Quality Account 2011/12 Barts and The London NHS Trust

Bringing excellence to life

Quality Account 2011/12 Contents

Chief Executive’s statement 3

Looking forward – our priorities for quality improvement 6

Looking back – our assurances about good governance 10

Review of our quality and safety performance in 2011/12 20 Quality dimension one – patient safety 20 Quality dimension two – patient-centered care and acting on patient experience 35 Quality dimension three – clinical effectiveness and efficiency 59

Staff experience and organisational development 73

Third party stakeholder commentaries 81

Appendices 86 Appendix 1: Participation in mandatory national projects in 2011/12 86 Appendix 2: External Auditor’s opinion 91 Appendix 3: Glossary 93

Further information and advice 102

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Quality Account 2011/12 Chief Executive’s statement

Continuous quality improvement at Barts Health I am delighted to introduce the 2012 Quality Account for Barts Health NHS Trust. We are the newest, and the largest, NHS Trust in the country, providing a wide range of general and specialist healthcare services for one million people in the City and east London. Barts Health brings together three former organisations: Barts and The London, Newham University Hospital and Whipps Cross University Hospital NHS Trusts. In one trust we will draw on the immense talent, commitment and expertise within our organisations to create, with our partners, a truly world-class health system.

Our vision is to provide the highest quality healthcare that meets the needs of our local population, and to be recognised locally, nationally and internationally for outstanding clinical services, research and education. We want to be known for distinctive quality, safety and consistency in the care we provide and in every setting. We want to be an organisation that all our staff can be proud of, one which they recommend and one in which they feel they are valued in making a huge difference to people’s lives.

The organisations that merged on 1 April 2012 have all shown that they, and now we, can deliver excellence in healthcare. The challenge now is to realise the potential of Barts Health for consistent, dependable delivery and for continuous improvement in a very constrained financial climate. Team working within the new organisation is going to be even more essential than ever. Collaboration for higher quality across the NHS system is going to be vitally important too. As an organisation we must listen, learn and act.

Only by doing all of these things will we make the most of Barts Health, and play our substantial role in improving healthcare and the health and wellbeing of local people. With our partners, we must also play our part in eliminating inequalities in health that have existed in east London for far too long.

Our starting point in Barts Health is a detailed review of quality and safety across the three former organisations using information from the Clinical Due Diligence process and the quality and safety letters of representation from each legacy trust. These findings have assisted us to identify key quality and safety priorities for Barts Health, maintain the progress that has already been made and set our quality improvement actions for the year ahead.

All three legacy trusts have made some improvements in the National Inpatient Survey results but further improvements, which are detailed in the Barts Health Patient Experience Strategy 2012, are required. In particular, patient experience improvements will be focused on listening and responding to patient concerns in order to enhance services.

In addition the three legacy trusts have a common priority of improving the experience of all staff, specifically making staff feel valued such that they would recommend Barts Health as an employer of choice.

Transformational change is already underway. We can see the major investment in our hospitals coming to life. We have the opportunity to build on the work NHS Tower Hamlets previously led in community health services, enabling us to deliver more joined up care for patients along their whole healthcare journey. And we have joined University College London Partners (UCLP), as a founding

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Quality Account 2011/12 partner of a leading academic health science centre. All of these developments, coming together now, will help us to provide ever higher quality, cost-effective healthcare, at greater pace, for the people we serve.

Thank you for the valued contribution that you make in helping us to achieve our aims.

I hope you find our Quality Account informative and useful. We want to hear your opinions on how we run our services and any improvements you think we can make. You can get in touch with us by emailing: [email protected]

Peter Morris Chief Executive, Barts Health NHS Trust

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Quality Account 2011/12

About this Quality Account The directors are required under the Health Act 2009, National Health Service (Quality Accounts) Regulations 2010 and National Health Service (Quality Account) Amendment Regulation 2011 to prepare Quality Accounts for each financial year. The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporate the above legal requirements).

In preparing the Quality Account, directors are required to take steps to satisfy themselves that:

• The Quality Account presents a balanced picture of the Trust’s performance over the period covered; • The performance information reported in the Quality Account is reliable and accurate; • There are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, and these controls are subject to review to confirm that they are working effectively in practice; • The data underpinning the measures of performance reported in the Quality Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review; and the Quality Account has been prepared in accordance with Department of Health guidance.

The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Account.

By order of the Board

Peter Morris Stephen O’Brien Chief Executive Chairman

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Quality Account 2011/12 Looking forward – our priorities for quality improvement

“I strongly believe that by sharing the expertise that is present in each of our three trusts, we can create a world- class health organisation – one that builds strong relations with our local communities and partners, and which ensures that the needs of our patients always come first.” Stephen O’Brien, Chair, Barts Health NHS Trust

For our first year as Barts Health NHS Trust, our quality improvement theme will be ‘People’ – i.e. patients, staff, our clinical partners and the community. People will be put first – and this ethos will underpin our policies and philosophies. Our staff will receive the training and backup that they need to provide world-class clinical care. Our clinical partners will be supported as we pool resources, research and expertise to improve the services that we offer. The communities that we serve will have faster access to high-quality healthcare and more opportunities to work with us to drive our standards up even further. And our patients will benefit from even better facilities, cutting-edge technology and a caring, compassionate culture.

Whilst the vision and values of Barts Health are in development, the key words that are defining our emerging approach are value, respect, listen, act and partnerships. These should not be just words – they should come to define how Barts Health will conduct relationships with all our stakeholders. In particular, the words will describe our interactions with:

• Our patients - valuing, respecting, keeping them safe from harm • Our staff - valuing, listening, and acting on their concerns • Our clinical partners - valuing, listening, and working together to improve health and services.

We are committed to improving care and services so that all patients, and in particular our most vulnerable patients, are kept safe and are always treated with respect and dignity.

These are also the principles at the heart of the emerging Barts Health Patient Experience and Engagement Strategy. The strategy will support organisational development and culture, so that patients’ experiences of care and their perspectives will drive up the standard of care and influence the way care is delivered. It will provide the framework for staff to deliver compassionate, respectful, safe and high-quality care. We will continue to develop the delivery framework and then implement it throughout the new organisation.

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Quality Account 2011/12

The Barts Health quality priorities that will redefine the patient experience The three distinctive Barts Health Trust Board quality priorities for 2012/13 are:

• To keep patients (and their carers) better informed about their care and treatment, so that they feel safe and involved before and after they leave the hospital, and able to make informed choices • To improve the feedback given to staff when they report and raise quality and safety concerns • To improve our patient administration systems, with a focus on the quality standard and timeliness of letters and discharge summaries that we send to GPs. We will continue to work in partnership with GPs to deliver a high quality clinical service with the best possible outcome for every patient.

Table 1 lists specific improvement projects and developments that the Barts Health clinical teams will lead and implement in collaboration with corporate and clinical colleagues and partners. The teams are currently in divisions and services, but will develop into new Clinical Academic Groups (CAGs) through the integration of our merged organisation.

Some of the indicators were agreed with commissioners of the three legacy trusts as part of the Commissioning for Quality and Innovation (CQUIN) schemes. Others derive from intelligence gathered from staff and patient feedback and as part of pre-merger preparation work, such as the Phase 1 and 2 Clinical Due Diligence reviews.

Table 1: Projects for 2012/13 that will be led by Barts Health clinical teams

Patient safety Clinical effectiveness What clinical and corporate teams will do to What clinical and corporate teams will do to improve patient safety improve quality

Adopt the NHS Safety Thermometer tool to Increase the number of patients over 75 who collect prevalence data in all wards and district have a dementia assessment and screen carried nursing teams for the four harms (pressure out. ulcers, falls, urinary catheter infections and blood clots). Refer a higher number of smokers to NHS smoking cessation services and support them Lead safety improvement to prevent the four to quit. harms (above) and other harm occurring to patients such as poor nutrition and hydration. Ensure that there is a safe and effective out-of- hours medical cover service for all the Barts Measure the team and organisational safety Health hospital sites. culture at least once more during the year using staff and team survey questionnaires Divisions (and then the new Clinical Academic designed for this purpose. Groups) will continue to develop integrated clinical services and pathways, so that patients Maintain zero tolerance against hospital- experience individual and consistent care and acquired infections in all our hospitals. standards. Where appropriate, clinicians will implement approaches such as the national Enhanced Recovery Surgical Pathways to ensure optimum recovery after surgery.

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Quality Account 2011/12

Patient experience Staff experience What corporate and clinical teams will do to What corporate and clinical teams will do to improve quality improve quality

At every meeting, the Trust Board will listen to We will measure key staff satisfaction and patient experiences and any concerns about experience indicators during the year and focus the safety and quality of the care we provide. If Organisational Development delivery in less well weaknesses are identified, the Board will take performing areas (eg feel valued, listened to, action to make clinical improvements. subject to bullying and harassment, recommend the Trust as a place to work). We will measure and improve how well prepared patients feel before going home. We will engage and facilitate an open dialogue with staff to help shape and realise the new Barts The Trust will undertake discovery interviews Health vision and organisational values. (where the patients are encouraged to talk about themselves) and conduct focus groups The executive team and senior leaders will to listen and learn from the experiences of our continue to undertake quality and safety most vulnerable patients and their carers. walkabouts – listening to, and acting on, feedback. We will improve the nutritional key performance indicator for ‘help with feeding’ We will aim to ensure that incident reports are providing a dignified service for all patients who acknowledged, so that the member of staff knows need it. that their concern has been acted upon.

The Trust will show a measurable improvement in the reported experiences of women using Barts Health maternity services, including community midwifery.

The role of innovation and technology in 21st century healthcare Coming together as Barts Health NHS Trust gives us all an ideal opportunity to share best practice and research. It also helps us to identify innovative new ways of working and delivering healthcare that reflect our world-class aspirations and our commitment to the people we serve. In response to the Department of Health document, Innovation, Health and Wealth – Accelerating Adoption and Diffusion in the NHS, published in December 2011, we will undertake a scoping exercise across the organisation in 2012/13. The aim is to ensure that our quality and development plans have innovation and technology at their core – so that patients can benefit from the very latest advancements in clinical care.

Monitoring and assurance of our quality standards and performance One of our fundamental priorities for the coming year is to establish robust systems for monitoring our performance against key quality indicators, and assuring our patients and staff that our services are safe and high performing at all times.

We are developing a clear governance framework to closely monitor performance against our Commissioning for Quality and Innovation (CQUIN) priorities, which we are currently agreeing with

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Quality Account 2011/12 our commissioners. The framework will include regular reporting against these and other key priorities to our Quality Improvement Board and Quality Assurance Committee, which is a sub- committee of the Barts Health Board. As was the case at the previous three trusts, the new Barts Health Trust Board will continue to receive a range of performance reports for all key areas of our operations, with clear information on trends and results, which will enable areas of weakness to be quickly identified and effectively tackled.

A number of new job roles are being developed to lead the new organisation through our eight Clinical Academic Groups (CAGs). The CAGs will directly oversee the delivery and development of all our services, and quality assurance and scrutiny will be a key priority for all senior leaders. The CAGs will be led by a clinician (such as a doctor, a pathologist or a therapist), a nurse and senior manager, who will all report directly to the Trust Board.

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Quality Account 2011/12 Looking back – review of services and governance

Review of services During 2011/12, Barts and The London NHS Trust reviewed all the data available to us on the quality of care in 170 of our NHS services, as measured by individual service lines. These service lines cover the range of regulated activities (as specified in the previous Care Quality Commission’s registration statement of purpose) undertaken by the Trust (before 1 April 2012).

The income generated by the services reviewed in 2011/12 represents 100% of the total income generated from the provision of NHS services by Barts and The London NHS Trust for 2011/12.

Quality is reviewed by systematic data collection against a suite of quality and operational metrics, which inform the Trust’s performance management framework and dashboard (the performance management framework covers each of the five clinical divisions and the Clinical Academic Units within them). The Trust also operates a robust system of risk management.

Quality is reviewed through the Quality and Safety Committee, Trust Management Executive and for assurance via the sub board Quality Assurance Committee. In 2010/11 there have been several deeper service reviews undertaken in response to specific operational or safety concerns.

Some of the data available to the Trust Board was reviewed at a more aggregated level, than at the individual service level, and the detail and depth of individual service reviews varies according to type and need.

Faster access to emergency surgery Following concerns raised by our clinical staff, we commissioned an external review to examine waiting times for non-life-saving emergency surgery. This review was conducted by the Royal College of Surgeons in January 2012, and we are currently awaiting their report. The team looked at theatre access for emergency treatment, with a particular focus on access to orthopaedic surgery.

At the time of their visit, plans were already underway to transform emergency care for our patients. Last year, the Trust Board established monitoring for theatre access and put in place plans to fundamentally change access pathways for emergency surgery, utilising our state-of-art facilities at the new Royal London, and the very latest models of care. In addition, six new orthopaedic consultants have been recruited by the Trust.

Early indications are that the changes we have implemented have led to significant improvements in emergency theatre access.

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Quality Account 2011/12

Responding to the London Health Programme The Trust supports and is involved in the London Health Programme (LHP) initiative to improve the standards and outcomes of emergency care. Significant work – such as consultant job planning, and extended cover for Accident and Emergency consultants at The Royal London Hospital site - has already taken place. This summer and autumn, as part of the LHP, all the acute sites of Barts Health will be part of a London-wide detailed external review and audit.

The Trust will continue to work toward delivering these standards and will work closely with commissioners to ensure that emergency care pathways in North East London are safe and sustainable. The Trust’s aim is to have senior review for any emergency patient within 12 hours of admission.

Further investment in our neurosurgical services The Trust has commissioned an external review to examine our neurosurgical services. We hope to establish what sort of provision we would be best placed to offer, on a sustainable basis, given the increased need to work collaboratively with in-house and external services (such as trauma care, and brain cancer care within London Cancer). The report has been received and the Trust has agreed to make a further investment in these services.

In addition, following concerns being raised by a member of staff, and through the Trust’s serious incident reporting process, a mortality review was undertaken for all neurosurgical deaths over a one- year period. Many of these deaths related to very severe and non-survivable trauma, but, in a limited number of cases, improved communication may have improved the chances of survival. An action plan to address this has been developed.

Participation in clinical audit During 2011/12, 50 mandatory national clinical audits and two national confidential enquiries covered the NHS services provided by Barts and The London NHS Trust. During that period, Barts and The London participated in 98% of national clinical audits and 100% of the national confidential enquiries that we were eligible to participate in.

The Clinical Audit Participation table in Appendix 1 shows the audits and enquiries where the data collection was completed in 2011/12. It also shows the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.

Learning from national clinical audit Barts and The London has substantially improved levels of participation in national audits this year and strengthened the mechanisms in place to learn from and act on the findings.

National clinical audit is a system to improve patient outcomes by engaging all healthcare professionals in systematic evaluation of their clinical practice against recognised standards and to support and encourage improvement in the quality of treatment and care.

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Quality Account 2011/12

Participating in research The reports from 17 national clinical audits were reviewed by Barts and The London NHS Trust in 2011/12. Barts and The London intends to take the following actions to improve the quality of healthcare that we provide:

• Improve data quality in national audit submissions to ensure that improvements are based on reliable information, and checked by senior consultants • Commission local audit to identify causes of low performance, e.g. to follow up on low histological diagnosis figures in the lung cancer audit.

In addition a National Clinical Audit day was held in March 2012. Clinicians presented audit results and compared their performance with peer NHS trusts. The presentations were recorded for wider distribution on the Trust intranet so that clinicians and trainees across the organisation can all learn from exemplary practice and find out more about ways to improve care for patients.

Learning from local clinical audit Clinicians are strongly encouraged to instigate local in-depth audits to follow up on national audit findings. As a result, registration of local audits increased by 57% at the Trust in 2011.

During 2011/12, 267 local clinical audits were registered by Barts and The London NHS Trust. The Trust intends to take the following actions to improve the quality of healthcare that we provide:

• Implement integrated care pathways, so that higher numbers of patients can be discharged by 2pm • Amend the discharge policy to include new performance indicators for discharge • Introduce standardised criteria for wound infection following caesarean section to promote increased surveillance and continuity of care from hospital to the community health services • Introduce a wound care section in our maternity services caesarean section information leaflet, to ensure that all women are given wound care advice before going home.

Working proactively with commissioners to establish joint audits In response to comments from Clinical Commissioning Group colleagues, who were shown an earlier draft of this Quality Account, we would like to provide the following additional information.

Bart’s Health is committed to developing a proactive and joint approach with CCGs and GPs on co audit and planning design. As a result of an enhanced audit registration process now in place, specialty audit programmes can be made available to the CCGs in the future to encourage the development of joint audit and this is something we will progress.

The Dermatology Team is currently designing an audit to assess experiences in primary care. If a specialist recommends medication that cannot be dispensed by the acute hospital, the patient’s GP will be contacted so that they can issue a prescription. The Dermatologists will look at how effective this process is and whether patients receive the prescribed medicines.

In March 2012, Commissioners were represented at the merger’s Clinical Due Diligence workshops about audit content, participation levels, and coverage. However individual GPs were not as successfully engaged with Clinical Due Diligence Phase 2 as we would have liked, despite email contact and workshop invites, and this is something we are keen to take forward and address for Phase 3.

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Quality Account 2011/12

Case study

Reducing health inequalities In 2011, the Trust participated in the National Health Promotion in Hospitals Audit. This is a national clinical audit which looks at the health promotion interventions by staff who are caring for patients assessed to be at risk of smoking, alcohol misuse, obesity and lack of physical activity.

The Clinical Effectiveness Unit Team reviewed the notes of 100 adult patients, to audit which health promotion activities had taken place during a particular hospital admission period (activities could include referral to support services or providing advice or specific information). The results were then submitted to the national audit team to enable the Trust’s local results to be compared to the national average and to the expected standards (to reflect specific criteria such as the population we serve and the size of the organisation).

Smoking 75% of patients were asked about their smoking habits, and 33% were found to be smokers. However, these patients were not offered any health interventions. The expected standard was 35% and the national average was 23%.

Alcohol abuse Patients were asked about their alcohol consumption. 46% of patients at risk of alcohol abuse were offered advice. This was above the national average of 41%. The expected standard was 50%.

Obesity Patients had their weight measured and their diet assessed. 40% of patients who were found to be obese were offered health promotion advice. This was far higher than the national average of 14% but below the expected standard of 45%.

Physical activity The results for physical activity are difficult to judge as the national audit team believes that auditors confused ‘activity’ with ‘mobility’. However, the Trust offered health promotion advice to 25% of those who they considered to be at risk. This was below both the expected standard and the national average.

This year, Barts Health NHS Trust will be developing a public health policy that will set out an integrated approach to tackling smoking, obesity, alcohol abuse, and lack of physical activity. It will also incorporate mental health and wellbeing services that will further benefit our patients. The Barts Health Trust Board has pledged to reduce health inequalities, and we are clearly already moving in the right direction with this initiative.

To keep track of our progress, the Trust will participate in the Health Promotion in Hospitals audit in 2012/13.

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Quality Account 2011/12

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Quality Account 2011/12

Case study

Improving the speed and quality of care for heart attack patients The London Chest Hospital is the heart attack centre for the North East London Cardiac Network, receiving referrals from six district general hospitals.

Initially, our wide geographical referral area presented us with logistical problems. National audits found that we needed to improve our call-to-balloon standard (the percentage of eligible patients receiving primary angioplasty treatment within 150 minutes of calling for professional help). We were also told that we needed to improve the outcome heart attack patients.

Our response was to embark upon a quality improvement programme. The Trust and local cardiac network funded a Heart Attack Centre (HAC) coordinator and a dedicated HAC team. Further investment enabled us to analyse the data in real time to support a process of formal weekly reporting.

We then focused on improving the clinical pathway. The first challenge was to increase the direct transfer rate, as patients who came via the network A&Es rarely achieved the call-to-balloon national standard. The HAC team collaborated with the London Ambulance Service and A&E departments sharing audit data, analysing feedback and the causes of delays.

We also worked hard to improve our door-to-balloon times. For example, a dedicated nurse was employed to meet all heart attack patients and any individual delay was investigated.

Weekly reports helped us to assess our performance and the team were encouraged by the results.

In 2010/11 Barts and the London NHS Trust achieved the national standard for call-to-balloon times and our performance for 2011/12 has continued to improve. Now more than 90% of heart attack patients receive emergency treatment within 150 minutes of the call for help (the UK national target is 75%). Mortality rates have also reduced for heart attack patients.

Percentage of patients who were given PPCI (emergency angioplasty) to restore blood flow (reperfusion) within 150 minutes of the call for help (April 2010 – Mar 2012)

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Quality Account 2011/12

Case study

Helping patients with heart failure Data from the Central Cardiac Audit Database, and readmission audit data, has revealed that a few of our heart failure patients repeatedly returned to hospital within 14-28 days of being discharged.

The common reasons were:

• Lack of understanding about the illness (by the patient or their family)

• Poor recognition of any symptoms of deterioration (and then help was sought at a late stage)

• Poor compliance with medication.

In 2011, we established a new post-discharge clinic for patients previously admitted with heart failure. The participants are closely monitored, from the first week or two after their discharge, and we provide ongoing education for the patients and their families. Patients are able to attend the clinic on a weekly basis, until their condition has stabilised.

Our most recent data shows a very low rate of readmission (between zero-two patients every month are now readmitted within 14-28 days of discharge).

Participation in research The number of patients receiving NHS services provided or sub-contracted by Barts and The London NHS Trust in 2011/12, and who were recruited during that period to participate in research approved by a research ethics committee, was 12,473.

Participation in clinical research has the potential to improve quality of care, the patient experience and clinical outcomes. It also gives our patients access to a range of technological developments in healthcare, including a wide range of experimental drugs, devices and procedures that can enhance the quality and scope of the care packages we can offer.

In 2011/12, a total of 5,473 patients were recruited to National Institute for Health Research (NIHR) adopted studies and it is estimated that a further 8,000 patients were recruited to studies that are not adopted by the Clinical Research Network.

Barts and The London NHS Trust was the second highest recruiter to NIHR adopted studies out of the 30 trusts in the North Central and North East London Comprehensive Local Research Network (CLRN). This is one of the top performing networks in the UK, which would indicate that the Trust continues to perform very well at a national level. There has also been a 19% increase in the number of Barts and The London trials registered with the CLRN. There are now 363 registered studies compared with 304 studies in 2010/11.

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Quality Account 2011/12

In terms of the Trust’s externally funded research portfolio, the Trust continues to record a steady increase in turnover. In 2011/12, turnover was £13,655,499 – representing a rise in research project income of 3% over the 2010/11 figure. The number of funded projects has risen by 25%, from 332 in 2010/11 to 415 in 2011/12.

The Trust has a continuing commitment to improve the quality of care that we offer our patients, and to contribute to wider health improvement. This is demonstrated by the substantial number of staff leading research projects in the Trust. A total of 128 researchers are registered as chief or principal investigators this year.

The development of Barts Health provides a unique opportunity to synthesise the benefits of the high-quality research programs run at all of our hospitals and widens the opportunities for participation in research for our patient population.

Barts and The London NHS Trust, and our partner medical school – Barts and The London School of Medicine and Dentistry – run high-quality, well-governed clinical research studies, many involving multidisciplinary work with input from clinical physicists, imaging, pathology, nurses and allied health practitioners. All research is approved through the National Research Ethics process and adheres strictly to the national clinical trials regulations, ensuring a high level of safety for patients consenting to participate in the studies.

Output from the Trust’s research has been presented extensively in national and international research forums, and included in high-impact journals. These studies are not only of interest to the scientific community, but have led to real changes in clinical practice for the benefit of patients both locally and internationally.

Case study

Largest ever heart attack trial led by Barts Health In January 2012, Barts Health secured €5.9m of European Commission funding for the largest ever trial of adult stem cell therapy. Three thousand heart attack patients are being recruited from across the EU. The trial will explore whether stem cells administered shortly after heart attacks can repair damaged hearts and, if so, how these cells should be administered to patients. The trial is led by Professor Anthony Mathur and aims to determine if adult stem cells can save the lives of heart attack patients across Europe.

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Quality Account 2011/12

Case study

Barts’ breakthrough in fighting pancreatic cancer Research at the Barts Cancer Institute has found that Vitamin A holds the key to beating pancreatic cancer, the world’s deadliest cancer. Mr Hemant Kocher, consultant pancreatic and liver cancer surgeon at Barts, led the team during a four year joint project with University of Cambridge and Dutch Hubrecht Institute. This research is based on the ‘seed and soil’ theory for targeting cancer that was originally pioneered by Barts surgeon Stephen Paget in 1889. The team has shown that if normal amounts of Vitamin A are restored to the ‘soil’ (non-cancerous cells) that surrounds the ‘seed’ (the cancerous cell) then further cancerous growth is inhibited.

Commissioning for Quality Improvement and Innovation (CQUIN) A proportion of Barts and The London NHS Trust’s income in 2011/12 was conditional on achieving 18 acute and six community services quality improvement and innovation goals, agreed between Barts and The London NHS Trust and the North East London and City Commissioners.

Details of our achievements and the progress we have made against the goals agreed for 2011/12, are provided in the Looking Back sections of the Quality Account.

Care Quality Commission registration Barts and The London NHS Trust is required to register with the Care Quality Commission (CQC) and its registration status in 2011/12 was full registration with no conditions. The Care Quality Commission did not take enforcement action on any issue against Barts and The London NHS during 2011/12.

Action taken in response to CQC routine inspections in 2011/12 Barts and The London NHS Trust participated in five unannounced inspections by the Care Quality Commission in 2011/12, including a follow-up visit to The Royal London Hospital in November 2011.

The assessors talked to patients, carers and staff about their experiences at the Trust. The CQC’s quality and safety standards (known as ‘desired Outcomes’) were observed and assessed.

Mile End Hospital was inspected in January 2012. The assessors found that all the standards were met, with only minor improvements required for Outcome 13 (staffing) and Outcome 21 (records).

A CQC visit to The London Chest Hospital took place in early March 2012. The assessors found high standards of care and service but two specific issues were raised regarding ward temperatures (the environment) and staffing.

Outcome 12 – the Trust declared non-compliance In December 2011, following internal self-assessment against the essential standards, the Trust declared non-compliance with Outcome 12 requirements relating to workers. At that time, we did not have complete assurance of the effectiveness of the controls in place to ensure that Criminal Records Bureau (CRB) staff checks were being undertaken and recorded for all employees.

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Quality Account 2011/12

The Trust informed the Care Quality Commission of the planned action it would undertake to address risk and ensure compliance against this standard. The majority of actions and changes to practice are implemented across all our hospital sites to ensure that essential standards are consistently applied. This is exampled in our nutrition work (Outcome 5) and improvements in the recording and audit of Mental Capacity Act decisions where patients who are unable to give consent are given routine nursing care in their ‘best interests’ (Outcome 2). We also implemented Intentional Rounding in all our wards (Outcome 4) and not just at The Royal London.

Please see page 74 for more information on the subsequent action that we have taken to remedy the situation with CRB checks. For patient nutrition, please also see page 46 for information on the improvements made this year to our meal service, our work with volunteers and steps to ensure that all patients get the help they need with eating and drinking. For more information about intentional rounding please see page 21. The Trust also ensures that on all the wards, the number and ratio of qualified and unqualified nursing staff are frequently reviewed, to ensure safety and quality (Outcome 13). Following the CQC inspection, and an external review of Services for Older People commissioned by the Chief Nurse, recruitment plans were developed and have been undertaken at Barts Hospital in the Cancer and Cardiac services, and at Mile End Hospital.

Table 2: Quality and safety improvements required by the Care Quality Commission (31 March 2012)

Location Outcome Issue

The Royal London Outcome 5: meeting Although some people were observed nutrition needs enjoying food, further improvements are needed to ensure that all patients eat sufficient food in a comfortable manner, and with the support they need.

St Bartholomew’s Outcome 4: care and Patients experience effective, safe and (Barts) Hospital welfare appropriate care, treatment and support, which meets their needs and protects their rights. However, some patients experienced postponed or delayed treatments, without additional support to help them understand when their procedure would take place.

Barts Hospital Outcome 13: staffing There were enough suitably qualified staff in some of the areas visited. However, there was evidence that insufficient skilled staff were available to cover shift shortages, in some of the wards and departments, at certain times.

The London Chest Outcome 10: safety and In some areas, the ward temperature was Hospital suitability of premises not being adequately maintained to promote wellbeing.

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Quality Account 2011/12

The London Chest Outcome 13: staffing Temporary staff were not always available Hospital to fully cover staff absences or vacancies at the hospital. As a result there were at times insufficient numbers of suitably qualified staff on duty in some areas.

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Quality Account 2011/12

Data quality Barts and The London NHS Trust will be taking the following actions in 2012/13 to improve data quality:

• Holding regular data quality clinics for the staff to discuss any issues • Reviewing common data quality errors, locating the source of any errors, and arranging appropriate training for any staff who need it • Working with the training department to ensure that all data quality errors are covered appropriately and accurately.

NHS number and General Medical Practice Code validity Barts and The London submitted records during 2011/12 to the Secondary Uses Service for inclusion in the Hospital Episode Statistics. These records are included in the latest published data. The percentage of records that included the patients’ valid NHS number was:

• 94% for admitted patient care • 97% for outpatient care • 79% for accident and emergency care.

The percentage that also included the patients’ valid General Medical Practice Code was:

• 100% for admitted patient care • 100% for outpatient care • 100% for accident and emergency care.

Clinical coding Barts and The London NHS Trust was subject to the Payment by Results clinical coding audit during 2011/12 by the Audit Commission. During that period, the error rates reported in the latest published audit, for diagnoses and treatment coding (clinical coding) were as follows:

• Primary diagnoses incorrect: 4.5% • Secondary diagnoses incorrect: 1.1% • Primary procedures incorrect: 19% • Secondary procedures incorrect: 21.1%.

Information governance The Trust is committed to ensuring that it manages all the information it holds and processes in an efficient, effective and secure manner. This is achieved through the application of robust information governance policies and procedures, in accordance with information management legislation and Department of Health guidelines, supported by training and awareness activities.

The Trust’s Information Governance (IG) Toolkit return for 2011/12 was submitted to the Department of Health in 2012. The Trust’s overall score for 2011/12 was 74% (which was graded red ‘not satisfactory’). This was nevertheless an improvement on last year’s score (70%).

The Trust’s data quality action plan, and the work that is underway to ensure compliance with all mandatory training requirements, will contribute to our improved performance in 2012/13.

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Quality Account 2011/12 Review of our quality and safety performance in 2011/12

Quality dimension one – patient safety

Working towards harm-free care with Safety Express Safety Express is a national safety initiative, and part of the Department of Health’s Safe Care quality improvement programme (QIPP). Safety Express aims to assist organisations in the health and social care sectors, so that they can collaborate to develop safer care systems and practices across hospital, community and social care settings.

The ultimate goal of the initiative is the provision in all settings of harm-free care and reduced harm associated with four key areas:

• Falls in care settings • Blood clots (deep vein thrombosis and pulmonary embolism) • Urinary tract infections in patients with catheters • Pressure ulcers.

Barts and The London NHS Trust participated in Safety Express throughout 2011/12. We will continue to work toward harm-free care this year as part of our quality priorities. We have also added nutrition as the fifth key area to focus on, so that we can reduce the harm that can be associated with patients (usually elderly) becoming under-nourished and dehydrated.

Specialist leads for the key areas have been meeting to look at how they can improve care and co-ordinate their approach. Their work has been overseen by a steering group of senior managers and clinicians and key stakeholders (including a patient, commissioner and a local authority safeguarding lead).

The impact of their work was monitored by point prevalence audits undertaken in four pilot wards. The monthly audits, which measure the proportion of patients affected by the four key areas, at defined moments in time, are known as the ‘Safety Thermometer’. From sample data of 467 patients collected by the Trust between June and January 2011, 402 patients – that is, 86% – were harm free. This figure was consistent (in fact slightly better) than the national picture for the same period (which was that 83% of patients across the whole programme were harm free).

Harm-free care – fall prevention One of the key objectives of Safety Express is to reduce the number of patient falls. Patient falls account for a high number of reported incidents throughout the organisation. There were 1,100 patient falls this year – 476 of these were recorded as ‘harm events’, and 19 of them were ‘serious harm events’.

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Quality Account 2011/12

Tackling this issue is inevitably challenging as there are many potential reasons why patients fall in hospital. It is also difficult to devise a preventative strategy that does not affect a patient’s independence and rehabilitation.

Action has focused on the robust monitoring of patients who do fall. Wherever possible, steps are taken to prevent a recurrence. This is in line with the requirements of the National Patient Safety Agency’s Alert 001 issued in January 2011. A specific falls root cause analysis tool has been designed and implemented by the Patient Safety Team to investigate falls resulting in moderate/ serious harm. Preliminary analysis has not yet identified any key themes or trends that are not already covered by the Falls Committee action plan for 2011/12.

Harm-free care – introducing intentional rounding One key achievement this year has been the introduction of ‘intentional rounding’ in all the wards. These are also known as ‘comfort checks’. At regular intervals, the nursing staff visit every patient at their bedside, to check that they are comfortable and that the nurse call bell is within easy reach. The patients are asked if they want a drink or need to visit the toilet. On one elderly care ward, the number of falls reduced from 18 to two in one month, following the introduction of two hourly rounding and particularly by focusing on more ‘at risk’ patients in side rooms.

Harm-free care – monitoring catheter practices The continence nurse specialists (who are also part of the Safety Express group) carry out weekly clinical rounds to monitor urinary catheter care and provide teaching/training for staff when necessary.

They undertook four audits in 2011/12 to assess the insertion and continuing care techniques used for patients with urinary catheters. The Care Records Service (our electronic health records system) was used to check on how many catheter samples of urine had been sent for testing and whether or not any bacteria had been detected.

The findings of the audits were discussed with the ward managers. As a result of their efforts, we have seen improvements in the following areas:

1. Better documentation in the medical notes 2. Improved documentation on the Trust’s pink form (for insertion and removal of devices) 3. Better use of the catheter pack’s identity sticker 4. Increased use of the Statlock device (which holds the catheter in place and reduces the risk of infection) 5. More rigorous routine practices (e.g. dating the catheter bag when it is changed every seven days) 6. Improved follow-up of catheter specimens of urine sent for testing 7. Better catheter management by nurses (e.g. daily review and prompt removal).

We will continue to build on the progress that we have made in these areas. In addition, an education and training video has been made about safe and dignified male/female urinary catheterisation.

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Quality Account 2011/12

Harm-free care – preventing venous thromboembolism Some conditions are more likely to occur in a healthcare setting, such as venous thromboembolism (VTE).or blood clots. Our blood clots naturally when we are injured. Sometimes this takes place in the blood vessels of the leg forming a ‘plug’ which can interrupt the normal flow of blood in an artery or vein. There are two types of blood clot – a thrombus and an embolus. An embolus is a blood clot that breaks away from the main clot and moves in the bloodstream. A thrombus is a blood clot that does not move. A pulmonary embolus is a blood clot that has broken off from a clot in the legs and has travelled to the lungs. This type of clot can cause chest pain and difficulty in breathing.

Being ill, immobile and having major surgery are all risk factors for these largely preventable disorders but adopting certain measures can reduce the risks. We constantly strive to improve our safety levels on recorded risk assessments for VTE. However, having initially made good progress, the Trust has fallen behind other organisations. The lack of a primary electronic risk assessment tool has hampered our efforts to meet the national target.

Chart 1 below shows that in March 2012 we achieved our best ever monthly performance at 83% against the 90% target.

An action plan is now in place that will help address our unsatisfactory performance. The VTE Board has been established to oversee all elements of VTE prevention. A bespoke report has been developed for each ward, and this is used to identify any patients who are not registered on the system (either because an assessment has not been undertaken on hand-written prescription charts or because the assessment has not been recorded on the Trust’s computer system). The Trust backs up this register with regular audits of the prescription sheets, and root cause analysis of any VTE episodes that we believe should have been avoided.

Chart 1: The percentage of adult patients at the Trust who had a risk assessment for venous thromboembolism carried out in 2011/12 (monthly target 90%)

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Quality Account 2011/12

Harm-free care – nutritional improvements We added ‘nutrition’ to our Safety Express programme – as we recognise that diet and hydration play an important role in keeping patients safe (particularly our elderly and vulnerable patients). Improvements have been made to daily ward menus and meals, and the wards have upped their compliance with key nutrition performance indicators. These standards are in place to ensure that risk assessments are carried out on patients, and that if they need help, they are referred for specialist dietician care, or given assistance with eating their meals.

You can also read more about our achievements in this area in the patient experience section on page 35.

Harm-free care – preventing tissue ulcers Last year, we reported that we had achieved our improvement target for hospital-acquired grade three and four pressure ulcers. Our target was to reduce the incidence by 15% (to no more than 49 pressure ulcers) and this was achieved with a total of 33 grade three and four pressure ulcers.

Unfortunately, this year, the targets for reducing tissue ulcers in 2011/12 have not been met. We did not achieve the level of improvement we expected and will work hard to do better.

Grade three and four pressure ulcers We tried hard to meet the ambitious Commissioning for Quality and Innovation (CQUIN) target of a 30% reduction for grade 3 and 4 pressure ulcers. However this was particularly challenging, given the 15% reduction that we had achieved in 2010/11. With 34 pressure ulcers reported in total, we exceeded our target by 12 cases in 2011/12.

Chart 2: This shows how the Trust performed against our targets for reducing tissue ulcer prevalence from April 2010 until March 2012

Pressure Ulcers patients acquiring a grade 3 or 4 pressure ulcer Threshold

10

8

6 Patients

of 4

2 Number

0 11 10 11 10 12 11 11 11 11 11 11 10 10 10 10 10 12 12 11 11 11 11 10 10 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Jul Jul Jan Jun Jan Jun Feb Oct Sep Apr Feb Oct Sep Apr Dec Aug Dec Aug Nov Nov Mar Mar May May Month 25

Quality Account 2011/12

Grade one and two pressure ulcers We worked hard to meet a new 20% reduction target for lower-grade pressure ulcers (no more than 297 grade one or two pressure ulcers). Regrettably, we failed to meet this target, as 524 lower-grade pressure ulcers were reported in 2011/12.

We recognise that our performance to date has been disappointing and unacceptable. Meeting our targets has been challenging, in part because of our patient mix, the numbers of patients with complex injuries, and the available resources within the Tissue Viability Team (TVT). The high profile given to pressure ulcers through initiatives such as Safety Express and Safety Net has also led to increased reporting. Spot check audits and surveillance also reveals that a proportion of the grade one and two tissue ulcers reported by nurses are likely to be moisture lesions, as opposed to being caused by pressure damage.

The Trust is committed to reducing tissue ulcer harm. For the past two years, all grade three and four pressure ulcers have been reviewed as serious incidents by the nursing teams. The teams undertake a root cause analysis of each case, and actions are identified and implemented. This has been extremely informative for the individual teams, and a bank of information is now available to the TVT on issues to be taken forward in 2012/13. Areas to be targeted are: inconsistent undertaking of initial risk assessment, unclear daily care plans, and inconsistent grading by ward nurses.

Where we have succeeded We have been striving to make our hospitals safer than ever and achieve harm-free care. As a result:

• Heel pressure ulcers (in the highest grade three and four category) have been targeted through training and specialist equipment – and have decreased from 17 (in 2010/11) to 9 (in 2011/12) • Each ward now has a tissue viability link nurse to champion best practice • Tissue ulcer e-learning modules are available on the Trust’s intranet.

Key actions to reduce pressure ulcers Over the next year, the Tissue Viability Service will focus on avoiding preventable pressure ulcers. This will be achieved by taking the following steps:

• All policies, systems and processes will be standardised for pressure ulcer avoidance. • The prevalence across our sites will be measured using robust methodology that is currently being developed. • Networks are being formed with NHS Trusts that have better outcomes than ours, to understand their approach and management strategies. We will also be liaising with UCLPartners to gain further perspective. • Front line staff will be better trained to avoid and manage pressure ulcers. There will be link nurses within each CAG, and a more rigorous training programme will be introduced. • We will use a root cause analysis tool (and/or other methodology) to capture patient and relative experiences. Their comments will be fed back to staff and used to enhance our training.

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Quality Account 2011/12

Dr Foster’s Hospital Standardised Mortality Ratio (HSMR) The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that measures whether the death rate at a hospital is higher or lower than you would expect taking into account a number of factors, such as the acuity of patients treated. It looks at the expected rate of death, compared with the actual rate of death, from 56 common conditions that are treated within the NHS and account for 80% of hospital deaths. The measurement system uses data from hospital episodes collected over the last 13 years.

If the observed rate of death at the hospital is the same as the expected rate of death, the hospital scores 100. Numbers below 100 indicate a lower death rate than expected (i.e. better). Numbers above 100 indicate a higher death rate than expected (i.e. worse). The Trust regularly uses the ratio as a tool to monitor individual areas, and then if the rates are higher than expected, we will investigate on a case by case basis.

The current three-year rolling HSMR covers the financial years 2008/09, 2009/10 and 2010/11. Over this period, Barts and The London NHS Trust achieved a score of 84.54.

New Summary Hospital-level Mortality Indicator (SHMI) SHMI is a new hospital-level mortality indicator. It provides a ratio of the observed deaths in a Trust over a period of time, divided by the expected number, given the characteristics of patients treated by that Trust. Deaths within 30 days of discharge are also included.

As with the HSMR, if the observed rate of death is the same as the expected rate of death, the hospital scores 100. Numbers below 100 indicate a lower death rate than expected (better). Numbers above 100 indicate a higher death rate than expected (worse).

The SHMI for Barts and The London was reported and uploaded to the NHS Information Centre at the beginning of January 2012. It covers the period from July 2010 to June 2011, and we are pleased to report that the Trust scored 69.34.

Our ward safety champions and the work of the Patient Safety Forum The Patient Safety Forum is comprised of safety champions from each ward, who attend a monthly meeting to explore patient safety issues, and plan audits.

This year the forum covered a number of topics including:

• Safety briefings – ensuring that staff are aware of the safety issues on every shift • Safety metrics – auditing the quality of Patient At Risk (PAR) scores and observations taking place in the clinical areas • Reflections and feedback on reported incidents and lessons learnt • Infection control awareness and pressure ulcer prevention.

At the end of 2011, we asked the safety champions to evaluate the Patient Safety Forum. The feedback we received was excellent, with 100% of respondents stating that the forum had made them more aware of patient safety issues, leading to changes on the wards. We were told that the forums provide useful ideas and that the sessions are interesting and informative.

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Quality Account 2011/12

Ward-led patient safety projects Over the past six months, each safety champion has been working on a safety project related to their clinical area. In recognition of their hard work and commitment to patient safety, four of the champions have been selected to attend the national Patient Safety Congress 2012 in May.

Case study

On the urology ward: a winning example of safety excellence in action A baseline audit on the urology ward revealed the need for improvements in catheter care, particularly regarding the dating and labelling of catheterisation equipment. Clear labelling is known to reduce the risk of urinary track infections.

A number of improvement initiatives were launched. These included highlighting the areas to be improved at ward meetings, sending reminder emails out to staff, adding ongoing catheter care to the weekend job list and stressing the importance of catheter care at each shift handover.

The final audit showed that compliance with dating catheter bags has improved – and work in this area continues.

Safety Net: an early warning IT tool for safety or quality issues at ward level Safety Net has been used by the Trust since June 2011, to support the delivery of safe and high- quality care for our patients.

It provides a weekly report of safety incidents, and workforce data, and acts as a management early- warning and improvement tool. It is designed to enhance existing risk management arrangements and enables all staff to monitor their clinical area or department on a weekly basis. The report displays six weeks of incident information so that any trends can be viewed. Staff are able to assess safety on individual wards, associated clinical academic units, at a site level and across the Trust as a whole.

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Quality Account 2011/12

Chart 3: A sample report (screen shot) from Safety Net showing the detailed information available including data on slips, trips and falls, and hospital acquired infections

We asked our staff for their views on patient safety… and the findings were reasonably encouraging In February 2012, we invited our staff to take part in a Safety Climate Survey designed by the Institute for Healthcare Improvement and The Health Foundation. A total of 139 staff responded to the questionnaire, the majority in clinical roles; 84% of respondents stated that they know how to raise patient safety concerns and 80% agreed that staff take responsibility for patient safety. However, only 52% of staff agreed that the organisational culture makes it easy to learn from the mistakes of others. Just 54% agree that leaders listen to and respond to their patient safety concerns. We are aware that we need to reassure staff, and demonstrate that their safety concerns are recognised and acted upon. The Barts Health Board has identified this one of the three Quality Account priorities for 2012/13.

Striving for safe, clean care – reducing hospital- and community-acquired infections One of our top priorities in 2011/12 was to continue to prevent and control healthcare-associated infections through providing a clean, safe environment for our staff and patients. We have continued to provide comprehensive training for staff, stressing the importance of meticulous hand hygiene, prudent use of antibiotics and continual reassessment of our knowledge.

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Quality Account 2011/12

A team of infection prevention and control practitioners work with the hospital pharmacists, estate managers and senior clinicians, monitoring infections and providing ward staff with advice on how to treat and prevent the spread of micro-organisms.

We said we would reduce the number of healthcare acquired infections again – and we have Our new hospital at The Royal London has 40% of the accommodation in single rooms, so that we can promptly isolate patients when necessary. This helps to reduce the risk of cross infections. As a result, we have seen a reduction in Methicillin-Resistant Staphylococcus Aureus (MRSA) and Clostridium difficile (C.diff) infections over the past two months.

C.diff – meeting and beating our targets We have worked hard to reduce the incidence of Clostridium difficile (C.diff), with gratifying results. The number of attributed cases has fallen from 122 last year to 61 this year. This is considerably lower than our Department of Health target (92).

Our Community Health Services have reported 10 cases of Clostridium difficile this year, which are just two cases above their target.

Our going forward target for 2012/13 is 59. Since this was set, we have introduced a new, even more sensitive diagnostic test for C.diff – and this may make compliance a greater challenge than we expected. We hope that this will be offset by our improved ability to isolate potentially infectious patients and our continuing strict control measures.

MRSA – aiming for zero tolerance The number of cases of Methicillin-Resistant Staphylococcus Aureus (MRSA) infections continues to fall every year. In 2010/11, there were 15 cases, and in 2011/12 we had 11. Our target of six proved very challenging, but we will attempt to meet it this coming year and indeed hope to achieve our ultimate goal of zero.

Our Community Health Services reported only one case of MRSA.

Building on our success in lowering infection rates Although infection rates at the Trust have consistently dropped since 2005, there is no room for complacency – and we will continue to expect and maintain consistent, reliable process and practice standards.

One example of improving practice is the Vascular Access Device Team’s introduction of the Aseptic Non-Touch Technique (ANTT). This is a standardised approach to aseptic practice that significantly helps to reduce healthcare-acquired infections. It is now used for intravenous drug administration (and features in the appendix of the Injectable Medicines Policy). Clinicians are assessed in their use of the technique across the Trust and are offered training and information, particularly in areas where an MRSA bacteraemia has been reported and a vascular access device identified as the source of the bacteraemia.

All new staff are taught about ANTT and blood culture sampling at induction sessions, and then given an update every year. We know this has contributed to the downward trend in MRSA cases.

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Quality Account 2011/12

Over the past year, we have been inviting colleagues to review our infection control measures (including a team from the Strategic Health Authority NHS London). Overall, they are satisfied with our efforts. It has been suggested that we should introduce a framework to isolate infectious patients into our new side rooms, within two hours of symptoms developing – and this is something that we will investigate further.

Good antimicrobial management to reduce risk of hospital acquired infection A team of specialist pharmacists closely monitors the use of antimicrobial medicines within the Trust and advises on safe and effective prescribing of these drugs. Antimicrobials are used to combat infection and examples include well known antibiotics such as penicillin and tetracyclines. However, their overuse has led to bacterial resistance and the development of ‘superbugs’ (e.g. C.diff and MRSA).

Over the past year, an Antimicrobial Review Group (ARG) has focused on a range of improvement activities as part of the overall infection control and prevention action plan. Key performance indicators (KPIs) have been developed to promote consistent and rigorous standards for antimicrobial usage throughout the Trust. One example is that a ‘Stop / Review‘ date is now marked on every drug chart to ensure the patient is not taking antimicrobial medicine for longer than is prescribed or necessary. KPI results per ward and team are reported to the Infection Control Committee. This year, the trend has mostly been for increased compliance with the KPIs.

The ARG was also involved with updating a quick reference guide for clinical staff and revising the Trust’s antibiotic and antibiotic prophylaxis guidelines.

Clinical practice has been improved in a number of key areas, such as the effective management of MRSA colonisation (i.e. for patients with the MRSA bacteria on or in their bodies, but who have not yet become infected) and the reliable use of surgical prophylaxis (i.e. giving patient’s antibiotics before surgery to reduce the risk of infection).

Managing the safety of acutely ill patients In line with national safety guidance, the Trust uses a Patient at Risk (PAR) early warning scoring system. Observations of factors such as the patient’s temperature, blood pressure and alertness are recorded, and a score derived, which helps staff to quickly identify deteriorating patients and take appropriate action.

As part of a CQUIN improvement this year we used sample audits each month to measure the percentage of staff that correctly uses the PAR score when recording patient observations. We have set a goal to achieve 95% accuracy by the end of the year (from a baseline of 75%). Please see Chart 4.

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Quality Account 2011/12

Chart 4: Correct Patient at Risk scores in 2011/12

Correct PAR score present for each set of observations in last 48 hours 100

90

80 % PAR Score Compliance Median 70 Target

% correct PAR scores 60

50

1 1 -11 -11 -11 n-11 r-11 n ul-11 v-11 n-12 b-12 a ar-11 J ug-11 aselineJ Feb M Ap May Ju A Sep-11Oct-1No Dec-1Ja Fe Mar-12 B month

Despite continuous staff training, we did not sustain the improved performance achieved in the summer months. It is possible that the move into our new hospital at The Royal London could in part be attributable to the lower performance in December 2011 and January 2012.

To help us meet our targets, PAR scoring compliance is now an operational safety performance issue and the monthly safety metric audits are included in each division’s governance dashboard so that the divisional nurses can focus on improving practice with their teams.

We will work towards ensuring that all emergency patients are reviewed by a consultant within 12 hours of admission Last year, the Trust participated in another CQUIN project that aims to improve the care and safety of acutely ill patients. We were asked to demonstrate that 90% or more of our patients were seen and assessed by a consultant within 24 hours of their admission to hospital.

Data was reviewed in three quarters of the year. Fifty non-elective patients were randomly selected and audited from the trauma, neurosurgery, general medicine and surgery and orthopaedic specialties. Please see Chart 5 below. The results improved toward the end of the year, but we fell short of the 90% target. This is something that we will be addressing this year with the challenge to ensure senior review for any emergency patient within 12 hours of admission.

.

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Quality Account 2011/12

Chart 5: Non-elective patients at the Trust seen by a consultant within 24 hours of admission

Consultant review of non-elective patients within 24 hours of admission

100 90 88 90

Q2 80 74 72 Q3 70 Q4 % of %patients of 60 Target

50 Q2 Q3 Q4 Target

Period

Responding to safety alerts – quickly and efficiently The National Reporting and Learning System (NRLS) collate and analyses clinical incidents from NHS organisations. This information is used by the National Patient Safety Agency (NPSA) to produce alerts that are aimed at improving patient safety.

During 2009/10, concern was expressed that the Trust had not been quick enough to react to NPSA alerts – and this is something that we were keen to tackle. Following the implementation of a new Trust policy in 2010, our performance has improved and this has been largely sustained during 2011/12. Please see Table 2 below.

Table 2: NPSA safety alerts for the past two years

NPSA alerts 2010/11 2011/12

Alerts open (within dates) at start of the year 5 8

NPSA Alerts overdue for completion at the start of the year 3 5 workload during year Alerts received 12 4

Total alerts to manage 20 17

Alerts closed 15 10 Status at year end Alerts overdue for completion at the end of the year 5 1 Alerts with ongoing action (within dates at year end) 8 6

Other alerts are issued by the Central Alerting System (CAS), originating from a number of sources, including the Department of Health, the Medicines and Healthcare products Regulatory Agency (MHRA) and the Chief Medical Officer. These are summarised below in Table 3.

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Quality Account 2011/12

Table 3: CAS alerts over the past two years

CAS alerts (excluding NPSA) 2010/11 2011/12

Alerts open (within dates) at start of the year 19 14

CAS Alerts overdue for completion at start of the year 2 14 workload during year Alerts received during year 120 132

Total alerts to manage 141 160

Alerts closed during year 113 149 Status at year end Alerts overdue for completion at the end of the year 14 8 Alerts open within dates at end of year 14 11

Demonstrating our safety culture through accurate reporting of incidents At Barts and The London NHS Trust, a total of 12,426 incidents were reported by our staff in 2011/12, and 8,515 of these incidents involved patients. The latest published comparative data shows that Barts and The London is a relatively high-reporting Trust, which indicates a strong safety culture. This means staff are more likely to be confident in reporting incidents without fear of blame or inappropriate reprisal, and important safety and operational issues are known about and can be addressed. Please see Chart 6 below.

Chart 6: The number of incidents reported per 100 admissions

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Quality Account 2011/12

Chart 7: Breakdown of incidents at the Trust by severity (in 2011/12)

Chart 7, above, uses Trust incident data captured on Datix, our Risk Management System Database. It gives a breakdown of incidents over the past 12 months (categorised according to the harm that resulted, ranging from ‘no harm’ to ‘death’). The largest numbers of incidents reported were within the ‘no harm’ category.

The noticeable rise from July 2011 reflects the integration of the Community Health Services into the Trust (previously managed by Tower Hamlets PCT). The sharp peak in December 2012 corresponds with the start of moves into the new Royal London Hospital. The elevated figures during this period can be explained by logistical problems that have since been largely resolved.

Learning from serious harm incidents The Trust is extremely concerned about any incident resulting in severe harm or death. Over the past year, 52 serious incidents were reported (0.6% of all incidents). This is lower than the figure recorded in the most recent National Reporting and Leaning System data for the Trust (0.9% of all incidents).

Sixteen of the incidents were associated with obstetric and maternity care. The majority of the others were associated with diagnosis and treatment, but with no overall pattern. All severe harm incidents are investigated and action is taken to reduce their recurrence.

Monitoring ‘never events’ to reduce risks to patients ‘Never events’ are defined as ‘serious, largely preventable’ patient safety incidents that should not occur if the recognised safety measures are implemented. While the term ‘never’ remains an aspiration, the occurrence of one of these events is potentially indicative that a hospital has not implemented the correct systems and processes required to protect patients.

Barts and The London reported and investigated four ‘never events’ in 2011/12. A brief synopsis of the incidents is provided below.

As with all serious incidents (SI), each of the ‘never events’ results in a detailed investigation, and action plan, with the progress monitored by the Trust Board.

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Quality Account 2011/12

‘Never event’ What action and learning was taken

A patient had a naso-gastric An image from a mobile x-ray unit was used to confirm placement. tube inserted and feeding Following this incident, staff have been advised that confirmation commenced. However the must only take place on an appropriate x-ray viewing screen. naso-gastric tube was misplaced in the patient’s lung rather than in their stomach.

The surgeon began an There were many significant factors identified as contributing to this emergency procedure on the incident and a comprehensive action plan was developed. Key wrong side. learning around leadership in theatres and the importance of teamwork have been shared with all theatre staff. This case also highlighted the importance of carrying out the WHO safer surgery checklist in all cases, no matter how urgent the surgery.

Two incidents where patients Since 2009, there have been five incidents where patients have had had swabs left inside them swabs left inside them (including these two cases). The Trust plans following surgery. to formally review the related policy and processes using failure modes and effects analysis (FMEA) methodology. We will ensure that the risks associated with this process are being managed appropriately and that we are doing everything we can to prevent any recurrence.

Meeting national safety standards in maternity care Our maternity services are assessed against clinical risk management standards defined by the Maternity Clinical Negligence Scheme for Trusts (CNST). The Royal London Hospital’s maternity unit passed the Level 2 assessment with high pass rates in all five standards including organisation, clinical care, high risk conditions, communication and postnatal and newborn care.

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Quality Account 2011/12 Quality dimension two – patient-centred care and acting on patient experience

Listening to concerns and learning from feedback We are keen to promote an open culture where feedback is welcomed and acted upon. Much of the feedback that we get from patients and their families is extremely positive, praising our staff, services and new facilities. However, we know that we can only continue to grow as a forward-thinking organisation if we learn from the more critical comments too.

The Patient Advice and Liaison Service (PALS), and the complaints teams, continue to work together with divisional governance teams to encourage patients to raise and report any concerns. Their aim is to improve the services that we offer by responding to feedback and taking any appropriate action. PALS can usually resolve concerns quickly, before they become complaints. In 2011/12, a total of 2,905 people contacted PALS (many of them were asking for information and advice) and 798 people raised concerns that PALS helped to resolve.

Examples of concerns resolved by PALS

Keeping people informed A patient’s mother contacted PALS as she was concerned about how long her son had to wait for a procedure and she was unable to get more information about when it would take place.

PALS were able to resolve this by contacting the medical secretary and raising the concerns with her. The consultant then called PALS to explain the reasons for the wait and gave an update on the timescales. The patient’s mother was then informed and reassured.

Problem solving on behalf of patients A patient’s wife contacted PALS as hospital transport had arrived to collect her husband for his appointment without the stretcher that was needed to carry him to hospital.

PALS informed the clinic and arranged a new appointment date. PALS also informed the Travel Shop (where transport is booked). The patient’s wife was advised about the booking process for transport and given the contact details of a senior member of the Travel Shop staff.

Tightening up procedures A patient’s family contacted PALS as they were concerned that their relative had been discharged from hospital without a follow-up appointment being made with his GP, and his stitches had not been removed.

PALS arranged for updated information to be sent to his GP, and an urgent appointment was made to remove his stitches. The consultant then used the incident as a learning event and the protocol for removing stitches is now more rigorously followed.

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Quality Account 2011/12

When concerns become complaints When it is not possible to resolve issues, PALS will support patients through the Trust’s complaint process (they helped 523 people raise complaints last year).

A total number of 1,214 reportable complaints were received for 2011/12 – which is 109 more complaints than last year. The vast majority have since been closed (1,157). There were no ‘high risk’ complaints (the level of risk is defined by our risk management tool, and high risk requires the attention of our Chief Nurse or Medical Director). See Table 4 below.

Table 4: Breakdown of complaints at the Trust (by severity) in 2011/12

High risk Medium risk Low risk Ungraded

0 128 973 56

We are getting better at dealing with complaints Our performance target is that any reportable complaint must be acknowledged within three working days and that the complaint should be answered within a timescale agreed between the Trust and the person making the complaint.

Of the complaints closed during the year, 94% were acknowledged within three working days and 91% were responded to on time. This is an improvement on the 89% acknowledgement performance and the 86% response performance reported last year. See Chart 8 below.

Chart 8: The Trust’s complaints performance compared with last year

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Quality Account 2011/12

The issues that people raised The most common theme of complaint continues to be communication (verbal, written and electronic), and its accuracy, style and timeliness. This is disappointing as we have made great efforts in this area e.g. rewriting patient literature and letter templates, and improving our accessibility through the use of social media.

Patients also told us that we still have work to do to improve our appointment systems and clinics (however, there were 57 fewer complaints compared with last year). See Chart 9. A more detailed breakdown by theme is shown in Chart 10.

Chart 9: Common themes for complaints at the Trust in 2011/12 and 2010/11.

350

300

250

number of 200 complaints 150 2010/11

100 2011/12

50

0 Communication Diagnosis and Appointments Delays in Care Treatment and Clinics subject of complaint

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Quality Account 2011/12

Chart 10: breakdown of complaints received at the Trust in 2011/12

Themes

Advice and Information

Appointments / Clinics 32 Blood and Blood products 10

3 Communication - verbal / written / 12 electronic Consent 13 29 2 6 Delays in care 56 12 10 193 Diagnosis / Treatment 2

14 Environment

16 1 Equipment and supplies

Food

Healthcare records / X-rays / Scans 273 Infection related 324 Medication / Radiation

Obstetrics

142 7 Patient falls

Privacy and dignity

Security and unacceptable behaviour Specimen issues / Pneumatic tube Surgical / Invasive procedures

Transport

The numbers refer to the numbers of complaints under each theme.

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Quality Account 2011/12

Working with the Parliamentary and Health Service Ombudsman Over the past year, a total of 28 cases were referred to the Parliamentary and Health Service Ombudsman (PHSO). Of these 28 cases:

• Nine have been closed with no further action required by the Trust • Twelve are undergoing assessment to ascertain if any further work is needed to reach a resolution • Four of the cases are still under investigation • Three of the cases have been upheld and PHSO has recommended that we take further action to resolve the complaints.

All three of the complaints upheld by the ombudsman state that the administration of the complaints process contributed to the complaint review being upheld. However these are long-standing complaints that predate 2010 when substantial improvements to the way complaints are handled were implemented.

Following the ombudsman reviews, the Trust has taken the following action:

• Revision and re-launch of all falls documentation and polices by the Trust falls group, with specialist input from other organisations • A review and ongoing monitoring of all falls incidents and trends (within ward and specialist group areas) using the ‘safety net’ tool • Introduction of the Wong-Baker FACES Pain Rating Scale in the Accident and Emergency Department – this is a pain assessment tool that helps staff to judge how much pain a patient is in by their facial expression (suitable for patients with learning disabilities or patients unable to verbalise their pain) • Further training for staff, for example, a pain study day with a vulnerable adults session (and a vulnerable adults day with a pain session) • An on-call anaesthetist is regularly available to advise on complex pain issues, which will benefit patients and help to prevent unnecessary admissions.

We have continued to use patient real time feedback to listen and respond to patients concerns Real time feedback (RTF) enables us to monitor and continually improve the patient experience through the use of touch-screen technology. Kiosks are placed throughout our sites, so that patients and other visitors can tell staff how they did and what could be better. In 2011, over 30,000 patients gave us feedback using the devices (5,000 more than last year). Engagement was variable across the organisation.

The divisions, clinical academic units and wards continue to access their monthly and quarterly RTF results and use them with other methods of patient engagement to drill further into any hot spots and areas indicating concern. This has been important because variations in satisfaction levels are often noted using different engagement methods.

In June 2011, we carried out a review of all the survey questions in order to reduce variation and to better align them with the questions used in the annual national inpatient survey. The number of questionnaires in use has reduced from nine to six and they are now shorter and easier to complete. Further changes were made to the inpatient version in September to enable us to monitor patients’

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Quality Account 2011/12 views on a number of key priority areas. However some questions remained constant, including the three following patient experience indicators:

• Were you involved as much as you wanted to be in decisions about your care and treatment? • Were you given information on who to contact if you were worried when you got home? • Did you have enough privacy when discussing your condition and treatment?

As can been seen in the pie charts below, and from what we know through trend analysis, overall patients are reporting an improved experience in being involved in decisions (yes, always 59%) and having enough privacy when discussing treatment and care (yes, always 51%).

Information about who to contact if worried or concerned after going home remains a key area for improvement (yes, definitely 49%)

This data is from RTF surveys completed by patients between January and March 2012 and the scores indicated are results from the last month of the year (March 2012).

Plans to pilot different language surveys have not yet progressed. Initial reviews of research into this area suggest that that different language surveys do not increase participation and that the barriers are more complex than language alone, encompassing issues such as literacy and cultural acceptability. However, our view is that, as we are in an area of such diversity we should test this for ourselves. The outpatient areas intend to pilot translated surveys this year.

One rationale for making the changes to the survey was to test if real time feedback, using the same scoring system as that used by the Information Centre (Department of Health), could prompt improvements in specific areas of care. During the final three months of 2011, improvements were noted in the domain of safe co-coordinated care. This was consistent with improvements reported through the national survey. However, as different methodologies were used, the results should be treated with caution.

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Quality Account 2011/12

Priorities for the coming year are:

• To introduce and develop methodologies, using RTF data as a base, to talk to and about patients • To review options and implement a solution for ongoing connectivity problems • To further develop the surveys and use engagement to test consistency with external measures.

Reaching out to the local population This year, we participated in a wide range of patient involvement events. We welcome these opportunities to engage with our patients and community partners, so that we can share ideas, and respond to any concerns.

Recent initiatives have included:

• An event in the fracture clinic to get feedback from patients. • A hospital food tasting session, attended by a representative from the Tower Hamlets Involvement Network (THINk), and staff and patients from the renal wards. • Manning an information stall at an event held by Apasenth (a local charity supporting children and young people with learning disabilities). We talked to parents and carers and encouraged them to make use of the passport system that was launched in 2010 for patients with a learning disability. The hospital passport is used to record information about patients’ individual needs and preferences as well as medications, treatment plans and contact details. • Visiting St Hilda’s East Community Centre in Bethnal Green to meet Bangladeshi women with mental health problems. The Trust’s Patient Advice and Liaison Service (PALS) talked to the women about the services that we offer. • Hosting an information stall at the borough’s Older People's Day. PALS collected feedback about appointments, transport and waiting times, and reported back to the relevant services. • Attending the East London and the City Safeguarding Children Summit, to explore staff experiences and new ways of working.

The information gained helps to further shape the integration the Trust’s acute and community services as we develop and bring together good practice.

Working with the local involvement networks to improve the experiences of the elderly A group of ‘older people’s champions’ visited Wellington Ward in November 2011, and there was a follow up visit in February 2012 following the move into the newly built hospital. Wellington Ward is The Royal London’s ward for the elderly – and the champions were working in partnership with Age UK and Tower Hamlets Local Involvement Network (THINk). The team met with the nursing staff and spoke to a number of patients about their experiences on the ward.

Overall, the visitors were impressed, and noted that our staff were enthusiastic and caring. The atmosphere was described as friendly and positive. The team commented that the ward was well run, and could see the benefits of intentional rounding (the new ‘comfort checks’).

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Quality Account 2011/12

The group made the following constructive suggestions:

• Patients should receive better information about what will happen when they are discharged. Family members should not be relied upon to pass information on • Patients should be better informed about the importance of physiotherapy and the benefits of receiving it while they are in hospital • Communication with doctors should be improved – perhaps patients could be allocated a five minute one-to-one slot with their consultant to discuss their condition • More consideration needs to be given to food choices for the elderly white population (ethnic diets are very well catered for).

Ensuring that people with disabilities can use our facilities The new hospital at The Royal London provides patients and staff with a more spacious and pleasant environment – and as a Trust we are committed to ensuring that the facilities are equally accessible to anyone with a disability.

A group of people from the Tower Hamlets Involvement Network visited the new Royal London Hospital to review facilities for disabled people. The visit raised a number of questions and concerns.

The most pressing issues were the signage, seating areas, and access through the heavy fire doors in the hospital.

Real (a disabled people’s organisation in Tower Hamlets) and other groups for disabled people have also provided helpful input. Their recommendations have been reported to the way finding and signage review group at the Trust.

As a result, the seating has been rearranged so that the high chairs with arms are more easily accessible at both entrances. Other chairs are still being moved around the new hospital as wards and departments determine how best to meet patients’ and visitors’ needs. The doors will be subject to an ongoing review by the New Hospitals Team.

Improving experiences for patients with long-term conditions This year, we will be working with Tower Hamlets Involvement Network (THINk) to improve the experiences of patients with long-term conditions. We will start by focusing on patients who have heart disease as well as chronic obstructive airways disease.

Providing better information for patients leaving hospital – our work with City LINks Patients may have a number of concerns when they leave hospital, according to research by the City Local Involvement Network (LINk).

We have worked with them to get further feedback on this subject (using surveys, information stalls on the hospital sites, and data from existing sources such as PALS and the Care Quality Commission reports). As a result, City LINk has made a number of valuable suggestions that will help to protect patients’ dignity, and ensure that they are better informed if they want to challenge discharge assessments. In addition, they are producing a leaflet with information on the follow-up care available in the City of London and nearby areas.

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Quality Account 2011/12

Recommendations were also made about the position of PALS (which has since moved to a new location in The Royal London Hospital). We will be working with City LINk this year to bring about further improvements for our patients.

Forward thinking collaborations with the London LINks A series of meetings has been held with representatives from City LINk, Hackney LINk, and Tower Hamlets LINk. Hosted by Barts and The London NHS Trust, the agendas have been led by the LINKs and have covered a variety of topics. For the past six months, the main subjects have been the Quality Account, the new hospital and the merger project – and the sessions have been constructive and forward thinking.

We will build on this model in the new organisation, and join with the Newham and Waltham Forest LINKs, and the developing HealthWatch organisations. Together, we will welcome in a new era of patient-centred care at Barts Health NHS Trust.

Developing the new Barts Health strategy to improve the patients’ experience We are working with patient advisors from the three legacy Trusts, Newham, Whipps Cross and Barts and The London, to develop a new integrated strategy to improve our patients’ experience. The strategy aims to provide a framework in our new organisation that supports the provision of an exemplary patient experience, while maintaining and building on what is both excellent and unique in each hospital.

The central component of the strategy is our Promise to Patients which states that patients will:

• Feel safe • Feel cared for with kindness and compassion • Have a choice about what care and treatment they receive • Be supported in making decisions about their care • Know that the Trust is listening to them and learning from them.

To underpin the work of the strategy, an involvement model is being developed. A joint patients’ forum will come into operation, appointed by the Trust Board and chaired by the Trust Chairman or non-executive director. Each hospital will continue to host its own patients’ panel and each panel will be represented on the Trust forum. The model will illustrate how each clinical academic group will ensure that the patients’ perspective influences all aspects of the service, from design to delivery.

We care: and compassionate care is embedded into our clinical practice The Trust has continued its involvement in the East London Partnership for Compassionate Care (launched in July 2010). A pilot project was undertaken from September 2010 until April 2011, to define compassionate care from the perspectives of service users and staff.

A number of recommendations emerged from the project. It was suggested that we should:

• Understand that doctors and senior managers play a lead role in promoting compassionate care • Prioritise time-out for staff to think critically about their routines so that they can identify small changes that could lead to more patient-centred care • Undertake a compassionate care impact analysis on all new or revised Trust policies

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Quality Account 2011/12

• Promote appreciative inquiry as a core value in the organisation, to strengthen the capacity of staff to address poor practice and complaints (and develop relationships throughout the organisation). • Prioritise sustainable and improved mechanisms for patient and public involvement • Undertake a listening event focused on compassionate care.

These recommendations were used to develop and implement our own pilot project. For a three month period from August 2011, four wards/departments participated in a project which explored the adoption of HeartMath to improve staff wellbeing and emotional resilience.

HeartMath is a methodology developed in the USA and designed to help people reduce stress, self- regulate emotions and build energy and resilience, through the use of simple self-assessment tools. The companies that have used the HeartMath stress-reducing approach have seen improvements in staff retention within the first year of implementation and increased employee and patient satisfaction.

The evaluation tool measures changes in personal and organisational factors. At the end of our trial it showed that there were statistically significant improvements in eight of the ten personal factors: calmness, fatigue, resentfulness, stress symptoms, gratitude, anxiety, depression and anger management. A statistically significant improvement was also seen in ‘confidence in the organisation’.

Three domains moved into the above average range: communication effectiveness, time pressure, and morale issues. Further work is being undertaken to consider how to sustain the improvements in staff wellbeing as the Trust moves into a new merged organisation – with all the challenges and opportunities that this brings.

Offering privacy and dignity in pleasant surroundings We are pleased to report that we are now fully compliant with the Government’s requirement to eliminate mixed-sex accommodation. Please see Chart 11 below. The only exceptions will be when it is in the patient’s overall best interest, or when it reflects their personal preference.

The new Royal London Hospital opened in December 2011 to offer state-of-the-art facilities, in a welcoming environment, with the highest standards of clinical care. The new Cancer Centre at St Bartholomew’s Hospital (Barts) has been providing exemplary care in attractive surroundings since it opened in 2010.

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Quality Account 2011/12

Chart 11: Achieving the single sex accommodation standard

All patients at St Bartholomew’s Hospital and The Royal London now benefit from:

• More space – the hospitals are generously proportioned with 25% more space for each patient compared with our previous layouts • Improved clinical layout – clinicians have provided input to ensure that the layout and facilities are safe and patient focused, offering privacy, dignity and comfort • Better ward accommodation – more than 40% of the accommodation is in single rooms with en-suite bathroom facilities. The remaining accommodation is in roomy two-bedded and four- bedded bays, with en-suite bathrooms.

For those areas that are not currently located in new facilities, the Trust has invested in upgrading the sleeping accommodation and has fitted new toilet and bathroom signage to ensure that patients are clear about the single sex facilities available. We have adapted mixed-sex wards to provide patients with the privacy that they are entitled to, creating fully enclosed bays, and putting opaque film on windows in public corridors.

Information leaflets and posters help to inform patients about our commitment to maintaining privacy and dignity and the provision of single sex accommodation. Patients are also told about the facilities available on the admission ward.

The PEAT audit agrees: we provide a pleasant environment Our commitment to providing a clean, pleasant environment was recognised in the annual Patient Environment Action Team (PEAT) audit in February and March 2012. PEAT is an annual inspection of inpatient facilities at healthcare sites in England. It is a self-assessment process and examines standards of food, cleanliness, infection control and the patients’ environment. Hospitals are rated from ‘unacceptable’ to ‘excellent’ for standards of privacy and dignity, environment and food. The inspection team included a patient representative from the Tower Hamlets LINk.

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Quality Account 2011/12

The PEAT results published in June 2012 indicate that we have scored ‘good’ in all categories at The Royal London and Barts – and ‘excellent’ at The London Chest Hospital. Please see Table 5 below.

Table 5: PEAT inspection results in 2011/12

Privacy and dignity Food Environmental

2011 2012 2011 2012 2011 2012

The Royal Excellent Good Excellent Good Good Good London

Barts Good Good Good Good Good Good

London Excellent Excellent Excellent Excellent Good Excellent Chest

Providing privacy for our patients in new, purpose built surroundings The Trust has been transforming the landscape of healthcare in the Capital with an ambitious redevelopment programme. At Barts, a state-of-the-art Cancer Centre opened in 2010, to complement the existing Breast Care Centre. A Cardiac Centre of Excellence will open in 2014. There are many improved features at Barts, including better baby changing and public toilet facilities. Disposable curtains have been introduced (for hygiene and privacy) and ‘no entry’ signs give patients more seclusion and dignity.

At The Royal London, wards and departments have moved into the striking modern buildings at the Whitechapel site. The new hospital has been designed to upgrade the patient and public experience – for example, the number of public toilets has increased from 25 (in the old building) to 145 (in the new block). We have improved the baby changing facilities and these are now separate from the toilets. We have also introduced disposable curtains and ‘no entry’ signs to ensure that patients’ privacy and dignity needs can be met.

Patients have told us that the food should be better… and we are listening and reacting During 2011/12, we have been listening to patients and working hard to improve their experiences of hospital food. Currently only 54% of patients using the real time feedback surveys rate the food as ‘good’ or ‘excellent’ – and our target is 95%.

The Trust’s Nutrition Committee, with Safety Express, has introduced a number of changes this year. As well as rolling out the ‘help at meal times’ volunteer programme, which began last year, we introduced a new patient menu in November 2011 and began working with another catering supplier. The new menu is betted suited to our demographic profile and, after extensive tasting sessions with patients, was piloted for three months.

The new menu has been assessed by real time feedback, a ‘how did we do?’ questionnaire, and observation at meal times. The changes have been positively received, although patients asked us to

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Quality Account 2011/12 bring back the ‘hot dessert’ at lunchtime. We will respond to this and a tweaked menu will be launched in May 2012.

Other changes we have made this year include:

• The introduction of a fruit bowl on all the wards (very popular). • Ensuring that patients with ethnic diets (such as Halal and Kosher) have a choice at mealtimes • Introducing plate covers so that meals are kept hotter during service (this was in response to a recommendation by the Care Quality Commission) • Reviewing and re-launching the Trust’s food chart so that staff can improve their record keeping for patients who need their nutritional intake monitoring.

We are continuing to build on the progress we have made. In 2012 we plan to introduce a pictorial menu to help patients choose their food. We also hope to increase the number of patients who receive their first choice of meal.

How nutritional performance is monitored across the Trust To ensure that standards of nutrition are equally high across the Trust, the wards are assessed using a number of key indicators. Over the past year, monthly ward audits have shown increased average scores each quarter against the standards set. This is shown in Table 6 below. Green means the standard of 95% was achieved, amber is close to the target at 75% or above and red is below 70%.

Table 6: how the Trust measured up to nutrition standards

Nutrition practice indicator Target Average Average scores scores Q4 Q4 2011/12 2010/11

Evidence of action taken for medium risk patients 95% 74% 90%

High risk patients are given a food chart 95% 77% 81%

Patients saying that the food is excellent or good 95% 36% 54%

Patients saying that they always get a choice of 95% Not collected 65% food

Protected mealtimes operated on the ward (to 95% Not collected 95% ensure that patients eat properly at dedicated times)

Do patients think we are doing a better job keeping the hospitals clean? Yes they do. The two pie charts below (Charts 12 and 13) show our patients’ views on the standards of cleanliness. The data comes from real-time feedback devices placed throughout the hospitals, clinics and public areas and questionnaires completed by patients and visitors between January and March 2012.

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Quality Account 2011/12

75% found the cleanliness of the wards ‘excellent’ or ‘good’. 69% found the toilets or bathrooms ‘excellent’ or ‘good’.

Charts 12 and 13: Patients’ views on the standards of cleanliness

National Patient Experience CQUIN – we have improved from last year An important tool to assess the patient experience is the NHS National Inpatient Survey. The results undergo adjustment depending on the demographic profile of patients, and then each Trust is given an overall Commissioning for Quality and Innovation (CQUIN) rating or score for meeting and being responsive to patients’ personal needs.

Last year our CQUIN score was 60.8 (out of a maximum of100 – highest scores are best). An improvement target of 5% was set. This year the patients who responded gave us an improved rating in all five of the following key questions:

Q41: Were you involved as much as you wanted to be in decisions about your care Agreed – and treatment? 68.1%

Q44: Did you find someone on the hospital staff to talk to about your worries and fears? Agreed – 51.7%

Q46: Were you given enough privacy when discussing your condition or treatment? Agreed – 79.6%

Q65: Did a member of staff tell you about medication side effects to watch for when you Agreed – went home? 45.8%

Q70: Did hospital staff tell you who to contact if you were worried about your condition Agreed – or treatment after you left hospital? 71.7%

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Quality Account 2011/12

Despite the improved scores, we did not reach the full 5% CQUIN improvement target but made a partial improvement of 3.4% (our composite CQUIN score for 2011 was 63.6). However two areas showed a significant improvement – Q46 (being given enough privacy to discuss condition/treatment) and Q70 (being told who to contact after discharge if there are any concerns).

The inpatient survey suggested that different ethnic groups report different experiences at the Trust… we want to find out more.

Chart 14: Breakdown showing the different ethnic groups participating in the National Inpatient Survey 2011/12

The National Inpatient Survey gives us valuable feedback every year. The sample size in 2011/12 was increased to 1700 – and 690 patients responded (in 2010, with a smaller sample, only 324 patients responded). The larger sample showed some significant differences between the participating ethic groups. A breakdown by ethnicity is shown in Chart 14. The differences are outlined below.

Admission to hospital Asian/Asian British patients were significantly more likely to be emergency admissions than white patients. However Asian/Asian British patients who had planned admissions were significantly more likely to report being given a choice of admission dates (when compared with the white group).

Food and eating White patients were more likely than Asian/Asian British patients to say that they had a choice of food at mealtimes. Asian/Asian British patients were less likely than white patients to report that they had all the help that they needed at mealtimes.

Information and communication Compared with white group, Asian/Asian British patients were the most likely to say that they didn’t fully understood how to take their medication and felt the least involved in decisions about their care and treatment. Compared with white patients, Asian/Asian British patients were more likely to state that they didn’t get clear answers to their questions from the doctors. They were more likely to say that the doctors talked in front of them as if they weren’t there.

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Quality Account 2011/12

Compared with white patients, Asian/Asian British patients were also more likely to say that they didn’t get clear answers to their questions from the nurses. They had less confidence and trust in the nursing team – and a higher proportion felt that there were not enough nurses on duty to care for them.

The Trust was founded upon the principle of equal opportunity, and this ethos underpins the entire organisation. These differences in how patients rate their care will be looked at in more detail over the coming year. We now need to assess where adjustments need to be made, or if there are any indications of genuine inequality (in which case robust measures will be put in place to prevent any recurrence).

We asked for feedback on Community Health Services… and found that more of our patients are satisfied with what we offer In 2011/12 our Community Health Services also had a CQUIN for improving ‘patient experience’ for the following services: adult community nursing, clinical assessment, community sexual health, dental, diabetes, health visiting, four inpatient wards and the physiotherapy service at Mile End Hospital.

Eleven touch screens (real time feedback devices) were used to capture patients’ views and experiences and establish baseline data over the first two quarters of the year. Over the full year, more than 2,500 patients used the touch screens (684 in the first six months, increasing to 1848 in the final six months).

The overall satisfaction in relation to four questions increased steadily throughout the year, rising from 68% in Quarter 1 to 86% in Quarter 4. Please see Chart 15.

In the coming year, Community Health Services will continue to gather patient experience data through a variety of means, including surveys and discovery interviews (which encourage patients to talk about themselves rather than the services that they have received). The CQUIN data collection in 2012/13 will continue to focus on the inpatient wards at Mile End, health visiting, district nursing and foot health.

Chart 15: This shows the high levels of satisfaction with Community Health Services (based on responses to a survey in the final quarter of 2011)

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Quality Account 2011/12

Patients tell us what they think in the National Inpatient Survey… and every year, the news is better Many patients express their gratitude for the care that we provide. They point to how patient-centred we are and how we treat each person as an individual. Patient representatives also tell us how they value the kindness of our staff, and the many ways that we keep patients and carers well informed and involved. Every year, we assess how we are measuring up to our patients’ expectations in the NHS National Inpatient Survey. In 2011 we doubled the number of patients being surveyed at the Trust. There were 690 surveys returned – giving us a 42% response rate.

Who were the respondents? 43% of patients were on a waiting list or receiving planned treatment and 50% came as an emergency or urgent case. 71% had an operation or procedure during their stay. 53% were male; 43% were female and 4% did not want to say.

What did they tell us? Please see Chart 16. The majority of patients reported that:

• Their care was good/excellent: 87%. • Doctors and nurses worked well together: 88%. • They always had confidence and trust in the doctors: 78%. • Hand-wash gels were visible and available for patients and visitors to the hospital: 90%. • They always had enough privacy when being examined or treated: 85%. • The hospital room or ward was very/fairly clean: 92%. • The hospital toilets and bathrooms were very/fairly clean: 84%.

Chart 16: The results of the 2011 inpatient survey showing the percentage of patients who agreed with the statement in the survey

The findings are a great improvement on last year’s results. This year we scored significantly better on eight questions (see Table 7 below).

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Quality Account 2011/12

Table 7: Improvements in the Inpatient Survey results since 2010

The Trust has improved significantly on the following questions:

2010 2011

Doctors: did not always get clear answers to questions 40% 33%

Care: staff contradict each other 48% 38%

Care: not always enough privacy when discussing condition or treatment 40% 32%

Surgery: anaesthetist / other member of staff did not fully explain how they 25% 17% would put to sleep or control pain

Discharge: not fully told purpose of medications 31% 23%

Discharge: not told who to contact if worried 30% 23%

Discharge: did not receive copies of letters sent between hospital doctors 28% 16% and GP

Overall: not asked to give views on quality of care 77% 71%

Patients rate us as having improved significantly in several aspects relating to communication. A higher percentage reported that they received clear answers from doctors. A greater proportion stated that they were given full explanations about pain control and how they would be put to sleep before surgery. A lower percentage thought that staff contradicted each other.

We have also been told that the information given on discharge has improved. A higher proportion of respondents reported that they were fully informed about the purpose of their medication and knew who to contact with any concerns. A higher percentage of patients received copies of the letters that we sent to their GPs and more reported that they were asked for feedback on their care before they left hospital. In addition, a higher proportion of patients reported that they always had enough privacy to discuss their treatment.

There was only question that we did not do so well on – and this was regarding patients sharing sleeping areas with the opposite sex. Since the move to the new Royal London building, the Trust has declared full compliance with the mixed sex accommodation standards and its expected that this will improve our results next year.

However there is still a lot of work to do in order for Barts Health to be rated in the top 20% of Trusts. Patients continue to rate us as about the same as others Trusts in most aspects of care. This is something that we are keen to improve upon in the coming year.

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Quality Account 2011/12

Future scope for improvement We are very disappointed that aspects of our nursing care, and our nurses, were judged to be in the bottom 20% of Trusts nationally, according to the Care Quality Commission’s published ratings. Our ratings were also worse than average for patients’ confidence and trust in nurses; nurses talking in front of the patients; and patients reporting that they when they asked nursing staff important questions, they did not fully understand the answers.

There is no doubt that the quality of the relationships that patients have with our nurses is fundamental to a good experience of care. It is possible that issues such as poor staff morale, stress and lack of pastoral and administrative support may have had a detrimental effect in both constraining and reducing the quality of compassionate care that the nurses provide.

This is being addressed through the development of a patient-centred culture for the new Barts Health organisation. The corporate team will collaborate with, and support, the Clinical Academic Groups to implement a patient experience strategy incorporating leadership and compassionate care as priorities. We hope that this work, along with plans to develop nursing leadership, will have a positive impact on how patients view nurses and will enhance the work of the compassionate care project started at Barts and The London last year (see page 43).

Children and young people tell us what they want… we listen and then improve our services We routinely use patient feedback to help improve our services. At Barts and The London Children’s Hospital we encourage communication through real time feedback, ‘Tell Matron’ cards, ‘Meet Matron’ evenings and a special questionnaire designed by young people, and overseen by one of our school teachers. In 2011/12, we gave 850 young inpatients or their parents/carers a questionnaire. 839 of them were eligible to take part, and 243 returned a completed questionnaire, giving an overall response rate of 29%.

Two questionnaires were used: one for parents and carers with children aged 0-7 years, and another for children and young people aged 8-17 years. 50% of the surveys returned were from parents/carers and 50% were from children and young people (CYP).

This is what they told us… 95% of young inpatients rated their hospital care as excellent, very good or good. 93% of parents/carers rated their child’s overall hospital care as excellent, very good or good.

We were informed that:

• There should be more preadmission appointments available for patients receiving planned care • The food should be better • Food and tea/coffee making facilities for parents should be improved • Visiting hours should be increased • We should provide better information when patients leave hospital.

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Quality Account 2011/12

This is how we have responded… Since the survey was conducted, all wards and units have transferred into the new building at The Royal London. This has vastly improved the environment for babies, children, young people and their families. The new Children’s Hospital offers enhanced clinical facilities and comfortable, modern and attractive surroundings.

A senior sister from day care is leading a project to increase the number of preadmission appointments. We are exploring new menus with the Catering Manager (and this work should be finished by the early summer). There are now dedicated parental facilities on all wards and units within the new Children’s Hospital – and we will be monitoring feedback to ensure that we are giving parents everything they need.

We are liaising with our infection control colleagues over visiting hours. There are issues regarding balancing the benefits that visitors bring, with the infection risk to vulnerable patients, particularly during the flu season. In the future we shall ensure that these issues are better communicated with families.

Senior nurses and clinical nurse specialists have been liaising with families to find out what information would helpful when a patient is discharged (e.g. when to return to school/nursery, when to restart games/PE, follow up care and appointments). Our literature will be updated to reflect their concerns.

A better, brighter future for children Since the move into the new Children’s Hospital in February 2012, we have received the following feedback:

‘Serving of the food has improved, dining area very organised.’ ‘Accommodation very nice and neat to suit both patients and visitors.’ ‘The lifts are a bit confusing but on the whole this hospital is fantastic – well done!’ ’The TV services should be free for young children’.

These issues will be monitored and explored more fully throughout the year.

Case study

The young people’s forum that shapes the future The young people’s forum meets once a month to discuss their health-related issues and make recommendations about improvements to our services. The members of the forum are current or previous patients of Barts and The London Children’s Hospital. This year, they have helped us to make decisions about artwork for the dental unit, and purchasing iPads and medical teaching dolls, and they have advised us on bringing in a scheme that allows young people to connect with school and friends via the web.

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Quality Account 2011/12

We want more people to tell us what they think We are keen to encourage more feedback from patients and their families. There are more than 100 touch-screen kiosks across our hospitals, so that people can give feedback there and then – telling staff how they did and what could have been better. Senior sisters and charge nurses will encourage even more people to use the devices this year. All the feedback we get is reviewed at staff away days, where staff compile action plans to address outstanding issues, and previous actions are reviewed, tracked and monitored. We will continue the use of the ‘Tell Matron’ card initiative on the children’s inpatient wards and ‘Meeting Matron’ on the Neonatal Intensive Care Unit.

In addition we will be adapting our questionnaires for use in the new Paediatric Assessment and Short Stay Unit (PASSU).

Women tell us what they want from maternity services… we listen and improve the care we offer We make continual efforts to improve the care we provide for women using the Trust’s maternity services. Every quarter, we assess how we are doing against a CQUIN patient experience improvement target set for 2011/12. Women are asked a number of questions in a birth reflections questionnaire – for example, did they feel cared for in labour, did they feel confident with the doctors and midwives, were they able to access the service easily when pregnant, and did they feel supported with feeding their baby in the hospital.

The service has been able to demonstrate sustained improvement over the past 12 months and we have exceeded our target. We are confident that the recent move to the new Royal London Hospital will further improve maternity experiences over the coming year, as we now provide a more modern, attractive environment for women and their families.

We asked what you think of the Central Appointments Call Centre… and you told us We regularly monitor what people think of the Central Appointments Call Centre. This year, every month, around 100 callers were asked 14 customer-focused questions.

For 2011/12, the trends have remained consistent and positive. A pleasing 88% of callers reported being very or fairly satisfied. 99% said that they would recommend the Trust to their friends and family. The vast majority said that their enquiry was resolved in one call. See Charts 17 and 18.

However we are aware that many patients and GPs still experience problems when booking appointments and that more needs to be done, and will be done, to get this right. As a result of further feedback, the following steps are being taken to improve the appointment booking process:

• Each call handler is asked to review and improve the quality and accuracy of their calls. • Each month a random sample of 80 referrals are audited to check the accuracy of information entered into the NHS Care Records Service (for 2011/12, the accuracy rate was 99% or above). • The overall call centre performance is measured against a number of key performance indicators to enable us to quickly identify when service levels are below par.

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Quality Account 2011/12

Chart 17: We asked callers if they’d recommend the Trust to the others – and this shows the very high proportion of respondents who said they would in 2011.

Recommend others to BLT? % Ye s 100% 90%99% 99% 100% 10 0 % 100% 100% 100% 100% 100% 97% 95% 95% 80% 70% 60% 50% 40% 30% 20% 10% 0%

y e ly t r ch ay u s er r M un J b ber be r April J Ma ugu to m January A Februa ptem Oc e ove S N December

Chart 18: We asked people if their query was resolved in the first call – and 93% or more agreed in 2011.

Query Resolved on 1st Call % Ye s 100% 99% 99% 10 0 % 99% 99% 90% 98% 98% 97% 98% 96% 93% 94% 80% 70% 60% 50% 40% 30% 20% 10% 0%

y il r ry r ay e r e n ust er uar M July g be b n Ap Ju m March e ctob em ember Ja Au t v Februa O c ep S No De

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Quality Account 2011/12

Listening to cancer patients… and responding to their concerns In last year’s Quality Account we reported on the findings from the 2010 national cancer patient satisfaction survey. Disappointingly, the scores for Barts and The London were below average. It was clear that we needed to address a number of concerns, particularly around communication and the patients’ environmental experience. Many of those issues have since been resolved by the move into the Cancer Centre at St Bartholomew’s.

The new Centre has the very latest facilities and provides a comfortable, relaxing environment for patients and families. A number of measures have been introduced to further improve the patient experience:

• To ensure that we can keep track with patients’ views, we have placed a number of touch screen patient feedback devices in the outpatient and ward areas. • The national survey showed that communication could be improved at Band 3 and Band 6 level in the nursing teams, so we have run targeted training sessions for these groups. • We have refreshed our patient information leaflets, which were considered out of date at the 2010 survey. • We are focused on reducing outpatient waiting times. The standard is that no patient should wait more than 30 minutes beyond their appointed time. Our audit shows that we are improving considerably and now 84%-100% of patients are seen within 30 minutes at our cancer clinics. • The national cancer patient survey has recently been re-run and we are looking forward to receiving the results in the summer. We will report on the findings in next year’s Quality Account.

Your comments are being used to check on our outpatient standards Patients are invited to complete postcard-sized comment cards at all clinic and reception waiting areas. As well as being a key source of patient feedback, they enable us to monitor standards. Patient comment cards have been in circulation since March 2011, and we have received feedback from over 16,000 patients. Overall results have been positive – 97% said they would recommend the Trust to their friends and family, and 98% felt that they were well treated. However, only 67% of patients reported that they were seen on time.

The comments made have helped to inform the development of the Trust’s Outpatient Transformation programme. The programme aims to improve and standardise the level of service received by patients before, during and after their outpatient appointment. In 2010 the Trust set itself 25 outpatient standards in response to complaints and issues raised by patients and GPs.

The cards show an overall improvement in patient experience (with the exception of waiting times). However the last Picker Institute report still highlighted some areas of concern. New cards are currently being produced to focus on problem areas (one card will focus on the overall experience, and a second will focus on the clinical contact time).

The comment card system is also being rolled out to the Community Health Services division, which recently joined the Outpatient Transformation programme.

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Quality Account 2011/12

National Outpatient Survey 2011 The National Outpatient Survey 2011 compares favourably with the 2010 survey in many respects. In 2011, patients rated us as having improved significantly in several aspects relating to communication. A higher percentage reported that they received clear answers from doctors. A greater proportion stated that they were given full explanations about pain control and how they would be put to sleep before surgery. A lower percentage thought that staff contradicted each other.

We have also been told that the information given on discharge has improved. A higher proportion of respondents reported that they were fully informed about the purpose of their medication and knew who to contact with any concerns. A higher percentage of patients received copies of the letters that we sent to their GPs and more reported that they were asked for feedback on their care before they left hospital.

In addition, a higher proportion of patients reported that they always had enough privacy to discuss their treatment.

What do we need to improve about the outpatient experience? The results were (significantly) worse than the previous survey in three areas:

• Having enough time to fully discuss any problems with the doctors • Doctors listening to what the patient had to say, and • Doctors giving clear answers to questions.

The feedback also showed that we could improve on consultations with other health professionals and the organisation of the outpatient clinic.

In response to this, we have developed and launched two new comment cards for outpatients. One focuses on the quality of the clinical consultation and the other one looks at the organisation of the outpatient appointment. We will use the findings to address specific area of concerns with individual services and specialties.

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Quality Account 2011/12 Quality dimension three – clinical effectiveness and efficiency

Access and waiting time performance In last year’s Quality Account, we reported on the substantial improvements that we had made to reduce waiting times for patients. This year, we have made even bigger strides to improve access to care.

In particular we have:

• Met the NHS standard for emergency waiting times in Accident and Emergency (again) • Met the NHS standard for cardiac access (again) • Met the NHS standard for planned care – i.e. the '18 week' rule (again) • Provided 100 percent access to sexual health services within two days (for the fourth year in a row) • Met the new standards for rapid access to specialist stroke services • Further improved our high performance on access to antenatal care • Met the NHS standard for new born babies’ access to a health visitor for the first time in Tower Hamlets.

Regrettably, for the first time in three years, we have not met all of the mandatory waiting time standards for cancer. We fully intend to do so in 2012/13 and have the capability to do so. As a merged Trust, we will be able to utilise our combined resources, and achieve our aim through outstanding integration between general practice, the district general hospitals and the tertiary centre at Barts.

We said that we would achieve single sex standards on all our sites… and we have kept our promise For the past few years, a key focus has been on meeting single sex standards on all our sites by April 2012. In 2010 we made a major investment to help us achieve this, and halved the number of occasions when a patient was asked to share a ward with a member of the opposite sex.

The new Royal London Hospital, which officially opened on 1 March 2012, has four times as many single rooms as our previous premises. In addition, our re-design of the emergency pathway has meant that we now have single sex accommodation for patients admitted overnight.

You wanted faster access to A&E… and we delivered Last year, we reported on how we were determined to maintain our record on the percentage of patients admitted or discharged to Accident & Emergency within four hours. The Department of Health standard is 95%.

Table 8 below shows how we have achieved our target for the second year running. We have met the four hour waiting standard, even as patient arrival numbers have risen sharply. The opening of

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Quality Account 2011/12 the new Royal London has been instrumental in our success and will help us to manage the increased demand for our services in the future.

Table 8: Number of patients assessed in the A&E departments over the past two years

Green = met target

2010/11 2011/12

Total attendances (in Type 1, 24-hour Consultant-led A&E departments) 123,394 130,426

Total number of patients waiting beyond four hours 5,472 6,160

Total number of patients treated in under four hours 117,922 124,266

Performance (target=95%) 95.6% 95.3%

To further improve the patient experience, we are working closely with local GPs and pharmacists to transfer care back to primary healthcare teams when we can. Services from the Whitechapel Walk In Centre have now largely been transferred into the new building or to our community health team. The new department provides a wholly separate service for children. The Barts Minor Injuries Unit continues to provide a local facility for city residents and workers.

We are also developing quality services for patients who attend as emergencies but who have wider underlying health and social needs. For example, our new homeless healthcare team, linked to the Health E1 Homeless Medical Centre, is trialing an innovative model of care for a large number of patients – the 12 month project started in December 2011 to find out if ‘enhanced care’ reduces the length of time in hospital for homeless patients. We also offer liaison services for patients with alcohol related needs and we are exploring how this might be extended further in the months ahead.

We continue to deliver short waits for outpatient, diagnostic and surgical care Patients should have to wait no more than 18 weeks for non-admitted or admitted care. That is according to the national 18 week ‘wait standard’. In 2009 we failed to meet this target – but due to a successful programme of transformation, this was achieved in 2010 and sustained in 2011.

Chart 19 below shows how the number of patients waiting for care has improved over a three year period. The increase in 13 week waits for outpatient care in 2011/12 was due to a specific problem in our Dental Hospital that has since been resolved.

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Quality Account 2011/12

Chart 19: The Trust’s performance against waiting time targets over the past three years

Overall, the Trust’s record has been excellent – please see Table 9, which show how we have performed over the past two years for admitted patients, and Table 10 which shows our performance for non-admitted patients.

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Quality Account 2011/12

Table 9: Compliance with wait standards over a two year period for admitted patients

Green = complied with wait standard Red = failed to comply with wait standard

Admitted patients (inpatients and daycases)

2010-11 Clock stops* 2011-12 Clock stops*

Within Over Within Over 18 18 18 18 Month weeks weeks Total Performance weeks weeks Total Performance

Apr-10 1,489 225 1,714 86.9% 1,966 155 2,121 92.7%

May-10 1,769 263 2,032 87.1% 2,264 177 2,441 92.7%

Jun-10 2,118 198 2,316 91.5% 2,485 210 2,695 92.2%

Jul-10 2,464 176 2,640 93.3% 2,277 289 2,566 88.7%

Aug-10 2,320 143 2,463 94.2% 2,271 149 2,420 93.8%

Sep-10 2,481 213 2,694 92.1% 2,607 152 2,759 94.5%

Oct-10 2,284 167 2,451 93.2% 2,537 174 2,711 93.6%

Nov-10 2,384 167 2,551 93.5% 2,589 206 2,795 92.6%

Dec-10 1,755 115 1,870 93.9% 1,881 126 2,007 93.7%

Jan-11 2,220 129 2,349 94.5% 2,213 235 2,448 90.4%

Feb-11 2,158 154 2,312 93.3% 2,255 250 2,505 90.0%

Mar-11 2,385 184 2,569 92.8% 2,343 260 2,603 90.0%

Total 25,827 2,134 27,961 92.4% 27,688 2,383 30,071 92.1%

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Quality Account 2011/12

Table 10: Compliance with wait standards over a two year period for non-admitted patients

Green = complied with wait standard Red = failed to comply with wait standard

Non-admitted

2010-11 Clock stops 2011-12 Clock stops

Within Over Within Over 18 18 18 18 Month weeks weeks Total Performance weeks weeks Total Performance

Apr-11 7,905 328 8,233 96.0% 7,407 124 7,531 98.4%

May-11 8,045 364 8,409 95.7% 8,929 99 9,028 98.9%

Jun-11 10,579 251 10,830 97.7% 9,239 118 9,357 98.7%

Jul-11 10,359 290 10,649 97.3% 8,353 73 8,426 99.1%

Aug-11 10,051 283 10,334 97.3% 7,721 93 7,814 98.8%

Sep-11 10,580 262 10,842 97.6% 8,451 60 8,511 99.3%

Oct-11 9,645 208 9,853 97.9% 8,605 119 8,724 98.6%

Nov-11 10,386 199 10,585 98.1% 9,025 158 9,183 98.3%

Dec-11 7,726 126 7,852 98.4% 7,231 118 7,349 98.4%

Jan-12 9,169 140 9,309 98.5% 8,315 149 8,464 98.2%

Feb-12 9,385 169 9,554 98.2% 7,987 205 8,192 97.5%

Mar-12 9,590 172 9,762 98.2% 8,401 351 8,752 96.0%

Total 113,420 2,792 116,212 97.6% 99,664 1,667 101,331 98.4%

* The ‘clock starts’ when you book your first appointment or your referral letter is received by the hospital. The ‘clock stops’ (or your waiting time ends) if no treatment is necessary or your treatment begins.

In 2012/13, we will be monitored against an additional standard, and that is to have less than 8% of people waiting beyond 18 weeks. This is the so-called ‘incompletes’ national standard – and it is designed to ensure that patients are not unduly delayed or ‘parked’ in the system. Our performance will be monitored by the Trust, at a specialty level.

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Quality Account 2011/12

To date, Barts and The London has met this standard in almost all specialties – and we predict that the new Barts Health will show the same high compliance. In the areas where we do not meet the standard, we are exploring how we can offer a better service – for example changing the pathway of care for outpatients to provide faster access to diagnostic tests. This could save repeat attendances at hospital and speed up the diagnosis and treatment

We continue to excel in providing high quality antenatal care In our Quality Account last year, we focused on the measurable improvements in maternity care at the Trust. The quality and performance of maternity services is measured using a number of key public health and clinical indicators. The CQUIN target for early booking in pregnancy is an important measure of access to services, pathway management and reducing maternal and perinatal mortality and morbidity.

The national target is for 90% of all women to be booked with a full antenatal assessment by their 12th week of pregnancy. The Royal London Hospital has achieved the target for the previous 12 months with an average of 93-94%.

Chart 20 provides evidence of our sustained improvement. It shows the percentage of women who were seen by a midwife or a maternity healthcare professional by 12 completed weeks of pregnancy. The results for this year show that more women than ever have fast access to antenatal care at an early stage of their pregnancy.

Chart 20: The percentage of antenatal patients seen at the Trust by 12 weeks (in 2011/12)

Women seen for a maternity appointment by 12 weeks 100% 97.73%

95%

90%

85%

2011-2012 2010-2011 80% Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12

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Quality Account 2011/12

We also have a target to increase the proportion of women breast-feeding in the first two days of birth by 2% a year (set by Hospital Episode Statistics or HES). However despite the gains that we have made in previous years, we saw a slight fall of 4.1% this year for exclusive breast-feeding. This is currently being addressed through improved ward management practices and over the past two months we have seen a sharp increase in exclusive breast-feeding.

The maternity service was successful in achieving a Baby Friendly Stage 2 assessment in 2011. This is an official benchmark awarded by UNICEF and the World Health Organisation to hospitals that can show a high standard of care for pregnant women and breastfeeding mothers and babies. We have a pending result for Level 3 in March 2012, which will further demonstrate our baby friendly status.

We planned to reduce the number of operations that we cancel on the day – and this is something that we will continue to strive for There are many reasons why hospitals need to cancel planned procedures on the day (e.g. when emergency cases take priority). At a leading specialist trauma centre, such as The Royal London, this is particularly likely to happen. However we appreciate the huge inconvenience to patients and have been trying to reduce cancellations as much as possible.

During 2009/10, we routinely cancelled 50-60 operations each month. During 2010/11 we reduced that figure and Chart 21 shows the downward trend in 2011/12.

Chart 21: Number of cancelled operations at the Trust gp 80

60 53

40

31 20 Operations cancelled Operations

0 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12

The new NHS standard is a cancellation rate of below 5%. Our current performance is an impressive 0.9% – and we remain determined to achieve an even lower rate of 0.5% for all elective care.

We have the resources in place to further reduce cancellations in 2012/13. The Royal London Hospital’s new A&E department opened in January 2012, with a ring-fenced elective facility for day case and short-stay surgery. We are improving the way that we do pre-operative assessments so that we can better identify any complications before surgery is booked. Plans are in place to give patients more notice for their surgery, and a choice of dates when that is clinically appropriate. In addition, from early 2013, we will start putting patients’ medical notes onto our computer system, which should ultimately eliminate cancellations due to misplaced clinical information.

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Quality Account 2011/12

We have not met the standards that we need to for cancer waiting times – and will act quickly to address this The cancer waiting time target regime continues to evolve – and until now, we have met national mandatory waiting time standards. However in 2011/12 we have seen a fall in our performance in two areas:

• Increased breaches of the 14 day standard (for the time it takes from an urgent GP referral for suspected cancer, to the first hospital assessment). This rise is directly associated with changes to the rules regarding how choice is recorded. If patients opt out of their appointment within the 14 day period, they still remain coded to this standard. • We did not meet the 62-day standard (for the time it takes from an urgent GP referral for suspected cancer, to the first treatment). However, to put this in context, more than half of the patients who were not seen in time experienced delays before arriving at the Trust.

Table 11 shows how our performance has dipped over the past year. We are actively working with our partner organisations to see how these issues could be tackled. To help coordinate our approach, we have compiled a single list of all the patients being looked after by multi-disciplinary teams in every hospital in the region. We are involving experts from outside East London to review how we could further improve our processes to meet the challenging targets. In addition we are talking to GPs to find out how we can speed up access to care for patients who need to be seen very quickly. We are confident that by the second half of 2012/13 we will meet the standards consistently and sustainably.

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Quality Account 2011/12

Table 11: How the Trust has performed against waiting list targets over the past two years

Performance against targets

2010/11 2011/12 Waiting time target

Number Number Percent Percent within exceeding compliance compliance target target

Urgent GP referrals seen within two weeks 99.9% 97.27% 4517 127

Cancer treatments started within one month of decision to treat 98.6% 97.78% 1582 36

Cancer treatments started within two months of urgent GP referral 86.5% 79.47% 360 93

Cancer treatment starts within two months from national screening programme 93.9% 88.34% 144 19

Cancer treatment starts within two months from consultant up-grade 87.0% 77.42% 24 7

Subsequent treatments within one month of decision to treat (drug) 99.1% 99.80% 495 1

Subsequent treatments within one month of decision to treat (radiotherapy) 90.9% 98.07% 1323 26

Subsequent treatments within one month of decision to treat (surgery) 98.7% 97.93% 379 8

Assessing our cancer services against the IOG’s national standards The Cancer Clinical Academic Unit measures its services against the Improving Outcomes Guidance (IOG), which defines the national standards and recommended guidance for cancer care. Our services are assessed through internal validation and external inspection by the Cancer Network.

How are we doing? The Trust was recently internally inspected and a peer review team visited the following multidisciplinary teams: paediatrics; liver, pancreas and biliary; head and neck; skin; colorectal; and endocrine. The research found that the Trust has increased its level of compliance overall and good practice was noted in all teams.

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Quality Account 2011/12

There were, however, two immediate risks identified:

• The Trust’s colorectal surgeons were not carrying out sufficient numbers of operations as required by the IOG • Not all brain cancer patients were being discussed at a single multidisciplinary team meeting.

What are we doing to tackle these issues? The Trust has resolved both these issues – the overall number of colorectal surgeons performing operations has been reduced, and all brain cancer patients are now discussed in a single multidisciplinary team meeting.

Introducing new ways of working so that surgery patients recovery more quickly The Enhanced Recovery Pathway (ERP) model is a combination of practices aimed at accelerating the recovery time for patients undergoing elective surgery.

Our ERP CQUIN quality improvement work in 2011/12 focused on the colorectal, musculoskeletal and gynaecological procedures but the general principles of ERP could be transferred to any specialty in the future. In fact, we have already extended the ERP to all gynae-oncology surgery (initially only endometrial cancer patients were selected).

According to the scheme’s principles, ERP is optimised when the patient:

• Is in the best possible condition to undergo surgery (e.g. their high blood pressure is under control) and we are aware of any other health conditions that they may have • Has the best possible management during and immediately after their procedure (e.g. appropriate anaesthetics are given, fluids provided, and minimally invasive surgery techniques are used when suitable) • Experiences the best post-operative rehabilitation (e.g. with a suitable diet and early mobilisation after surgery).

This new exercise in patient care has resulted in reviews and changes at a departmental level. For example, not all patient groups needing bowel preparations are required to come in the day before their surgery – more patients are undergoing this procedure on the morning of their surgery.

Determined efforts have been made to ensure that our gynaecology and musculoskeletal patients receive prompt nutrition and mobilisation after their surgery. (This is not always possible for the colorectal patients due to their condition following complex surgery). Access to our therapy services has been increased and more use is being made of regional blocks (i.e. pain medication for specific joints), which helps patients to move around more quickly after their operation.

ERP has not resulted in any additional surgical cancellations or subsequent readmissions.

Communicating the benefits to patients has been the key to the scheme’s success. We know that 85- 95% of our patients will attend a detailed pre-operative assessment and this gives us an ideal opportunity to discuss the advantages at an early stage of their journey. We are also aware that good pre-admission practices have helped speed up recovery times. As a result, the feedback from patients who have gone on the ERP has been positive – giving us added impetus to roll out the scheme to other areas within the Trust.

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Quality Account 2011/12

Table 12 below shows how we have tightened up our practices at the Trust in 2011/12 to give patients faster recovery time for a number of procedures.

Table 12: Enhanced Recovery Pathways – compliance with CQUIN standards and targets in 2011/12

Trust Apr May Jun Jul Aug Sep Oct Nov Dec Jan target

National ERP Q1 73% Q2 82% Q3 97% 92% 70% database (Y)

Operated on day of Q1 70% Q2 85% Q3 94% 88% 60% admission (Y)

Fluid loading (Y) (colorectal 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 95% only

Reduction in 6.0 median length 7.0 8.0 5.0 6.5 8.0 5.5 6.0 6.0 6.0 5.0 (days) of stay (hips)

Reduction in median length 6.0 5.5 7.0 6.5 5.0 5.0 7.0 9.0 5.0 4.0 5.0 of stay (knees)

Reduction in median length of stay 3.0 3.0 3.0 3.0 4.0 4.0 2.5 3.0 4.0 24.0 3.0 (hysterectomy abdominal)

Reduction in median length of stay 4.0 2.0 3.0 1.0 2.0 3.5 4.0 3.5 2.5 2.0 2.0 (hysterectomy vaginal)

Reduction in median length 37.5 15.0 19.0 13.0 14.0 8.5 13.0 10.0 14.0 N/A 7.0 of stay (colectomy)

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Quality Account 2011/12

In terms of the CQUIN data in the table above, we have seen significant improvements with regard to the number of patients being operated upon on the day of admission. Also our fluid loading performance to date has been 100%, which clearly demonstrates that this practice is now clinically embedded.

The difficulty has been in meeting the median length of stay targets. It has been particularly challenging to meet the targets for our colorectal patients, as the caseload is small (so each patient’s recovery has a greater impact on the figures) and the procedures and recoveries are typically complex. The length of stay has been significantly shortened for gynae-oncology patients. However we treated a few complex cases and that has had an impact on the average.

Learning from PROMs so that we can monitor our services from the patients’ perspective Patient Reported Outcome Measures (PROMs) measure quality from the patient perspective. Initially covering four clinical procedures, PROMs calculate the health gain after surgical treatment using pre and post operative postal surveys.

The four procedures are:

• Hip replacements • Knee replacements • Hernia • Varicose veins procedures.

Over the past year, 487 patients at the Trust were eligible to give us PROM feedback, and 294 of them did (60.4%). This was less than the national response rate, which was 77.6%, and our response rate varied from 50.9% to 75.3% depending on the procedure. We continuously review our pre admission clinic processes to try and ensure good participation rates and also try to understand why our return rates are low. Only 176 post operative questionnaires were completed so therefore we only able to report on the valid results as shown in Chart 22. Post operative participation is entirely voluntary and some patients are clearly choosing not to participate any further when the procedure is over.

The graph indicates that the findings at the Trust are very similar to the changes in score observed nationally, for both pre and post operative surveys. There is a clear tendency for improved scores for groin hernia, hip and varicose vein procedures. The results of the analysis have been shared with the relevant teams and will inform their quality improvement programmes for 2012/13.

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Quality Account 2011/12

Chart 22: PROMs post operative improvement scores compared to the national averages

EQ-5D Index

EQ-VAS

EQ-5D Index

EQ-VAS

Oxford Hip Score

EQ-5D Index

EQ-VAS

Oxford Knee Score

EQ-5D Index

EQ-VAS

Aberdeen Varicose Vein Varicose VeinVaricose Knee Replacement Hip Replaceemnt Hernia Groin Score

100.0% 75.0% 50.0% 25.0% 0.0% 25.0% 50.0% 75.0% 100.0%

Got Worse Improved National Got Worse % National Improvement %

We need to do more to improve patient administration and information sharing with GPs Working with GPs, and championed by the Director of Primary, we have made a number of administrative process changes to improve the way that information is transferred from clinical services to GPs. We have developed quality standards to improve the quality, timely dispatch and receipt of discharge summary and outpatient appointment information.

But we need to do more, as evidenced by the GP communication CQUIN results in 2011/12 and our own internal performance monitoring. For this reason, and because we have heard this key message from our clinical commissioning group colleagues, getting patient administration right is one of the top three quality priorities for Barts Health in 2012/13.

CQUIN performance

Quality of the discharge summaries and OPD letters A sample (n= 30) of summaries and OPD letters were audited by GP practices for quality each quarter using a scorecard and given a score (1-4). The results are shown in the graph below. The quality of discharge summaries improved from the Q1 baseline by 2 points. The quality score for OP letters however deteriorated from Q1.

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Quality Account 2011/12

Timeliness of dispatch and receipt The summaries and letters were also assessed against criteria for timeliness. Timeliness was judged by whether summaries were received by GP practices within three working days and OP letters within seven working days. The graph shows the change in results between Q1 and Q4.

There was some improvement in the timeliness of discharge summaries. The % received late has fell by one % point, but the average and median number for days to receipt has also fallen. All OP letters in Q4 were received late (and this has remained consistently high). However the average number of days from appointment to receipt has fallen from the Q1 benchmark.

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Quality Account 2011/12 Staff experience – organisational and staff development

Transformation through education and staff development Our staff experience quality improvement priorities will be achieved through our Organisational Development (OD) strategy.

Our organisational development activities in 2011/12 A variety of education models have been used throughout the year, to support workforce development and assess our investment in education. The most significant programmes are described below.

Bands 1-4 development Accredited and non-accredited courses are being used to develop personal and managerial skills, and priority competences such as customer service. Examples include the Institute of Leadership and Management (ILM) Level 2 and Boost Your Confidence.

Apprenticeships As part of a wider apprenticeship initiative funded by NHS London we have provided programmes in Administration and Clerical and Care (Clinical). Apprentices are recruited from existing staff and the local community. There are also Foundation Degrees and a Bridge Into Nursing programme that recruits from the local community and is run in conjunction with Tower Hamlets College.

Core management development New resources for managers were developed and implemented in 2011/12. The Manager’s Handbook now provides a practical, comprehensive and online one-stop-shop. Plus we have introduced a structured core modular management development programme and managers’ induction programme called ‘Managing People and Performance’. Managers are coached to ensure that they can manage staff in difficult circumstances (e.g. sickness absence, performance management and disciplinaries).

General manager and service manager development A bespoke programme was developed for general and service managers using a tailored competency framework and assessment centres to diagnose strengths and development needs against a competency framework. Areas covered include demand management, problem solving, coaching skills and one-to-one leadership coaching. The programme has had positive interim evaluation.

Clinical leadership We have provided bespoke leadership programmes for doctors, nurses and allied health professionals utilising competency frameworks, diagnostic techniques and appropriate interventions (including forums and modules for critical thinking, managing patient flow and emotional intelligence). We have also provided coaching skills and one-to-one leadership training.

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Quality Account 2011/12

The Trust has also piloted e-learning clinical leadership modules by the British Medical Journal/Open University. We plan to launch a Barts Health programme in the first quarter of 2012/13 comprising of an e-learning programme for clinical leadership, action learning sets and service improvement evaluation and presentations.

Leadership forums We have held a series of monthly forums for senior leaders across the Trust. This has helped to create a leadership community and a forum for communication with the executive team. The forums have been structured to include discussion, debate, sharing of learning and networking.

Promoting happier, healthier staff Barts Health NHS Trust is proud of our association with The Health Promoting Hospital scheme. We now have a Health and Wellbeing Board run by the Medical Director, with representatives from Public Health, Occupational Health, Human Resources and Organisational Development.

From aromatherapy to Zumba… how we help to encourage greater wellbeing In June 2011 we hosted an open day that was supported by our community partners. This was well attended, and has helped to shape our service development across the year.

Acting on feedback, we have expanded our wellbeing activities for staff to include Weight Watchers, reflexology, massage, aromatherapy, Zumba, pilates, yoga, five-a-side football, badminton and reduced gym memberships. Between July 2011 to February 2012, 285 staff have benefited from using these services.

An outreach campaign to staff and the wider community has resulted in over 70 referrals to smoking cessation sessions at Barts, The Royal London and The London Chest Hospital. In addition, all our staff continue to have immediate, free and confidential access to qualified counsellors around the clock, with an advice line and an online support tool.

Case study

A case study in caring: helping staff to beat flu In 2011/12, we ran our most successful ever Seasonal Influenza Campaign. 3147 immunisations were given to Trust staff (43.5% of the frontline healthcare worker population). This was above the average uptake across London, which was 36%.

Identifying and addressing weak staff experience performance and risk issues

CRB checks The Trust declared non-compliance with Outcome 12 of the Care Quality Commission’s essential standards in December 2011, due to an inadequate level of assurance provided by a Criminal Records Bureau (CRB) recheck programme.

During the first phase of a recheck project, problems were identified concerning our capacity to undertake CRB checks. The Trust’s Executive and Board concluded that there was insufficient assurance of robust systems to minimise risks, although there was no evidence of harm occurring.

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The CRB status and documentation for all relevant employees and workers has since been checked. Risk assessments were undertaken, and any issues were tracked, reported and escalated to executives. This work was completed in March 2012. An external Serious Incident investigation was commissioned and the results are expected back in May 2012. We will take any further action recommended to provide assurances and to improve our practises or processes.

Mandatory training The Trust set a target of 100% compliance for training in Safeguarding Children, Safeguarding Adults, Fire and Infection Control. Following a disappointing take-up and progress by October 2011, the Trust Executive approved a multifaceted action plan to provide high quality, innovative and accessible in-house training. We also took steps to improve the recording and reporting of compliance.

By March 2012 the compliance rates had increased by up to 30%. Significant increases in e-learning have helped our progress (this was confirmed in the 2011 NHS Staff Survey). Our action plan will continue with Barts Health over the coming year.

Mixed results from the national staff survey – and the emergence of a positive action plan… Our staff were asked for feedback on how they rate us as a Trust in the annual NHS national staff survey. Two thousand employees were asked for their views and the response rate of 64% was one of the highest recorded for an acute hospital trust in England, and matched our highest ever rate last year.

Since 2008, the Trust’s identified priorities for staff have focused on appraisals, personal development plans and the delivery of agreed training. In addition, this year, new indicators have been selected to measure our progress against the Trust’s core PRIDE values – Passion, Respect, Innovation, Delivery and Education.

In 2011, the Trust ranked ‘above average’ for 16 indicators. A lower proportion of staff feel under pressure at work than the national average. We have continued to improve our communication with employees, and the Trust is now ranked within the top 20% for communication. We also ranked highly (again) for management support of staff, and our appraisals and personal development plans. This year the level of equalities training (linked to improved performance) has also increased.

The staff were asked to respond to statements to measure if they would recommend the Trust as a place to work or receive treatment. Our composite score was 3.5 (the median for acute trusts). This is very similar to last year’s score and comparable to the scores achieved by our new partners at Whipps Cross and Newham. Nevertheless the performance does not meet our expectations and will be addressed in our action plans this year. See Chart 23 below.

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Chart 23: Staff at Barts and The London were asked to rate the Trust on a number on indicators. This is how we measured up to other acute hospital trusts in 2008-2011.

Ranking of Key Findings 2008 to 2011

18 16 16

14 12 12 11 11 10 10 10 2008 10 9 2009 8 7 7 6 6 6 2010 6 5 5 55

No. of KFs per rank per KFs No. of 4 2011 4 3 2 2

0 Worst 20% Below Average Above Best 20% average average

Ranking categories Despite our measurable successes, we are concerned that the Trust has, for the first time in four years, seen deterioration in our overall ranking status.

Our staff were asked to respond to the statement ‘If a friend or relative needed treatment, I would be happy with the standard of care provided by this Trust’ – and 60% agreed. This is 2% less than last year and also 2% less than the median for all acute trusts.

For another key indicator – ‘staff intention to leave jobs’ – the score increased this year and places Barts and The London in the bottom 20% of acute trusts.

It is particularly disappointing that our scores and rankings for ‘violence from staff’, ‘harassment from patients’, ‘career progression’ and ‘discrimination’ are worse than they were last year – despite the fact that we have worked hard to make considerable progress in these areas. Please see Table 13 below.

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Table 13: NHS Staff survey results showing how we performed in 2010 and 2011

Key ▲ Improved in 2011 ▼ Deterioration in 2011 ◊ No change in 2011

Action Key finding 2010 2011 2010 2011 rank score score rank (and change in rank over the past year)

Increased management skills Support from 3.68 3.66 Top Above immediate 20% average ▼ manager

Commitment to 3.46 3.40 Better Better than work life than average ◊ balance average

Suffering work 26% 31% Better Worse than related stress than average ▼ average

Feeling work 3.12 3.13 Average Better than pressure average ▲

Well structured 3.72 3.72 Better Worse than team than average ▼ average

Increase involvement Reporting good 31% 32% Better Top 20% ▲ communications than average

Quality of job 3.46 3.46 Top Top 20% ◊ design 20%

Job satisfaction 3.49 3.46 Average Worse than average ▼

Improve appraisals Staff appraised 81% 86% Better Better than than average ◊ average

Performance 74% 77% Top Top 20% ◊ development 20% plan

Access to training Job relevant 79% 77% Better Worse than training than average ▼ average

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Tackle bullying, harassment and Valued by 75% 73% Average Bottom 20% violence colleagues ▼

Indicators Satisfied with 78% 76% Top Better than quality of work 20% average▼

Role makes a 92% 92% Top Top 20% ◊ difference 20%

Availability of 52% 51% Bottom Bottom 20% ◊ handwash 20% materials

Would 57% 50% Compares to recommend 52% median Trust as a place for English to work acute trusts ▼

We know that we could do better – and should do better. The Trust has the motivation and capacity to improve. Over the coming year, we will endeavour to improve our scores and rankings for infection control training, health and safety training, ‘harassment from staff’, and equality and diversity. We will redouble our efforts to be ‘the employer of choice for staff, supporting their health and wellbeing and helping them to thrive in their work’.

As we move forward with Barts Health NHS Trust we will analyse the staff and patient surveys from our constituent organisations to help inform how we will proceed at both a Trust and service unit level. We will learn from the best practises and work towards creating a culture with uniformly high standards.

All the staff will be involved and engaged across the Trust, and driven by the senior team at chief executive and director level. The models of working that were developed as part of the merger programme will start to define our new organisation. Regular monitoring will occur to ensure that accountability is clear, and that there is a joined-up approach regarding staff experiences, the patient experience, education and our research performance.

Celebrating our outstanding staff and excellence in action In January 2011, the Trust launched our Bringing Excellence to Life awards for outstanding teams and individuals. These accolades are awarded monthly and annually, for staff who excel in their work through demonstrating the Trust’s PRIDE values – Passion, Respect, Innovation, Delivery and Education. They reinforce our commitment to delivering the highest standards of patient care and service. The awards are open to anyone working at the Trust, whether they are directly employed, working for a partner organisation, or as a volunteer.

The Celebrating Success Awards were presented at a ceremony in October for categories including the Outstanding Individual Award; Team of the Year Award; Team Excellence in Safety Award; GP Award; Ministry of Defence Operational Service Medal for Afghanistan; Education Achiever Awards; Long-service awards; and Barts and The London Charity Awards.

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For the first time, the Trust asked Inner North East London GPs and practices to nominate a team (clinical or non-clinical) that has delivered excellent patient care, and developed good relationships with GP practices, over the past year. The Trust's Renal Team were chosen as the worthy winners, for demonstrating excellent communication with GPs and referrers, using clear letters and summaries. The team was praised for being responsive and easy to reach by email and telephone. They have taken part in numerous educational events and developed an innovative Chronic Kidney Disease Clinic in Hackney, working closely with GPs and practices.

Shaping Barts Health over the coming year Barts Health NHS Trust was created on 1 April 2012 following the approved merger of Barts and The London NHS Trust, Newham University Hospital NHS Trust and Whipps Cross University Hospital NHS Trust. The new organisation has been developed in consultation with staff at all levels. The Organisational Development (OD) team has worked with all the stakeholders to create and shape the new organisation.

Five components underpinned the merger:

• Recognising the importance of Clinical Academic Groups (CAGs) as the fundamental building blocks of the new organisation and creating the conditions for their success in the pre and post merger work programme • Driving Organisational Development from CAG level with specialist support and intervention • Maximising the existing talent available across the three existing organisations and ensuring that talent is made readily available to contribute to the development of the new organisation • Proactively seeking out and using best practice from the three organisations through recognised rapid improvement methodologies • Learning from the Monitor guidance regarding service line management (this emphasises the importance of a business unit structure, and devolving autonomy to the front line of patient services).

The Barts Health strategy To enable us to plan for the future, the Trust has identified three critical time periods, and six key outcomes, with key deliverables at each phase:

Phase 1 – Pre-merger, lead up to April 2012

Phase 2 – First 100 days after April 2012

Phase 3 – First year through to April 2013

Outcome 1 – One shared vision and values.

Outcome 2 – Strong clinical leadership and structures that deliver and lead world-class patient care.

Outcome 3 – High performing workforce that achieves excellent clinical, operational and financial outcomes.

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Outcome 4 – World-class Board leadership and organisation design fit for Foundation Trust approval.

Outcome 5 – Set of integrated systems, processes and frameworks that enable a mobile and flexible workforce in a multi site context.

Outcome 6 – Strong and clear mechanisms for engaging the workforce in the creation and sustainability of the new organisation.

Moving forward, we shall offer locally accessible, high quality and sustainable services that are focused on clinical excellence. Barts Health NHS Trust will provide a high quality health service that prioritises the patient experience – delivering excellence to patients, staff, and the wider community.

Safeguarding children through effective staff training This year, we have made progress in meeting the Care Quality Commission’s requirement that 80% of staff should be trained at Levels 1, 2 and 3, as defined in the document Safeguarding Children: Roles and Competencies of Health Staff (2010). For example, staff who directly and frequently care for children need the highest level of training (Level 3). Other staff may require more basic awareness training.

We have updated our training action plan and introduced additional classroom based sessions for Levels 2 and 3. User names and passwords have been issued to all staff without a smartcard, allowing them access to Level 2 training (which was previously not available). A more robust system to monitor non compliance or take up has been introduced, and the Deputy Chief Nurse now contacts individuals who have no record of attendance.

Table 14 shows how the uptake for training at all levels has increased since September 2011

Course September October November December January Feb March April 2011 2011 2011 2011 2012 2012 2012 2012

Level 1 60.22% 64.38% 62.7% 68.5% 65% 69% 71% 72%

Level 2 42.66% 45.78% 43.7% 47.6% 46% 48% 49% 52%

Level 3 48.39% 51.72% 51.3% 55.6% 59% 61% 62% 66%

Total 52.99% 56.76% 54.9% 57.5% 58% 61% 63% 63%

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Quality Account 2011/12 Third party stakeholder commentaries

The Trust would like to thank stakeholders who have provided commentaries. These have been provided verbatim.

NHS North East London and the City NHS North East London and the City welcomes the opportunity to provide this statement on Barts and the London NHS Trust’s Quality Account.

We have reviewed the content of the Quality Account and confirm that it complies with the prescribed information, form and content as set out by the Department of Health. We believe that it gives a fair, representative and balanced overview of the quality of care at Barts and the London NHS Trust. We have discussed the development of this Quality Account with Barts and the London NHS Trust over the year and have been able to contribute our views on consultation and content.

This Quality Account has been reviewed by NHS North East London and the City commissioners, quality and clinical governance and performance teams, Clinical Commissioning Groups (CCGs), as well as specialists in infection control and safeguarding. We confirm that we have reviewed the information contained in the Account and checked its accuracy against data sources gathered as part of our contract and performance monitoring processes.

Overall, we welcome the vision described in the Quality Account, agree on the priority areas and will continue to work with Barts and the London NHS Trust, now operating as Barts Health NHS Trust, to continually improve the quality of services provided to patients.

Alwen Williams Chief Executive Officer

Tower Hamlets Involvement Network Statement This Quality Account was considered by members of the THINk Steering Group and in their opinion is a fair reflection of the range and the quality of healthcare services provided by the Trust. It is comprehensive, informative, contains meaningful and comprehendible statements and is a vast improvement on the previous year.

Over the past year the Trust has shown a genuine commitment to working with THINk members to improve patient experience and we hope that this will continue under the new Barts Health structure. We are keen to further develop our joint working on improving older people’s services and on greater integration of services for people with a long-term condition.

The main concerns expressed by local people in relation to the Royal London Hospital are still cleanliness, food and the discharge process. Other issues include:

• Communications • Customer care

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• Empowering patients • Waiting times • The specific needs of ‘frequent users’

Our opinion is based on feed-back from members of the community, comments from various user groups, our visits to various hospital facilities and engagement with the Trust's management.

Communication issues There are two key areas of concern; the information flow to patients and the information flow between the hospital and other health providers. There are additional concerns related to public signposting at the hospital and electronic information.

Most patients want to have at least basic information about their condition, treatment or care. Much of what we hear from dissatisfied patients relates to insufficient information about what to expect and what options are available. This information should be a priority at all points in the process; before, during and after.

Accessibility for patients specifically means using plain language that is easy to understand by everyone, jargon-free and in cases where the person is not adequately fluent in English to provide an interpreter in their chosen language. Medical staff particularly would benefit from ‘plain English’ communications training.

The second communications issue is related to health providers and practitioners adequately communicating with each other about patients. So often what the public experience is described as ‘the right hand doesn’t know what the left hand is doing’. One area already identified as a potential help here is greater patient held information and improved information sharing technology. Lastly, having adequate signage and signposting for the public in the hospital is a basic yet critical factor in the patient experience. We are still experiencing inadequate signage, especially for people with additional support needs or those with disabilities.

Empowering patients Patients want to be involved as a key decision-maker in their treatment choices and prefer to be treated as a resource rather than a liability when it comes to their care. Patients might be empowered in any number of ways and this could include information, physical support (and comfort) and emotional support. Hospital staff (particularly consultants) must understand that people with low confidence levels (especially older people) see them as intimidating, regardless of their intention, and they may need to consciously remove barriers to empowerment. Examples of disempowered situations include people having to wear gowns that do not fit properly, people being rushed through appointments with no time for questions, providers talking to colleagues about patients as if they were not present and wards with clocks that don’t work and no access to news or snacks. Most importantly, Barts need to make it easy for patients and carers to ask questions and be informed and confident about their treatment and care. Most people want to feel that their health concerns have been listened to and heard by providers.

Customer care This includes both the attitudes of staff as well as physical practicalities that enable a better experience. If we see the patient and carers as customers, they want to be treated with a certain amount of dignity and respect and there are still complaints about the attitudes of staff with the words ‘rude’ and ‘unfriendly’ coming to the top of the list. The more physical aspects of customer care

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Quality Account 2011/12 include having adequate seating in waiting areas and access to refreshments as well as facilities for disabled people, especially wheelchair users.

Waiting times and appointments People are frustrated with the time it takes to get certain appointments, with delays reported in weeks and months. Common concerns are raised regarding cancelled and rescheduled appointments with no explanation.

Food and hygiene issues Food and hygiene are linked to empowerment and dignity. People have cultural associations with food and having choice and high quality healthy meals makes a big difference, especially when a person is ill. We are still receiving complaints from people about the quality of food and cleanliness in the Royal London Hospital. Food choice is important to people, especially those who are frequent hospital users and hygiene is even more important. We are getting reports that there are a minority of staff who do not practice basic hygiene skills of hand-washing between patients and using gloves.

The specific needs of ‘frequent users’ Many people with long term conditions and older people are frequent users of hospital services and would benefit from a more integrated approach e.g. specialist LTC wards and streamlined approaches to treatment and testing or perhaps an LTC ‘one stop shop’. These users could also be considered a resource to Barts Health as they often have extensive knowledge of treatment approaches, history and success factors. Self-management is often key to positive outcomes for patients and what ‘super-users’ have told us about self-management is that in order to be successful, there needs to be high levels of information, choice and empowerment.

The impact of budget cuts on services Many people have commented on the current financial situation in terms of the budget cuts to health services and people feel that decreased staff numbers and poorly organised discharge processes are a direct result of this.

We would like to thank everybody at BLT for supporting THINk activities this year and particularly Jane Canny and Motin Uz Zaman (who left during the course of the year).

The City of London Local Involvement Network The City LINk welcomes the opportunity to comment on Barts Health NHS Quality Account, acknowledging the Trust’s commitment to engaging the network in several ways. During the recent merger process, LINk members have been grateful for regular updates, presentations from staff, meetings with the Trust Chair and invitations to stakeholder events. The City LINk cannot stress strongly enough, the need to provide appropriate consultation and engagement opportunities, to target specific communities – such as City residents and working populations. Several concerns have been raised regarding the merger, such as: the wide geographical area and number of hospitals involved; disparate medical standards and financial situations; and the level of staffing and number of beds required.

Having investigated patient experience at Barts and the London Hospitals, the LINk has recently published a Leaving Hospital report, which highlights the need for: improved information for patients, carers and relatives; greater awareness of patient dignity and better communication between services, on discharge from hospital (p.41). These issues are clearly reflected in statistics, for

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Quality Account 2011/12 example, the number of complaints received about communication (p.35). The LINk therefore supports the Trust’s focus on “people” and anticipates marked improvements, as it takes forward priorities to include: keeping patients more informed and working closely with GPs on discharge summaries. The LINk has been made aware of distressing cases where discharge procedures have not been followed correctly, with concerns raised directly with the Chair of the Trust.

Maintaining close links with Trust staff and receiving regular updates on patient feedback and complaints reports, the LINk will continue to monitor and scrutinise service provision. Members have noted several matters of concern presented in the Quality Account, which will be taken up with the Trust, such as: staff dissatisfaction and perceived resistance to change; rates of incorrect diagnosis and issues highlighted in real-time feedback machine responses.

As the City LINk prepares to transition into HealthWatch, the network looks forward to working with the Trust to ensure the voice of the City of London community is heard.

City LINk June 2012

London Borough of Tower Hamlets Health Scrutiny Committee We appreciate the opportunity to comment on this Quality Account and appreciate the time that senior representatives from Barts Health and its predecessor organisations have taken to engage with us as a committee over the last year, at a time of significant change and therefore pressure on time and resources.

We as a Committee are particularly interested in strengthening the voice of patients in their care and in building the accountability between local people and the Trust. This is always vital and will be increasingly central in the coming period as significant changes are made post merger. There are a number of issues covered in the Quality Account which correspond with our own knowledge of how local people interact with services.

Our experience reflects continuing issues with communications which are shown in the complaints received. We would connect this with the issues set out on p49 of the account around Asian/Asian British people particularly feeling that they are not always listened to or involved in decisions around their care. We welcome the commitment to of the Trust to patient centred care into the future, and will be doing some work as a committee on how this can be made real, through increased trust between health and social care providers and local people. Apprenticeships are mentioned – we would be grateful for more information about the numbers of apprentices who are new starts as a proportion of the apprentice cohort as a whole, and numbers on how many people hired over the last year have been from Tower Hamlets. A part of building trust with local people is being a good local employer. We are particularly interested in how community health services will be integrated and managed, and how accountability will work, as Barts is specifically responsible for these services in Tower Hamlets. We will seek to retain oversight of this.

We are particularly keen that management structures are designed in a way that enables THINk/HealthWatch and others to feed in a way that it transparent and manageable for the individuals involved. In a big organisation there is a risk that channels of communication and decision making multiply, without the resources of THINk/HealthWatch or Health Scrutiny multiplying correspondingly.

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We hope to spend a significant part of our time over the next year working with Barts Health NHS Trust to maximise transparency and accountability, and hope that we can build on the work we have done together this year.

Councillor J Saunders Chair Health Scrutiny Panel London Borough of Tower Hamlets June 2012

City of London Corporation Community & Children’s Services Committee

Thank you for providing us with an opportunity to comment on your Quality Account for 2011/12. We have reviewed the final draft and in general we are pleased with the progress that the trust is making in improving services to patients at a time of significant change for the organisation.

In particular we were pleased to see the performance of the Trusts in responding to complaints set out on Page 35 and the first indications of improvements to the service that the New Royal London Hospital facilities are bringing. This is exemplified by the achievement of the single sex standards on Page 44.

We were also pleased to see patients positive views of the Central Appointments Call Centre set out on Page 54. Our own experience has been that the call centre is helpful but we are less certain of the efficiency of the overall appointments system and this is reflected by the fact that only 67% of patients reported that they were seen on time (Page 56).

We had some concerns about the dip in some of the standards for cancer waiting times on Page 65 and would welcome some feedback from the Trust on the progress you are making over this year.

In previous years commentary on your accounts we have asked for more information to be included about the Bart’s Minor Injuries Unit and for more information about the people responding to surveys and using services so we can ensure that the needs of City residents and workers are being met.

Unfortunately this information does not form part of this year’s Quality Account. This is particularly relevant to the Minor Injuries Unit as we are aware that you are considering some significant changes to the services provided from there. To date we have not been kept sufficiently informed about the proposals and their impact. We expect to be fully engaged from this point forward and the outcome of any service changes to be reflected in next year’s Quality Account.

We are seeking to arrange a visit to the Royal London Hospital for next month and would be happy to discuss some of these issues further at our visit.

Yours sincerely

The Revd Dr Martin Dudley FSA FRHistS Member for Aldersgate Ward Chairman, Community & Children's Services Committee Chairman, Audit Committee of the Museum of London

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Quality Account 2011/12 Appendices

Appendix 1: Participation in mandatory national projects in 2011/12

The following list shows Barts and The London’s participation in mandatory national projects in 2011/12. Some are in the National Clinical Audit and Patient Outcomes Programme. Participation in the programme is mandated by the NHS Operating Framework. Others are recommended for inclusion in Quality Accounts 2012 by the National Clinical Audit Advisory Group.

Key: CRMS – Circulatory, Respiratory and Metabolic Division

Audit title National clinical audit Clinical Barts and Barts and The supplier division The London London coverage - participation clinical cases submitted in 2011/12

Peri- and neonatal

Perinatal mortality HQIP Acute and √ 100% Family Neonatal intensive and Royal College of Acute and √ 100% special care (NNAP) Paediatrics and Child Family Health

Children

Paediatric pneumonia British Thoracic Society Acute and √ 100% (29/29) Family Paediatric asthma British Thoracic Society Acute and √ 100% (21/21) Family Pain management College of Emergency Acute and √ 100% (50/50) Medicine Family Childhood epilepsy Royal College of Acute and √ 100% (21/21) (RCPCH National Paediatrics and Child Family Childhood Epilepsy) Health Paediatric intensive care PICANet Acute and √ 100% (379/379) Family Paediatric cardiac NICOR Acute and NA to BLT NA to BLT surgery (NICOR Family Congenital Heart Disease Audit)

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Diabetes (RCPCH Royal College of Acute and √ 100% National Paediatric Paediatrics and Child Family Diabetes Audit) Health

Acute care

Emergency use of British Thoracic Society CRMS √ 100% (13/13) oxygen 2011 Adult community British Thoracic Society CRMS √ NA - data entry ends acquired pneumonia in April 2012 Non invasive ventilation British Thoracic Society CRMS √ NA - data entry ends (NIV) - adults (British in April 2012 Thoracic Society) Pleural procedures British Thoracic Society CRMS √ 100% (10/10)

National Cardiac Arrest ICNARC Acute and √ 100% Audit Family Severe sepsis & septic College of Emergency Acute and √ 100% (30/30) shock Medicine Family Adult critical care ICNARC CMPD Acute and √ 100% Family Potential donor audit NHS Blood and Acute and √ 100% Transplant Family Seizure management National Audit of Acute and √ 100% (30/30) Seizure Management Family (NASH)

Long term conditions

Diabetes (NDA) NHS Information CRMS √ 100% (6330/6330) Centre Heavy menstrual Royal College of Acute and √ NA - patient survey bleeding Gynaecologists Family National Pain Database British Pain Society Acute and √ 100% Audit (Chronic pain) and Dr Foster Family Research Ltd Ulcerative colitis and UK IBD Audit Regional √ CD: 100% 20/20; Crohn's disease Services UC: 80% 16/20; organisational audit submitted. Parkinson's disease Parkinson's UK Regional √ 100% Services

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Chronic Obstructive British Thoracic Society CRMS Re-audit NA - no data entry Pulmonary Disease planned required in 2011/12 (COPD) Adult asthma British Thoracic Society CRMS √ 100% (14/14)

Bronchiectasis British Thoracic Society CRMS √ 100% (38/38)

Food and Nutrition Audit King's College London, Trust Audit NA - no data entry (1 year development KCL planned required in 2011/12 project) Continence Care Audit Royal College of Acute and Re-audit NA - no data entry Physicians Family planned required in 2011/12

Elective procedures

Hip, knee and ankle National Joint Registry Acute and √ 100% (311/311) replacements Family Elective Surgery PROMs NHS Information Acute and √ NA - patient survey Centre Family Intra-thoracic NHS Blood and NA NA to BLT NA to BLT transplantation Transplant UK Transplant Registry Liver transplantation NHS Blood and NA NA to BLT NA to BLT Transplant UK Transplant Registry Coronary angioplasty NICOR CRMS √ 86% (2010)

Peripheral vascular VSGBI Vascular CRMS √ 100% surgery Surgery Database Carotid interventions Carotid Intervention CRMS √ 72% Audit CABG and valvular Adult Cardiac Surgery CRMS √ 100% surgery

Cardiovascular disease

MINAP 2011: acute MINAP CRMS √ London Chest myocardial infarction & Hospital: 100% other acute coronary (1580) syndromes Heart failure NICOR CRMS √ 30% (73/240) to date (June 2012 data entry deadline)

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Acute stroke SINAP Acute and √ 100% Family Stroke care National Sentinel Acute and √ 100% Stroke Audit Family Cardiac arrhythmia NICOR CRMS √ 100%

Adult Cardiac Surgery NICOR CRMS √ 100% Audit Congenital Heart NICOR CRMS NA to BLT NA to BLT Disease Audit (including paediatric surgery)

Renal disease

Renal Services Audit Renal Registry CRMS NA to BLT NA - no data entry (vascular access; patient required in 2011/12 transport) Renal transplantation NHS Blood and CRMS √ 100% (c. 120 pa) Transplant

Cancer

Lung cancer NHS Information Regional √ 100% Centre Services Bowel cancer NHS Information Regional √ 100% Centre Services Head & neck cancer NHS Information Regional √ 100% Centre Services 1) Oesophago-gastric NHS Information Regional √ 100% cancer-CURRENT audit Centre Services 2) Oesophago-gastric NHS Information Regional √ NA - Data collection cancer Centre Services ends 01/10/2012

Trauma

Hip fracture National Hip Fracture Acute and √ 90.3% (131/145) Database Family Severe trauma TARN Acute and √ 100% Family Falls and non-hip National Falls & Bone Acute and √ NA fractures Health Audit (RCP) Family

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Mental health

Prescribing in mental POMH NA NA to BLT NA health services Schizophrenia Royal College of NA NA to BLT NA Psychiatrists National Audit of Royal College of CHS Re-audit NA - no data entry Psychological Therapies Psychiatrists planned required in 2011/12 National Audit of Royal College of Acute and √ 100% Dementia Psychiatrists Family

Blood transfusion

Bedside transfusion National Comparative Clinical and √ 50% (20/40 cases) Audit of Blood Diagnostic Transfusion Medical use of blood National Comparative Clinical and X BLT did not Audit of Blood Diagnostic participate Transfusion

Health promotion

Risk factors National Health Clinical and √ 100% (100/100) Promotion in Hospitals Diagnostic Audit

End of life

Care of dying in hospital NCDAH Acute and √ 100% (78/78) Family

Confidential Enquiries Subarachnoid Regional Activity data NCEPOD √ Haemorrhage Services submitted Alcohol Related Liver Regional Activity data NCEPOD √ Disease (ARLD) Services submitted Cardiac arrest NCEPOD CRMS √ 100% (3/3) procedures Surgery in children, "Are Acute and NCEPOD √ 100% (4/4) we there yet?" Family Perioperative care, Acute and NCEPOD √ 54% (7/13) "Knowing the risk" Family Bariatric surgery NCEPOD N/A NA to BLT NA to BLT

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Appendix 2: External Auditor’s opinion

INDEPENDENT AUDITOR’S LIMITED ASSURANCE REPORT TO THE DIRECTORS OF BARTS HEALTH NHS TRUST ON THE ANNUAL QUALITY ACCOUNT FOR BARTS & THE LONDON NHS TRUST

We are required by the Audit Commission to perform an independent assurance engagement in respect of Barts & the London NHS Trust’s Quality Account for the year ended 31 March 2012 (“the Quality Account”) as part of our work under section 5(1)(e) of the Audit Commission Act 1998 (the Act). NHS Trusts are required by section 8 of the Health Act 2009 to publish a quality account which must include prescribed information set out in The National Health Service (Quality Account) Regulations 2010 and the National Health Service (Quality Account) Amendment Regulations 2011 (“the Regulations”). We are required to consider whether the Quality Account includes the matters to be reported on as set out in the Regulations.

Respective responsibilities of Directors and auditors The Directors are required under the Health Act 2009 to prepare a Quality Account for each financial year. The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporates the legal requirements in the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended by the National Health Service (Quality Accounts) Amendment Regulations 2011).

In preparing the Quality Account, the Directors are required to take steps to satisfy themselves that:

• the Quality Account presents a balanced picture of the trust’s performance over the period covered; • the performance information reported in the Quality Account is reliable and accurate; • there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, and these controls are subject to review to confirm that they are working effectively in practice; • the data underpinning the measures of performance reported in the Quality Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, and is subject to appropriate scrutiny and review; and • the Quality Account has been prepared in accordance with Department of Health guidance.

The Directors are required to confirm compliance with these requirements in a statement of directors’ responsibilities within the Quality Account.

Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that the Quality Account is not consistent with the requirements set out in the Regulations.

We read the Quality Account and conclude whether it is consistent with the requirements of the Regulation and to consider the implications for our report if we become aware of any inconsistencies.

This report is made solely to the Board of Barts Health NHS Trust in accordance with Part II of the Audit Commission Act 1998 and for no other purpose, as set out in paragraph 45 of the Statement of Responsibilities of Auditors and Audited Bodies published by the Audit Commission in March 2010.

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Assurance work performed We conducted this limited assurance engagement under the terms of the Audit Commission Act 1998 and in accordance with the NHS Quality Accounts Auditor Guidance 2011/12 issued by the Audit Commission on 16 April 2012. Our limited assurance procedures included: − making enquiries of management; − comparing the content of the Quality Account to the requirements of the Regulations.

A limited assurance engagement is narrower in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement.

Limitations The scope of our assurance work did not include consideration of the accuracy of the reported indicators, the content of the quality account or the underlying data from which it is derived.

Non-financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information. It is important to read the Quality Account in the context of the criteria set out in the Regulations.

Conclusion Based on the results of our procedures, nothing has come to our attention that causes us to believe that the Quality Account for the year ended 31 March 2012 is not consistent with the requirements set out in the Regulations.

Paul Dossett Senior Statutory Auditor, for and on behalf of Grant Thornton UK LLP

Grant Thornton House, Melton Street, Euston Square, London, NW1 2EP

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Appendix 3: Glossary

Abuse Abuse is defined by the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 as:

• Sexual abuse • Physical or psychological ill-treatment • Theft, misuse or misappropriation of money or property, or • Neglect and acts of omission which cause harm or place at risk of harm.

Acute trust A trust is an NHS organisation responsible for providing a group of healthcare services. An acute trust provides hospital services (but not mental health hospital services, which are provided by a mental health trust).

Audit Commission The Audit Commission regulates the proper control of public finances by local authorities and the NHS in England and Wales. The Commission audits NHS trusts, primary care trusts and strategic health authorities to review the quality of their financial systems. It publishes independent reports highlighting risks and good practice, to improve the quality of financial management in the health service. In addition, the Commission works with the Care Quality Commission to conduct national value-for-money studies. Visit: www.audit-commission.gov.uk

Board (of the Trust) The Trust Board is accountable for setting the strategic direction of the Trust, monitoring performance against objectives, ensuring high standards of corporate governance and helping to promote links between the Trust and the community. The Board has 12 members and includes the Chairman, Chief Executive, four Executive Directors and six Non-Executive Directors

Care Quality Commission (CQC) The Care Quality Commission (CQC) is the independent regulator of health and social care in England. It replaced the Healthcare Commission, Mental Health Act Commission and the Commission for Social Care Inspection in April 2009. The CQC regulates health and adult social care services provided by the NHS, local authorities, private companies and voluntary organisations. Visit: www.cqc.org.uk

Centre for Maternal and Child Enquiries (CMACE) CMACE is an independent charity dedicated to improving the health of mothers, babies and children. They carry out confidential enquiries and other related audit and research work across the UK. Midwives, obstetricians and paediatricians at Barts Health Trust participate in CMACE enquiries and review their published reports to ensure that any recommendations are put into place.

Choose and Book Choose and Book is a national electronic referral service that lets people choose which hospital or clinic they would like to be seen at. Patients can make their first appointment at any hospital in England funded by the NHS (this includes NHS hospitals and some independent hospitals). Bookings can be made at the doctors’ surgery, on the telephone or via the internet.

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Clinical Academic Group There will be eight Clinical Academic Groups (CAGs) in the new Barts Health NHS Trust: Ambulatory care, Cancer services, Cardiovascular services, Children’s services, Clinical support services, Emergency care and acute medicine, Surgery, Women’s services (including maternity).

Each CAG will be led by a senior clinician, with a director of nursing and governance, an operations director, and an education and research lead. The CAGs will provide commissioners with a range of services, offering high standards of clinical quality, patient safety, and value for money.

Clinical Academic Unit/Clinical Division Barts and The London’s clinical services are organised into 18 Clinical Academic Units (CAUs). Each CAU is headed by a CAU Director, who is also a clinician. The CAUs are accountable to one of the Clinical Divisions within the Trust: Acute and Family Services, Regional Services, Clinical and Diagnostic Services and Circulatory, Respiratory and Metabolic Division.

Clinical audit Clinical audit measures the quality of care and services against agreed standards and suggests or makes improvements where necessary.

Clinical coding Clinical Coding Officers are responsible for assigning a code for every inpatient stay and day case visit (or ‘episode’). The Officers use special classifications for diagnosis (diagnostic coding) and procedures (procedural coding) and enter the relevant codes onto the Patient Administration System. The coding process enables patient information to be easily sorted for statistical analysis. When complete, codes represent an accurate translation of the statements or terminology used by the clinician and provides a complete picture of every patient’s care. A variety of sources are used within Barts and The London to extract the information needed for coding, including case notes, theatre record sheets and documents and results available electronically such as discharge summaries and Histopathology and Radiology results.

Clinical Effectiveness Unit (CEU) The Clinical Effectiveness Unit, within the Business Intelligence Unit, consists of a manager and a small team of clinical audit staff. They ensure that the clinical services in the Trust are of a high standard, evidence-based and meet best practice. In partnership with a wide range of clinicians, they ensure that national guidelines are adhered to, so that we can continually improve the patient experience and deliver high-quality care.

Clostridium difficile or C. difficile Clostridium difficile (also known as C. difficile or C.diff) is a bacterium that occurs naturally in the gut of two-thirds of children and 3% of adults. It does not cause any problems in healthy people. However, some antibiotics can lead to an imbalance of bacteria in the gut and then the C.diff bacteria can multiply and produce toxins that may cause symptoms including diarrhoea and fever. This is most likely to happen with the over 65s. The majority of patients will make a full recovery, however in rare cases, it can be life-threatening. Most cases arise in a healthcare environment, such as a hospital or care home. Infections can usually be prevented by good hygiene (e.g. washing hands and bleaching surfaces).

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Commissioners of services These are organisations that buy services on behalf of people living in a defined geographical area. They may purchase services for the population as a whole, or for individuals who need specific care, treatment and support. Healthcare services are commissioned by primary care trusts. Social services are commissioned by the local authorities.

Commissioning for Quality and Innovation (CQUIN) A groundbreaking report into the future of the NHS, entitled High Quality Care for All (2008), included a commitment to make a proportion of providers’ income conditional on quality and innovation. This is achieved through the Commissioning for Quality and Innovation (CQUIN) payment framework. Visit: www.dh.gov.uk

Complaint This is an expression of dissatisfaction that can relate to any aspect of a person’s care, treatment or support. It can be expressed orally, through gestures or in writing.

Culture Learned attitudes, beliefs and values that define a group or groups of people.

Department of Health The Department of Health is the department of the UK government responsible for policies on health, social care and the NHS (in England only).

Dignity Dignity is concerned with how people feel, think and behave in relation to the worth or value that they place on themselves and others. To treat someone with dignity is to respect them as a valued person, taking into account their individual views and beliefs.

Discharge The point at which a patient leaves hospital to return home; or is transferred to another service; or the provision of a service is formally concluded.

Divisional Director Each clinical division within the Trust has a Divisional Director. They are responsible for the achievement of local and national targets and for the tripartite mission of excellence in service, research and education.

Divisional Nurse Each clinical division within the Trust has a Divisional Nurse. They provide strategic nursing leadership to ensure consistently high quality, cost effective nursing care for patients.

Enforcement action This is action taken to cancel, prevent or control the way a service is delivered using the range of statutory powers available to the Care Quality Commission. It can include action taken against services that should be, but are not, registered.

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Enhanced Recovery Programme (ERP) The enhanced recovery programme is about improving patient outcomes and speeding up a patient's recovery after surgery.

There are four elements to the enhanced recovery programme:

1. Pre-operative assessment, planning and preparation before admission. 2. Reducing the physical stress of the operation. 3. A structured approach to immediate post-operative and during (peri-operative) management, including pain relief. 4. Early mobilisation.

It results in benefits to both patients and staff. The programme focuses on making sure that patients are active participants in their own recovery process. It also aims to ensure that patients always receive evidence based care at the right time.

Foundation Trust A foundation Trust is a type of NHS trust in England that has been created to devolve decision- making from central government to a local level, so that the community’s needs and wishes can be prioritised. The trusts are independent from the Department of Health and provide and develop healthcare according to core NHS principles – that is, free care, based on need and not on ability to pay. NHS foundation trusts are accountable to their membership base (which will include patients, the public and staff), and are governed by a board of governors who come from, and are elected by, the members.

Healthcare Healthcare is the organised provision of care for an individual or community. It incorporates therapies and resources for physical and mental health, medical and surgical treatments, and procedures such as cosmetic surgery that may not be linked to a medical condition.

Healthcare associated infection This is an avoidable infection that occurs as a result of the healthcare that a person receives.

Hospital Episode Statistics (HES) This is a data warehouse containing a vast amount of information on the NHS, including details of all admissions to NHS hospitals and outpatient appointments in England. HES is an authoritative source used for healthcare analysis by the NHS, Government and many other organisations.

Indicators for Quality Improvement (IQI) The IQIs are a set of measures that provide a perspective on hospital quality of care using hospital administrative data. The indicators include inpatient mortality for certain procedures and conditions, and are used by the clinical teams for quality improvement. The IQI can be found on the NHS Information Centre website. Visit: www.ic.nhs.uk/

Information Governance (IG) IG is concerned with the structures, policies and practices in place to ensure the confidentiality and security of health and social care service records.

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Integrated care pathways – also called protocol based care Integrated care pathways enable NHS staff to put evidence into practice by deciding what should be done, when, where and by whom at a local level. It provides a framework for working in multi- disciplinary teams. This standardisation of practice reduces variation in the treatment of patients on the same pathways, thereby improving the quality of care and reducing delays for patients.

Working to stipulated protocols also provides the opportunity for redesigning and extending roles, for example nurse-led discharge can improve the patient experience, reduce the length of stay and release some of the doctors’ capacity.

Local Involvement Networks (LINks) LINks are comprised of individuals and community groups, such as faith groups and residents’ associations, working together to improve local services. Their job is to find out what the public like and dislike about local health and social care, and then feed the views back to the people who plan and run these services. They may talk directly to healthcare professionals about a service that is not being offered or make recommendations about an existing facility. Visit: www.nhs.uk/NHSEngland/links/Pages/links-make-it-happen.aspx

Methicillin-Resistant Staphylococcus Aureus (MRSA) MRSA is a bacterium responsible for several difficult-to-treat infections in humans. MRSA is, by definition, any strain of Staphylococcus aureus bacteria that has developed resistance to antibiotics including penicillins and cephalosporins. It is especially prevalent in hospitals, as patients with open wounds, invasive devices and weakened immune systems are at greater risk of infection than the general public.

National Confidential Enquiry into Patient Outcome and Death (NCEPOD) NCEPOD is an independent body concerned with maintaining and improving standards of medical and surgical care. It does this by reviewing the management of patients and undertaking confidential surveys and research, which are then published for the public’s benefit. Clinicians at Barts and The London participate in the national enquiries and review the published reports to ensure that any recommendations are put in place. Visit: www.ncepod.org.uk/

National Health Service Litigation Authority (NHSLA) The NHSLA is a special health authority responsible for handling negligence claims made against NHS bodies. It also aims to raise safety standards and reduce the number of negligent or preventable incidents through its risk management programme. This incorporates organisational, clinical, and health and safety risks. Most healthcare providers, including Barts and The London, are assessed against their standards. The NHSLA also monitors human rights case law on behalf of the NHS, co-ordinates claims for equal pay in the NHS, and handles Family Health Service appeals (i.e. disputes between doctors, dentists, opticians and pharmacists and NHS primary care trusts). Visit: www.nhsla.com

National Institute for Health and Clinical Excellence (NICE) NICE is an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health. Visit: www.nice.org.uk

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National Patient Safety Agency (NPSA) The NPSA promotes improved, safe patient care by informing, supporting and influencing the health sector. It is an arm’s length body of the Department of Health, established in 2001 with a mandate to identify patient safety issues and find appropriate solutions. Visit: www.npsa.nhs.uk

National Service Frameworks (NSFs) These are NHS policies that define the requisite standards of care for major medical issues such as cancer, coronary heart disease, mental health and diabetes. There are also NSFs for some key patient groups including children and older people. The policies are evidence-based and developed in partnership with health professionals, patients, carers, health service managers, voluntary agencies and other experts.

NHS Number This is the national unique patient identifier that makes it possible to share patient information across the whole of the NHS, safely, efficiently and accurately. The NHS Number is fundamental to the development of the National Programme for IT.

Overview and scrutiny committees Since January 2003, all local authorities with responsibilities for social services have had the power to review and report on local health services. ‘Overview and scrutiny committees’ have taken on this role, and have been instrumental in helping to plan services and bring about change. They bring democratic accountability into healthcare decision-making and make the NHS more responsive to local communities.

Patient This is a person who receives health or social care through a regulated activity. Patients are defined as ‘service users’ in the Health and Social Care Act 2008.

Patient at Risk (PAR) The Patient at Risk (PAR) score is an early warning scoring system and alert score, used to facilitate the detection of deteriorating patients. This enables early referral to specialist clinicians, so that early intervention can help to prevent deterioration.

It also helps to facilitate the early transfer of these patients to an appropriate higher care facility e.g. the Intensive Care Unit (ITU). Its use should also help prevent avoidable in-hospital cardiac arrest.

Patient Environment Action Team (PEAT) PEAT is an annual assessment of inpatient facilities at healthcare sites across England with more than 10 beds. PEAT is self-assessed and inspects standards including food, cleanliness, infection control and patient environment. The scheme was established in 2000 and is now managed by the National Patient Safety Agency. It acts as a benchmarking tool to ensure that improvements are made in the non-clinical aspects of a patient’s experience. Organisations are given scores from 1 (unacceptable) to 5 (excellent) for standards of privacy and dignity, environment and food.

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Picker Institute Europe This is a not-for-profit organisation that works with patients, professionals and policy makers to promote a patient centred approach to care. The Institute uses surveys, focus groups and other methods to gain a greater understanding of patients’ needs. Many Trusts, including Barts and The London, commission the Picker Institute to carry out annual surveys and we have also asked worked with them on other patient experience projects, so that we can continually improve our standards of care. Visit: www.pickereurope.org/

Primary care trust (PCT) PCTs are part of the NHS in England and responsible for improving the health of local people. They provide a range of community health services; funding for general practitioners and medical prescriptions; and commission hospital and mental health services from appropriate NHS trusts or from the private sector. By April 2013, PCTs will be replaced with consortia of GPs, who will manage the budgets.

Privacy and dignity To respect someone’s privacy involves recognising when they would like to be alone (or with family or friends), and showing sensitivity to their wishes for a private conversation and preventing others from looking or listening in. It also means respecting their confidentiality and personal information. To treat someone with dignity is to respect them as a valued person, taking into account their individual views and beliefs.

Providers Providers are the organisations that provide NHS services, for example NHS trusts, and their private or voluntary sector equivalents.

Quality and Safety Committee The Trust’s Quality and Safety Committee has been setting and monitoring standards since 2006. The Committee meets monthly and is chaired by the Medical Director and Chief Nurse. Its membership includes senior representatives from each of the Clinical Divisions and other safety specialists. Its key function is to fulfil a leadership, monitoring, and improvement role to ensure that the clinical care and services provided in each Clinical Division and Clinical Academic Unit:

• Are safe and of the highest quality possible • Deliver good patient experiences • Deliver good clinical outcomes • At least meet, and if possible exceed, the performance targets and benchmarks set internally and nationally in relation to quality • Continuously improve, and • Ensure clinical and cost effectiveness.

The Committee reports regularly to the Trust Management Executive and Quality Assurance Committee, and highlights any uncontrolled risks or issues that could impact on patient care, quality or safety.

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Quality Assurance Committee The Quality Assurance Committee reports to the Board and monitors, reviews and reports on the quality of services provided by the Trust. This includes a review of:

• Governance, risk management and internal control systems to ensure that the Trust’s services deliver safe, high quality, patient centred care. • Performance against internal and external quality improvement targets and follow-up whenever required, and • Progress in implementing action plans to address shortcomings in the quality of services, if any have been identified.

Quality monitoring A continuous system of monitoring to ensure that local quality measures are effective.

Registration From April 2009, every NHS trust that provides healthcare directly to patients must be registered with the Care Quality Commission (CQC).

Research Clinical research and clinical trials are an everyday part of the NHS, and often conducted by medical professionals who also see patients. A clinical trial is a particular type of research that tests one treatment against another. It may involve either patients, or people in good health, or both.

Safeguarding Safeguarding means putting measures in place to enable people to live free from harm, abuse and neglect. The measures protect their health, wellbeing and human rights. Children, and adults in vulnerable situations, need to be safeguarded. For children, the measures typically focus on care and development; for adults, they are usually concerned with independence and choice. Visit www.scie.org.uk/publications/reports/report39.asp to download a 2011 report entitled ‘Protecting adults at risk: London multi-agency policy and procedures to safeguard adults from abuse’

Secondary Uses Service (SUS) The SUS uses data from patient records to provide reports and statistics for research, planning and public health delivery. The information is used for management and clinical purposes rather than direct patient care. Visit: www.ic.nhs.uk

Social care Social care includes all forms of personal care and other practical assistance provided for people who by reason of age, illness, disability, pregnancy, childbirth, dependence on alcohol or drugs or any other similar circumstances, are in need of care or other assistance. For the purposes of the Care Quality Commission, it only includes care provided for, or mainly for, people over 18 years old in England. This is sometimes referred to as adult social care.

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Strategic health authorities Strategic health authorities (SHAs) were created by the Government in 2002 to manage the local NHS on behalf of the Secretary of State. SHAs (there are ten in total) are responsible for:

• Developing plans for improving health services in their local area • Making sure that local health services are of a high quality and are performing well • Increasing the capacity of local health services, so they can provide more services, and • Making sure that national priorities (for example, programmes for improving cancer services) are integrated into local health service plans.

SHAs manage the NHS locally and are a link between the Department of Health and the NHS.

Vascular Access Devices A vascular access device is any device that is inserted into the vascular system (a vein or an artery) for monitoring, diagnostic, or therapeutic purposes. Examples include an arterial line to monitor blood pressure, a central venous catheter to administer chemotherapy, and a peripheral venous cannula to administer intravenous fluids.

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PALS For free information or advice about NHS services, please contact the Patient Advice and Liaison Service (PALS). Tel: 020 3594 2050 or 020 3594 2040 Fax: 020 3594 3235 Email: [email protected]

Requesting a copy of the Quality Account A copy of this Quality Account can be downloaded from the Trust’s website at www.bartshealth.nhs.uk. To request a printed copy, please contact Judith Bottriell, Associate Director of Quality Improvement on 020 7480 4600. To receive this document in large print, please call the Patient Advice and Liaison Service (PALS) on 020 3594 2050.

Translations If you would like help interpreting this leaflet, please call the Health Advocacy Administrator on 020 7377 7280.

Data Protection Act 1998 The Trust processes your personal information in accordance with the Data Protection Act 1998 for delivery of high quality healthcare. The information ensures that clinicians have a complete and continuous record about your past, current and future treatment. In addition to this, your health records could also be used for teaching, clinical audit and research, which enables us to deliver the best possible care across the Trust. Further information can be found at www.bartsandthelondon.nhs.uk/forpatients/know_your_rights.asp

St Bartholomew’s Hospital The Royal London Hospital The London Chest Hospital West Smithfield Whitechapel Road Bonner Road London EC1A 7BE London E1 1BB London E2 9JX Tel: 020 7377 7000 Tel: 020 7377 7000 Tel: 020 7377 7000

Barts Health NHS Trust Switchboard: 020 3416 5000 www.bartshealth.nhs.uk

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