up-skilling existing frontline staff: 60 emergency care assistants to train to become emergency medical technicians (EMTs) and 50 EMTs to start their training to become paramedics. The BSc Paramedic Science pathway has recently started. This will be the ongoing long term pathway for entry to the Trust as a paramedic and will be the vehicle for delivering the Trust‟s longer term workforce needs. The numbers of student paramedics means a very significant level of mentorship support is needed from existing staff. There is a drive to increase the pool of mentors, ensuring they have the support and training to deliver this crucial role.

42

The Trust has further enhanced the level of e-learning leadership and management resources available to managers. The provision of this will be tailored to particularly support front line managers.

43

Risk management and information governance Principal risks and uncertainties In 2013/14, 414 new risks were recognised, assessed and recorded on the Trust‟s risk register, ranging from operational through to project risks. 181 risks were closed due to either successful mitigation or eradication of the risk. This demonstrates an increasing identification of risks in relation to the work streams being undertaken during the Trust‟s transition, and successful management and closure of operational risks during business. There has however been in increase in both the number of principal risks and an increase in their risk scores over the 2013/14 financial year. This shows an increasing risk profile across the organisation, and demonstrates the significant challenge that the organisation faces in sustainably effecting change. There is clear evidence that this is predominantly due to the multiple and wide ranging causes of each risk, which have influence upon each other. The Audit Committee has identified that although the Principal Risks are reviewed in committees, increased scrutiny needs to occur in relation to the controls and assurances in order to facilitate improvements to the Trust‟s risk profile. As a result in preparation for the 2014/15 financial year, the Business Assurance Framework has been amended to provide more meaningful information, with each of the committees to take on a more functional and analytical role in relation to risk assurances. It is anticipated that this will result in more effective risk management of the key risks faced by the organisation. Lapses in data security During 2013/14 two potentially serious information-related incidents were recorded by the Trust and reported to the Information Commissioner‟s Office. In the first incident a number of paper documents containing personal data were lost from outside secure NHS premises. The majority of these records were recovered at the scene. In the second incident an allegation was made by a member of the public that patient records were being disposed of inappropriately, although this was found to be not proven in the subsequent investigation. Both these incidents were formally investigated using the Trust‟s established procedures and reported to the Serious Incident Panel. Where necessary, recommendations for changes and improvement to existing operational practices have been made. The Information Commissioner‟s Office did not take any further action in relation to these incidents. However, the Trust will continue to monitor its information risks in order to identify and address any weaknesses and ensure continuous improvement of its processes. Information Governance compliance The Trust has completed its annual self-assessment against the Information Governance Toolkit at the end of March 2014. For 2013/14 the Trust has declared an overall „satisfactory‟ rating, having achieved level 2 or level 3 on all applicable Toolkit standards. Compliance with NHS Pension Scheme regulations As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employer‟s contributions and payments in to 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.

44

Counter fraud The Trust is committed to preventing fraud or bribery within the organisation. The Trust is fully compliant with the directions issued by the Secretary of State in 2004 and the NHS Counter Fraud and Corruption Manual, and the Standards for Providers: Fraud, Corruption and Bribery as set out by NHS Protect. The Local Counter Fraud Specialist (LCFS) reports to the Interim Director of Finance & Commercial Service and attends Audit Committee meetings to report on the work achieved. The LCFS works to ensure that counter fraud is integrated into all Trust activity in a positive way. Throughout the past financial year the counter fraud culture has continued to be embedded into the Trust and work has been undertaken against each of the four areas of action set out in the Standards for Providers: Fraud and Bribery as set out by NHS Protect, namely Inform and Involve, Prevent and Deter, Hold to Account and Strategic Governance. The Trust takes a positive stance in countering fraud against the organisation and the NHS in general and actively seeks to ensure that an appropriate, yet proportionate response is taken to allegations of fraud and bribery. Where appropriate sanctions and redress are sought. The Trust has identified fraud losses of around £4,200 and is seeking criminal sanction in respect of this case. NHS Litigation Authority (NHSLA) The Trust has made a number of changes in 2013/14 to increase senior operational management awareness of claims within their respective areas. The quarterly report is being replaced with live data reporting for General Managers to enable more robust monitoring, this will enable them to react to current trends and encourage more proactive engagement. The Trust also has a Learning Group in place whose aim is to triangulate themes and trends from various data sources; incidents, claims, complaints and patients concerns. A number of actions have also been implemented during the year to address issues identified from claims, incidents and complaints as a whole to include:

Implementation of a Trust improvement plan to address ambulance delays

Clinical bulletins and manual issued to all staff to improve clinical assessment/care

Increasing make ready services

Better monitoring of slips, trips and falls Care Quality Commission (CQC) registration The Trust was registered with the CQC under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2009 on 1 April 2010. The Trust was registered without conditions or restrictions and is registered to provide services under three of the regulated activities to cover the services agreed under contract and service level agreements. As a registered healthcare provider the Trust has to demonstrate continuous compliance to the Essential Standards of Quality and Safety and uses a database system to upload evidence against each outcome and prompt. In addition the Trust holds a provider compliance assessment (PCA) document for each outcome which describes the evidence held and why the Trust is claiming compliance against the prompts within the outcome. The Trust‟s Quality Risk Profile (QRP) is published regularly by the CQC and highlights the estimated risk of non-compliance against each of the Essential Standards of Quality and Safety against the evidence that has been captured from a variety of sources. The Trust has used the CQC QRP reports during the year to identify potential risks to the organisation and to inform the self-assessment process.

45

In January and February 2013, the CQC undertook a routine inspection of the Trust examining provider compliance evidence against 5 of the 16 Essential Standards of Quality and Safety which directly relate to the quality and safety of patient care. The CQC report was published in March 2013 and concluded that the Trust was compliant in all areas with the exception of Regulation 9 Outcome 4 (care and welfare of people who use services). The non-compliance was judged as a moderate impact on people who use the service and was based on the Trust‟s performance in relation to the deterioration of ambulance response times. The Trust received a further visit from the CQC with an unannounced routine inspection in December against 7 of the 16 Essential Standards of Quality and Safety which directly relate to the quality and safety of patient care:

Regulation 9 Outcome 4 (care and welfare of people who use services)

Regulation 16 Outcome 11 (safety, availability and suitability of equipment)

Regulation 21 Outcome 12 (requirements relating to workers)

Regulation 22 Outcome 13 (staffing)

Regulation 23 Outcome 14 (supporting workers)

Regulation 10 Outcome 16 (assessing and monitoring the quality of service provision)

Regulation 19 Outcome 17 (complaints) The Trust remains non-compliant in Regulation 9 Outcome 4 (care and welfare of people who use services) however, the CQC acknowledged that since that time the Trust had made significant improvements in a number of areas; decrease in staff sickness absence rates, complaints relating to ambulance delays, the number of Serious Incidents, long waits (over 25 minutes) for back up vehicles to transport people to hospital in life threatening instances in some areas as well as spending on private ambulance services. In addition, the CQC concluded that the Trust were also non-compliant with Regulation 22 Outcome 13 (staffing). The CQC found that the Trust did not have the numbers of suitably qualified staff it required to ensure that national ambulance response times were met and people received the care they needed in a timely way. The Trust is taking steps to address this to mitigate the risk to patients. After careful consideration, the CQC found that the Trust is taking reasonable steps to address the breaches in regulations and therefore it would not be appropriate to take further enforcement action at this point. However as the impact for people waiting to be transported to hospital remains as a moderate concern, their concerns have been escalated to the NHS Trust Development Authority and they will continue to closely monitor the Trust, inspecting it as required and working with NHS England to review its progress. The Trust‟s new Chief Executive has reviewed the previous action plan and set new objectives for the Trust. Clinical Audit and Patient Experience Programme The clinical audit and patient experience programme forms part of the quality governance framework and provides the Trust with assurance that services are being delivered to patients at the required standard in order to meet the dimensions of quality: patient safety, patient experience and clinical effectiveness. It provides an essential view of the care we deliver in terms of the patient experience and the clinical outcome of the care that we provide to them. Where audit and experience reports highlight standards are being delivered below those expected it also serves as an early warning indicator so that corrective action can be agreed and taken in a responsive way. The results enable us to share good practice across the Trust along with viewing us against other ambulance trusts. The results of audits

46

and experience audits are used to review and develop training for our staff. The examples, themes or trends have enabled us to identify areas that draw out the quality measures. All audits are presented to the Clinical Audit and Patient Experience (CAPE) Group who report directly into the Clinical Quality and Safety Group. CAPE approves recommendations for actions to improve the quality of service provision and patient outcomes. The proposed audit and patient experience programme for 2013/14 consists of national, strategic, regulatory and locally driven audit projects and these have been prioritised in line with the Trust‟s Clinical Audit Policy. Moving forward it is important to link clinical development with audit and experience measures. Being able to gather a wide range of information ensures a focus on key priorities or identify areas to discuss with commissioners and other providers of care. The link with research produces an evidence base of patient need that allows a continued search for the delivery of clinical excellence. Currently the patient experience audits have allowed, in part, the review of the effectiveness of changing or introducing services. A variety of other mechanisms have been used in maintaining and reviewing the effectiveness of the system of internal control, including the following:

The work of the Board Committees

The activities of the Executive Management Team who manage the operational delivery of services and provide monitoring information, reports on performance, business, risk and professional advice to the Board;

Managers within the organisation who have responsibility for the development and maintenance of the system of internal control provide assurance.

Monthly and quarterly quality reports.

Monthly Trust Board corporate dashboard reports including quality, operational and financial performance.

Lead commissioner provider development meetings and other commissioning meetings monitoring the delivery of contracts.

Regular review and reports on the position of the principal risks by the Quality and Risk Assurance Committee and the monitoring of the risk management process by the Risk Management Group to ensure that action is taken to resolve key risks at the appropriate level and assign the necessary resources where required.

Regular reviews and reports on progress against the organisation‟s objectives through the Trust‟s Annual Plan „tracker‟ system.

Go and see visits undertaken at station level by Board members

Local clinical focus groups that review the audit and experience data for their respective areas.

Compliance with the NHS Constitution The Trust‟s vision and values are in line with the NHS constitution and the new Board will be nominating a non-executive director as its constitution champion whose remit is to ensure the continued promotion of the rights and pledges of the constitution throughout the organisation as well as at Board meetings. The Board, as part of its CQC registration, has made a full declaration of compliance and the CQC confirmed our registration without conditions.

47

Significant issues Under achievement of ambulance response times During 2013/14 the Trust has experienced significant challenges that have prevented achievement of key national and local ambulance response time targets that directly impact on patient care particularly in the more rural areas of the Trust. There have been a number of factors including:

a lack of resources to meet rising demand for the 999 service – in particular a lack of double staffed ambulances

a lack of staff to crew the required resources

a lack of fleet and equipment to provide the core resourcing requirements

poor governance review on the operational performance external audit

high staff sickness rates

Loss of Patient Transport Service contracts

Poor staff skill mix resulting in high levels of multiple deployments and backup requirements

Consistent high levels of Acute Trust patient handover delays, reducing resource availability

This has resulted in

increasing delays in reaching patients and transporting them (when required) to hospital

increase in complaints and incident investigations

non-compliance with regulation 9 Outcome 4 and Regulation 22 Outcome 13 of the CQC essential standards (as outlined earlier)

low staff morale

adverse media and other external stakeholder interest in the Trust The Trust‟s Performance Improvement Action which is monitored by the newly set up Operational Delivery Board chaired by the Chief Executive includes the following six priorities:

1. Recruit 400 student paramedics in 2014/5

2. Up-skill ECAs to EMTs and EMTs to paramedics

3. Maximise clinical staff on frontline vehicles

4. Reduce response cars and increase ambulances

5. Accelerate fleet and equipment replacement programme

6. Reinvest corporate spend in frontline delivery

48

Trust Board

In 2013/14 the Board changed considerably due to the resignation of all the non-executive directors and changes to the executive directors. As a result, a number of interim appointments were made to stabilise the leadership team whilst the recruitment process for permanent Board members began. By the end of the year, the Trust had completed recruitment to five non-executive directors and the recruitment process for substantive executive directors and a Chair will run throughout 2014/15. Board of Directors The Trust is led by a Trust Board of non-executive and executive directors which provides leadership through internal controls whilst promoting innovation, vision and challenging any performance issues. The corporate governance arrangements for the organisation faced challenges during 2013/14 with the resignation of a significant number of board members. Interim appointments to both executive and non-executive directors were made to provide sufficient leadership on an interim basis. The non-executive directors and executive directors form a unitary body which functions as a corporate decision-making body. It should consist of six non-executive directors (including the Chair) and five executive directors. As already outlined there has been a significant lack of continuity in the composition of the Board but by the end of 2013/14 the Board consisted of an interim Chair, five non-executive directors, an interim Chief Executive Officer and interim Director of Finance and Commercial Services, three acting executive directors (one of whom is the Medical Director). All are full and equal members. An Associate Non-Executive Director has been appointed to provide further continuity and along with two senior managers (with the title „director‟ and providing advice on business planning and workforce issues respectively), they have attended Board meetings routinely. These three roles are non-voting positions. Voting directors: Non-executives Sarah Boulton Chair Sarah Boulton has worked at NHS Board level for many years, chairing a number of NHS organisations, most recently as chair of NHS Midlands and East Strategic Health Authority. Sarah has a background in business and finance having worked as a business and management lecturer and more recently as a management consultant advising on strategy, change and Board development. Appointed to the Trust Board for Interim term: March 10, 2014 to December 31, 2014

49

Sheila Childerhouse Chair of Patient Safety and Care Standards Committee With a wide breadth of experience within the public, health and voluntary sectors, Sheila has served in various local and regional health bodies since 1984 in non-executive and chair roles, including interim chair of The Queen Elizabeth Hospital King‟s Lynn NHS Trust in 2005 and chair of the national NHS Confederation Rural Sub Group. Recently she was chair of NHS Norfolk and Waveney cluster and deputy chair of the East of England Development Agency. Sheila‟s background was in education and she was a local authority member for more than 20 years. She has led rural and urban regeneration organisations, most significantly the Keystone Development Trust, one of the largest trusts of its kind in the country. Sheila is establishing a consultancy portfolio including executive coaching, organisational leadership support and partnership development building on her broad experience of strategic leadership, innovation and change at local, regional and national level. Appointed to the Trust Board for an interim term: July 15, 2013 to January 14, 2014 Appointed to the Trust Board for first term: January 15, 2014 to January 14, 2018 Andrew Egerton-Smith MBE Associate Non-executive Director Andrew qualified as a chartered surveyor in the 1960s and spent 30 years practising in the eastern counties until his retirement in 1994. During the 1980s he was closely involved as a Trustee of Garden House Hospice in Letchworth which was established in 1985 as one of the first hospice charities working in partnership with the NHS, and he remained a Trustee until 1998 when he was appointed Chairman of East Anglian Ambulance NHS Trust, a position which he held until 2006. In 2000 he was one of the trustees involved in establishing the East Anglian Air Ambulance charity of which he remains Chairman – a position which he has held since the inception of the charity. He is much involved in his own property activities and has been a Board member of various organisations including Flagship Housing from which he retired in 2013 and as deputy chairman of NHS Norfolk from 2006 -2012. Andrew was awarded the MBE in the 2013 Queen‟s Birthday Honours.

Appointed to the Trust Board for Associate term: October 7, 2013 to October 6, 2015 (subject to annual review) Peter Kara Non-executive Director Peter is a Fellow of the Chartered Association of Certified Accountants. He is a director of two private companies and runs a consultancy providing financial and strategic planning help to small and medium-sized companies. He has had a wide range of involvement in the voluntary sector in Milton Keynes since 1991 and with a national charity in London. He was non-executive director to the Milton Keynes Community NHS Trust from October 1993 until its dissolution in October 2000. Peter was previously a Non-Executive Director of the Milton Keynes Primary Care Trust before its dissolution in April 2013. He has lived in Milton Keynes since 1980 and remains a trustee of the Milton Keynes Community Foundation and a director of its subsidiary, MK Community Properties Limited, having served terms as chairman of both organisations. Appointed to the Trust Board for first term: December 2, 2013 to January 6, 2017

50

Judith Lancaster Non-executive Director Judith is a barrister and has been with the Tribunal Service since 1989 where she is currently a judge in the property chamber. She was vice chairman of the Suffolk Police Authority from 2010 - 2012 and was chair of the monitoring and audit committee during this time. She previously held vice-chairman posts at West Suffolk Hospital NHS Trust and Norfolk Mental Healthcare NHS Trust. She has also held several voluntary sector appointments including trustee at Macmillan Cancer Support from 2005 to 2010. Appointed to the Trust Board for first term: September 9, 2013 to September 8, 2017 Valerie Morton Chair of Remuneration and Terms of Service Committee Valerie has more than 35 years experience in the voluntary sector specifically in fundraising and management. She has held senior positions at Help the Aged, NSPCC and RNIB. Valerie set up her own third sector consultancy business 15 years ago and she is currently a trustee of Central YMCA and of the Julia Norris Almshouse Trust. She was a non-executive Director at Bedfordshire Heartlands Primary Care Trust from 2001 -2006, East of England Strategic Health Authority from 2006-2011 and Midland and East Cluster SHA from 2011- 2013. She has been awarded the honour of Fellow of the Institute of Fundraising, is the author of the best selling fundraising textbook Corporate Fundraising and is a regular columnist in Third Sector magazine. Appointed to the Trust Board for Associate term: December 2, 2013 to January 14, 2014 Appointed to the Trust Board: January 15, 2014 to January 14, 2018 Dean Parker Chair of Audit Committee Dean lives in Welwyn Garden City, Hertfordshire, and qualified as an accountant with the Audit Commission. He is also a member of the Chartered Institute of Public Finance and Accountancy. Dean has more than 18 years‟ professional experience and expertise in audit, financial reporting, risk management and corporate governance. For the last five years he was a Financial Audit Director at the National Audit Office, leading projects at the Department of Health, Monitor, the National Institute for Health and Clinical Excellence, the Health Protection Agency and the Department for Business Innovation and Skills. Appointed to the Trust Board for first term: December 2, 2013 to December 1, 2016 Voting directors: Executives Dr Anthony Marsh QAM SBStJ DSci (Hon) MBA MSc FASI Chief Executive Officer Starting his ambulance service career in Essex in 1987, Dr Marsh held a number of senior posts with services in Hampshire, Lancashire and Greater Manchester before returning to Essex as Chief Executive in 2003. Relocating to the West Midlands, he became the Chief Executive Officer of the West Midlands Ambulance Service in 2006. In 2011, Dr Marsh was decorated with the Order of St John. In addition to his responsibilities as Chief Executive he was appointed Chair of the Association of Ambulance Chief Executives and is the lead for the National Ambulance Resilience Unit. He also holds the national portfolio for Emergency Planning, Response and Resilience. Dr Marsh is a regional and national Cadre Major Incident Gold Commander.

51

Dr Marsh holds a Master of Science Degree in Strategic Leadership as well as a Master in Business Administration (MBA) and has been awarded a Doctorate with the University of Wolverhampton. Dr Marsh was awarded Queens Ambulance Service Medal in the 2014 New Year‟s Honours. Appointed to the Trust Board: January 1, 2014. Rob Ashford Acting Director of Service Delivery October 2013-March 2014 Essex Locality Director April 2014-present Rob has 25 years‟ ambulance experience, and joined EEAST in 2013 as Sector Leader for Essex. He began his career in Patient Transport Services in London, progressing on to front line and through operational managerial positions. In 2005 he joined Essex Ambulance Service as General Manager for west Essex. Following the merger of ambulance services, Rob was Locality Chief Operating Officer for the Bedfordshire and Hertfordshire area before moving to West Midlands Ambulance Service as Chief Operating Officer in 2008. Appointed to the Trust Board: October 14, 2013 to March 31, 2014 Stephen Day Interim Finance and Commercial Services Director A highly successful and experienced finance and commercial director, Stephen is also a management consultant and qualified accountant with a proven track record in senior management within the support services and public sectors. During his career, Stephen has worked in the private sector, working for a number of FTSE 250 PLCs in a number of roles predominately as Finance and Commercial Director and in the public sector as a Finance and Turnaround Director(s) within the NHS for primary care trusts, CSUs and acute trusts. Appointed to the Trust Board: May 31, 2013 to May 31, 2014 John Martin Director of Patient Safety and Clinical Standards* John took up the post of Interim Director of Clinical Quality in February 2013. Prior to this he was the Consultant Paramedic with a portfolio including research and development, clinical training and professional leadership. John studied to be a paramedic with the University of Hertfordshire and the London Ambulance Service completing a BSc (Hons) in Paramedic Science in 2002. He has worked as a paramedic, team leader, lecturer and innovation and development lead. He has undertaken various national and regional secondments including chairing the UK wide review of the paramedic curriculum in 2008. John is vice chair and executive of the College of Paramedics and is currently studying for a Professional Doctorate in Health at the University of Bath with a research interest in the causes of variation in ambulance demand between geographical areas. John continues to practice clinically and is passionate about developing safer patient care. Appointed to the Trust Board: February 1, 2013 to June 30, 2014 *This role was retitled as Director of Patient Safety and Clinical Standards with effect from December 11, 2013. Dr. Scott Turner Acting Medical Director Scott is passionate about people and medicine and has a successful and distinguished medical career. He qualified in medicine in 1988 at Edinburgh University. He trained as a General Practitioner (GP) and worked, on a full-time basis, for 12 years at a Norfolk market town practice. He has a special interest in the field of A&E and pre-hospital emergency medicine. Scott‟s career includes more than 20 years‟ experience, on a part-time basis, in A&E and a number of years‟ experience on an air ambulance.

52

Scott joined the ambulance trust in 2004 as an out of hours GP and quickly became involved in helping to manage this service. He duly progressed into the wider medical management of the ambulance trust. Scott continues to provide a clinical response to patients for the ambulance trust. Appointed to the Trust Board: September 1, 2013 to June 30, 2014 Non-voting directors: Ngozika (Francesca) Okosi Director of Workforce, Engagement and Organisational Development Francesca joined EEAST last May, with more than 16 successful years at executive director level, serving on the boards of several public and not-for-profit sector organisations. She is responsible for human resources, organisational development and education and development. Previously Francesca was Director of Corporate Resources at British Transport Police responsible for operational and strategic support services; including human resources, finance, corporate services and information and communications technology. As Director of Support Operations with the East Thames Group, a social housing, care and regeneration agency in East London and Essex, she was responsible for the corporate services portfolio included human resources, corporate governance, procurement, IT, property and marketing and communications. Francesca also led the Group's transformation programme. Prior to this Francesca was Director of Change and Strategy at DEFRA where she oversaw a £135m system-wide change programme to reform strategy, delivery, processes and people. Past members of the Board during the year

Name and role Term of office

Paul Remington, Non-executive Director Acting Chair from 08/04/13 to 27/05/13

01/07/06 to 27/06/13

Caroline Bailes, Non-executive Director 01/08/06 to 27/06/13

Phil Barlow, Non-executive Director 01/08/07 to 09/07/13

Anne Osborn, Non-executive Director 01/07/11 to 28/06/13

Margaret Stockham, Non-executive Director 01/07/12 to 26/06/13

Frances Pennell-Buck, Interim Non-executive Director 15/07/13 to 14/01/14

Dr Pamela Chrispin, Medical Director 04/01/10 to 31/08/13

Paul Scott, Director of Finance 17/05/10 to 02/06/13

Dr Geoff Harris, Interim Chair 28/05/13 to 28/01/14

Andrew Morgan, Interim Chief Executive Officer 17/12/12 to 31/12/13

Neil Storey 1/11/2012 to 13/8/13

Christina Youell 13/08/12 to 24/05/13

Ngozika (Francesca) Okosi 25/5/13 to 16/5/14

53

Directors’ responsibilities The Trust Board continues to adopt the National Leadership Council‟s principles as defined within The Healthy NHS Board Principles of Good Governance (February 2010). These are:

formulate strategy for the organisation

ensure accountability by holding the organisation to account for the delivery of strategy and through seeking assurance that all systems of control are robust and reliable

shape a positive culture for the Board and the organisation. The Board recognises the importance of the principles of good corporate governance and is committed to ensuring these are effective and efficient. In executing this, it has agreed that the governance of the Trust is best achieved by delegation of its authority for executive management to the Chief Executive, subject to monitoring and limitations as defined within the policies and procedures of the Trust, including Standing Financial Instructions and the Scheme of Delegation. The limitations set require that any executive action taken in the course of business does not compromise the integrity and reputation of the Trust and takes account of any potential risk, health and safety, patient experience, finance and working with partner organisations. Appointment and Support to Board directors Due consideration is given to the composition of the Board in terms of the protected characteristic groups in the Equality Act 2010. Each Board member is appointed for their experience, their business acumen and their links with the community. The Appointments Commission, an independent organisation, is responsible on behalf of the Secretary of State for appointment, on-going support through appraisal, mentoring and training of the Chair and Non-Executive Directors. The Appointments Commission was abolished on 31 October 2012 and the responsibility for these appointments transferred to the NHS Trust Development Authority (NHS TDA). The Secretary of State for Health continues to have the power to make these appointments but has delegated this to the NHS TDA. All appointments are made by a public advertisement. Terms of appointment are normally for periods of four years with members eligible to be re-appointed or to re-apply up to a maximum of 10 years. The Non-Executive Directors responsibilities include:

Helping to plan for the future growth and success of the organisation

Making sure that the management team meets its performance targets

Ensuring that finances are properly managed with accurate information

Helping the Board ensure it is working in the public interest. The Chief Executive and the Trust Board Executive Directors are appointed, via public advertisement, by members of the Remuneration & Terms of Service Committee. External assessors are also part of the recruitment process. Disclosures of the remuneration paid to the Chair, Non-Executive Directors and Executive Directors are given in the Remuneration Report. New directors receive a full, formal and tailored induction on joining the Board. Facilitated through the Trust Secretary, all directors have access to independent professional advice, at the Trust‟s expense, where they judge it necessary to discharge their responsibilities as directors. All directors, also have access to training courses and/or materials that are consistent with their individual and collective development programme.

54

Register of Interests At the time of their appointment, all directors are asked to declare any interests on the Register of Directors‟ Interests. Board members are asked at each formal Board meeting to register any changes to their declarations and to confirm, in writing, on an annual basis, that the declarations are accurate. The Register is maintained by the Trust Secretary and is available to anyone who wishes to see it. Enquiries should be made to the Trust Secretary at the following address: Trust Secretary, East of England Ambulance Service NHS Trust, Whiting Way, Melbourn, Cambridgeshire, SG8 6EN Trust Board and Subcommittee Meetings and their Evaluation Processes The Trust Board, in accordance with the Public Bodies (Admission to Meetings) Act 1960, holds its meetings in public. The Trust Board has powers to delegate and make arrangements to exercise any of its functions through a committee, sub-committee or joint committee. The inter-relationship of these is shown in the diagram below:

The Trust Board has four sub-committees: Audit Committee, Remunerations & Terms of Service Committee (RemCom), Patient Safety and Care Standards Committee (PS&CS), and Charitable Funds Committee. How the Trust Conducts its Board Meetings The Trust has maintained its support of the Nolan principles for public life and has continued to make the majority of decisions at Board meetings held in public. During 2013/14 the Trust Board met each month, conducting a series of different meetings throughout the day. These included eight meetings in public one of which was the Annual Public Meeting (held on 31st July 2013). Eleven private sessions of the Board were held, eight prior to the public meetings. These private sessions considered items which were of a confidential or commercially sensitive

Trust Board

Remuneration & Terms of Service

Committee

Audit Committee

External Audit

Internal Audit

Counter Fraud & Security Management Charitable Funds

Committee

Patient Safety & Care Standards

Committee

Direct Report Risk Exception Report

55

nature or considered the Annual Report and Accounts and the Quality Account which could not be presented in public until they had been submitted to the Department of Health (DH). In addition seven workshop sessions were held to allow the Board to forward plan and implement its Board development plan. Membership attendance at Trust Board and sub-committee meetings is monitored throughout the year and is reported in the Trust‟s Annual Report and Accounts. A formal schedule of matters reserved for the Board and a Scheme of Delegation detail the types of decisions that are to be taken by the Board and which decisions are to be delegated to management by the Trust Board. Attendance Membership attendance at Trust Board and sub-committee meetings for 2013/14 is summarised in the tables below:

AUDIT COMMITTEE MEETING ATTENDANCE

2013 2014

MEMBERS 01.05.13 29.05.13 04.09.13 06.11.13 07.01.14

04.02.14

04.03.14 Total

Dean Parker (NED) Appointed Committee Chair from 31.01.14 n/a

n/a n/a

√

√ 3/3

Sheila Childerhouse n/a n/a Apology √ √ 3/4

Judith Lancaster (Acting Committee Chair from 06.11.14 to 31.01.14) n/a

n/a

√ Apology 3/4

Andrew Egerton-Smith (Associate NED) n/a

n/a n/a

√

√ 2/3

Peter Kara (NED) n/a n/a n/a Apology √ 2/3

Valerie Morton (NED) n/a n/a n/a √ √ 3/3

EX-MEMBERS 01.05.13 29.05.13 04.09.13 06.11.13 07.01.14

04.02.14

Total

Anne Osborn 2/2

Frances Pennell-Buck n/a n/a 2/2

Paul Remington 2/2

Margaret Stockham Apology 1/2

Caroline Bailes Apology 1/2

PATIENT SAFETY & CARE STANDARDS COMMITTEE WITH EFFECT FROM 31.01.14

2014

MEMBERS 07.01.14 04.03.14 Total

Sheila Childerhouse NED Appointed Committee Chair 31.01.14

√ √ 2/2

Frances Pennell-Buck Interim NED √ 1/1

Peter Kara NED √ 1/1

Judith Lancaster NED Apology 0/1

Valerie Morton NED √ 1/1

John Martin Director of PS&CS √ √ 2/2

Andrew Egerton-Smith Associate NED

Apology √ 1/2

Rob Ashford Director of Service Delivery

√ √ 2/2

56

REMUNERATION COMMITTEE MEETING ATTENDANCE 2013/14

MEMBERS

08/0

5/1

3

26/0

6/1

3

31/0

7/1

3

22/0

8/1

3

25/0

9/1

3

22/1

0/1

3

30/1

0/1

3

27/1

1/1

3

11/1

2/1

3

07/0

1/1

4

06/0

2/1

4

21/0

2/1

4

19/0

3/1

4

Total

Valerie Morton

n/a n/a n/a n/a n/a n/a n/a n/a n/a √ √

2

Sheila Childerhouse

n/a n/a √ √

2

Peter Kara n/a n/a n/a n/a n/a n/a n/a n/a n/a √ √

2

Judith Lancaster

n/a n/a n/a n/a √ Apology

1

Sarah Boulton

√

1

EX MEMBERS

8/5 26/6 31/7 22/8 25/9 22/10 30/10 27/11 11/12 7/1 6/2

Total

Dr Geoffrey Harris OBE

n/a

5

Anne Osborn Apology n/a n/a n/a

1

Frances Pennell-Buck

n/a n/a Apology

3

Paul Remington

Apology

1

Caroline Bailes

Apology n/a n/a n/a n/a n/a

0

Phil Barlow n/a n/a n/a n/a

2

Margaret Stockham

Apology

1

Disestablished Committees

QUALITY AND RISK ASSURANCE COMMITTEE (QRAC) MEETING ATTENDANCE

QRAC MEMBERS 16.05.13

Phil Barlow

Anne Osborn

Paul Remington

Margaret Stockham Apology

Pam Chrispin Apology

PERFORMANCE AND FINANCE COMMITTEE MEETING ATTENDANCE

2013

PAFC MEMBERS 08/05

Phil Barlow

Anne Osborn

Paul Remington

BUSINESS DEVELOPMENT AND INVESTMENT COMMITTEE MEETING ATTENDANCE

2013

BDIC MEMBERS 18.04.13

Caroline Bailes Apology

Phil Barlow

Margaret Stockham

57

The values shown are number of attendances against number of meetings held during the year. Where there is no entry this means the director is not a member of that committee

Review of Effectiveness of the Trust Board and Sub-Committees The Board and its sub-committees last reviewed their effectiveness as part of the Trust‟s 2012 NHS Foundation Trust application. The Board utilised the services of an external body to undertake an independent review of its performance as a unitary body and as individual Board Members. The sub-committees reviewed their effectiveness informally on a regular basis and formally once a year through the Board‟s approved evaluation process. The Audit Committee utilised the self-assessment questionnaire available from the Audit Committee Handbook 2011 and provided an annual report to the Trust Board. During the year under review, and with the lack of continuity and stability in the Board composition a formal review of the effectiveness of the Board and its committees has not been completed. Indeed all existing sub-committees (with the exception of Audit Committee and the Remuneration Committee) were put on hold in June by the Interim Chair. A committee restructure was then carried out by the Interim Chair and Acting Trust Secretary resulting in the establishment of the three board committees as set out above. Revised Terms of Reference for each of these Committees have been approved by the Trust Board.

58

Remuneration report Trust Board Remuneration Committee The Remuneration Committee is responsible for advising on the appointment and/or dismissal of executive directors, directors and Trust Secretary (Company Secretary). The committee is also responsible for the approval of their remuneration and terms of service and for the monitoring of their performance against delivery of organisational objectives. Membership is drawn from the non-executive directors of the Trust Board. The Chief Executive is entitled to attend the committee and be consulted with when the appointment and remuneration of the executive directors and Trust Secretary is being considered. He is excluded from meetings on his own position. An appointments panel of the Remuneration Committee is convened when appointments are to be made. All appointments are by public advertisement, and external assessors are part of the recruitment process. During the reported period there were a number of changes to the directorship positions on the Trust Board and these are detailed earlier in the report. Remuneration and performance conditions The remuneration of the Chair and the Non-Executive Directors is decided by the Secretary of State. The time commitment required is approximately three days per week for Chairs and two and a half days per month for non-executive directors. To determine an Executive Director‟s salary level, the Remuneration Committee used one or more of the following independent benchmarking comparative data during 2013/14:

Hay Group

NHS Foundation Trust Network

NHS ambulance services The policy of the Trust on remuneration of senior managers fully reflects the national guidance issued by the Department of Health. Salaries are set in accordance with Very Senior Managers‟ requirements and are approved by the Strategic Health Authority‟s Remuneration Committee. The performance of senior managers is assessed by regular performance against objectives. Payment in respect of the contractual VSM discretionary performance bonus was limited to the Director of Finance in the financial year. The bonus proposed by the Remuneration Committee was declined by the Director of Finance due to the economic constraints on the service. There were no other awards to past senior managers in the year. Executive directors have permanent employment contracts with termination periods of six months. The exception to this policy is by agreement of the Remuneration Committee. Reporting of other compensation schemes – exit packages There are no special contractual compensation provisions for early termination of Executive Director‟s contracts. Early termination by reason of redundancy is subject to normal NHS terms and conditions of service handbook or, for those above the minimum retirement age, early termination by reason of redundancy or „in the interests of the efficiency of the service‟ is in accordance with the NHS Pension Scheme. Employees above the minimum retirement age who themselves request termination by reason of early retirement are subject to the normal provisions of the NHS Pension Scheme. Salary and pension entitlement of the Trust Board The Chief Executive has determined that senior managers are those persons in senior positions having authority or responsibility for directing or controlling the major activities of the NHS Body. This means those who influence the decisions of the entity as a whole rather than the decisions of the individual directorates or departments. These are:

59

Executive and Non-Executive Directors of the Trust Board

Director of Strategy and Business Development

Director of Business Transformation Detailed below are the remuneration, salary and pension entitlements of the senior managers. These disclosures have been audited.

60

Salary and Allowances

Name Title

2013-14 2012-13

(a) (b) (c) (d) (e) (f) (a) (b) (c) (d) (e) (f)

Salary

(bands of

£5,000)

Expense

payments

(taxable)

total to

nearest

£100

Performance

pay and bonuse

s (bands

of £5,000)

Long term

performance

pay and bonuse

s (bands

of £5,000)

All pension-

related

benefits

(bands of

£2,500)

TOTAL (a to e)

(bands of

£5,000)

Salary

(bands of

£5,000)

Expense

payments

(taxable)

total to

nearest

£100

Performance

pay and bonuse

s (bands

of £5,000)

Long term

performance

pay and bonuse

s (bands

of £5,000)

All pension-

related

benefits

(bands of

£2,500)

TOTAL (a to e)

(bands of

£5.000)

Senior Managers in post at 31 March 2014

Sarah Boulton Interim Chair 0-5 Nil Nil Nil Nil 0-5 Nil Nil Nil Nil Nil Nil

Sheila Childerhouse

NED 0-5 Nil Nil Nil Nil 0-5 Nil Nil Nil Nil Nil Nil

Judith Lancaster NED 0-5 Nil Nil Nil Nil 0-5 Nil Nil Nil Nil Nil Nil

Peter Kara NED 0-5 Nil Nil Nil Nil 0-5 Nil Nil Nil Nil Nil Nil

Valerie Morton NED 0-5 Nil Nil Nil Nil 0-5 Nil Nil Nil Nil Nil Nil

Dean Parker NED 0-5 Nil Nil Nil Nil 0-5 Nil Nil Nil Nil Nil Nil

Andrew Egerton-Smith

Associate NED 0-5 Nil Nil Nil Nil 0-5 Nil Nil Nil Nil Nil Nil

Anthony Marsh Interim Chief Executive 45-50*

Nil Nil Nil Nil 45-50

Nil Nil Nil Nil Nil Nil

Stephen Day Interim Director of Finance & Commercial Service Director

245-250

Nil Nil Nil Nil 245-250

Nil Nil Nil Nil Nil Nil

Rob Ashford Acting Director of Service Delivery 40-45

3,000 Nil Nil 17.5-

20 60-65

Nil Nil Nil Nil Nil Nil

Ngozika (Francesca) Okosi

Director of Workforce, Engagement & Organisational Development

85-90

1,400 Nil Nil 0-2.5 85-90

Nil Nil Nil Nil Nil Nil

Dr Scott Turner Interim Medical Director 35-40

1,800 Nil Nil 12.5-

15 50-55

Nil Nil Nil Nil Nil Nil

John Martin Interim Director of Patient Safety and Clinical Standards

85-90

900 Nil Nil 10-12.5

95-100

10-15

700 Nil Nil 5-7.5 20-25

This includes salary, pension costs and employer national insurance contributions

61

Senior Managers who left the Trust Board in 2013/14

William (Geoff) Harris

Interim Chair 20-25

Nil Nil Nil Nil 20-25

Nil Nil Nil Nil Nil Nil

Paul Remington NED and Interim Chair 0-5 Nil Nil Nil Nil 0-5 5-10 Nil Nil Nil Nil 5-10

Caroline Bailes NED 0-5 Nil Nil Nil Nil 0-5 5-10 Nil Nil Nil Nil 5-10

Phil Barlow NED 0-5 Nil Nil Nil Nil 0-5 5-10 Nil Nil Nil Nil 5-10

Ann Osborn NED 0-5 Nil Nil Nil Nil 0-5 5-10 Nil Nil Nil Nil 5-10

Margaret Stockham

NED 0-5 Nil Nil Nil Nil 0-5 0-5 Nil Nil Nil Nil 0-5

Frances Pennell-Buck

NED 0-5 Nil Nil Nil Nil 0-5 Nil Nil Nil Nil Nil Nil

Dr Pamela Chrispin

Medical Director 50-55

2,000 Nil Nil 60-62.5

110-115

120-125

5,200 Nil Nil (35-37.5)

85-90

Paul Scott Director of Finance 15-20

400 Nil Nil 22.5-

25 40-45

105-110

2,600 Nil Nil 5-7.5 115-120

Adrian Matthews Director of Strategy and Business Development

60-65

1,800 Nil Nil 5-7.5 65-70

90-95

2,900 Nil Nil 5-7.5 100-105

Andrew Morgan Interim Chief Executive 105-110

4,000 Nil Nil 7.5-10

120-125

Nil Nil Nil Nil Nil Nil

Christina Youell Interim Director of HR and Organisational Development

15-20

Nil Nil Nil Nil 15-20

90-95

Nil Nil Nil Nil 90-95

Neil Storey Director of Emergency Operations 35-40

200 Nil Nil 2.5-5 35-40

85-90

1,500 Nil Nil 10-12.5

95-100

Senior Managers who left the Trust Board in 2012/13

Maria Ball Chair Nil Nil Nil Nil Nil Nil 20-25

Nil Nil Nil Nil 20-25

Hayden Newton Chief Executive Nil Nil Nil Nil Nil Nil 100-105

Nil Nil Nil 12.5-

15 115-120

Lesley Bradley Director of Business Transformation Nil Nil Nil Nil Nil Nil 30-35

3,800 Nil Nil 0-2.5 35-40

Sheilagh Reavey Director of Clinical Quality Nil Nil Nil Nil Nil Nil 85-90

Nil Nil Nil 2.5-5 90-95

Alan Murray Interim Director of Operations/ Director of Service Delivery

Nil Nil Nil Nil Nil Nil 5-10 Nil Nil Nil 22.5-

25 30-35

Paula Grayson NED Nil Nil Nil Nil Nil Nil 0-5 Nil Nil Nil Nil 0-5

The benefit in kind relates to car benefit charge.

62

Andrew Morgan Interim Chief Executive, 2012/13 seconded to the East of England Ambulance Service NHS Trust from NHS Norfolk and Waveney PCT. 2012/13 all costs retained by NHS Norfolk and Waveney PCT.

Christina Youell, Interim Director of HR and Organisational Development, invoiced fees and travel expenses of £19,871 to the Trust through People and Performance.

The costs to the Trust in respect of Stephen Day, Interim Director of Finance & Commercial Services, for fees and expenses total £246,273 for the period, this figure excludes £49,255 of irrecoverable VAT. These costs were charged by Cadence Partners.

The costs to the Trust in respect of Anthony Marsh, Interim Chief Executive, for fees total £49,794 for the period. These costs were charged by West Midlands Ambulance Service NHS Foundation Trust.

The following senior managers served for part of the financial year 2013/14:

Geoff Harris Appointed to Trust Board 28th May 2013; Left the Trust Board on 28th January 2014

Sheila Childerhouse Appointed to Trust Board 15th July 2013

Frances Pennell-Buck Appointed to Trust Board 15th July 2013; Left the Trust Board on 14th January 2014

Judith Lancaster Appointed to Trust Board 9th September 2013

Peter Kara Appointed to Trust Board 2nd December 2013

Valerie Morton Appointed to Trust Board 2nd December 2013

Dean Parker Appointed to Trust Board 2nd December 2013

Andrew Egerton-Smith Appointed to Trust Board 7th October 2013

Anthony Marsh Appointed to Trust Board 1st January 2014

Stephen Day Appointed to Trust Board 31st May 2013

Rob Ashford Appointed to Trust Board 14th October 2013

Ngozika (Francesca) Okosi Appointed to Trust Board 25th May 2013; Left the Trust Board on 16th May 2014

Scott Turner Appointed to Trust Board 1st September 2013

Paul Remington Left the Trust Board on 27th June 2013

Phil Barlow Left the Trust Board on 9th July 2013

Anne Osborn Left the Trust Board on 28th June 2013

Margaret Stockham Left the Trust Board on 26th June 2013

Caroline Bailes Left the Trust Board on 27th June 2013

Dr Pamela Chrispin Left the Trust Board on 31st August 2013

Paul Scott Left the Trust Board on 2nd June 2013

Adrian Matthews Left the Trust Board on 30th November 2013

Andrew Morgan Left the Trust Board on 31st December 2013

Christina Youell Left the Trust Board on 24th May 2013

Neil Storey Left the Trust Board on 13th August 2013

63

Signed on behalf of East of England Ambulance Service NHS Trust on 28th May 2014: Sarah Boulton Anthony Marsh Interim Chair Interim Chief Executive Senior managers’ pension benefits 2013/14 The following pension benefits have accrued for those senior managers directly employed by the Trust.

Title Name

Real increase

in pension at age 60 (bands of

£2,500)

Real increase in

pension lump sum at aged 60 (bands of

£2,500)

Total accrued

pension at age 60 at 31 March

2014 (bands of

£5,000)

Lump sum at age 60 related to accrued pension

at 31 March 2014

(bands of £5,000)

Cash Equivalent Transfer Value at 31 March

2014 £'000

Cash Equivalent Transfer Value at 31 March

2013 £'000

Real increase in Cash

Equivalent Transfer

Value £'000

Employer’s contribution

to stakeholder

pension £'000

Interim Chief Executive Andrew Morgan 0-2.5 5 - 7.5 55 - 60 170 - 175 1,052 982 71 Nil

Medical Director Dr Pamela Chrispin 15 - 17.5 45 - 47.5 60 - 65 185 - 190 0 931 -931 Nil

Acting Medical Director Dr Scott Turner 2.5 - 5 7.5 - 10 15 - 20 55 - 60 340 274 66 Nil

Director of Finance Paul Scott 5 - 7.5 17.5 - 20 25 - 30 80 - 85 379 285 93 Nil

Acting Director of Service Delivery Robert Ashford 2.5 - 5 12.5 - 15 25 - 30 75 - 80 396 32 364 Nil

Interim Director of Finance & Commercial Service

Adrian Matthews 0 - 2.5 2.5 - 5 25 - 30 85 - 90 532 489 43 Nil

Director of Workforce, Engagement & Organisational Development / Deputy Chief Executive

Ngozika (Francesca) Okosi

0 - 2.5 0 0 - 5 0 15 0 15 Nil

Interim Director of Patient Safety and Clinical Quality

John Martin

2.5 - 5 7.5 - 10 10 - 15 35 - 40 149 113 36 Nil

Director of Emergency Operations Neil Storey 0 - 2.5 2.5 - 5 20 - 25 60 - 65 262 241 21 Nil

As non-executive members do not receive pensionable remuneration, there are no entries in respect of pensions for Non-Executive members.

64

Cash Equivalent Transfer Values A Cash Equivalent Transfer Value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member‟s accrued benefits and any contingent spouse‟s pension payable from the scheme. A CETV is a payment made by a pension scheme or arrangement to secure pension benefits in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits that the individual has accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity to which disclosure applies. The CETV figures and the other pension details include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS pension scheme. They also include any additional pension benefit accrued to the member as a result of their purchasing additional years of pension service in the scheme at their own cost. CETVs are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries. Real Increase in CETV This reflects the increase in CETV effectively funded by the employer. It takes account of the increase in accrued pension due to inflation, contributions paid by the employee (including the value of any benefits transferred from another scheme or arrangement) and uses common market valuation factors for the start and end of the period. Median Remuneration 2013/14 2012/13

Band of Highest Paid Director’s Total Remuneration (Bands of £5,000) £'000

245-250 120-125

Median Total Remuneration £'s

27,007 26,770

Ratio 9.16 4.68

NHS Trusts are required to disclose the relationship between the remuneration of the highest-paid director in their organisation and the median remuneration of the organisations' workforce. Due to changes in the Board personnel during the year, and interim positions, there is a change to the highest paid director compared to 2012/13. The banded remuneration of the highest-paid director in the organisation in the financial year 2013/14 was £245,000 - 250,000. This banding is 9.16 times the median remuneration of the workforce, which was £27,007.

65

The large increase in the ratio is due to the highest paid Director post being held by a Consultant rather than a substantive employee. Recalculating the median salary and ratio using the Chief Executive as the highest paid Director, would show the banding as 5.32 times higher than the median remuneration of the workforce at £26,971, and a more accurate comparator to the prior year. Total remuneration includes salary, non-consolidated performance-related pay and benefits-in-kind as well as severance payments. It does not include employer pension contributions and the cash equivalent transfer value of pensions. Agency and Consultancy staff are included on the basis of those occupying a vacant post as at 31st March 2014. These agency costs are annualised based on the expenditure on that individual in the week ending 31st March 2014, less an agency commission fee of between 7.25% and 9%. Locum GP's and Nurses are included using their actual income earned from the Trust in year. They are not annualised on the basis that they are not contracted to specific shifts throughout the year, but collectively they cover the sessional shifts of the GP out of hours service. Annualising GP and Nurse remuneration in this position would distort employee remuneration. Remuneration for all individuals ranged from £245,000-250,000 to £7

66

Reporting of other compensation schemes - exit packages

Exit Packages agreed in 2013-14

2013-14 2012-13

Exit package cost band (including any special payment element)

Number of redundancies

Number of other

departures agreed

Total number of

exit packages

Number of redundancies

Number of other

departures agreed

Total number of

exit packages

Less than £10,000 2 0 2 0 3 3

£10,001-£25,000 1 4 5 3 7 10

£25,001-£50,000 0 2 2 1 3 4

£50,001-£100,000 0 6 6 4 3 7

£100,001 - £150,000 0 7 7 0 0 0

£150,001 - £200,000 0 3 3 0 0 0

>£200,000 0 2 2 0 0 0

Total number of exit packages by type (total cost 3 24 27 8 16 24

Total resource cost (£000s) 21 2,622 2,643 384 482 866

Redundancy and other departure costs have been paid in accordance with the provisions of the NHS Scheme. Exit costs in this note are accounted for in full in the year of departure. Where the Trust has agreed early retirements, the additional costs are met by the Trust and not by the NHS pensions scheme. Ill-health retirement costs are met by the NHS pensions scheme and are not included in the table. Other departures includes costs associated with a national voluntary severance scheme designed to help NHS organisations manage workforce redesign and reductions. The scheme is titled Mutually Agreed Resignation Scheme (MARS). This disclosure reports the number and value of exit packages agreed in the year. Note: The expense associated with these departures may have been recognised in part or in full in a previous period.

67

Exit packages - Other Departures analysis

2013-14 2012-13

Agreements Total value of agreements

Agreements Total value of agreements

Number £000s Number £000s

Voluntary redundancies including early retirement contractual costs

23 2,470 0 0

Mutually agreed resignations (MARS) contractual costs 0 0 16 482

Total 23 2,470 16 482

This disclosure reports the number and value of exit packages agreed in the year. Note: the expense associated with these departures may have been recognised in part or in full in a previous period. As a single exit packages can be made up of several components each of which will be counted separately in this Note, the total number above will not necessarily match the total numbers in Exit Packages Agreed in 2013/14 which will be the number of individuals. 19 non-contractual payments totalling to £2,475k were made to individuals where the payment value was more than 12 months‟ of their annual salary. The Remuneration Report includes disclosure of exit payments payable to individuals named in that Report.

68

Off-payroll engagements note An „Off-Payroll‟ arrangement is where contracted individuals are paid directly or through their own companies (and so are responsible for their own tax and NI arrangements) and not being classed as employees.

Off-Payroll Engagements Table 1

For all off-payroll engagements as of 31 March 2014, for more than £220 per day and that last longer than six months:

Number

Number of existing engagements as of 31 March 2014 128

Of which, the number that have existed:

for less than one year at the time of reporting 6

for between one and two years at the time of reporting 14

for between 2 and 3 years at the time of reporting 8

for between 3 and 4 years at the time of reporting 5

for 4 or more years at the time of reporting 95

All existing off-payroll engagements 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. Prior to service commencement, each engagement must have signed a contract stating that they are responsible for accounting to the relevant taxes, national insurance, liabilities, charges, and duties. All engagements listed in Table 1 are with General Practitioner's or Nurse Practitioners, contracted to deliver the Primary Care Out of Hours service.

69

Off-Payroll Engagements Table 2

For all new off-payroll engagements between 1 April 2013 and 31 March 2014, for more than £220 per day and that last longer than six months:

Number

Number of new engagements, or those that reached six months in duration, between 1 April 2013 and 31 March 2014. 6

Number of new engagements which include contractual clauses giving the East of England Ambulance Service NHS Trust the right to request assurance in relation to income tax and National Insurance obligations.

6

Number for whom assurance has been requested 6

Of which:

assurance has been received 6

assurance has not been received 0

engagements terminated as a result of assurance not being received 0

Number of off-payroll engagements of board members, and/or senior officers with significant financial responsibility, during the year

1

Number of individuals that have been deemed “board members, and/or senior officers with significant financial responsibility” during the financial year. This figure includes both off-payroll and on-payroll engagements*

26

*All individuals who occupied a Board member position, for a period of time in the financial year, have been included in this figure.

70

Declaration of Interests

Name and Position Declaration of Interest

Sarah Boulton Chair, Non-executive Director

Director – Healthy Board Services Ltd Associate (Governance) – Capsticks Solicitors LLP

Sheila Childerhouse Non-executive Director

Partner – T&D Childerhouse Self-employed executive coach Chair – Keystone – Keystone Development Trust Trustee – Burrell Museum Trustee – East Anglian Children‟s Hospice Associate – Capsticks Associate – Oliver & Company (UK) Ltd

Andrew Egerton-Smith Associate Non-executive Director

Chairman – East Anglian Air Ambulance

Peter Kara Non-executive Director

Mental Health Act Manager – Central & North West London NHS Foundation Trust

Judith Lancaster Non-executive Director

Judge in First Tier Property Tribunal

Valerie Morton Non-executive Director

Proprietor of Valerie Morton Fundraising & Consultancy – some clients may be health related charities. Currently no conflicts to disclose.

Dean Parker Non-executive Director

Wife is the Chief Finance Officer at the following Clinical Commissioning Groups – Westminster, Ealing, Hounslow, Kensington and Chelsea, Hammersmith and Fulham Independent Member of Audit & Risk Assurance Committee – Equalities & Human Rights Commission

Dr Anthony Marsh Chief Executive Officer

Trustee of West Midlands Ambulance Service NHS Foundation Trust General Charity IMAS Partner IMAS Board member Major Incident Regional Commander National Major Incident Commander (Management in Crisis Cadre) Chair of the Association of Ambulance Chief Executives Ambulance Advisor Health Education England NHS Trust Development Authority National Ambulance Advisor West Midlands Ambulance Service NHS Foundation Trust

Stephen Day Interim Director of Finance & Commercial Services

Director/owner – Entrusted Group Limited

71

Name and Position Declaration of Interest

John Martin Acting Director of Patient Safety and Clinical Standards

Director: College of Paramedics. Director: British Paramedic Association. Director: Challenge Your Thinking Limited. Self-employed consultant. Vice Chair: College of Paramedics. Chair: National Ambulance Lead Paramedic Group (Part of Association of Ambulance Chief Executives). Advisory Board member: Paramedic Education Evidence-based Project. Committee Member: Joint Royal Colleges Ambulance Liaison Committee. Committee Member: Allied Health Professions Federation. Health and Care Professions Council: Registration Partner & Education Partner. Jones & Bartlett Section Editor: Emergency Care in the Streets. NHSLA approved expert witness. Council member: East of England Clinical Senate (NHS England).

Andrew Morgan Interim Chief Executive

Nil

Neil Storey Director of Emergency Operations

Executive Representative – British Association of Public Safety Communication Officials Chairman – CAD Suppliers Group

Scott Turner Acting Medical Director

GP: Part-time partner in general practice, including shareholding in Norwich Practices Ltd (NPL). Executive member of Norfolk Accident Rescue Service. Race-course medical officer.

Rob Ashford Acting Director of Service Delivery

Director: Elite Advanced Driver Training Ltd.

72

Annual accounts Financial Report This annual report has been prepared to reflect the activities and financial position of the East of England Ambulance Service NHS Trust for the year ending 31 March 2014. During the financial year we were pleased to meet the three important financial targets: Break even, External Financing Limit and Capital Resource Limit. Plans submitted to the NHS Trust Development Authority (TDA) were used for monitoring our financial performance during the year. We are reporting a retained deficit of £2,525,000 after impairments of £2,904,000 which gives rise to an adjusted retained surplus of £379,000 for the year ending 31 March 2014. This was marginally ahead of a revised planned surplus of £100,000. The surplus is considerably lower than the reported surplus of £4,175,000 for the previous financial year and reflects the difficult conditions within which the Trust has had to operate in 2013-14. Looking at the financial statements for 2013/14 compared with the previous year, operating expenses have increased by 2.9% or £6.7m (excluding the asset impairments in 2012/13), in order to attempt to meet performance standards, whilst revenue has not increased by the same margin, resulting in a reduced surplus. One important measure of cash generation is Earnings Before Interest, Tax, Depreciation and Amortisation excluding impairments (EBITDA). For the year 31 March 2014 it was £6.5million (£9.8miliion in 2012/13). This positive number means that there has been sufficient cash generated to be re-invested into front line services. We are close to securing all our contracts and therefore our revenue for 2014/15 and our budgets for the year have been agreed by the Board. Included in these budgets is a challenging savings target which will need to be achieved whilst maintaining our quality standards. The Trust Board will continue to monitor our financial position and key risks; the most significant financial risk being the delivery of the savings plans. The financial statements for the year ending 31 March 2014 presented in this Annual Report are a summary of the full set of accounts which have been prepared in accordance with the section 98(2) of the National Health Service and Community Care Act 1990, in a form which the Secretary of State, with the approval of the Treasury, directed. Details of Directors‟ remuneration are included in the remuneration report. The Trust Annual Report, including this finance review, has been prepared in accordance with the NHS Trusts Manual for Accounts for 2013/14, as directed by the Secretary of State. Kevin Smith Acting Director of Finance

0

Appendix A

East of England Ambulance Service NHS Trust

Annual Accounts

Year Ended 31 March 2014

East of England Ambulance Service NHS Trust Trust Headquarters Whiting Way Melbourn SG8 6EN

1

Statement of the Chief Executive's Responsibilities as the Accountable Officer of the Trust The Chief Executive of the NHS Trust Development Authority has designated that the Chief Executive should be the Accountable Officer to the trust. The relevant responsibilities of Accountable Officers are set out in the Accountable Officers Memorandum issued by the Chief Executive of the NHS Trust Development Authority. These include ensuring that:

there are effective management systems in place to safeguard public funds and assets and assist in the implementation of corporate governance;

value for money is achieved from the resources available to the trust;

the expenditure and income of the trust has been applied to the purposes intended by Parliament and conform to the authorities which govern them;

effective and sound financial management systems are in place; and

annual statutory accounts are prepared in a format directed by the Secretary of State with the approval of the Treasury to give a true and fair view of the state of affairs as at the end of the financial year and the income and expenditure, recognised gains and losses and cash flows for the year.

To the best of my knowledge and belief, I have properly discharged the responsibilities set out in my letter of appointment as an Accountable Officer. Dr Anthony Marsh Chief Executive 30

th May 2014

2

Statement of Directors' Responsibilities in respect of the Accounts The directors are required under the National Health Service Act 2006 to prepare accounts for each financial year. The Secretary of State, with the approval of the Treasury, directs that these accounts give a true and fair view of the state of affairs of the trust and of the income and expenditure, recognised gains and losses and cash flows for the year. In preparing those accounts, directors are required to:

apply on a consistent basis accounting policies laid down by the Secretary of State with the approval of the Treasury;

make judgements and estimates which are reasonable and prudent;

state whether applicable accounting standards have been followed, subject to any material departures disclosed and explained in the accounts.

The directors are responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the trust and to enable them to ensure that the accounts comply with requirements outlined in the above mentioned direction of the Secretary of State. They are also responsible for safeguarding the assets of the trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities. The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the accounts. By order of the Board. Dr Anthony Marsh Stephen Day Chief Executive Interim Director of Finance 30

th May 2014 30

th May 2014

3

Governance Statement Scope of Responsibility As Accountable Officer and as set out in the Accountable Officer Memorandum, the Chief Executive has responsibility for maintaining a sound system of internal control that supports the achievement of the Trust‟s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which he is personally responsible, in accordance with the responsibilities assigned to him. The Accountable Officer is also responsible for ensuring that the Trust is administered prudently and economically and that resources are applied efficiently and effectively. The Chief Executive has responsibility for ensuring that there is effective liaison with the NHS Trust Development Authority (TDA), the NHS England Local Area Teams (LAT), and the commissioners in the development of strategic priorities for the organisation through the Trust‟s Integrated Business Plan (IBP). The Chief Executive ensures both national and local targets are met and risks are mitigated to acceptable levels. The NHS TDA monitors the achievement of key priorities on an on-going basis. In addition, senior managers participate fully across the region in all strategic and operational planning, preparation and commissioning issues. The Governance Framework of the Organisation The Trust Board continues to adopt the National Leadership Council‟s principles as defined within The Healthy NHS Board Principles of Good Governance (2013). These are:

Formulate strategy for the organisation.

Ensure accountability by holding the organisation to account for the delivery of strategy and through seeking assurance that all systems of control are robust and reliable.

Shape a positive culture for the Board and the organisation. The Board recognises the importance of the principles of good corporate governance and is committed to ensuring these are effective and efficient. This is implemented through key governance documents, policies and procedures of the Trust, including:

The Trust Standing Orders.

The Reservation of Powers to the Trust Board and Scheme of Delegation.

The Standing Financial Instructions.

The Annual Plan.

Terms of reference of the sub-committees of the Trust Board. The Trust has applied the principles of the relevant codes of corporate governance in the following manner:

The Trust is led by a Board comprising non-executive and executive directors which provides leadership within a framework of internal control whilst promoting innovation and vision, and challenge to any performance issues. The corporate governance arrangements for the organisation were challenged during 2013/14 with the resignation of a significant number of board members. Interim appointments to both executive and non-executive director positions were made to provide sufficient leadership on an interim basis whilst permanent recruitment was commenced.

The Trust Board monitors the effectiveness of the internal control systems and processes through clear accountability arrangements.

Each executive director provides an account of control systems and processes, monitoring methods and weaknesses within their Directorates during the year; cross checking evidence of compliance with statutory functions to ensure that the Trust remains legally compliant.

The Trust has developed clear information for directors highlighting Key Performance Indicators (KPIs) in the form of a dashboard report which is published monthly (the „Vital Signs‟ report).

4

Delegation of authority for executive management to the Chief Executive, subject to monitoring and limitations as defined within the policies and procedures of the Trust, including Standing Financial Instructions and the Scheme of Delegation. The limitations require that any executive action taken in the course of business does not compromise the integrity and reputation of the Trust and takes account of any potential risks, health and safety, patient experience and finance issues, and also working with partner organisations.

The Audit Committee has been affected by the changes in Board membership but is now fully functioning with a Chair of Audit with the requisite financial qualifications.

The Trust Board has continued to communicate with its members (notwithstanding the deferment of its Foundation Trust application), patients and the local community by member newsletters, member recruitment events and an Annual Public Meeting. Shadow governors appointed in the Autumn of 2012 have been stood down due to the ongoing deferment of the Trust‟s Foundation Trust application by Monitor.

The Trust Board Directors’ Responsibilities The Trust Board comprises the non-executive directors and executive directors that form a unitary body. The Board functions as a corporate decision-making body and should consist of six non-executive directors (including the Chair) and five executive directors. As already outlined there has been a significant lack of continuity in the composition of the Board, however, by the end of the 2013/14 year the Board now consists of an interim Chair, five non-executive directors, an Interim Chief Executive Officer an Interim Director of Finance & Commercial Services, and three acting executive directors (one of whom is the Medical Director). All are full and equal members. An associate non-executive director has been appointed to provide further expertise, and the Director of Workforce, Engagement & Organisational Development, attends Board meetings routinely. These latter two roles are non-voting positions. Appointment of Board Directors Due consideration is given to the composition of the Board in terms of the protected characteristic groups in the Equality Act 2010. Each Board member is appointed for their experience, their business acumen and their links with the local community. The Secretary of State for Health has the power to make the appointments of the Chair and Non-Executive Directors but has delegated this role to the NHS TDA. As a result the NHS TDA is responsible on behalf of the Secretary of State for their appointment and removal, on-going support through appraisal, mentoring and training. All appointments are made by a public advertisement. Terms of appointment are normally for periods of four years with members eligible to be re-appointed or to re-apply up to a maximum of ten years. The Non-Executive Directors‟ responsibilities include:

Helping to plan for the future growth and success of the organisation.

Making sure that the management team meets its performance targets.

Ensuring that finances are properly managed with accurate information.

Helping the Board ensure it is working in the public interest. The Chief Executive and the Trust Board Executive Directors are appointed, via public advertisement, by members of the Remuneration Committee. The Remuneration Committee is composed of five Non-Executive Directors including the Chair of the Trust. Register of Interests At the time of their appointment, all directors are asked to declare any interests on the Register of Directors‟ Interests. Board members are asked at each formal Board meeting to register any changes to their declarations and to confirm, in writing on an annual basis, that the declarations are accurate. The Register is maintained by the Trust Secretary and is available to anyone who wishes to see it. This information is also published in the Annual Report and Accounts.

5

Trust Board and Sub-Committee Meetings and Their Evaluation Processes The Trust Board, in accordance with the Public Bodies (Admission to Meetings) Act 1960, holds its meetings in public. The Trust Board has powers to delegate and make arrangements to exercise any of its functions through a committee, sub-committee or joint committee. Following a review of its committee structure during the year the Trust Board reduced the number of committees from five to three, namely, the Audit Committee, Remuneration & Terms of Service Committee and Patient Safety & Care Standards Committee (PS&CS). How the Trust Conducts its Board Meetings The Trust has maintained its support of the Nolan principles for public life and has continued to make the majority of decisions at Board meetings held in public. During 2013/14 the Trust Board met each month, conducting a series of different meetings throughout the day. These included eight meetings in public, one of which was the Annual Public Meeting which was held on 31 July 2013. Eleven private sessions of the Board were held; eight prior to the public meetings with three convened to discuss confidential or commercially-sensitive matters. In addition, seven workshop sessions were held during 2013/14 to allow the Board to forward plan and implement its Board development plan. Membership attendance at Trust Board and sub-committee meetings is monitored throughout the year and is reported in the Trust‟s Annual Report and Accounts. Review of Effectiveness of the Trust Board and Sub-Committees The Board and its sub-committees last reviewed their effectiveness as part of the Trust‟s 2012 NHS Foundation Trust application. The Board utilised the services of an external body to undertake an independent review of its performance, both as a unitary body and as individual Board Members. The sub-committees review their effectiveness informally on a regular basis and formally once a year through the Board‟s approved evaluation process. The Audit Committee utilises the self-assessment questionnaire available from the Audit Committee Handbook 2011 and provides an annual report to the Trust Board. Due to the lack of continuity and stability in the Board composition during 2013/14 a formal review of the effectiveness of the Board and its committees has not been completed. All existing sub-committees (with the exception of the Audit Committee and the Remuneration Committee) were put on hold in June 2013 by the Interim Chair. A committee restructure was then carried out by the Interim Chair and Acting Trust Secretary resulting in the establishment of the three board committees as set out above. Revised Terms of Reference for each of these Committees have been approved by the Trust Board. Board Effectiveness Moving forward into 2014/15 the Board will review and build its effectiveness, particularly via the development of an organisational culture that values empowerment, collaboration, innovation and a client and commercial focus. Audit Committee The Board now has a fully established Audit Committee comprising five non-executive directors and an associate non-executive director. The Chair has recent and relevant financial experience and is a qualified accountant. The Audit Committee‟s primary role is to review the adequacy and effective operation of the organisation‟s overall internal control system. In performing that role, the Committee‟s work predominantly focuses upon the framework of risks, controls and related assurances that underpin the delivery of the organisation‟s objectives (the Board Assurance Framework (BAF)). As a result, the Committee has a pivotal role to play in reviewing the Board‟s disclosure statements that flow from the organisation‟s assurance processes i.e. this Annual Governance Statement and the declarations required by the Care Quality Commission (CQC) Registration and the Quality Account. These declarations are independently assessed by the Committee as part of the annual report and accounts sign-off process and action recommended to the Trust Board.

6

The Committee also provides assurance to the Board on compliance with relevant regulatory, legal and code of conduct requirements. The Committee reviews the arrangement by which the Trust‟s staff may raise, in confidence, concerns about possible improprieties in matters of financial reporting and control, clinical quality, patient safety or other matters in accordance with the Trust‟s Whistleblowing Policy. The Committee‟s aim is to ensure that arrangements are in place for an independent investigation of such matters and for appropriate follow-up action through Internal Audit or the Counter Fraud Service. It maintains appropriate relationships with the organisation‟s auditors, both internal and external, as well as the Local Counter Fraud Specialist and Security Management. Key activities during the course of 2013/14 included:

Reviewing in detail the annual Accounts 2013/14 for the Trust and its Charitable Fund, and considering the Annual Governance Report from External Audit for 2013/14.

Monitoring the delivery of an agreed programme of internal audit reviews, considering the findings of those reviews and monitoring the timely and effective implementation of agreed recommendations.

Monitoring of internal financial control matters, such as safeguarding of assets, the maintenance of proper accounting records and the reliability of financial information.

Reviewing the risks regarding disclosure statements (Annual Governance Statement and CQC) which are supported by the Head of Internal Audit Opinion and other opinions provided.

Reviewing the assurances as detailed in the Board Assurance Framework (BAF).

Reviewing the adequacy of relevant policies, legality issues and the Codes of Conduct.

Reviewing the policies and procedures related to fraud and corruption. The Audit Committee, with the exception of the review of effectiveness, completed all items included in the plan for 2013/14. The Committee agreed that it could report to the Trust Board that:

In its view and taking into account the impact on Board composition and Board committee functions, the Trust had maintained an adequate system of governance, risk management and internal control across the whole of the Trust‟s activities (clinical and non-clinical), that supported the achievement of the Trust‟s objectives.

There was an effective internal audit function, including counter fraud services, established by management that met mandatory NHS Internal Audit standards and provided appropriate independent assurance.

Financial reports were complete and accurate, as reflected in the External Auditor‟s report to those charged with Governance. The audit opinion confirms that the accounts give a „true and fair view‟ of the state of the Trust‟s income and expenditure for the year and that they were properly prepared in accordance with the accounting policies relevant to the NHS in England. Following independent assessment of the PS&CS Committee‟s review of the Quality Account that this represented a balanced picture of the Trust‟s performance during 2013/14 and that the information reported therein was reliable and accurate, there were proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, and these controls were subject to review to confirm that they were working effectively in practice; the data underpinning the measures of performance reported in the Quality Account was robust and reliable, conformed to specified data quality standards and prescribed definitions, and was subject to appropriate scrutiny and review; and the Quality Account had been prepared in accordance with Department of Health guidance.

7

Ernst and Young LLP are appointed as the Trust‟s external auditor to independently audit the financial statements and the part of the remuneration report to be audited in accordance with relevant legal and regulatory requirements, i.e. the International Financial Reporting Standards (IFRS). The Trust ensures that the external auditors‟ independence is not compromised by work outside the audit code by having an agreed protocol for non-audit work. Non-audit work may be performed by the Trust‟s external auditors where the Audit Committee‟s approved procedure is followed. This ensures that all such work is properly considered and the auditors‟ objectivity and independence is safeguarded. The statutory audit fee for 2013/14 audit work was £87,680. No non-audit services were undertaken during the reporting period.

Patient Safety & Care Standards (PS&CS) Committee (from January 2014) The PS&CS Committee was informally formed in November 2013 and has had two formal meetings since its inception. Prior to the formation of PS&CS the Trust had a Quality and Risk Assurance Committee (QRAC), which had a similar remit and comprised four non-executive directors. The QRAC met once before being disbanded in June 2013. The PS&CS is accountable to the Trust Board for assurance on quality, risk, clinical governance frameworks, internal controls and related assurances which underpin the Trust achieving its strategic objectives. It plays a pivotal role in the assurance processes linked to the Quality Account and the CQC Registration and Quality Risk Profile (QRP). The PS&CS sets out to scrutinise patient safety performance, clinical performance, agree the clinical audit programme, review clinical audit findings and monitor plans to address deviation from expected clinical performance. It is also required to review patient experience feedback (e.g. complaints, surveys, etc.) and seek assurance on plans to address shortcomings. The PS&CS work plan also includes scrutiny of the CQC standards, principally on patient safety and clinical performance and a review of the performance of the Trust‟s risk management, health and safety regimes and the Equality Delivery System (EDS). Key activities during the course of 2013/14 were limited due to the disbanding of the Quality and Risk Assurance Committee to the following:

Establishing the revised terms of reference for the new PS&CS Committee

Establishing clear criteria for reporting

Reviewing the level of compliance with CQC essential standards and action plans related to CQC inspection reports

Reviewing the Clinical Audit Plan for 2014/15, the Health and Safety Strategy 2014/15 and the Annual Safeguarding Report 2013/14.

During the interregnum between the two committees the ongoing duties relating to quality, risk and clinical governance frameworks, internal controls and related assurances have been met by the Trust Board in its formal meetings. Performance and Finance Committee (PAFC) (until June 2013) The PAFC comprised three non-executive directors and met once before being disbanded in June 2013. Its work plan set out a review of the financial statement, activity and performance information of the organisation, including capital development, and providing assurance to the Board on appropriate action. In particular the work plan required a scrutiny of the following:

Financial and non-financial performance against plans and forecasts, highlighting and seeking assurance on deviation or recovery.

Activity against contractual plans and performance against the relevant CQC standards and Monitor‟s compliance measures, principally on access.

Implementation of the capital programme, workforce resourcing and operational capacity.

8

Key activities during the course of 2013/14 were limited due to the disbanding of the Committee to the following:

Reviewing the Information Governance Strategy, the Reference Costs Methodology, the Staff Survey Implementation Plan

Monitoring and reviewing the Principal Risks in the Board Assurance Framework & Risk Register

Considering in detail the Finance Report (including Cost Improvement Plans, Risk, Capital Programme, Trade Debtors Better Payment Practice Code, Cash Flow, Balance Sheet and Forecast Position)

Considering in detail the „Vital Signs‟ report for the Board Dashboard

Considering in detail the Finance Report (including Cost Improvement Plans, Risk, Capital Programme, Trade Debtors Better Payment Practice Code, Cash Flow, Balance Sheet and Forecast Position)

Since the disestablishment of the committee the ongoing duties relating to the review of the financial statement, activity and performance information of the organisation, including capital development have been met by the Trust Board in its formal meetings. Business Development and Investment Committee (BIDC) (until June 2013) The Committee comprised three non-executive directors and met once before being disbanded in June 2013. The role of the BIDC was to provide independent advice and assurance to the Board on business developments and strategic/commercial issues, including investments and risk appetite. Its work plan also assured the Board on the business planning process and monitored implementation plans. The work plan also included the review of new business development, acquisitions and potential investment and disinvestments in line with the Commissioning Framework. Key activities during the course of 2013/14 were limited due to the disbanding of the Committee to the following:

Scrutinising the Clinical Capacity Review and the Trust Governance Review

Reviewing the Emergency Operations and Urgent Contract for 2013/14 NHS National Standard Contract and the contract negotiation for 2013/14

Analysing contracts greater than £1m and those that fall between £500k and £999k where it was recommended that they required Trust Board approval.

Reviewing the Rapid Response Vehicle Replacement Plan for 2013/14 The ongoing duties of the Committee were met by the Trust Board in its formal meetings including gaining assurance on the contracting process for services in excess of £1 million. Remuneration & Terms of Service Committee The Remuneration & Terms of Service Committee is responsible for advising on the appointment and/or dismissal of the executive directors, directors and Trust Secretary. The committee is also responsible for the approval of their remuneration and terms of service and for the monitoring of their performance against delivery of organisational objectives. Membership is from the non-executive directors of the Trust Board. The Chief Executive is entitled to attend the committee and be consulted upon when the appointment and remuneration of the executive directors and Trust Secretary is being considered. The Chief Executive is excluded from meetings on his own position. An appointments panel of the Remuneration Committee is convened when appointments are to be made. All appointments are by public advertisement, and external assessors are part of the recruitment process.

9

The Committee has met fifteen times during the year and has been actively involved in the following:

Establishing and implementing the process for both interim and substantive appointments to the role of CEO.

Reviewing and scrutinising the Assignment Agreement with West Midlands Ambulance Service.

Considering and recommending the appointments and terms of condition for interim and acting appointments to executive directors roles.

Reviewing, scrutinising and approving business cases submitted under the Trust‟s Voluntary Redundancy Scheme.

The Risk and Control Framework The Trust‟s Risk Management Strategy and Procedure describe the risk management process to identify potential risks that exist within the Trust. The Strategy outlines the principles that are applied to all Trust activities and services to ensure that any risks identified and analysed are suitably evaluated and treated, thereby mitigating any risks which could prevent the Trust from achieving its strategic objectives. All risk registers for the Trust are managed via an electronic database. This system is supported through monthly risk review processes led by the Risk Manager; risk register reports are then scrutinised at both the Risk Management Group (RMG) and the Audit Committee. The Executive Leadership Team (ELT) has delegated responsibility for the implementation of risk management systems and processes to the RMG, which is Director-led; its terms of reference are reviewed and updated annually and attendance of members is proactively monitored. There is detailed scrutiny of the Trust‟s principal risks at the RMG to monitor progress against actions, consistency of scoring and identification of controls. A detailed review of at least one directorate risk register is undertaken at each meeting for the purposes of gaining assurance that risk is being managed effectively at a local level. This ensures that all levels of risk are being considered during the year and that focus does not only rest with the highest scoring risks. Risk Assessment The identification of risk is now considered to form a business as usual component throughout the organisation‟s practices, with directorates and teams responsible for management of their own risk registers which in turn, feed principal risks into the BAF. There is clear evidence that risks are identified through a variety of sources ranging from incident reporting and team meetings, through to external assessments and regulatory activities. The Trust has a well-established risk management and Board Assurance process that is both top-down and bottom-up:

The Board will identify the strategic risks being faced by the Trust.

Operational risks will be identified through operations and activities of the Trust in going about the achievement of the Trust‟s objectives.

Electronic system of incident reporting – web-based incident reporting system in place so that staff can now report incidents by telephone.

Learning Group – production of the Complaints, Litigation, Incidents and PALS (CLIP) report which triangulates information held on the incident reporting system and has become highly effective in drawing to the attention of the Risk Management Group (RMG) which reports in to QRAC, any potential or actual risks.

Continual review of the Trust‟s performance in relation to external assessors and regulators - ie internal and external audit, CQC, NHS Litigation Authority (NHSLA), NICE etc.

Compliance with Statutory Requirements – eg Health and Social Care Act 2008 (Code of Practice, December 2009), Equality Act 2010 public sector duties.

Reviews of the external environment – ie publication of Liberating the NHS led to a new strategic risk relating to the uncertainties surrounding the Trust‟s future commissioning.

10

Once identified, a risk assessment is undertaken using standard risk management principles, focusing upon causes and effects and assessing the risk against impact and likelihood using the internationally recognised 5x5 matrix. Controls are then implemented and mitigating actions established to reduce the risk. The major risks identified within the 2013/14 financial year have been monitored and acted upon by the Board and committees regularly through scrutiny of the Principal Risk Report and BAF. The risks identified can be split into the Strategic Risks agreed by the Board at the beginning of the financial year and the Principal Risks (those escalated to the Board from operational risk registers). A summary of the Strategic Risks and the impact of the main Principal Risks is as follows:

Failure to deliver a timely service during the transition period the Trust is undergoing, as a result of insufficient levels of clinicians and emergency vehicles

Inability to provide a consistently high quality service to patients that is in line with national quality and safety indicators

Failure to develop a staff and organisational development framework that enables the organisation to continuously deliver and improve a high quality service

Inability to match financial resources with priorities, in order to ensure that the business remains financially viable

Failure to ensure the IT infrastructure meets the required standard to ensure delivery of a safe and quality service

Risk Management Overall, the Trust‟s risk management process can be seen to have been effective in identifying new risks. In 2013/14, 414 new risks were recognised, assessed and recorded on the Trust‟s risk register, ranging from operational through to project risks. 181 risks were closed due to either successful mitigation or eradication of the risk. This demonstrates an increasing identification of risks in relation to the work streams being undertaken during the Trust‟s transition, and successful management and closure of operational risks during business. There has however been in increase in both the number of principal risks and an increase in their risk scores over the 2013/14 financial year. This shows an increasing risk profile across the organisation, and demonstrates the significant challenge that the organisation faces in sustainably effecting change. There is clear evidence that this is predominantly due to the multiple and wide ranging causes of each risk, which have influence upon each other. In 2012/13 Risk Management Key Performance Indicators were established to measure compliance with the strategy and have continued to be monitored this financial year. These demonstrated robust management of the Principal Risks with monthly reviews. However, the Indicators continue to identify that further work is necessary in relation to timely completion of actions, as well as the development of effective controls without assurance gaps. These issues were identified in the risk management and BAF Internal Audit review in 2013/14, which showed deterioration from good to substantial assurance. This was attributed to evidence of silo working and risks being considered in isolation in spite of the integrated nature of the Trust‟s issues, as well as limited assurance on the effectiveness of key controls. The Audit Committee has identified that although the Principal Risks are reviewed in committees, increased scrutiny needs to occur in relation to the controls and assurances in order to facilitate improvements to the Trust‟s risk profile. As a result in preparation for the 2014/15 financial year, the BAF has been amended to provide more meaningful information, with each of the committees to take on a more functional and analytical role in relation to risk assurances. It is anticipated that this will result in more effective risk management of the key risks faced by the organisation.

11

Data Security Incidents During 2013/14 two potentially serious information-related incidents were recorded by the Trust and reported to the Information Commissioner‟s Office. In the first incident a number of paper documents containing personal data were lost from outside secure NHS premises. The majority of these records were recovered at the scene. In the second incident an allegation was made by a member of the public that patient records were being disposed of inappropriately, although this was found to be not proven in the subsequent investigation. Both these incidents were formally investigated using the Trust‟s established procedures and reported to the Serious Incident Panel. Where necessary, recommendations for changes and improvement to existing operational practices have been made. The Information Commissioner‟s Office did not take any further action in relation to these incidents. However, the Trust will continue to monitor its information risks in order to identify and address any weaknesses and ensure continuous improvement of its processes. Information Governance Compliance The Trust has completed its annual self-assessment against the Information Governance Toolkit at the end of March 2014. For 2013/14 the Trust has declared an overall „satisfactory‟ rating, having achieved level 2 or level 3 on all applicable Toolkit standards. Compliance with NHS Pension Scheme regulations As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employer‟s contributions and payments in to 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. Compliance with Equality, Diversity and Human Rights Legislation Control measures are in place to ensure that all the Trust‟s obligations under equality, diversity and human rights legislation are complied with. The Trust has a Steering Group whose purpose is to provide support, advice, assurance and governance for the Trust Board in relation to Equalities and Human Rights. The focus of this group is to maintain and monitor the execution of the general and public sector duties. This takes into account the NHS Constitution and guidance from the Equalities and Human Rights Commission. The Equality, Diversity and Human Rights policy was revised and published during 2012 in line with the Equality Act 2010 and public duties. During 2013/14 activities were undertaken to improve the Trust‟s evidence based data about the people who used the service so that a better understanding of how the service impacts upon them can be developed. The active engagement and involvement within the community has been maintained and developed, specifically with regard to the views of groups that represent people with disabilities. Training and development has included sessions to give staff an increased level of knowledge and awareness, giving them a broader understanding of the diversity agenda. Actions and priorities have been identified by the public interest group and an implementation plan has been developed to include engagement, enabling communication for the wider community, further developing cultural competence and embedding the Trust values. Counter Fraud The Trust is committed to preventing fraud or bribery within the organisation. The Trust is fully compliant with the directions issued by the Secretary of State in 2004 and the NHS Counter Fraud and Corruption Manual, and the Standards for Providers: Fraud, Corruption and Bribery as set out by NHS Protect. The Local Counter Fraud Specialist (LCFS) reports to the Interim Director of Finance & Commercial Service and attends Audit Committee meetings to report on the work achieved. The LCFS works to ensure that counter fraud is integrated into all Trust activity in a positive way.

12

Throughout the past financial year the counter fraud culture has continued to be embedded into the Trust and work has been undertaken against each of the four areas of action set out in the Standards for Providers: Fraud and Bribery as set out by NHS Protect, namely Inform and Involve, Prevent and Deter, Hold to Account and Strategic Governance. The Trust takes a positive stance in countering fraud against the organisation and the NHS in general and actively seeks to ensure that an appropriate, yet proportionate response is taken to allegations of fraud and bribery. Where appropriate sanctions and redress are sought. The Trust has identified fraud losses of around £4,200 and is seeking criminal sanction in respect of this case.

Review of the Effectiveness of Risk Management and Internal Control Reviewing the effectiveness of the risk and control framework is a continual process during the year, informed by individual performance reports, clinical audits, by evidence gathered in support of the NHS Litigation Authority assessment process, the registration process with the CQC and with the independent assurance from the Trust internal and external auditors. NHS Litigation Authority (NHSLA) Until April 2014 organisations have been assessed against organisation type specific risk management standards levels. During 2012/13 the NHSLA carried out a review of the standards and assessments process and, as a result of the feedback, changed the current process to one that is more outcomes focused. From April 2014 onwards in place of these assessments, the NHSLA is introducing a number of actions to:

Focus on improving outcomes, learning from claims, reducing harm and improving patient and staff safety.

Support members to learn from claims.

To be proportionate to risk.

To measure and be measurable. The Trust has made a number of changes in 2013/14 to increase senior operational management awareness of claims within their respective areas. The quarterly report is being replaced with live data reporting for General Managers to enable more robust monitoring, this will enable them to react to current trends and encourage more proactive engagement. The Trust also has a Learning Group in place whose aim is to triangulate themes and trends from various data sources; incidents, claims, complaints and patients concerns. A number of actions have also been implemented during the year to address issues identified from claims, incidents and complaints as a whole to include:

Implementation of a Trust improvement plan to address ambulance delays.

Clinical bulletins and Manual issued to all staff to improve Clinical assessment/care.

Increasing Make ready services.

Better monitoring of slips, trips and falls. Care Quality Commission (CQC) Registration The Trust was registered with the CQC under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2009 on 1 April 2010. The Trust was registered without conditions or restrictions and is registered to provide services under three of the regulated activities to cover the services agreed under contract and service level agreements. As a registered healthcare provider the Trust has to demonstrate continuous compliance to the Essential Standards of Quality and Safety and uses a database system to upload evidence against each outcome and prompt. In addition the Trust holds a provider compliance assessment (PCA) document for each outcome which describes the evidence held and why the Trust is claiming compliance against the prompts within the outcome.

13

The Trust‟s Quality Risk Profile (QRP) is published regularly by the CQC and highlights the estimated risk of non-compliance against each of the Essential Standards of Quality and Safety against the evidence that has been captured from a variety of sources. The Trust has used the CQC QRP reports during the year to identify potential risks to the organisation and to inform the self-assessment process. In January and February 2013, the CQC undertook a routine inspection of the Trust examining provider compliance evidence against 5 of the 16 Essential Standards of Quality and Safety which directly relate to the quality and safety of patient care. The CQC report was published in March 2013 and concluded that the Trust was compliant in all areas with the exception of Regulation 9 Outcome 4 (Care and Welfare of People who use services). The non-compliance was judged as a moderate impact on people who use the service and was based on the Trust‟s performance in relation to the deterioration of ambulance response times. The Trust received a further visit from the CQC with an unannounced routine inspection in December 2013 against 7 of the 16 Essential Standards of Quality and Safety which directly relate to the quality and safety of patient care:

Regulation 9 Outcome 4 (Care and Welfare of People who use services).

Regulation 16 Outcome 11 (Safety, availability and suitability of equipment).

Regulation 21 Outcome 12 (Requirements relating to workers).

Regulation 22 Outcome 13 (Staffing).

Regulation 23 Outcome 14 (Supporting workers).

Regulation 10 Outcome 16 (Assessing and monitoring the quality of service provision).

Regulation 19 Outcome 17 (Complaints). The Trust remains non-compliant in Regulation 9 Outcome 4 (Care and Welfare of People who use services) however, the CQC acknowledged that since that time the Trust had made significant improvements in a number of areas; decrease in staff sickness absence rates, complaints relating to ambulance delays, the number of Serious Incidents, long waits (over 25 minutes) for back up vehicles to transport people to hospital in life threatening instances in some areas as well as spending on private ambulance services. In addition, the CQC concluded that the Trust were also non-compliant with Regulation 22 Outcome 13 (Staffing). The CQC found that the Trust did not have the numbers of suitably qualified staff it required to ensure that national ambulance response times were met and people received the care they needed in a timely way. The Trust is taking steps to address this to mitigate the risk to patients. After careful consideration, the CQC found that the Trust is taking reasonable steps to address the breaches in regulations and therefore it would not be appropriate to take further enforcement action at this point. However as the impact for people waiting to be transported to hospital remains as a moderate concern, their concerns have been escalated to the Trust Development Authority and they will continue to closely monitor the Trust, inspecting it as required and working with NHS England to review its progress. The Trust‟s new Chief Executive has reviewed the previous action plan and set new objectives for the Trust.

Clinical Audit and Patient Experience Programme The clinical audit and patient experience programme forms part of the quality governance framework and provides the Trust with assurance that services are being delivered to patients at the required standard in order to meet the dimensions of quality: patient safety, patient experience and clinical effectiveness. It provides an essential view of the care we deliver in terms of the patient experience and the clinical outcome of the care that we provide to them. Where audit and experience reports highlight standards are being delivered below those expected it also serves as an early warning indicator so that corrective action can be agreed and taken in a responsive way. The results enable us to share good practice across the Trust along with viewing us against other ambulance trusts. The results of audits and experience audits are used to review and develop training for our staff. The examples, themes or trends have enabled us to identify areas that draw out the quality measures.

14

All audits are presented to the Clinical Audit and Patient Experience (CAPE) Group who report directly into the Clinical Quality and Safety Group. CAPE approves recommendations for actions to improve the quality of service provision and patient outcomes. The proposed audit and patient experience programme for 2013/14 consists of national, strategic, regulatory and locally driven audit projects and these have been prioritised in line with the Trust‟s Clinical Audit Policy. Moving forward it is important to link clinical development with audit and experience measures. Being able to gather a wide range of information ensures a focus on key priorities or identify areas to discuss with commissioners and other providers of care. The link with research produces an evidence base of patient need that allows a continued search for the delivery of clinical excellence. Currently the patient experience audits have allowed, in part, the review of the effectiveness of changing or introducing services. A variety of other mechanisms have been used in maintaining and reviewing the effectiveness of the system of internal control, including the following:

The work of the Board Committees

The activities of the Executive Management Team who manage the operational delivery of services and provide monitoring information, reports on performance, business, risk and professional advice to the Board;

Managers within the organisation who have responsibility for the development and maintenance of the system of internal control provide assurance.

Monthly and Quarterly Quality Reports.

Monthly Trust Board corporate dashboard reports including quality, operational and financial performance.

Lead commissioner provider development meetings and other commissioning meetings monitoring the delivery of contracts.

Regular review and reports on the position of the principal risks by the QRAC and the monitoring of the risk management process by the RMG to ensure that action is taken to resolve key risks at the appropriate level and assign the necessary resources where required.

Regular reviews and reports on progress against the organisation‟s objectives through the Trust‟s Annual Plan „tracker‟ system.

Go and See visits undertaken at station level by Board members

Local clinical focus groups that review the audit and experience data for their respective areas.

The Head of Internal Audit Opinion and Annual Internal Audit Programme The Head of Internal Audit provides an opinion on the overall arrangements for gaining assurance through the BAF and on the controls reviewed as part of the internal audit work. In addition, the Board is advised by auditor and assessors providing an opinion on the adequacy and effectiveness of risk management, governance and control processes, service delivery, financial management and control, human resources, operational and other reviews levels. The overall Head of Internal Audit opinion has concluded that significant assurance can be given that there is a generally sound system of internal control, designed to meet the Trust‟s objectives, and that controls are generally being applied consistently. However, some weakness in the design and/or inconsistent application of controls, put the achievement of particular objectives at risk. As described above, any such weaknesses are identified and managed as part of the risk management process.

15

During 2013/14 the following six internal audits were awarded an assurance rating of limited assurance:

Safeguarding

Procurement

Community First Responders (CFR)

Clinical Audit

Private Ambulances

Data Quality – Performance Management Actions have been agreed based on the recommendations from these audit reports and the implementation of these actions will be followed up by the Audit Committee Risk Summits There were two Risk Summits with NHS England this financial year. The first Risk summit was held in April 2013 following the routine inspection by CQC where the Trust was found to be non-compliant with Regulation 8 outcome 4 of the Essential Standards framework. A series of meetings followed to assess the progress against actions agreed during the Summit which included the following:

Response times

Hospital turnaround delays

Serious Incidents

Staffing levels

External relationships The second Risk Summit was again following an unannounced inspection by the CQC when the Trust was found to be non-compliant with Regulation 8 outcome 4 and Regulation 22 Outcome 13 (Staffing). A series of interim floor standards relating to maximum response times towards improving patient safety and experience were set following the Risk Summit as part of the Trust‟s work towards improving patient safety and experience. Every occasion where there has been a breach in the floor standard, the incident is reviewed by the clinical directorate and declared as a Serious Incident if patient harm has been caused by the delayed response. The Trust also received a qualified Value for Money conclusion from External Audit which was based on the funding in relation to the 15/16 financial plan Significant Issues Under achievement of ambulance response times During 2013/14 the Trust has experienced significant challenges that have prevented achievement of key national and local ambulance response time targets that directly impact on patient care particularly in the more rural areas of the Trust. There have been a number of factors including:

a lack of resources to meet rising demand for the 999 service – in particular a lack of double staffed ambulances

a lack of staff to crew the required resources

a lack of fleet and equipment to provide the core resourcing requirements

poor governance review on external audit

high staff sickness rates

Loss of PTS Contracts

Poor staff skill mix resulting in high levels of multiple deployments and backup requirements

Consistent high levels of Acute Trust delayed turnaround reducing resource availability

16

This has resulted in

increasing delays in reaching patients and transporting them (when required) to hospital

increase in complaints and incident investigations

non-compliance with regulation 9 Outcome 4 and Regulation 22 Outcome 13 (Staffing) of the CQC essential standards (as outlined above)

low staff morale

adverse media and other external stakeholder interest in the Trust The Trust‟s Performance Improvement Action which is monitored by the newly set up Operational Delivery Board chaired by the CEO and includes the following six priorities:

1. Recruit 400 student paramedics in 2014/5 2. Up-skill ECAs to EMTs and EMTs to paramedics 3. Maximise clinical staff on frontline vehicles 4. Reduce response cars and increase ambulances 5. Accelerate fleet and equipment replacement programme 6. Reinvest corporate spend in frontline delivery

Dr A Marsh Chief Executive 30

th May 2014

17

Membership attendance at Trust Board and sub-committee meetings for 2013-2014 is summarised in the tables below:

Trust Board Audit

Committee Business Develop- ment &

Investment Committee

Perfor- mance & Finance

Committee

Quality & Risk

Assurance Committee

Patient Safety &

Care Standards Committee

Remunera- tion

Committee

Formal Meetings Private/ Public/

Workshop

BOARD DIRECTORS Paul Remington

(Acting Chair) Dr Geoff Harris (Interim Chair)

Sarah Boulton (Interim Chair)

Caroline Bailes (Chair)/ Dean

Parker

(Chair) Judith

Lancaster (Acting Chair)

Maria Ball/ Margaret Stockham

(Chair)

Paul Remington

(Chair)

Phil Barlow/ Anne

Osborn (Chair)

Maria Ball (Chair)/ Valerie

Morton (Chair)

Paul Remington (i) 2/3 2/3 2/2 1/1 1/1 2/4

Acting Chair

Dr Geoff Harris OBE (ii) 5/5 5/5 4/4 1/1 8/8

Interim Chair

Sarah Boulton 1/1 1/1 1/1 1/1 1/1

Interim Chair

Caroline Bailes (iii) 0/3 0/3 1/2 0/1 0/2

Non-Executive Director

Phil Barlow (iv) 3/3 3/3 1/1 1/1 1/1 2/4

Non-Executive Director

Anne Osborn (v) 2/3 2/3 2/2 1/1 1/1 2/4

Non-Executive Director

Margaret Stockholm (vi)

3/3 3/3 1/2 1/1 0/1 2/4 Non-Executive Director

Frances Pennel-Buck (vii)

2/3 2/3 4/4 2/2 1/1 5/7 Non-Executive Director

Sheila Childerhouse

5/5 5/5 7/7 3/4 1/1 1/1 9/10 Non-Executive Director

Andrew Egerton-Smith

2/3 2/3 6/6 3/3 0/1 1/1 4/5 Non-Executive Director

Peter Kara

1/2 1/2 4/4 2/3 1/1 3/4 Non-Executive Director

Judith Lancaster

4/4 4/4 7/7 3/4 0/1 7/8 Non-Executive Director

Dean Parker

2/2 2/2 4/4 3/3 2/2 Non-Executive Director

Valerie Morton

2/2 2/2 4/4 3/3 1/1 4/5 Non-Executive Director

Andrew Morgan (viii)

6/6 6/6 4/4 Interim Chief Executive Officer

Dr Anthony Marsh

2/2 2/2 3/3 Chief Executive Officer: on secondment

18

Membership attendance at Trust Board and sub-committee meetings for 2013-2014 continued:

Trust Board Audit Committee

Business Develop- ment &

Investment Committee

Perfor- mance & Finance

Committee

Quality & Risk

Assurance Committee

Patient Safety &

Care Standards Committee

Remunera- tion

Committee

Paul Scott (ix)

1/2 1/2 0/1 1/1 Director of Finance

Stephen Day

6/6 6/6 7/7 3/4 Interim Director of Finance & Commercial Services

Dr Pam Chrispin (x)

1/2 1/2 0/1 Medical Director

Dr Scott Turner

0/5 0/5 1/1 1/1 Acting Medical Director

John Martin

8/8 8/8 7/7 1/1 1/1 Acting Director of Patient Safety & Clinical Standards

Neil Storey (xi)

4/4 4/4 1/1 Director of Emergency Operations

Rob Ashford

2/3 2/3 6/6 1/1 1/1 Acting Director of Service Delivery

Trust Board Audit Committee

Business Develop- ment &

Investment Committee

Perfor- mance & Finance

Committee

Quality & Risk

Assurance Committee

Patient Safety &

Care Standards Committee

Remunera- tion

Committee

Formal Meetings Private/ Public/

Workshop

ATTENDEES

Paul Remington

(Acting Chair) Dr Geoff Harris (Interim Chair) Sarah Boulton (Interim Chair)

Caroline Bailes (Chair)/ Dean

Parker (Chair) Judith

Lancaster (Acting Chair)

Maria Ball/ Margaret Stockham

(Chair)

Paul Remington

(Chair)

Phil Barlow/ Anne

Osborn (Chair)

Maria Ball (Chair)/ Valerie Morton (Chair)

Adrian Matthews

6/6 6/6 3/3 1/1 1/1 Director of Strategy & Business Development

Christina Youell

0/1 0/1 0/1 1/2 Interim Director of HR & OD

Francesca Okosi

7/7 7/7 7/7 1/1 11/11 Director of Human Resources & Organisational Development

Values shown are numbers of attendances against number of meetings during the year. Where there is no entry this means the director is not a member of that committee.

19

Membership attendance at Trust Board and sub-committee meetings for 2013-2014 continued: i. Paul Remington: resigned 27th June 2013 ii. Dr Geoff Harris OBE: resigned 28th January 2014 iii. Caroline Bailes: resigned 27th June 2013 iv. Phil Barlow: resigned 9th July 2013 v. Anne Osborn: resigned 28th June 2013 vi. Margaret Stockham: resigned 26th June 2013 vii. Frances Pennell-Buck: interim term of office ended 14th January 2014 viii. Andrew Morgan: interim term of office ended 31st December 2013 ix. Paul Scott: resigned 2nd June 2013 x. Dr Pamela Chrispin: resigned 31st August 2013 xi. Neil Storey: stepped down from the Board on 13th August 2013 xii. Adrian Matthews: post delete as part of Trust Board restructure, stepped down from the

Board 30th November 2013 xiii. Christina Youell: interim term of office ended 24th May 2013

20

Independent Auditor's Report to the Directors of East of England Ambulance Service NHS Trust We have audited the financial statements of East of England Ambulance Service NHS Trust for the year ended 31 March 2014 under the Audit Commission Act 1998. 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 1 to 29. The financial reporting framework that has been applied in their preparation is applicable law and the accounting policies directed by the Secretary of State with the consent of the Treasury as relevant to the National Health Service in England. We have also audited the information in the Remuneration Report that is subject to audit, being:

the table of salaries and allowances of senior managers and related narrative notes on pages 60 to 62;

the table of pension benefits of senior managers and related narrative notes on pages 63 to 64; and

the table of pay multiples and related narrative notes on pages 64 to 65. This report is made solely to the Board of Directors of East of England Ambulance Service NHS Trust in accordance with Part II of the Audit Commission Act 1998 and for no other purpose, as set out in paragraph 44 of the Statement of Responsibilities of Auditors and Audited Bodies published by the Audit Commission in March 2014. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Directors, for our audit work, for this report, or for the opinions we have formed. Respective responsibilities of Directors and auditors As explained more fully in the Statement of Directors‟ Responsibilities in respect of the Accounts, set out on page 2, the Directors are 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 and International Standards on Auditing (UK and Ireland). Those standards also require us to comply with the Auditing Practices Board‟s Ethical Standards for Auditors. 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 Trust; 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.

21

Opinion on financial statements In our opinion the financial statements:

give a true and fair view of the financial position of East of England Ambulance Service NHS Trust as at 31 March 2014 and of its expenditure and income for the year then ended; and

have been prepared properly in accordance with the accounting policies directed by the Secretary of State with the consent of the Treasury as relevant to the National Health Service in England.

Opinion on other matters In our opinion:

the part of the Remuneration Report subject to audit has been prepared properly in accordance with the requirements directed by the Secretary of State with the consent of the Treasury as relevant to the National Health Service in England; and

the information given in the annual report for the financial year for which the financial statements are prepared is consistent with the financial statements.

Matters on which we report by exception We report to you if:

in our opinion the governance statement does not reflect compliance with the Trust Development Authority‟s Guidance;

we refer the matter to the Secretary of State under section 19 of the Audit Commission Act 1998 because we have reason to believe that the Trust, or an officer of the Trust, is about to make, or has made, a decision involving unlawful expenditure, or is about to take, or has taken, unlawful action likely to cause a loss or deficiency; or

we issue a report in the public interest under section 8 of the Audit Commission Act 1998 We have nothing to report in these respects. Conclusion on the Trust’s arrangements for securing economy, efficiency and effectiveness in the use of resources Respective responsibilities of the Trust and auditors The Trust is responsible for putting in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources, to ensure proper stewardship and governance, and to review regularly the adequacy and effectiveness of these arrangements. We are required under Section 5 of the Audit Commission Act 1998 to satisfy ourselves that the Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. The Code of Audit Practice issued by the Audit Commission requires us to report to you our conclusion relating to proper arrangements, having regard to relevant criteria specified by the Audit Commission. We report if significant matters have come to our attention which prevent us from concluding that the Trust has put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources. We are not required to consider, nor have we considered, whether all aspects of the Trust‟s arrangements for securing economy, efficiency and effectiveness in its use of resources are operating effectively.

22

Scope of the review of arrangements for securing economy, efficiency and effectiveness in the use of resources We have undertaken our audit in accordance with the Code of Audit Practice, having regard to the guidance on the specified criteria, published by the Audit Commission in October 2013, as to whether the Trust has proper arrangements for:

securing financial resilience; and

challenging how it secures economy, efficiency and effectiveness. The Audit Commission has determined these two criteria as those necessary for us to consider under the Code of Audit Practice in satisfying ourselves whether the Trust put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2014. We planned our work in accordance with the Code of Audit Practice. Based on our risk assessment, we undertook such work as we considered necessary to form a view on whether, in all significant respects, the Trust had put in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources. Basis for a qualified conclusion In response to a declining performance in ambulance response times and critical reports from the Care Quality Commission the Trust has, during the year, developed a performance improvement plan which requires significant investment in 2014/15 and 2015/16. The Trust has not yet been able to develop a medium-term financial plan which properly reflects its performance improvement plan. In particular, its budgets for 2014/15 and 2015/16 do not include planned expenditure necessary to deliver that plan. This means that the Trust is not currently able to demonstrate its financial resilience over the medium term. The Trust is developing plans to address these issues. Conclusion On the basis of our work, having regard to the guidance on the specified criteria published by the Audit Commission in October 2013, with the exception of the matter reported in the basis for qualified conclusion paragraph above, we are satisfied that, in all significant respects, East of England Ambulance Service NHS Trust put in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources for the year ending 31 March 2014. Certificate We certify that we have completed the audit of the accounts of East of England Ambulance Service NHS Trust in accordance with the requirements of the Audit Commission Act 1998 and the Code of Audit Practice issued by the Audit Commission. Rob Murray for and on behalf of Ernst & Young LLP One Cambridge Business Park, Cambridge, CB4 0WZ, United Kingdom 4th June 2014

23

Statement of Comprehensive Net Expenditure for year ended 31st March 2014 2013-14 2012-13

NOTE £000s £000s

Gross employee benefits 7.1 (160,213) (155,508)

Other costs 5 (79,096) (77,088)

Revenue from patient care activities 2 235,194 230,532

Other Operating revenue 3 2,531 4,967

Operating (deficit)/surplus (1,584) 2,903

Investment revenue 9 61 95

Other gains/(losses) 10 25 (60)

Finance costs 11 (81) (99)

(Deficit)/surplus for the financial year (1,579) 2,839

Public dividend capital dividends payable (946) (1,133)

Retained (deficit)/surplus for the year (2,525) 1,706

Other Comprehensive Expenditure 2013-14 2012-13

£000s £000s

Impairments and reversals (600) 0

Net gain on revaluation of property, plant & equipment 1,115 125

Total comprehensive (expenditure)/income for the year (2,010) 1,831

Financial performance for the year

Retained (deficit)/surplus for the year (2,525) 1,706

Impairments 2,904 2,469

Adjusted retained surplus 379 4,175

PDC dividend: balance receivable at 31 March 2014 154

PDC dividend: balance receivable at 1 April 2013 107

The notes on pages 27 to 59 form part of this account.

24

Statement of Financial Position as at 31st March 2014 31 March

2014 31 March

2013

NOTE £000s £000s

Non-current assets:

Property, plant and equipment 12.1 43,102 44,995

Intangible assets 13.1 0 5

Investment property 15 880 0

Trade and other receivables 19.1 0 822

Total non-current assets 43,982 45,822

Current assets:

Inventories 18 1,627 1,639

Trade and other receivables 19.1 21,555 13,127

Cash and cash equivalents 20 18,048 21,185

Total current assets 41,230 35,951

Total assets 85,212 81,773

Current liabilities

Trade and other payables 21 (27,810) (25,024)

Provisions 23 (3,389) (1,286)

Total current liabilities (31,199) (26,310)

Non-current assets plus/less net current assets/liabilities 54,013 55,463

Non-current liabilities

Provisions 23 (5,061) (4,502)

Total Assets Employed: 48,952 50,961

FINANCED BY:

TAXPAYERS' EQUITY

Public Dividend Capital 66,091 66,091

Retained earnings (17,679) (15,160)

Revaluation reserve 1,953 1,443

Other reserves (1,413) (1,413)

Total Taxpayers' Equity: 48,952 50,961

The notes on pages 27 to 59 form part of this account. The financial statements on pages 23 to 59 were approved by the Board on 28th May 2014 and signed on its behalf by Dr Anthony Marsh Chief Executive 30

th May 2014

25

Statement of Changes in Taxpayers' Equity for the year ended 31 March 2014

Public Dividend

capital

Retained earnings

Revaluation reserve

Other reserves

Total reserves

£000s £000s £000s £000s £000s

Balance at 1 April 2013 66,091 (15,160) 1,443 (1,413) 50,961

Changes in taxpayers’ equity for 2013-14

Retained deficit for the year 0 (2,525) 0 0 (2,525)

Net gain on revaluation of property, plant, equipment 0 0 1,115 0 1,115

Impairments and reversals 0 0 (600) 0 (600)

Transfers between reserves 0 5 (5) 0 0

Reclassification Adjustments

Transfers between Revaluation Reserve & Retained Earnings in respect of assets transferred under absorption

0 1 0 0 1

Net recognised (expense)/revenue for the year 0 (2,519) 510 0 (2,009)

Balance at 31 March 2014 66,091 (17,679) 1,953 (1,413) 48,952

Balance at 1 April 2012 61,241 (16,872) 1,327 (1,413) 44,283

Changes in taxpayers’ equity for the year ended 31 March 2013

Retained surplus for the year 0 1,706 0 0 1,706

Net gain on revaluation of property, plant, equipment 0 0 125 0 125

Transfers between reserves 0 6 (6) 0 0

Release of reserve following disposal of property, plant and equipment 0 0 (3) 0 (3)

New PDC Received 4,850 0 0 0 4,850

Net recognised revenue for the year 4,850 1,712 116 0 6,678

Balance at 31 March 2013 66,091 (15,160) 1,443 (1,413) 50,961

The Trust's originating capital on 1 July 2006 was set equal to the aggregate of the predecessor Trusts closing net assets as at 30 June 2006. However, the calculation of the originating capital included predecessor Trusts' donated assets and government grant reserves. The 'other reserves' of £1,413,000 has been established at 31 July 2008 to account for this omission.

26

STATEMENT OF CASH FLOWS FOR THE YEAR ENDED 31st March 2014 2013-14 2012-13

NOTE £000s £000s

Cash Flows from Operating Activities

Operating (Deficit)/Surplus (1,584) 2,903

Depreciation and Amortisation 5,189 4,408

Impairments and Reversals 2,904 2,469

Dividend Paid (993) (1,161)

Decrease/(Increase) in Inventories 12 (239)

(Increase)/Decrease in Trade and Other Receivables (7,559) 1,485

Increase in Trade and Other Payables 1,489 3,064

Provisions Utilised (1,001) (563)

Increase in Provisions 3,582 1,006

Net Cash Inflow from Operating Activities 2,039 13,372

CASH FLOWS FROM INVESTING ACTIVITIES

Interest Received 62 93

Payments for Property, Plant and Equipment (5,263) (10,141)

Proceeds of disposal of assets held for sale (PPE) 25 14

Net Cash (Outflow) from Investing Activities (5,176) (10,034)

NET CASH (OUTFLOW)/INFLOW BEFORE FINANCING (3,137) 3,338

CASH FLOWS FROM FINANCING ACTIVITIES

Public Dividend Capital Received 0 4,850

Net Cash Inflow from Financing Activities 0 4,850

NET (DECREASE)/INCREASE IN CASH AND CASH EQUIVALENTS

(3,137) 8,188

Cash and Cash Equivalents at Beginning of the Period 21,185 12,997

Cash and Cash Equivalents at year end 20 18,048 21,185

27

NOTES TO THE ACCOUNTS 1. Accounting Policies

The Secretary of State for Health has directed that the financial statements of NHS trusts shall meet the accounting requirements of the NHS Trusts Manual for Accounts, which shall be agreed with HM Treasury. Consequently, the following financial statements have been prepared in accordance with the 2013-14 NHS Manual for Accounts issued by the Department of Health. The accounting policies contained in that manual follow International Financial Reporting Standards to the extent that they are meaningful and appropriate to the NHS, as determined by HM Treasury, which is advised by the Financial Reporting Advisory Board. Where the NHS Trusts Manual for Accounts permits a choice of accounting policy, the accounting policy which is judged to be most appropriate to the particular circumstances of the trust for the purpose of giving a true and fair view has been selected. The particular policies adopted by the trust are described below. They have been applied consistently in dealing with items considered material in relation to the accounts. 1.1. Accounting convention

These accounts have been prepared under the historical cost convention modified to account for the revaluation of property, plant and equipment, intangible assets, inventories and certain financial assets and financial liabilities.

1.2. Acquisitions and discontinued operations Activities are considered to be „acquired‟ only if they are taken on from outside the public sector. Activities are considered to be „discontinued‟ only if they cease entirely. They are not considered to be „discontinued‟ if they transfer from one public sector body to another.

1.3. Movement of assets within the DH Group Transfers as part of reorganisation fall to be accounted for by use of absorption accounting in line with the Treasury FReM. The FReM does not require retrospective adoption, so prior year transactions (which have been accounted for under merger accounting) have not been restated. Absorption accounting requires that entities account for their transactions in the period in which they took place, with no restatement of performance required when functions transfer within the public sector. Where assets and liabilities transfer, the gain or loss resulting is recognised in the SOCNE/SOCNI, and is disclosed separately from operating costs. Other transfers of assets and liabilities within the Group are accounted for in line with IAS20 and similarly give rise to income and expentiture entries. For transfers of assets and liabilities from those NHS bodies that closed on 1 April 2013, Treasury has agreed that a modified absorption approach should be applied. For these transactions only, gains and losses are recognised in reserves rather than the SOCNE/SOCNI.

1.4. Charitable Funds For 2013-14, the divergence from the FReM that NHS Charitable Funds are not consolidated with bodies' own returns is removed. Under the provisions of IAS 27 Consolidated and Separate Financial Statements, those Charitable Funds that fall under common control with NHS bodies are consolidated within the entities' returns. In accordance with IAS 1 Presentation of Financial Statements, restated prior period accounts are presented where the adoption of the new policy has a material impact. The Trust does not consider that the East of England Ambulance Service NHS Charitable Funds is material therefore this has not been consolidated in the results of the Trust.

1.5. Revenue Revenue 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 revenue for the trust is from commissioners for healthcare services.

28

Where income is received for a specific activity that is to be delivered in the following year, that income is deferred. The Trust receives income under the NHS Injury Cost Recovery Scheme, designed to reclaim the cost of treating injured individuals to whom personal injury compensation has subsequently been paid e.g. by an insurer. The Trust recognises the income when it receives notification from the Department of Work and Pension's Compensation Recovery Unit that the individual has lodged a compensation claim. The income is measured at the agreed tariff for the treatments provided to the injured individual.

1.6. Employee Benefits Short-term employee benefits Salaries, wages and employment-related payments are recognised in the period in which the service is received from employees. The cost of leave 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. Retirement benefit costs Past and present employees are covered by the provisions of the NHS Pensions Scheme. The scheme is an unfunded, defined benefit scheme that covers NHS employers, General Practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. 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. 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 expenditure at the time the Trust commits itself to the retirement, regardless of the method of payment.

1.7. Other expenses Other operating expenses are recognised when, and to the extent that, the goods or services have been received. They are measured at the fair value of the consideration payable.

1.8. Property, plant and equipment Recognition Property, plant and equipment is capitalised if: ● it is held for use in delivering services or for administrative purposes; ● it is probable that future economic benefits will flow to, or service potential will be supplied to the Trust; ● it is expected to be used for more than one financial year; ● the cost of the item can be measured reliably; and ● the item has cost of at least £5,000; or ● Collectively, a number of items have a cost of at least £5,000 and individually have a cost of more than £250, where the assets are functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under single managerial control; or ● Items form part of the initial equipping and setting-up cost of a new building, ward or unit, irrespective of their individual or collective cost.

29

Valuation Where a large asset, for example a building, includes a number of components with significantly different asset lives, the components are treated as separate assets and depreciated over their own useful economic lives. All 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. Land and buildings used for the Trust‟s services or for administrative purposes are stated in the statement of financial position at their revalued amounts, being the fair value at the date of revaluation less any impairment. Revaluations are performed with sufficient regularity to ensure that carrying amounts are not materially different from those that would be determined at the end of the reporting period. Fair values are determined as follows: ● Land and non-specialised buildings – market value for existing use ● Specialised buildings – depreciated replacement cost HM Treasury has adopted a standard approach to depreciated replacement cost valuations based on modern equivalent assets and, where it would meet the location requirements of the service being provided, an alternative site can be valued. Properties in the course of construction for service or administration purposes are carried at cost, less any impairment loss. Cost includes professional fees but not borrowing costs, which are recognised as expenses immediately, as allowed by IAS 23 for assets held at fair value. Assets are revalued and depreciation commences when they are brought into use. Fixtures and equipment are carried at depreciated historic cost as this is not considered to be materially different from fair value. An increase arising on revaluation is taken to the revaluation reserve except when it reverses an impairment for the same asset previously recognised in expenditure, in which case it is credited to expenditure to the extent of the decrease previously charged there. A revaluation decrease that does not result from a loss of economic value or service potential is recognised as an impairment charged to the revaluation reserve to the extent that there is a balance on the reserve for the asset and, thereafter, to expenditure. Impairment losses that arise from a clear consumption of economic benefit should be taken to expenditure. Gains and losses recognised in the revaluation reserve are reported as other comprehensive income in the Statement of Comprehensive Income. Subsequent expenditure Where subsequent expenditure enhances an asset beyond its original specification, the directly attributable cost is capitalised. Where subsequent expenditure restores the asset to its original specification, the expenditure is capitalised and any existing carrying value of the item replaced is written-out and charged to operating expenses.

1.9. Intangible assets Recognition Intangible assets are non-monetary assets without physical substance, which are capable of sale separately from the rest of the trust‟s business or which arise from contractual or other legal rights. They are recognised only when it is probable that future economic benefits will flow to, or service potential be provided to, the trust; where the cost of the asset can be measured reliably, and where the cost is at least £5000.

30

Intangible assets acquired separately are initially recognised at fair value. Software that is integral to the operating of hardware, for example an operating system, is capitalised as part of the relevant item of property, plant and equipment. Software that is not integral to the operation of hardware, for example application software, is capitalised as an intangible asset. Measurement The amount initially recognised for internally-generated intangible assets is the sum of the expenditure incurred from the date when the criteria above are initially met. Where no internally-generated intangible asset can be recognised, the expenditure is recognised in the period in which it is incurred.

1.10. Depreciation, amortisation and impairments Freehold land, properties under construction, and assets held for sale are not depreciated. Otherwise, depreciation and amortisation are charged to write off the costs or valuation of property, plant and equipment and intangible non-current assets, less any residual value, over their estimated useful lives, in a manner that reflects the consumption of economic benefits or service potential of the assets. The estimated useful life of an asset is the period over which the Trust expects to obtain economic benefits or service potential from the asset. This is specific to the Trust and may be shorter than the physical life of the asset itself. Estimated useful lives and residual values are reviewed each year end, with the effect of any changes recognised on a prospective basis. Assets held under finance leases are depreciated over their estimated useful lives. At each reporting period end, the Trust checks whether there is any indication that any of its tangible or intangible non-current assets have suffered an impairment loss. If there is indication of an impairment loss, the recoverable amount of the asset is estimated to determine whether there has been a loss and, if so, its amount. Intangible assets not yet available for use are tested for impairment annually. A revaluation decrease that does not result from a loss of economic value or service potential is recognised as an impairment charged to the revaluation reserve to the extent that there is a balance on the reserve for the asset and, thereafter, to expenditure. Impairment losses that arise from a clear consumption of economic benefit should be taken to expenditure. Where an impairment loss subsequently reverses, the carrying amount of the asset is increased to the revised estimate of the recoverable amount but capped at the amount that would have been determined had there been no initial impairment loss. The reversal of the impairment loss is credited to expenditure to the extent of the decrease previously charged there and thereafter to the revaluation reserve. Impairments are analysed between Departmental Expenditure Limits (DEL) and Annually Managed Expenditure (AME). This is necessary to comply with Treasury's budgeting guidance. DEL limits are set in the Spending Review and Departments may not exceed the limits that they have been set. AME budgets are set by the Treasury and may be reviewed with departments in the run-up to the Budget. Departments need to monitor AME closely and inform Treasury if they expect AME spending to rise above forecast. Whilst Treasury accepts that in some areas of AME inherent volatility may mean departments do not have the ability to manage the spending within budgets in that financial year, any expected increases in AME require Treasury approval.

1.11. Donated assets Donated non-current assets are capitalised at their fair value on receipt, with a matching credit to Income. They are valued, depreciated and impaired as described above for purchased assets. Gains and losses on revaluations, impairments and sales are as described above for purchased assets. Deferred income is recognised only where conditions attached to the donation preclude immediate recognition of the gain.

31

1.12. Government grants The value of assets received by means of a government grant are credited directly to income. Deferred income is recognised only where conditions attached to the grant preclude immediate recognition of the gain.

1.13. Non-current assets held for sale Non-current assets are classified as held for sale if their carrying amount will be recovered principally through a sale transaction rather than through continuing use. This condition is regarded as met when the sale is highly probable, the asset is available for immediate sale in its present condition and management is committed to the sale, which is expected to qualify for recognition as a completed sale within one year from the date of classification. Non-current assets held for sale are measured at the lower of their previous carrying amount and fair value less costs to sell. Fair value is open market value including alternative uses. The profit or loss arising on disposal of an asset is the difference between the sale proceeds and the carrying amount and is recognised in the Statement of Comprehensive Income. On disposal, the balance for the asset on the revaluation reserve is transferred to retained earnings. Property, plant and equipment that is to be scrapped or demolished does not qualify for recognition as held for sale. Instead, it is retained as an operational asset and its economic life is adjusted. The asset is de-recognised when it is scrapped or demolished.

1.14. Leases Leases are classified as finance leases when substantially all the risks and rewards of ownership are transferred to the lessee. All other leases are classified as operating leases. The Trust as lessee Property, plant and equipment held under finance leases are initially recognised, at the inception of the lease, at fair value or, if lower, at the present value of the minimum lease payments, with a matching liability for the lease obligation to the lessor. Lease payments are apportioned between finance charges and reduction of the lease obligation so as to achieve a constant rate on interest on the remaining balance of the liability. Finance charges are recognised in calculating the trust‟s surplus/deficit. Operating lease payments are recognised as an expense on a straight-line basis over the lease term. Lease incentives are recognised initially as a liability and subsequently as a reduction of rentals on a straight-line basis over the lease term. Contingent rentals are recognised as an expense in the period in which they are incurred. Where a lease is for land and buildings, the land and building components are separated and individually assessed as to whether they are operating or finance leases. The Trust as lessor Amounts due from lessees under finance leases are recorded as receivables at the amount of the Trust‟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 the trust‟s net investment outstanding in respect of the leases. 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.

32

1.15. Inventories Inventories are valued at the lower of cost and net realisable value using the first-in first-out cost formula. This is considered to be a reasonable approximation to fair value due to the high turnover of stocks.

1.16. Cash and cash equivalents Cash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than 24 hours. Cash equivalents are investments that mature in 3 months or less from the date of acquisition and that are readily convertible to known amounts of cash with insignificant risk of change in value. In the Statement of Cash Flows, cash and cash equivalents are shown net of bank overdrafts that are repayable on demand and that form an integral part of the Trust‟s cash management.

1.17. Provisions Provisions are recognised when the Trust has a present legal or constructive obligation as a result of a past event, it is probable that the Trust will be required to settle the obligation, and a reliable estimate can be made of the amount of the obligation. The amount recognised as a provision is the best estimate of the expenditure required to settle the obligation at the end of the reporting period, taking into account the risks and uncertainties. Where a provision is measured using the cash flows estimated to settle the obligation, its carrying amount is the present value of those cash flows using HM Treasury‟s discount rate of 2.20% in real terms 1.8% for employee early departure obligations). 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. A restructuring provision is recognised when the Trust 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 arising from the restructuring, which are those amounts that are both necessarily entailed by the restructuring and not associated with ongoing activities of the entity.

1.18. Clinical negligence costs The NHS Litigation Authority (NHSLA) operates a risk pooling scheme under which the trust pays an annual contribution to the NHSLA which in return settles all clinical negligence claims. The contribution is charged to expenditure. Although the NHSLA is administratively responsible for all clinical negligence cases the legal liability remains with the Trust‟. The total value of clinical negligence provisions carried by the NHSLA on behalf of the trust is disclosed at note 23.

1.19. Non-clinical risk pooling The Trust participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the Trust pays an annual contribution to the NHS Litigation Authority and, in return, receives assistance with the costs of claims arising. The annual membership contributions, and any excesses payable in respect of particular claims are charged to operating expenses as and when they become due.

1.20. Contingencies A contingent liability is a possible obligation that arises from past events and whose existence will be confirmed only by the occurrence or non-occurrence of one or more uncertain future events not wholly within the control of the Trust, or a present obligation that is not recognised because it is not probable that a payment will be required to settle the obligation or the amount of the obligation cannot be measured sufficiently reliably. A

33

contingent liability is disclosed unless the possibility of a payment is remote.

1.21. Contingencies continued A contingent asset is a possible asset that arises from past events and whose existence will be confirmed by the occurrence or non-occurrence of one or more uncertain future events not wholly within the control of the Trust. A contingent asset is disclosed where an inflow of economic benefits is probable. Where the time value of money is material, contingencies are disclosed at their present value.

1.22. Financial assets Financial assets are recognised when the Trust becomes party to the financial instrument contract or, in the case of trade receivables, when the goods or services have been delivered. Financial assets are derecognised when the contractual rights have expired or the asset has been transferred. Financial assets are classified into the following categories: financial assets at fair value through profit and loss; 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 assets at fair value through profit and loss Embedded derivatives whose separate value cannot be ascertained are treated as financial assets at fair value through profit and loss. Loans and receivables Loans and receivables are non-derivative financial assets with fixed or determinable payments which are not quoted in an active market.

1.23. Financial liabilities Financial liabilities are recognised on the statement of financial position when the Trust becomes party to the contractual provisions of the financial instrument or, in the case of trade payables, when the goods or services have been received. Financial liabilities are de-recognised when the liability has been discharged, that is, the liability has been paid or has expired. Loans from the Department of Health are recognised at historical cost. Otherwise, financial liabilities are initially recognised at fair value.

1.24. Value Added Tax Most of the activities of the trust 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.

1.25. Public Dividend Capital (PDC) and PDC dividend Public dividend capital represents taxpayers‟ equity in the NHS trust. At any time the Secretary of State can issue new PDC to, and require repayments of PDC from, the trust. PDC is recorded at the value received. As PDC is issued under legislation rather than under contract, it is not treated as an equity financial instrument. An annual charge, reflecting the cost of capital utilised by the trust, is payable to the Department of Health as public dividend capital dividend. The charge is calculated at the real rate set by HM Treasury (currently 3.5%) on the average carrying amount of all assets less liabilities (except for donated assets, net assets transferred from NHS bodies dissolved on 1 April 2013 and cash balances with the Government Banking Service). The average carrying amount of assets is calculated as a simple average of opening and closing relevant

34

net assets.

1.26. Losses and Special Payments Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way that individual cases are handled. Losses and special payments are charged to the relevant functional headings in expenditure on an accruals basis, including losses which would have been made good through insurance cover had NHS Trusts not been bearing their own risks (with insurance premiums then being included as normal revenue expenditure).

1.27. Subsidiaries Material entities over which the Trust has the power to exercise control so as to obtain economic or other benefits are classified as subsidiaries and are consolidated. Their income and expenses; gains and losses; assets, liabilities and reserves; and cash flows are consolidated in full into the appropriate financial statement lines. Appropriate adjustments are made on consolidation where the subsidiary‟s accounting policies are not aligned with the Trust or where the subsidiary‟s accounting date is not co-terminus. Subsidiaries that are classified as „held for sale‟ are measured at the lower of their carrying amount or „fair value less costs to sell‟ From 2013-14, the Trust does not consolidate the results of East of England Ambulance Service NHS Charitable Funds over which it considers it has the power to exercise control in accordance with IAS27 requirements, due to it being considered immaterial.

1.28. Accounting Standards that have been issued but have not yet been adopted The Treasury FReM does not require the following Standards and Interpretations to be applied in 2013-14. The application of the Standards as revised would not have a material impact on the accounts for 2013-14, were they applied in that year: IAS 27 Separate Financial Statements - subject to consultation IAS 28 Investments in Associates and Joint Ventures - subject to consultation IFRS 9 Financial Instruments - subject to consultation - subject to consultation IFRS 10 Consolidated Financial Statements - subject to consultation IFRS 11 Joint Arrangements - subject to consultation IFRS 12 Disclosure of Interests in Other Entities - subject to consultation IFRS 13 Fair Value Measurement - subject to consultation IPSAS 32 - Service Concession Arrangement - subject to consultation

35

2. Revenue from patient care activities 2013-14 2012-13

£000s £000s

Primary Care Trusts 0 219,098

Strategic Health Authorities 0 183

CCGs 223,122 0

NHS England 369 0

NHS Trusts 917 1,559

NHS Foundation Trusts 5,739 7,288

Local Authorities 62 124

Department of Health 498 622

NHS other 362 0

Non-NHS:

Injury costs recovery 840 860

Other 3,285 798

Total Revenue from patient care activities 235,194 230,532

3. Other operating revenue 2013-14 2012-13

£000s £000s

Education, training and research 1,080 3,036

Income generation 1,088 1,438

Rental revenue from operating leases 363 493

Total Other Operating Revenue 2,531 4,967

Total operating revenue 237,725 235,499

4. Revenue 2013-14 2012-13

£000 £000

From rendering of services 237,725 235,499

Revenue is almost totally from the supply of services. Revenue from the sale of goods is immaterial.

36

5. Operating expenses 2013-14 2012-13

£000s £000s

Purchase of healthcare from non NHS bodies 22 1,892

Trust Chair and Non-executive Directors 59 53 Supplies and services - clinical 4,893 6,934

Supplies and services - general 2,967 3,036

Consultancy services 412 461

Establishment 6,842 6,607 Transport 41,523 38,940

Premises 6,230 5,818

Insurance 2,325 2,040

Legal fees 238 102

Impairments and Reversals of Receivables (87) 381

Inventories write down 289 3

Depreciation 5,184 4,402

Amortisation 5 6

Impairments and reversals of property, plant and equipment 2,904 2,466

Audit fees 87 105

Clinical negligence 282 550

Education and Training 2,218 2,245

Other 2,703 1,047

Total Operating expenses (excluding employee benefits) 79,096 77,088

Included in Other expenses is charges for occupational health services totalling £470k, (2012/13 £nil), losses and special payments £645k, (2012/13 £221k) see note 28 for details and injury benefit costs of £688k, (2012/13 £312k).

Employee benefits

Employee benefits excluding Board members 159,026 154,655

Board members 1,187 853

Total employee benefits 160,213 155,508

Total operating expenses 239,309 232,596

37

6 Operating Leases 6.1 Trust as lessee

Lease costs are incurred primarily on land and buildings and leased vehicles. Commitments are made on non cancellable operating leases.

2013-14 2012-13

Buildings Other Total Total

£000s £000s £000s £000s

Payments recognised as an expense

Minimum lease payments 1,957 10,033 11,990 11,613

Total 1,957 10,033 11,990 11,613

Payable:

No later than one year 1,222 8,628 9,850 8,094

Between one and five years 3,290 11,664 14,954 12,481

After five years 19,560 0 19,560 23,928

Total 24,072 20,292 44,364 44,503

6.2 Trust as lessor The Trust leases office space within some of the properties it occupies.

2013-14 2012-13

£000 £000s

Recognised as revenue

Rental revenue 363 493

Total 363 493

Receivable:

No later than one year 285 307

Between one and five years 250 224

Total 535 531

38

7 Employee benefits and staff numbers 7.1 Employee benefits

Total Permanently employed

Other

£000s £000s £000s

Employee Benefits - Gross Expenditure 2013-14

Salaries and wages 133,255 123,272 9,983

Social security costs 9,865 9,865 0

Employer Contributions to NHS BSA - Pensions Division 14,919 14,919 0

Other pension costs 3 3 0

Termination benefits 2,656 2,656 0

Total employee benefits 160,698 150,715 9,983

Employee costs capitalised 485 81 404

Gross Employee Benefits excluding capitalised costs 160,213 150,634 9,579

Total Permanently employed

Other

£000s £000s £000s

Gross Employee Benefits & Net expenditure 2012-13

Salaries and wages 131,444 121,735 9,709

Social security costs 9,351 9,351 0

Employer Contributions to NHS BSA - Pensions Division 14,426 14,426 0

Termination benefits 739 739 0

Total employee benefits 155,960 146,251 9,709

Employee costs capitalised 452 44 408

Net Employee Benefits excluding capitalised costs 155,508 146,207 9,301

7.2 Staff Numbers 2013-14 Restated

2012-13 Total Permanently

employed Other Total

Number Number Number Number

Average Staff Numbers

Medical and dental 35 0 35 36

Ambulance staff 1,629 1,629 0 1,641

Administration and estates 676 530 146 595

Healthcare assistants and other support staff 1,585 1,579 6 1,539

Nursing, midwifery and health visiting staff 48 27 21 21

TOTAL 3,973 3,765 208 3,832

Of the above - staff engaged on capital projects

9 2 7 5

39

7.3 Staff Sickness absence and ill health retirements 2013/14 2012/13

Number Number

Total days lost 55,280 57,684

Total staff years 3,747 3,648

Average working days lost 14.75 15.81

2013-14 2012-13

Number Number

Number of persons retired early on ill health grounds 22 10

£000s £000s

Total additional pensions liabilities accrued in the year 2,171 502

7.4 Exit Packages agreed in 2013-14 2013-14 2012-13

Exit package cost band (including any special payment element) Number of redundancies

Number of other

departures agreed

Total number of exit packages

Number of redundancies

Number of other departures

agreed

Total number of exit

packages

Number Number Number Number Number Number

Less than £10,000 2 0 2 0 3 3

£10,001-£25,000 1 4 5 3 7 10

£25,001-£50,000 0 2 2 1 3 4

£50,001-£100,000 0 6 6 4 3 7

£100,001 - £150,000 0 7 7 0 0 0

£150,001 - £200,000 0 3 3 0 0 0

>£200,000 0 2 2 0 0 0

Total number of exit packages by type (total cost 3 24 27 8 16 24

Total resource cost (£000s) 21 2,622 2,643 384 482 866

Redundancy and other departure costs have been paid in accordance with the provisions of the NHS Scheme. Exit costs in this note are accounted for in full in the year of departure. Where the Trust has agreed early retirements, the additional costs are met by the Trust and not by the NHS pensions scheme. Ill-health retirement costs are met by the NHS pensions scheme and are not included in the table. Other departures includes costs associated with a national voluntary severance scheme designed to help NHS organisations manage workforce redesign and reductions. The scheme is titled Mutually Agreed Resignation Scheme (MARS). This disclosure reports the number and value of exit packages agreed in the year. Note: The expense associated with these departures may have been recognised in part or in full in a previous period.

40

7.5 Exit packages - Other Departures analysis

2013-14

2012-13

Agreements

Total value of

agreements

Agreements

Total value of

agreements

Number

£000s

Number

£000s

Voluntary redundancies including early retirement contractual costs

23

2,470

0

0

Mutually agreed resignations (MARS) contractual costs

0

0

16

482

Total

23

2,470

16

482

This disclosure reports the number and value of exit packages agreed in the year. Note: the expense associated with these departures may have been recognised in part or in full in a previous period. As a single exit packages can be made up of several components each of which will be counted separately in this Note, the total number above will not necessarily match the total numbers in Note 7.4 which will be the number of individuals. 19 non-contractual payments £2,475k were made to individuals where the payment value was more than 12 months‟ of their annual salary. The Remuneration Report includes disclosure of exit payments payable to individuals named in that Report.

41

7.5 Pension costs Past and present employees are covered by the provisions of the NHS Pensions Scheme. Details of the benefits payable under these provisions can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions. The scheme is an unfunded, defined benefit scheme that covers NHS employers, GP practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The scheme is not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS Body of participating in the scheme is taken as equal to the contributions payable to the scheme for the accounting period. In order that the defined benefit obligations recognised in the financial statements do not differ materially from those that would be determined at the reporting date by a formal actuarial valuation, the FReM requires that “the period between formal valuations shall be four years, with approximate assessments in intervening years”. An outline of these follows:

a) Accounting valuation A valuation of the scheme liability is carried out annually by the scheme actuary as at the end of the reporting period. This utilises an actuarial assessment for the previous accounting period in conjunction with updated membership and financial data for the current reporting period, and are accepted as providing suitably robust figures for financial reporting purposes. The valuation of the scheme liability as at 31 March 2014, is based on valuation data as 31 March 2013, updated to 31 March 2014 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) valuation The purpose of this valuation is to assess the level of liability in respect of the benefits due under the scheme (taking into account its recent demographic experience), and to recommend the contribution rates. The last published actuarial valuation undertaken for the NHS Pension Scheme was completed for the year ending 31 March 2004. Consequently, a formal actuarial valuation would have been due for the year ending 31 March 2008. However, formal actuarial valuations for unfunded public service schemes were suspended by HM Treasury on value for money grounds while consideration is given to recent changes to public service pensions, and while future scheme terms are developed as part of the reforms to public service pension provision due in 2015. 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. The next formal valuation to be used for funding purposes will be carried out at as at March 2012 and will be used to inform the contribution rates to be used from 1 April 2015.

c) Scheme provisions The NHS Pension Scheme provided defined benefits, which are summarised below. This list is an illustrative guide only, and is not intended to detail all the benefits provided by the Scheme or the specific conditions that must be met before these benefits can be obtained.

42

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.

43

8 Better Payment Practice Code

8.1 Measure of compliance 2013-14 2013-14 2012-13 2012-13

Number £000s Number £000s

Non-NHS Payables

Total Non-NHS Trade Invoices Paid in the Year 49,220 65,543 48,556 68,549

Total Non-NHS Trade Invoices Paid Within Target

43,736 41,268 44,851 55,287

Percentage of NHS Trade Invoices Paid Within Target

88.86% 62.96% 92.37% 80.65%

NHS Payables

Total NHS Trade Invoices Paid in the Year 1,684 11,040 1,650 3,623

Total NHS Trade Invoices Paid Within Target 1,338 8,505 1,400 2,651

Percentage of NHS Trade Invoices Paid Within Target

79.45% 77.04% 84.85% 73.17%

The Better Payment Practice Code requires the NHS body to aim to pay all valid invoices by the due date or within 30 days of receipt of a valid invoice, whichever is later.

9 Investment Revenue 2013-14 2012-13

£000s £000s

Interest revenue

Bank interest 61 95

Total investment revenue 61 95

10 Other Gains and Losses 2013-14 2012-13

£000s £000s

Gain/(Loss) on disposal of assets other than by sale (PPE) 25 (60)

Total 25 (60)

11 Finance Costs 2013-14 2012-13

£000s £000s

Interest

Other interest expense 0 0

Total interest expense 0 0

Provisions - unwinding of discount 81 99

Total 81 99

44

12.1 Property, plant and equipment

Land Buildings excluding dwellings

Assets under construction & payments on account

Plant & machinery

Transport equipment

Information technology

Furniture & fittings

Total

2013-14

£000's £000's £000's £000's £000's £000's £000's £000's

Cost or valuation:

At 1 April 2013 12,000 23,795 851 15,375 6,147 9,352 748 68,268

Additions of Assets Under Construction 0 0 162 0 0 0 0 162

Additions Purchased 0 704 0 4,060 57 1,557 20 6,398

Reclassifications 0 101 (849) 748 0 0 0 0

Reclassification to Investment Property (34) (846) 0 0 0 0 0 (880)

Disposals other than for sale 0 0 0 (18) (506) 0 0 (524)

Upward revaluation/positive indexation 693 422 0 0 0 0 0 1,115

Impairments/negative indexation (483) (117) 0 0 0 0 0 (600)

Revaluation accumulated depreciation transfer (639) (9,409) 0 0 0 0 0 (10,048)

At 31 March 2014 11,537 14,650 164 20,165 5,698 10,909 768 63,891

Depreciation

At 1 April 2013 918 6,407 0 8,657 3,283 3,567 441 23,273

Disposals other than for sale 0 0 0 (18) (506) 0 0 (524)

Revaluation accumulated depreciation transfer (639) (9,409) 0 0 0 0 0 (10,048)

Impairments 812 3,966 0 0 0 0 0 4,778

Charged During the Year 0 914 0 1,570 988 1,661 51 5,184

Reversal of impairment (1,088) (786) 0 0 0 0 0 (1,874)

At 31 March 2014 3 1,092 0 10,209 3,765 5,228 492 20,789

Net Book Value at 31 March 2014 11,534 13,558 164 9,956 1,933 5,681 276 43,102

Purchased 11,534 13,558 164 9,956 1,933 5,681 276 43,102

Asset financing:

Owned 11,534 13,558 164 9,956 1,933 5,681 276 43,102

45

12.1 Property, plant and equipment (continued)

Revaluation Reserve Balance for Property, Plant & Equipment

Land Buildings Assets under

construction & payments on account

Plant & machinery

Transport equipment

Information technology

Furniture & fittings

Total

£000's

£000's

£000's

£000's

£000's

£000's

£000's

£000's At 1 April 2013 951

349

0

98

30

0

15

1,443

Movements 210

305

0

0

(5)

0

0

510

At 31 March 2014 1,161

654

0

98

25

0

15

1,953

Additions to Assets Under Construction in 2013/14

£000's

Land

0

Buildings excl Dwellings

162

Dwellings

0

Plant & Machinery

0

Balance as at YTD

162

46

12.2 Property, plant and equipment prior-year

2012-13 Land Buildings excluding dwellings

Assets under

construction & payments on account

Plant & machinery

Transport equipment

Information technology

Furniture & fittings

Total

£000s £000s £000s £000s £000s £000s £000s £000s

Cost or valuation:

At 1 April 2012 9,987 18,976 848 15,075 6,133 10,695 711 62,425

Additions - purchased 1,799 4,676 812 906 722 2,335 49 11,299

Reclassifications 174 58 (809) 577 0 0 0 0

Disposals other than by sale 0 0 0 (1,183) (708) (3,678) (12) (5,581)

Revaluation & indexation gains 40 85 0 0 0 0 0 125

At 31 March 2013 12,000 23,795 851 15,375 6,147 9,352 748 68,268

Depreciation

At 1 April 2012 144 3,965 0 8,320 3,217 5,859 403 21,908

Disposals other than for sale 0 0 0 (1,163) (706) (3,625) (9) (5,503)

Impairments 773 1,693 0 0 0 0 0 2,466

Charged During the Year 1 749 0 1,500 772 1,333 47 4,402

At 31 March 2013 918 6,407 0 8,657 3,283 3,567 441 23,273

Net book value at 31 March 2013 11,082 17,388 851 6,718 2,864 5,785 307 44,995

Purchased 11,082 17,388 851 6,718 2,864 5,785 307 44,995

Asset financing:

Owned 11,082 17,388 851 6,718 2,864 5,785 307 44,995

47

12.3 Property, plant and equipment Land and Buildings were re-valued as at 31 March 2014 by Montagu Evans LLP an Independent Chartered Surveyor. The valuation has been prepared in accordance with the RICS Valuation Standards (6th edition) which states that valuations for Public Sector Accounts shall be undertaken in accordance with the Code of Practice on Local Authority Accounting in the UK 2010/11. It was determined that all assets held by the Trust were operational property and therefore valued at Fair Value which is interpreted as the amount that would be paid for the asset in its existing use. Asset Lives Tangible non-current assets are depreciated on a straight line basis to write off the costs or valuation, less any residual value, over their estimated useful lives. No depreciation is provided on freehold land and asset surplus to requirements. Buildings, installations and fittings are depreciated on their fair value over the estimated remaining life of the asset as advised by the Valuer. Leaseholds are depreciated over the primary lease term. Equipment is depreciated on current cost evenly over the estimated life of the asset using the following lives: Years Medical equipment and engineering plant and equipment 5 to 10 Furniture 10 Mainframe information technology installations 8 Soft Furnishings 7 Office and information technology equipment 5 Set-up costs in new buildings 10 Ambulances and other vehicles 3 to 7

There were no changes to the Trust's assessment of asset lives or residual values during the year. Economic lives of property, plant & equipment The remaining lives of the Trusts property, plant and equipment are as follows; Minimum

Life Maximum

Life years years

Buildings (includes set up costs in new buildings) 1 59 Plant and machinery (includes medical equipment) 7 20 Transport equipment (includes ambulances and other vehicles) 5 7 Information technology (includes mainframe information technology, office and information technology) 3 10 Furniture and fittings (includes furniture and soft furnishings) 3 40

48

13.1 Intangible non-current assets 2013-14 Software

purchased Total

£000's £000's

At 1 April 2013 32 32

Additions - purchased 0 0

At 31 March 2014 32 32

Amortisation

At 1 April 2013 27 27

Charged during the year 5 5

At 31 March 2014 32 32

Net Book Value at 31 March 2014 0 0

Purchased 0 0

13.2 Intangible non-current assets prior year 2012-13 Software

purchased Total

£000s £000s

Cost or valuation:

At 1 April 2012 123 123

Disposals other than by sale (91) (91)

At 31 March 2013 32 32

Amortisation

At 1 April 2012 112 112

Disposals other than by sale (91) (91)

Charged during the year 6 6

At 31 March 2013 27 27

Net book value at 31 March 2013 5 5

Purchased 5 5

49

14 Analysis of impairments and reversals recognised in the year

2013-14 2012-13

Total Total

£000s £000s

Property, Plant and Equipment impairments and reversals taken to SoCI

Loss or damage resulting from normal operations 0 0

Over-specification of assets 0 0

Abandonment of assets in the course of construction 0 0

Total charged to Departmental Expenditure Limit 0 0

Unforeseen obsolescence 0 0

Loss as a result of catastrophe 0 0

Other 0 2,441

Changes in market price 2,904 25

Total charged to Annually Managed Expenditure 2,904 2,466

Total Impairments of Property, Plant and Equipment 2,904 2,466

Total Impairments charged to Revaluation Reserve 0 0

Total Impairments charged to SoCI - DEL 0 0

Total Impairments charged to SoCI - AME 2,904 2,466

Overall Total Impairments 2,904 2,466

Land and Buildings were re-valued as at 31 March 2014 by Montagu Evans LLP an Independent Chartered Surveyor. The valuation has been prepared in accordance with the RICS Valuation Standards (6th edition) which states that valuations for Public Sector Accounts shall be undertaken in accordance with the Code of Practice on Local Authority Accounting in the UK 2010/11. It was determined that all assets held by the Trust were operational property and therefore valued at Fair Value which is interpreted as the amount that would be paid for the asset in its existing use. 2012/13, the other impairment of £2,441k is in relation to land that was acquired in this financial year which was developed with a purpose built building. This was completed during the year and both the land and building were revalued at the year end and subsequently impaired.

50

15 Investment property 31 March

2014 31 March

2013 £000s £000s

At fair value

Balance at 1 April 2013 0 0

Transferred from Property, plant and equipment 880 0

Balance at 31 March 2014 880 0

16 Commitments Capital commitments

Contracted capital commitments at 31 March not otherwise included in these financial statements: 31 March

2014 31 March

2013 £000s £000s

Property, plant and equipment 73 752

Intangible assets 0 0

Total 73 752

17 Intra-Government and other balances

Current receivables

Non-current

receivables

Current payables

£000s £000s £000s

Balances with other Central Government Bodies 6,854 0 4,325

Balances with Local Authorities 10 0 1

Balances with NHS bodies outside the Departmental Group

0 0 0

Balances with NHS Trusts and Foundation Trusts 795 0 366

Balances with Public Corporations and Trading Funds 0 0 0

Balances with bodies external to government 13,896 0 23,118

At 31 March 2014 21,555 0 27,810

Prior period:

Balances with other Central Government Bodies 5,259 822 2,550

Balances with Local Authorities 7 0 120

Balances with NHS Trusts and Foundation Trusts 867 0 351

Balances with Public Corporations and Trading Funds 0 0 0

Balances with bodies external to government 6,994 0 22,003

At 31 March 2013 13,127 822 25,024

51

18 Inventories Drugs Consumables Energy Total

£000s £000s £000s £000s

Balance at 1 April 2013 27 1,326 286 1,639

Additions 188 3,350 1,543 5,081

Recognised as an expense in the period (171) (3,140) (1,493) (4,804)

Write-down of inventories (including losses) (7) (267) (15) (289)

Balance at 31 March 2014 37 1,269 321 1,627

19.1 Trade and other receivables Current Non-current

31 March 2014

31 March 2013

31 March 2014

31 March 2013

£000s £000s £000s £000s

NHS receivables - revenue 7,198 3,393 0 822

NHS prepayments and accrued income 0 1,398 0 0

Non-NHS receivables - revenue 1,067 395 0 0

Non-NHS prepayments and accrued income 8,835 6,500 0 0

Provision for the impairment of receivables (749) (875) 0 0

VAT 433 1,216 0 0

Other receivables 4,771 1,100 0 0

Total 21,555 13,127 0 822

Total current and non current 21,555 13,949

The great majority of trade is with Clinical Commissioning Groups, as commissioners for NHS patient care services. As Clinical Commissioning Groups are funded by Government to buy NHS patient care services, no credit scoring of them is considered necessary. Other receivables includes £4,493,937 (2013: £870,671) relating to new vehicles originally purchased by the Trust which will be sold to a financing company for leaseback to the Trust. 19.2 Receivables past their due date but not impaired 31 March

2014 31 March

2013

£000s £000s

By up to three months 1,886 1,130

By three to six months 899 90

By more than six months 123 0

Total 2,908 1,220

19.3 Provision for impairment of receivables 2013-14 2012-13

£000s £000s

Balance at 1 April 2013 (875) (830)

Amount written off during the year 39 336

Amount recovered during the year 186 23

Increase in receivables impaired (99) (404)

Balance at 31 March 2014 (749) (875)

Receivables that were 90 days old were reviewed and considered on an individual basis as to whether the amounts were recoverable.

52

20 Cash and Cash Equivalents

31 March 2014

31 March 2013

£000s £000s

Opening balance 21,185 12,997

Net change in year (3,137) 8,188

Closing balance 18,048 21,185

Made up of

Cash with Government Banking Service 18,006 21,125

Commercial banks 41 59

Cash in hand 1 1

Cash and cash equivalents as in statement of financial position

18,048 21,185

Cash and cash equivalents as in statement of cash flows 18,048 21,185

21 Trade and other payables

Current

31 March 2014

31 March 2013

£000s £000s

NHS payables - revenue 2,089 455

NHS accruals and deferred income 133 2,315

Non-NHS payables - revenue 7,124 8,074

Non-NHS payables - capital 4,436 3,139

Non-NHS accruals and deferred income 10,493 10,489

Social security costs 2,805 44

Other 730 508

Total payables (current and non-current) 27,810 25,024

Included above:

Outstanding Pension Contributions at the year end 1,964 13

Included in NHS accruals and deferred income is £nil (2013: £1,916k) in relation to penalties on the Trusts Emergency Operations Contract. CCG Commissioners opted to waive the contractual penalties in the year ended 31 March 2014. 22 Deferred revenue

Current

31 March 2014

31 March 2013

£000s £000s

Opening balance at 1 April 2013 81 1,905

Deferred revenue addition 0 273

Transfer of deferred revenue (81) (2,097)

Current deferred Income at 31 March 2014 0 81

53

23 Provisions Total Pensions

Relating to Other

Staff

Legal Claims

Other Redundancy

£000s £000s £000s £000s £000s

Balance at 1 April 2013 5,788 4,466 237 576 509

Arising During the Year 3,686 723 141 200 2,622

Utilised During the Year (1,001) (290) (93) (56) (562)

Reversed Unused (104) (6) (74) 0 (24)

Unwinding of Discount 81 75 0 6 0

Balance at 31 March 2014 8,450 4,968 211 726 2,545

Expected Timing of Cash Flows:

No Later than One Year 3,389 287 211 346 2,545

One to Five Years 1,404 1,097

0

307

0

Later than Five Years 3,657 3,584 0 73 0

Due After One Year 5,061 4,681 0 380 0

8,450 4,968 211 726 2,545

Amount Included in the Provisions of the NHS Litigation Authority in Respect of Clinical Negligence Liabilities: As at 31 March 2014 5,907

As at 31 March 2013 2,044

Pensions relating to other staff: These provisions relate to payments to the NHS Pension Agency for Early Retirements and Injury Benefit Awards and are based on amounts paid by the NHS Pensions Agency and average life expectancy for the individuals concerned. As these amounts are known with reasonable certainty there is no related balance in contingent liabilities. Legal Claims: The legal provision is for claims made against the Trust by employees and members of the public. Due to the nature of these provisions there is considerable uncertainty concerning when the provisions are likely to be realised. These claims also give rise to a contingent liability (see note 24). Other Provisions: Included within other provisions are Terms and Conditions of employment for Whitley Council ambulance staff changed in 1986 in respect of annual leave entitlement. The move from accrued to current leave entitlement resulted in the "freezing" of accrued leave to be paid at a future date on resignation/retirement from the Ambulance Service, at current rates of pay. A provision has been made for the estimated value of discharging this entitlement when staff leave the service. Redundancy: This includes departure costs which have been agreed in accordance with the provisions of the NHS Scheme.

54

24 Contingencies 31 March

2014 31 March

2013

£000s £000s

Contingent liabilities

Other (137) (176)

Net Value of Contingent Liabilities (137) (176)

The contingent liabilities relate to the provision for legal claims detailed in note 23. These claims are notified to the Trust by the NHS Litigation Authority. 31 March

2014 31 March

2013

£000s £000s

Contingent Assets

Contingent Assets 1,600 0

Net Value of Contingent Assets 1,600 0

The contingent asset relates to an incentive proposed by one of the Trusts Lessors to vacate the site prior to the lease termination date. 25 Financial Instruments 25.1 Financial risk management Financial reporting standard IFRS 7 requires disclosure of the role that financial instruments have had during the period in creating or changing the risks a body faces in undertaking its activities. Because of the continuing service provider relationship that the Trust has with commissioners and the way those commissioners are financed, the Trust is not exposed to the degree of financial risk faced by business entities. Also financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which the financial reporting standards mainly apply. The Trust has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the Trust in undertaking its activities. The Trust‟s treasury management operations are carried out by the finance department, within parameters defined formally within the Trust‟s standing financial instructions and policies agreed by the board of directors. Trust treasury activity is subject to review by the Trust‟s internal auditors. Currency risk The Trust is principally a domestic organisation with the great majority of transactions, assets and liabilities being in the UK and sterling based. The Trust has no overseas operations. The Trust therefore has low exposure to currency rate fluctuations. Interest rate risk The Trust borrows from government for capital expenditure, subject to affordability as confirmed by the strategic health authority. The borrowings are for 1 – 25 years, in line with the life of the associated assets, and interest is charged at the National Loans Fund rate, fixed for the life of the loan. The Trust therefore has low exposure to interest rate fluctuations. Credit risk Because the majority of the Trust's revenue comes from contracts with other public sector bodies, the Trust has low exposure to credit risk. The maximum exposures as at 31

st march 2014 are in

receivables from customers, as disclosed in the trade and other receivables note.

55

Liquidity risk The Trust‟s operating costs are incurred under contracts with Clinical Commissioning Groups, which are financed from resources voted annually by Parliament . The Trust funds its capital expenditure from funds obtained within its prudential borrowing limit. The Trust is not, therefore, exposed to significant liquidity risks. 25.2 Financial Assets

At ‘fair value

through profit and

loss’

Loans and receivables

Total

£000s £000s £000s

Receivables - NHS 0 6,566 6,566

Receivables - non-NHS 0 1,073 1,073

Cash at bank and in hand 0 18,048 18,048

Total at 31 March 2014 0 25,687 25,687

Receivables - NHS 0 3,385 3,385

Receivables - non-NHS 0 472 472

Cash at bank and in hand 0 21,185 21,185

Total at 31 March 2013 0 25,042 25,042

25.3 Financial Liabilities At ‘fair

value through

profit and loss’

Other Total

£000s £000s £000s

NHS payables 0 2,222 2,222

Non-NHS payables 0 20,730 20,730

Total at 31 March 2014 0 22,952 22,952

NHS payables 0 2,689 2,689

Non-NHS payables 0 20,134 20,134

Total at 31 March 2013 0 22,823 22,823

56

26 Related party transactions 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 the East of England Ambulance Service NHS Trust. The Department of Health is regarded as a related party. During the year the East of England Ambulance Service NHS Trust has had a significant number of material transactions with the Department, and with other entities for which the Department is regarded as the parent Department. These entities are: From the 1 April 2013, Primary Care Trusts ceased to exist and have been replaced by Clinical Commissioning Groups. Basildon & Brentwood Clinical Commissioning Group (CCG), Bedfordshire CCG, Cambridgeshire & Peterborough CCG, Castle Point & Rochford CCG, East & North Hertfordshire CCG, Great Yarmouth & Waveney CCG, Herts Valley CCG, Ipswich & East Suffolk CCG, Luton CCG, Mid Essex CCG, North East Essex CCG, North Norfolk CCG, Norwich CCG, Southend CCG, South Norfolk CCG, Thurrock CCG, West Essex CCG, West Norfolk CCG, West Suffolk CCG. S Childerhouse, Non Executive Director provided consultancy advice in the capacity of a Chair to Bedford CCG from October 2013 to March 2014. Cambridge University Hospitals NHS Foundation Trust, North Essex Partnership NHS Foundation Trust, Peterborough & Stamford Hospitals NHS Foundation Trust. Hinchingbrooke Health Care NHS Trust. NHS England NHS Litigation Authority NHS Business Services Authority NHS Pensions Health Education England Mr A Morgan, Interim Chief Executive was made an employee of the Trust from the 1 April 2013. 2012/13, Mr A Morgan was on secondment from NHS Norfolk and Waveney PCT. All costs were retained by NHS Norfolk and Waveney PCT equating to £40k-£45k. Mrs C Youell, Interim Director of HR and Organisational Development, invoiced fees and travel expenses of £19,871 (2012/13 £91,522) to the Trust though People and Performance Limited, a company jointly owned with Mr R Youell. In addition the Trust has had a number of material transactions with other government departments and other central and local government bodies. The Trust provides administrative and management services to the Charitable Trust totalling £400. All members of the Trust Board act on behalf of the Trust in its capacity as the Trustee of the Charitable Trust. The total funds of the charity in 2012/13 were £664k.

57

27. Financial performance targets The figures given for periods prior to 2009-10 are on a UK GAAP basis as that is the basis on which the targets were set for those years 27.1 Breakeven performance 2005-06 2006-

07 2007-

08 2008-

09 2009-10 2010-

11 2011-

12 2012-

13 2013-14

£000s £000s £000s £000s £000s £000s £000s £000s £000s

Turnover 0 189,026 192,842 213,814 228,076 222,389 226,874 235,499 237,725

Retained surplus/(deficit) for the year 1,157 104 283 (19,161) (445) 3,121 1,706 (2,525)

Adjustment for:

Timing/non-cash impacting distortions:

Adjustments for Impairments 201 19,918 2,809 2,469 2,904

Break-even in-year position 0 1,157 104 484 757 2,364 3,121 4,175 379

Break-even cumulative position 0 1,157 1,261 1,745 2,502 4,866 7,987 12,162 12,541

Due to the introduction of International Financial Reporting Standards (IFRS) accounting in 2009-10, NHS Trust‟s financial performance measurement needs to be aligned with the guidance issued by HM Treasury measuring Departmental expenditure. Therefore, the incremental revenue expenditure resulting from the application of IFRS to IFRIC 12 schemes (which would include PFI schemes), which has no cash impact and is not chargeable for overall budgeting purposes, is excluded when measuring Breakeven performance. Other adjustments are made in respect of accounting policy changes (impairments and the removal of the donated asset and government grant reserves) to maintain comparability year to year. 2005-

06 2006-

07 2007-

08 2008-

09 2009-

10 2010-

11 2011-

12 2012-

13 2013-

14 % % % % % % % % %

Materiality test (I.e. is it equal to or less than 0.5%):

Break-even in-year position as a percentage of turnover

0.61 0.05 0.23 0.33 1.06 1.38 1.77 0.16

Break-even cumulative position as a percentage of turnover

0.61 0.65 0.82 1.10 2.19 3.52 5.16 5.28

The amounts in the above tables in respect of financial years 2005/06 to 2008/09 inclusive have not been restated to IFRS and remain on a UK GAAP basis.

58

27.2 Capital cost absorption rate The dividend payable on public dividend capital is based on the actual (rather than forecast) average relevant net assets and therefore the actual capital cost absorption rate is automatically 3.5%. 27.3 External financing The Trust is given an external financing limit which it is permitted to undershoot. 2013-14 2012-13

£000s £000s £000s

External financing limit 3,240 5,062

Cash flow financing (3,137) (3,338)

Unwinding of discount adjustment (81)

External financing requirement (3,218) (3,338)

Undershoot 22 8,400

27.4 Capital resource limit The Trust is given a capital resource limit which it is not permitted to exceed. 2013-14 2012-13

£000s £000s

Gross capital expenditure 6,560 11,299

Less: book value of assets disposed of 0 (78)

Charge against the capital resource limit 6,560 11,221

Capital resource limit 7,000 11,850

Underspend against the capital resource limit 440 629

28 Losses and special payments The total number of losses cases in 2013/14 and their total value was as follows: Total

Value Total

Number of Cases of Cases

£s

Losses 478,019 783

Special payments 167,319 27

Total losses and special payments 645,338 810

The total number of losses cases in 2012/13 and their total value was as follows Total

Value Total

Number of Cases of Cases

£s

Losses 21,970 621

Special payments 199,463 29

Total losses and special payments 221,433 650

Included in losses are amounts in respect of prescription charges which total £7,563 (2013: £5,999) and 774 cases (2013: 612 cases).

59

29 Events after the end of the reporting period There are no events after the reporting period that need to be reflected in the financial statements.