The Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust

Annual Report 2001-2002

Awarded for excellence Page Introduction 1

Chairman’s Report 2 Contents Chief Executive’s Report 3

The Trust Board 4

Purpose 4 Membership 4 Sub-committees 4 Openness 4

Modernisation Through Continuous Improvement 5

Key Information 15

Activity 15 Finance 16 Internal Control

D S EO U ÆD AM ANTE ÆD Cover picture: peacock Annual Report 2001/02 Left: Mary Powell, who opened the Hospital Fête in 2002

Below: Institute of Orthopaedics Residents, 2001–2003 Introduction

The Hospital was founded in 1900 and this year is celebrating its one hundred and second year with an excellent track record of providing first class clinical services. The future of the hospital rests on continued improvement and developments which will ensure we have a history to celebrate in another hundred years time.

This years annual report focuses on the many achievements during 2001/02. As the NHS Plan: a plan for investment, a plan for reform gained momentum, the Trust played its part in ensuring the delivery of modern and dependable services.

The modernisation agenda is challenging and the Trust has had to work hard to achieve the targets that have been set. Throughout the report we describe ways in which the staff, through their work, are rising to meet this challenge, not just by meeting the targets but also by delivering high quality patient centred care.

During the year there were many notable achievements including the very positive outcome of the Commission for Health Improvement (CHI) review and a reduction in patient waiting times for treatment. There are numerous examples of improvements to patient services as well as the development of new services. At the time of publication of this annual report, the Trust was awarded the highest performance rating – 3 star rating, indicating that the Trust is among the top performing hospitals in England.

Continuous improvement is key to ensuring the Trust continues to provide the best possible care for the patients it serves. This report outlines many examples of the efforts of staff and volunteers to improve services even further.

Patient Comment

“There is not much to say about the overall care except that all staff are extremely concerned and dedicated to their patients and again this breeds confidence in the patient.”

“It isn’t very often that you look forward to hospital visits, but I am awaiting another operation on my left hand and I feel that the care and attention that I have experienced in the past

D S EO U ÆD AM will be here for me when I return.” ANTE ÆD

1 Annual Report 2001/02 I am pleased to say due to the commitment of our staff the Trust has continued to treat patients in a caring and professional manner. It is about each member of staff treating each individual patient as if they were part of their family. This is the ethos of our hospital, I hope we succeeded and I thank my staff for achieving these principles.

There have been a number of notable achievements this year. The Trust was very pleased to receive an excellent report following the visit from CHI (Commission for Health Improvement). This report gives some of Chairman’s Report Chairman’s the details contained within the CHI review. I believe the best accolade was from the CHI Review Manager who said, “If ever I had to have an orthopaedic operation then Oswestry is where I would come.”

This year two of our Non Executives completed their term on the Board, Sarah Biffen and Ian Lucas. Sarah moved to London with her husband John our former local MP, we thank both Sarah and John for the contribution they both made to our hospital. Ian Lucas we congratulated for being elected MP for Wrexham and our thanks and best wishes go to him.

This year we welcomed new Non-Executive Director Angela Vint along with Finance Director Andy Robinson. Jo Cubbon our previous Chief Executive moved to a larger acute Hospital, and we wish her well.

New Chief Executive Jackie Daniel joined the Trust in May 2002. I look forward to her joining our executive team and driving our development plans forward. We desperately need to bring our buildings up to date to enhance the excellent reputation for good specialist treatment and research, always pushing the boundaries forward to enhance the quality of life for our patients.

Ageing buildings gave us particular problems this year with the closure of Ercall Ward and the Swimming pool due to Health & Safety regulations. The League of Friends have come to our aid with a generous donation from the Penhill Trust to rebuild the swimming pool. The League, as ever does an excellent job in supporting the hospital.

I must also take the opportunity to thank all staff for the extra work they did following the sudden closure of Ercall Ward. I hope by the time you read this report a replacement will be operational.

The Torch Appeal was launched on 8th March 2002, with the aim of raising £4 million to create a unique facility for fully assessing and treating children with mobility problems. Further information about the Torch Appeal is contained in the report.

Michael Bolderston Chairman

D S EO U ÆD AM ANTE ÆD

Annual Report 2001/02 2 I was delighted to take up my appointment as Chief Executive at the hospital in May this year. During the first few weeks I have met many members of staff and patients.

The last year has seen significant achievements and developments at the hospital. Excellent clinical care is something that this hospital can be rightly very proud of. In January 2002 the Commission for Health Improvement (CHI) Report was published. This review of our clinical governance arrangements commended the Trust on the standards of service it provides and highlighted a number of areas of notable practice. Chief Executive’s Report Chief Executive’s

Patients are the most important part of the service we provide and during the last year we received the results of the first National NHS Patient Survey. The survey was carried out in all hospitals and invited the people who use our service to tell us about their experience as users of the service. The comments received were many and varied, but the majority extremely positive. Generally the feedback indicates that patients are treated with dignity and respect and that they feel well informed about their treatment. The work will be further enhanced with the implementation of a Patient and Public Involvement Strategy in the coming year.

There is always room for improvement and I have seen evidence that staff are actively listening to the feedback received and putting in place measures to further improve services. This indicates an organisation that is willing to learn and develop following feedback, a characteristic I very much want to encourage and one which will mean the hospital will continue to flourish.

Last year the work began on developing an Estates Strategy. This work is essential to ensure improved facilities and environments to support the delivery of the NHS Plan. The hospital requires high quality, well accounted buildings which are in the right condition to facilitate the delivery of modern patient care services.

Delivering the NHS Plan demands a great deal from the people who work so hard to continuously improve the services we provide, ensuring Robert Jones & Agnes Hunt Orthopaedic & District Hospital is a place where people want to come and work is key. Once here we will need to retain the skills and expertise they bring, making sure staff feel valued and able to contribute to the development of services in the future.

During my early days and weeks I have been impressed by the values and commitment held by staff and the determination to continue to build on the success that makes the hospital what it is today. I look forward to working with you and contributing to this aim.

Jackie Daniel Chief Executive

D S EO U ÆD AM ANTE ÆD

3 Annual Report 2001/02 Purpose The Trust Board is responsible for setting the overall strategic direction of the Trust. It decides on policy, and makes sure that the hospital continues to provide high quality services and to be financially sound. Membership Members of the Trust Board during 2001/02 are listed below. Chairman: Michael Bolderston Executive Directors: Chief Executive Mrs Jo Cubbon (to April 2002) Director of Finance Mrs Wendy Farrington (from April 01 – June 01) Mr David Icke (from June 01 – November 01) Mr Andrew Robinson (from December 2001) Director of Nursing Ms Sandra Buckley (from December 2000) Medical Director Dr Josh Dixey Non Executive Directors: The Trust Board The Trust Mrs Nonna Woodward Mrs Angela Vint Professor Peter Jones Mrs Sarah Biffen Mr Ian Lucas (to April 01) The Chief Executive was appointed through an appointments committee made up of the Trust Chairman, Chief Executive of the NHS Executive West Midlands, and an external chief executive assessor. The appointment is made on a permanent basis, and may be terminated by the Trust Board. The same appointments criteria apply to all board directors. The Trust keeps a Register of Directors’ interests, and a Hospitality Register. You can ask to see these if you wish. Sub-committees To help it do its job properly, the Board has a number of formal sub-committees. The Audit Committee is chaired by Nonna Woodward, and includes Peter Jones and Angela Vint (all non executive directors). The committee asks the Finance Director, Chief Executive and members of the Internal and External Audit to attend its meetings. The committee meets four times a year. It makes sure that the Trust has adequate systems of internal control to safeguard assets, avoid waste and inefficiency, produce reliable financial information, and continuously seek value for money. The Remuneration Committee decides the pay, benefits, and terms and conditions, for the executive directors. It comprises the Chairman and non executive directors. Pay levels are determined by the Remuneration Committee with reference to the achievement of hospital and individual objectives and to salary information from local and national comparitors. Other sub-committees cover: • Research and development • Clinical Governance/Risk Management • Complaints • Charitable Funds Clinical Governance and Risk Management Committee The Clinical Governance and Risk Management Committee is chaired by Michael Bolderston, the Chair of the Trust Board, membership includes the Chief Executive and Medical Director. The aim of the committee is to agree the plan for Clinical Governance, risk prioritisation and establish a framework to continuously improve the quality of care. The Trust operates an equal opportunities policy which opposes all forms of unlawful or unfair discrimination, including those on grounds of disability. This policy covers all aspects of employment including, recruitment, selection, training, promotion and career management. In addition, the Trust’s sickness absence policy provides guidelines and procedures for managing circumstances where an employee is unlikely to be able to return to usual duties, for example, where an employee has become disabled. Working With Our Staff The Trust is making good progress with the Improving Working Lives Standard and is involving staff in devising and implementing key initiatives. The Trust has developed policies and procedures with Trade Unions to ensure that staff are supported. The majority of staff are employed on national terms and conditions, however, those for Health Care Assistants and Support Workers are locally determined. Openness The Trust wishes to be open with you about the way the hospital is run, and all Board meetings are held in public. Details of where and when they are held are regularly advertised. We welcome comments on our publications and activities. Please feel free to contact: Jackie Daniel, Chief Executive, The Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust, Oswestry, Shropshire SY10 7AG Telephone: 01691 404358 Fax: 01691 404050 D S E U O M ÆDA DA NTE Æ Email: [email protected] Website: www.rjah.nhs.uk Annual Report 2001/02 4 Modernising Patient Services The NHS has embarked upon a decade of improvement. Over the next 10 years the delivery of care will be transformed as The NHS Plan is implemented. Care will be designed around the needs of patients and their carers. Prevention of ill health will be enhanced. Across the country, people will consistently get easy access to high quality clinical care at a time to suit them. Diagnosis and treatment that previously took weeks or months will be completed in days or even hours. Here are some examples of how we are modernising patient services across the Trust.

Local Modernisation Review A county wide project team sponsored by the Trust and spanning primary and secondary care involving frontline clinicians, a patient representative and a member of the public has been working on redesigning service delivery with the aim of “reducing orthopaedic wait times”. A project plan together with the financial implications was approved by Shropshire HIMP/LMR Steering Board. Three key areas of work were identified:- • to introduce referral protocols and an assessment framework across Shropshire. • achieving best practice in orthopaedics project. • integrated management of orthopaedic services across the Robert Jones & Agnes Hunt and Royal Shrewsbury Hospitals. From 1st April 2002 the Trust will hold the elective and outpatient contract for the West of the county for all elective and outpatient orthopaedic services. Waiting lists and outpatient referrals will also be centralised. The Royal Shrewsbury Hospital will continue to provide these services and will work closely with RJAH to improve the quality of service to patients and to maximise resources.

Providing Certainty for Patients Through “Booked Admissions” patients are offered a choice of when to attend for their admission and through “Partial Booking” they are offered a choice of when to attend for their outpatient appointment. The “third wave” reporting of the Booked Admission Programme was completed in March 2002. During 12 months of booking, 1,178 patients undergoing day case procedures were able to choose their date of admission and during 10 months some 2,316 inpatients benefited. The Modernisation Through Continuous Improvement Trust has made significant progress in improving the quality of the patients journey and a patient survey has shown that patients appreciate the chance to Patients booking their operation book their admission date. The Trust is now working alongside the Royal Shrewsbury Hospital, Princess Royal Hospital, Community Hospitals, PCTs, and GPs, to spread and improve all forms of booking, in all areas of healthcare across the county. Through improving patient access to services, giving patients choice, redesigning Patient Comment services and making booking systems the “norm” the aim is to embed “booking”, “Service extremely good.” rather than “waiting” into our culture.

Pre Operative Assessment Pre-operative assessment ensures that patients are as fit as they can be for their surgery and helps avoid abortive admissions. It enables patients to feel confident about their intended surgical treatment and post operative management and by being given information and time to ask questions minimises their anxiety. In the first 3 months of 2002 66.3% of adult orthopaedic patients had some form of assessment before admission. As well as outpatient anaesthetic assessments, we now offer 4 other methods of pre operative assessment:

D S EO U ÆD AM • Multidisciplinary Clinics, mainly for patients about to undergo major surgery. ANTE ÆD • Nurse Led Clinics for some Day Surgery Unit procedures. 5 Annual Report 2001/02 • Telephone Assessments for patients who are to be day cases or as part of health screening future inpatients. • Health Questionnaires for day cases, sometimes in conjunction with telephone assessments, and for health screening future inpatients. The introduction of telephone assessments and one stop Nurse Led Clinics for the Day Surgery Unit has aroused a great deal of interest from both Day Surgery and Pre Operative Assessment staff around the country. From this Summer, the Trust for the first time will have rooms dedicated to preoperative assessment, this small unit will be situated in the Nurses Home.

The Orthopaedic Services Collaborative The Trust participated in the 3rd wave of the Orthopaedic Services Collaborative in 2001/02. This was a quality improvement initiative which allowed the Trust to examine the potential changes that it could make in their processes and systems in order to bring about:- • Optimal outcomes • Improved patient experiences • Minimal waits and delays • Efficient use of resources A multidisciplinary team mapped the journey of patients undergoing primary hip and knee replacements and identified where improvements could be made. This resulted in better management of post operative pain; reducing preoperative delays and a trial of 7 day working for Occupational Therapists to ensure that patients are able to go home as soon as they are ready and not be delayed over the Orthopaedic Services team weekend. The work with the Collaborative has also facilitated the development of a £0.5 million project with the Trust and North East Wales NHS Trust. The aims of this project are to: • Achieve Welsh orthopaedic wait time targets for the two acute Trusts, ie by 2002/03 maximum inpatient wait of 12 months and outpatient wait of 6 months. • Develop multi professional team working with Primary Care to change demand in the medium term.

Modernisation Through Continuous Improvement • Develop a locally accessible pain relief service with reduced waiting times in line with targets set by North Wales.

Patient Comment “Excellent leaflet on forthcoming operation, everyone very helpful and understanding. Well done.” “Staff made me feel comfortable and at ease.”

Midlands Centre for Spinal Injuries – Modernisation Through Continuous Improvement 2001/02 saw the culmination of many individual’s aspirations, in the completion and occupation of the new purpose built spinal injuries centre. The opening of the new centre has given us the opportunity to fly the flag for spinal injury care and reinforce our position as an internationally renowned and respected centre. Also, and most importantly to recognise the input from many charitable trusts, local businesses, friends, patients and staff in helping us raise the money to build the new centre. The centre hosted The 18th Annual Ludwig

D S Guttmann Lecture, held in June and EO U ÆD AM ANTE ÆD Opening of the purpose built spinal injuries celebrated the official opening of the Centre in unit October. Annual Report 2001/02 6 The Guttmann Lectures gave us the opportunity to bring together colleagues from all the other centres within the United Kingdom. The lectures facilitated discussion in many areas of mutual interest, enabling the professionals within the field of spinal injury, to evaluate and compare treatments that could lead to improvement in care in other centres. The highlight of the year was the official opening of the MCSI. We were honoured to have guests from all over the world, including Mr Heber Percy, the Lord Lieutenant of Shropshire and Professor T Ikata who travelled from Japan specifically for the event, as well as Consultants from other centres past and present who had played a major role in the development of spinal cord rehabilitation. Neuromuscular Services This year the Trust was pleased to welcome Dr Quinlivan into a new full-time post as a Consultant Paediatrician. She has a speciality interest in neuromuscular disorders and is the clinical lead for this service. The muscle clinic cares for patients with genetically inherited neuromuscular disorders including muscular dystrophies, congenital myopathies, spinal muscular atrophy and hereditary neuropathies. The clinic incorporates a unique multidisciplinary team and three times a year we see patients with a rare metabolic myopathy called McArdle’s Disease. With over 30 confirmed cases on our books we are probably the largest centre in Europe. Each member of the team is a specialist in their own right. Our aim is to provide (where possible) an accurate diagnosis to enable genetic Dr Quinlivan with a patient counselling and prognosis. Thereafter, we seek to encourage independent living and quality of life for patients and their families. The combination of specialities represented, including adult and paediatric trained staff, enables more than one generation within a family to be seen in the same clinic and reduces the number of outpatient attendances for families. X-Ray A new reception area in the X-ray department was opened in September 2001 by Professor Rod Griffiths, CBE. It consists of a reception and waiting area for patients and contains a 3 metre by 1 metre aquarium containing a variety of tropical fish. Modernisation Through Continuous Improvement The area makes maximum use of natural light using roof lights providing a very pleasant waiting environment for patients awaiting imaging examinations. X-Ray reception Pharmacy This year has been a busy one for the hospital pharmacy with involvement in two government audits looking at the way medicines are used in hospitals. One of these reports “A Spoonful of Sugar. Medicines Management in NHS Hospitals” by the Audit Commission was published last December. It gave national recommendations about how medicines can be used more safely and effectively in hospitals. They also reported on how each hospital was progressing against some of the targets set out in the “NHS Plan for Pharmacy”. In the hospital’s Annual Report 2000/01, it was reported that a scheme had been started in pharmacy to meet these targets. This was completed in October 2001. The scheme allows patients to use their medication that has been prescribed by their GP, medicines are dispensed in advance of discharge and in certain areas patients can self administer their medicines. As a result of completing the “Scheme”, in the report by the Audit Commission, the hospital compared very favourably within

D West Midlands and nationally with other E S O U ÆD AM Patient discussing medicines with Senior orthopaedic hospitals against these NHS ANTE ÆD Pharmacy Technician Plan objectives. 7 Annual Report 2001/02 Modernising Non Clinical Support Services Modernisation is happening in all areas of the Trust including

Hotel Services Once again 2001 has been a very busy, productive and successful year for the Hotel Services Department.

Domestic Services and Patient Patient Comment Environment Action Team “Good domestic Staff.” (PEAT) The Trust received an unannounced inspection of its patient environment in 2001 and was awarded “Green” status. This has recently been maintained and improved upon in 2002, due in no small part to the hard work and dedication all the domestic services staff who ensure high standards of cleanliness. It is also due to the long standing co-operation that the Hotel Services Department enjoys with the nursing staff throughout the organisation.

Catering Services The department has implemented the NHS Plan, “Better Hospital Food” standards, which includes 24 hour catering services, snacks available throughout the day and an improved ward kitchen service. The department has also implemented major changes in its patient and meal services. Patients now enjoy a hostess service on the wards where meals are served from hostess trolleys by catering assistants thus improving the “meal experience” and ensuring the quality of food is improved Delivering meals to the patients upon at the point of service. The excellent standard of catering services provided at the Trust was noted during the PEAT inspection in March 2002.

Modernisation Through Continuous Improvement Improving Efficiency with E-Business EROS – Electronic Requisition Ordering System The Trust has introduced electronic requisitioning in order to improve the procurement process. The new system will reduce paper work and enable the Trust to Making use of EROS monitor non pay expenditure more effectively.

The Institute Library The Francis Costello Library, Institute of Orthopaedics, continues to support clinical governance and evidence based health care by providing all Trust staff with equal access to its services. During 2001/2002, the library has offered training in internet and database searching skills in clinical areas around the hospital, as well as in the library IT room, made possible by increased computer provision in wards and departments. Marie Carter, the Health Services Librarian won the 2001 Chairman’s Award in recognition of significant contribution to the work of the Trust during its

D S centenary year. Over 900 copies of her book on the EO U ÆD AM ANTE ÆD history of the hospital, “Healing & Hope”, have so far Marie Carter with the been sold worldwide. Chairman’s Award certificate Annual Report 2001/02 8 Involving Patients and the Public Involving the public and patients in care, treatment, and service planning and delivery is an NHS priority and central to service planing and provision. It is a major driver for service improvement and leads to a better patient experience of care. The Trust is committed to public and patients involvement and there is public representation on the Trust Board and Clinical Governance/Risk Management Committee and patient and public representation on the Local Modernisation Review Project Group. In November 2001, an audit was undertaken to Patient Comment assess whether inpatients were satisfied with the service they received at this Trust, and whether “Excellent in every way.” there were any areas for improvement form the patients’ perspective. The comments made showed that the patients believe that the Trust is an excellent facility with high quality care. Great praise was received for the nursing staff. The results of this audit were published in the Trust Patient Comment Brief and presented to the Ward Managers at their monthly meeting where an action plan was drawn “Toilets and showers could up to respond to the recommendations in the audit do with more attention.” which involved improving the environment in some of the ward areas. A survey of patients attending the nurse led booked admission clinic found that 100% of them reported that: • It was a beneficial to book their date. • It was convenient to have an assessment on the same day as their outpatient appointment. • The amount of written/verbal information they received was just right. • They were given the chance to ask questions, and were answered so that they understood. • That the environment and staff in the day surgery unit were welcoming, pleasant and friendly. Occupational Therapists are increasing their attendance at pre-operative clinics following the results of a patient survey. Patients said they found it very helpful to be able to discuss their concerns and talk over modifications they will need to make at home following surgery. Another survey found that patients also found it helpful to have their specialist equipment before surgery as this helped them with problems they were already having with mobility. Modernisation Through Continuous Improvement Patient Comment “Very helpful – allowed me to rearrange furniture at home, kitchen equipment, etc.” “It meant I could try and adapt the do’s and don’ts beforehand.” Occupational Therapist with Rheumatology patient An Age Concern conference was organised by the Rheumatology Nurse Specialist in November 2001. Dr Dixey (Medical Director) delivered the key note speech and the event was organised in conjunction with patients and arthritis care members. Four patients talked about their experience of living with arthritis. Also following feedback from patients, patient education sessions on the Rheumatology Unit have been remodelled. The Midland Centre for Spinal Injuries Occupational Therapists organised a Mobility Information Day aimed at both past and present patients and it was also open to the public. It was supported by local organisations and businesses and Dr Dixey at the Age Concern there were a number of cars with ramps, wheelchair conference lifts and adapted controls for people to see. PALS (Patient Advise and Liaison Service)

Integral to involving the public and patients will be the Patient Advice and Liaison Service D S EO U ÆD AM (PALS) which will provide information to patients, their carers and families and help them ANTE ÆD resolve problems and concerns quickly before they become more serious. 9 Annual Report 2001/02 In 2001/02 the Trust consulted with the voluntary organisations and patients within the Trust regarding the development of its PALS service. Their views and those of the CHC on the Patient and Public Involvement Strategy have been used in the plans to develop both the service and the strategy.

Clinical Leadership This year leadership development through Shropshire’s Clinical Leadership Programme and LEO (Leading and Empowered Organisation) across the Trust has continued to gain momentum and become increasingly multidisciplinary to include Doctors. One of the interventions used in the Shropshire Clinical Leadership Programme is Patients’ stories. Participants will interview a minimum of 6 patients over the period of the programme. The aim of the audio taped interviews is for the patient/client to talk about the experiences of care they have received. From the results, participants draw up an action plan indicating opportunities for improvement and also provide evidence of where and when services meet patient/client needs. Specific actions to address the opportunities for improvement have included: • The identification of a quiet room with no television or radio, for patients wanting to get away from noisy bays. • For patients feeling institutionalised, an agreement to include activities outside the hospital in patients’ rehabilitation programmes. • Reviewing visiting times to accommodate relatives who have to travel great distances. • To discuss with anaesthetists the possibility of having more choice regarding what pre- medication is prescribed. • To ease the loneliness and isolation of being barrier nursed by having flexible visiting times.

CLINICAL GOVERNANCE There are many systems of steps and procedures adopted by the Trust to ensure that patients receive the highest possible quality of care, examples of which are highlighted here. The Trust developed a Learning and Education Strategy during the year which was formally adopted by the Trust Board in January 2002. This emphasises the Trust’s commitment to Continuing Professional Development and lifelong learning with particular reference to supporting clinical governance within the hospital. The Trust is

Modernisation Through Continuous Improvement developing strong links with the Workforce Confederation to ensure that development opportunities are available to staff of all disciplines and is actively promoting the Individual Learning Account Scheme. Clinical Risk Management Clinical Risk Management involves clinicians, managers and health care provider organisations in identifying the circumstances which put patients at risk of harm and then acting both to prevent and control those risks. A set of Clinical Risk standards have been developed by the Clinical Negligence Scheme for Trusts (CNST). The CNST was established by the National Health Service Executive in 1994, to provide a means for Trusts to fund the cost of Clinical Negligence litigation and encourage and support effective management of claims and clinical risk. The NHS Litigation Authority (NHSLA), a special health authority administers the scheme. The Trust was assessed against the CNST standards during February 2002, and was successful in securing level 2 accreditation for the second time. (First accreditation March 1999). The assessment takes the form of an external review by CNST staff who visit the Trust to check that the standards are met calling on a range of documentary and other evidence to measure compliance. CNST reported that the Trust had worked hard to ensure clinical risk management processes were in place and acknowledged the obvious commitment throughout the organisation to ensure safe practices were maintained. Evidence of good practice throughout all of the standards was confirmed together with recognition of the excellent training initiatives for all staff. The accompanying process and inspection against CNST standards has been an important driving force for the development of Clinical Risk Management within the Trust.

D S EO U ÆD AM ANTE ÆD The Trust is to be assessed against the CNST highest level standard 3 during the autumn of 2002. Annual Report 2001/02 10 Complaints and Compliments From 1st April 2001 until 31st March 2002, the Trust received 47 written complaints. The standard for complaints acknowledged within two working days was achieved at 100%. 93% of complaints received a full written response within the 20 working day national standard with interim responses explaining delay or a progress update being sent to the remainder. 43 were resolved locally, and 4 requested independent review of which 1 request has been referred to an independent panel – result awaited at publication date; of the 3 cases requesting independent review 1 case was withdrawn, 1 case requested financial compensation and 1 was referred back to the Trust for local resolution. The number of complaints upheld for this year was 17 with changes in practice actioned where it has been appropriate. These have included the following: • Post-procedural check has been introduced to include a minimum of one check on all patients who are attending the Xray Department for investigations such as barium enemas. Patient will be kept under review if there is any concern over their condition. • Sound proofing of consultation rooms in the Xray Department to be undertaken to ensure patient confidentiality is maintained. • Review system of cancelled patients appointments in an attempt to avoid repetitive cancelling of the same patient’s appointment. • Review of discharge planning process to ensure family members are more involved in the process. Patient Appreciation Over the past year, 661 letters of appreciation, cards and gifts were recorded as being received by wards and departments. Comment cards are made available to patients to give them the opportunity to provide their comments and/or suggestions after their stay in hospital and 117 comment cards were received. The majority of cards received were very complimentary about all hospital staff, the food, ward environment and cleanliness. Any comment card received which raised an issue, was copied to the relevant ward/manager. Positive Comments Issues Raised Food was superb Unable to find car parking space Wonderful team spirit Poor visitors accommodation If it hadn’t been for the op, I could have been Bedside lockers were too small – lack of on holiday storage space Truly a centre of excellence Ward was too hot Modernisation Through Continuous Improvement

Research The Trust’s Research activities received an excellent report from the Commission for Health Improvement when they visited this year. Specially commended was the annual research open event when patients and other members of the public have an opportunity to see the many topics of musculoskeletal research which are underway. The Centre for Spinal Studies has been particularly successful this year in attracting external funding Opening of Lynne Murphy Laboratory for further development of tissue engineering approaches to the treatment of disc degeneration. April saw the opening of the Lynne Murphy Laboratory, named after the benefactor whose generosity facilitated it and with a Eurocell project on autologous cartilage transplantation being supported by EU Framework 5 funding, the space will be needed. The Commission for Health Improvement (CHI) Clinical Governance Review A clinical governance review was undertaken at the Trust between July and October 2001. During the review week in October 2001, CHI looked at clinical governance arrangements in three clinical teams:

D Orthopaedic Paediatric Services E S O U ÆD AM Medical Services ANTE ÆD Arthroplasty (elective hip and knee replacements) 11 Annual Report 2001/02 The staff at the Trust were praised for the hospital’s good clinical record. CHI were impressed by several of the Trust’s projects including the excellent electronic patient records and research open days to inform the public about the Trust’s work. Other key points included: • The Trust involves patients in their treatment but needs to involve the public more when developing services. • Clinical Audit needs additional resources and a more robust framework An action plan has been developed which will address the areas for development which CHI found within the Trust. This action plan will be monitored by the Trust Board and Strategic Health Authority over the next couple of years. A copy of the report and action plan can be obtained from the Chief Executive’s office.

National Clinical Standards In 2001/2002 the Trust has taken steps to ensure compliance with the National Clinical Standards which are applicable to the services it offers. These have included progress on: National Service Frameworks (NSFs) NSFs are a way of setting standards that will achieve greater consistency in the availability and quality of services for a range of major care areas and disease groups. The aim is to reduce unacceptable variations in care and standards of treatment, using best evidence of clinical and cost effectiveness. Cancer Services The National Health Service Cancer Plan (Department of Health 2000) sets out a national cancer programme for England and this is reflected in the services provided by the Trust which include:- • A specialised and focused service for the diagnosis and treatment of primary and secondary tumour of the bone and soft tissue • A specialised and focused service for site specific bone metastasis The West Midlands Cancer Peer Review Team performed a review of the cancer service in January 2002 and praised the Trust for the organisation of care of cancer patients. Older People Modernisation Through Continuous Improvement The National Service Framework for older people aims to ensure fair, high quality, integrated health care services for older people. It is a ten year programme, linking services to support independence and promote good health, specialist services for key conditions, and culture change so that all older people and their carers are always treated with respect and dignity. The Robert Jones & Agnes Hunt Orthopaedic and District Hospital NHS Trusts aim is to enhance existing local services and is collaborating in an interagency county wide mapping process, which includes users. A local implementation team has been formed within the Trust focussing on: • Rooting out age discrimination • Intermediate care • General hospital care • Falls NICE Guidance NICE (National Institute for Clinical Excellence) is a special health authority for England and Wales, and is part of the NHS. Its role is to provide patients, health professionals and the public with authoritative, robust and reliable guidance on current “best practice”. The guidance covers both individual health technologies (including medicines, medical devices, diagnostic techniques, and procedures) and the clinical management of specific conditions. As well as technology appraisals NICE also produces clinical guidelines to help health professionals and patients make the right decision about care in specific clinical circumstances. To date NICE have published 43 technology appraisals and 6 clinical guidelines. The Trust

D has a process in place to review all the appraisals and guidelines published by NICE and to S EO U ÆD AM ANTE ÆD decide on how it is going to implement the guidance, 5 of which have been applicable, most notable of which is the guidance on hip prosthesis. Annual Report 2001/02 12 NHS PLAN TARGETS – How have we done? The NHS Plan aims to make the NHS meet patients needs better. In 2001/02 we have achieved 3 of the standards which are a priority to the Trust and made significant progress on Patient Booking. Access 100% of Trusts to reduce the number of 12 month inpatient waiters and implement a maximum waiting time of 15 months. This standard has been achieved since November 2001. Outpatients To reduce the number of over 13 week waiters and implement a maximum waiting list of 26 weeks by March 2002. This target has been achieved. Emergency Care By March 2002 75% of patients attending A & E to wait 4 hours or less from arrival to admission, transfer or discharge. The Trust meets this target in the Minor Injuries Unit. Patient Booking All Trusts with outpatient waiting times greater that 13 weeks using partial booking for two specialities. Currently 21% of patients are booked manually with an increase to 50% by April 2002.

Future Developments Redevelopment of the Estate A key theme of the NHS Plan is to improve the patient’s journey by ensuring treatment

takes place in an appropriate environment. This, together with the need to expand the Modernisation Through Continuous Improvement elective surgery capacity of the hospital, is an ideal opportunity to plan the major redevelopment of the site. By careful consideration of levels of clinical activity and introducing new models of care, the building blocks of how the hospital should be configured can be established. A Development Control Plan is being evolved which sets out the physical shape of the future hospital. The major components of the Development Control Plan include the following new buildings: • Operating theatre suite and surgical beds • Diagnostic and Treatment Centre including Day Case Theatres, Pre Operative Assessment Suite and Ambulatory Care Centre • Radiology Centre It is anticipated that the above will be funded by public devolved monies. In addition to this the Trust has a successful track record in developing buildings through charitable funds/donations/grants and a further number of schemes are planned utilising such resources, including: • Therapeutic Swimming Pool • TORCH Paediatric Assessment Centre • Spinal Injuries Phase II The proposals for site development further include the opportunity to expand private patient facilities within a new stand alone building, funded by private investment.

TORCH

D S EO U ÆD AM In 2002, an appeal to raise £4 million was launched to create a unique facility for fully ANTE ÆD assessing and treating children with mobility problems. 13 Annual Report 2001/02 The Robert Jones & Agnes Hunt Orthopaedic & District Hospital NHS Trust is already one of the leading treatment centres in the UK for children with cerebral palsy, muscle diseases and orthopaedic disorders. This needs to be developed further to incorporate: • A dedicated childrens’ investigations unit • Improved facilities for parents and children with overnight accommodation, a garden and a soft play area. • A specific research team led by a specialist in paediatric care. A patient using the new facility • A multi-disciplinary assessment team setting rehabilitation goals. • An integrated clinical/engineering facility. Through research, we will widen the care we provide and improve our knowledge to treat these children more effectively. The hospital already has a purpose built childrens’ ward and dedicated outpatient facility along with an internationally known gait assessment laboratory. The new research facilities, will complement our existing unit and includes the following new areas: • A dynamic Electromyography (EMG) laboratory for assessing muscle activity during walking. • A physiological measurement laboratory, a neurophysiology suite, a treadmill, a moveable force platform and a muscle research laboratory. • A posture and balance laboratory. • A holistic therapy centre for evaluating Riding for the Disabled, lycra suit technology, reflexology etc. • A “hands on” indoor and outdoor gardening area. • A “snoezelen” room to improve sensory perception in children and adolescents. • A centre for developing the use of information technology for improving mobility. To improve our existing facilities we will add: • Family rooms and facilities for children who have a distance to travel to the Centre.

Modernisation Through Continuous Improvement • Information Technology as an information resource for children and parents, and an education centre. • A safe children’s play area • Multiple-use paediatric therapy rooms. • Gymnasium suitable for children • Updated monitoring equipment Department of Care of Elderly Medicine The publication of the National Service Framework (NSF) represents a milestone in the development of services for older people. This document sets out a set of national standards of care by which older people themselves can gauge service effectiveness. The NSF is focussed upon the needs of a group where services are provided across a range of health and social settings as well as by a variety of statutory and independent (voluntary and private providers). The goal of the NSF is the promotion of a fair, high quality, specialist service that will interlink health and social care in order to meet the needs of the older person.

An outline business case has been developed for investment in the Department of Care of Elderly Medicine at the Trust. It considers the opening of a “stroke unit” on Sheldon Ward, extension of the “Rapid Response” to a seven day service, screening for osteoporosis and developing a multi- disciplinary out reach team to result in a significant

D E S improvement in the quality of healthcare for older O U ÆD AM ANTE ÆD people in the local community. This business case Elderly patients doing Tai Chi will be further developed during 2002/03. Annual Report 2001/02 14 Clinical Activity 2001/02

Speciality Inpatients/ Outpatients Daycases

Trauma and Orthopaedic:

Hip, knee and ankle surgery 3,969 13,867 Key Information Paediatrics 703 4,605 Spinal surgery 733 4,439 Shoulder, elbow and hand surgery 1,707 6,770 Sub total 7,112 29,681 Casualty 1,001 5,531 General Medicine 391 8,407 Spinal injuries 516 1,541 Rheumatology 294 4,280 Care for the elderly 288 5,239

TOTAL 9,602 57,247

D S EO U ÆD AM ANTE ÆD

15 Annual Report 2001/02 Financial Performance 2001/02

As a NHS Trust, the hospital has three statutory financial duties to achieve. These are shown in the table below. The hospital achieved all its financial duties in 2001/02.

Statutory Target Achieved Duty

Balance Income & –9 Balance Expenditure (Underspend)

Achieve External

Finance Report 1585 1585 Financing Limit

Achieve Capital 6% 6% Absorption Rate

We are also measured on how many bills we pay within 30 days – we achieved 85% in 2001/02. The hospital generated over £35 million in income in 2001/02, an increase of 11% on the previous year. Of this income, £20 million, or 57% relates to pay costs. For every pound spent the breakdown is as follows: Nursing Costs 21p Medical Staff 18p Clinical supplies (Drugs, Dressings, Implants) 20p Therapy and Scientific staff 13p Premises costs (Fuel, Rates, Maintenance, Telephones, Postage) 7p Administrative and Clerical staff 5p Healthcare assistants/Support staff 6p Depreciation 6p General supplies (Food, Linen, Uniforms) 2p Senior and general managers 2p To develop the hospital facilities, the Trust received £2 million this year for Capital Expenditure, ie buildings and equipment. In 2001/02 the Trust used these resources to make improvements to the hospital environment. We are also indebted to the high level of donations made into our charitable funds each year which further enables us to improve the facilities for patients, staff and visitors. As a hospital we also benefit from the considerable fund raising undertaken by volunteers. During 2001/02 the Trust negotiated an additional £300,000 non-recurring income from Shropshire HA for the additional costs of expensive prostheses. Without this amount, the Trust would not have met its breakeven duty. Future Break-even Position In June 2002, the Board approved a balanced budget for the Trust, including the need to make financial improvements of £2m. This is a significant target for the Trust, representing 5.7% of Turnover, which has arisen for the following reasons:– £000s Host purchaser contract adjustment 766 OATs Contract adjustment 306 Purchaser cash releasing efficiency requirement 395 Internal Cost Pressures_____ 533 Total 2,000_____ The Trust has identified the following actions to address this situation:– Classification as capital expenditure 200 Maximisation of use of charitable funds 100 Operating surplus from sale of spare capacity 800 Cost reduction programmes_____ 478 1,578_____ Schemes yet to be identified_____ 422 Total 2,000_____ D S EO U ÆD AM ANTE ÆD The Trust has established a financial Improvement Board, which is tasked with identification of the balance, and performance monitoring of the other schemes. Annual Report 2001/02 16 Income and Expenditure Account

2001/02 2000/01 £000 £000

Income from activities: Continuing operations 31,127 27,456 Other operating income 4,427 4,621 Operating expenses: Continuing operations (34,102) (30,672)

Operating surplus Continuing operations 1,452 1,405 Exceptional Gain: on write-out of clinical

negligence provisions 2,166 0 Finance Report Exceptional loss: on write-out of clinical negligence debtors (2,166) (0) Cost of fundamental Reorganisation/restructuring 00 Profit (loss) on disposal of fixed assets 00

Surplus before interest 1,452 1,405

Interest receivable 32 34 Interest payable 00

SURPLUS FOR THE FINANCIAL YEAR 1,484 1,439 Public dividend capital dividends payable (1,475) (1,439)

RETAIN SURPLUS (DEFICIT) FOR THE YEAR 90

Balance Sheet

31/03/02 31/03/01 £000 £000

Fixed assets Intangible assets 00 Tangible assets 30,590 30,216

30,590 30,216 Current assets Stocks 1,341 1,350 Debtors 2,078 3,372 Cash at bank and in hand 38 63 3,457 4,785

CREDITORS: Amounts falling due within one year (2,510) ( 3,134)

Net current assets/(Liabilities) 947 1,651

Total assets less current liabilities creditors: 31,537 31,867 Amounts falling due after more than one year PROVISIONS FOR LIABILITIES AND CHARGES (25) ( 1,835)

TOTAL ASSETS EMPLOYED 31,512 30,032

FINANCED BY: CAPITAL AND RESERVES Public dividend capital 22,813 21,228 Revaluation reserve 3,204 2,942 Donation reserve 5,104 5,480 Income and expenditure reserve 391 382

D S EO U ÆD AM ANTE ÆD TOTAL CAPITAL AND RESERVES 31,512 30,032

17 Annual Report 2001/02 Cash Flow Statement

2001/02 2000/01 £000 £000

OPERATING ACTIVITIES

Net cash inflow from operating activities 1,611 2,631 Returns on Investments and Servicing of Finance Interest received 32 34 Interest paid 00 Finance Report Interest element of financial leases 00

Net cash (outflow) from returns on Investments and servicing of finance 32 34

CAPITAL EXPENDITURE

Payments to acquire fixed assets (1,753) (1,353) Receipts from sale of fixed assets (Payments to acquire)/ Receipts from sale of intangible assets 00

Net cash inflow (outflow) from capital expenditure (1,753) (1,353)

DIVIDENDS PAID (1,475) (1,439)

Net cash inflow (outflow) before Management of liquid resources and financing (1,585) (127)

FINANCING Government loans repaid – Long term

Net cash inflow/(outflow) from financing 1,585 77

Increase (decrease) in cash 0 (50)

Statement of Recognised Gains and Losses

2001/02 2000/01 £000 £000

Surplus (deficit) for the financial year before dividend payments 1,484 1,439

Unrealised surplus (deficit) on fixed asset re-valuations/indexation 305 396

Increases in the donation reserve Due to receipt of donated assets 31 1,194

Change in donation reserve in depreciation, of profit/loss on disposal of donated assets (450) (431)

Additions/reductions in “other reserves” 00

Total recognised gains and losses for the financial year 1,370 2,598 (prior period adjustment) 00

D S E U O M Total gains and losses recognised ÆD A ANTE ÆD in the financial year 1,370 2,598

Annual Report 2001/02 18 Details of Remuneration paid to Directors 2001/02

Real increase Total accrued Other in pension pension at age 60 Salary Remuneration Golden Hello/ at age 60 at 31/3/2002 (bands of (bands of compensation Benefits (bands of (bands of £5000) £5000) for loss of office in kind £2500) £5000) Name and Title Age £000 £000 £000 £000 £000 £000

Michael Bolderston 58 17 0 0 00 0 Chairman

Jo Cubbon 42 82 1 11 11 Finance Report Chief Executive Josh Dixey 46 17 0 5 Medical Director Sandra Buckley 57 2 13 17 Director of Operations (Consent to disclose age withheld) Wendy Farrington 12 Director of Finance Andy Robinson 42 21 2 2 Director of Finance Nonna Woodward 54 5 Non-Executive Director Peter Jones 56 5 Non-Executive Director Angela Vint 40 6 Non-Executive Director Ian Lucas 1 Non-Executive Director Sarah Biffen 3 Non-Executive Director

Benefits in kind includes cars. The Trust has complied with the Chief Executive of the NHS “Executives” letter of 9 April 2001 regarding NHS Managers’ pay in 2001/02. During the year none of the Board members or members of the management staff or parties related to them has undertaken any material transactions with Robert Jones & Agnes Hunt Trust.

2001/02 2000/01 Management Costs £000 % of income £000 % of income

Total trust income 35,584 32,212 Management costs 1,306 3.67% 1,222 3.79%

D S EO U ÆD AM ANTE ÆD

19 Annual Report 2001/02 Statement of Better Payment Policy Better Payment Code – Measure of Compliance

The NHS Executive requires that Trusts pay their non NHS trade creditors in accordance with the CBI prompt payment code and Government Accounting rules. The target is to pay non NHS trade creditors within 30 days of receipt of goods or a valid invoice (whichever is the later) unless other payment terms have been agreed with the supplier. The measure of compliance is:

2001/02 2000/01 Number £000 £000

Finance Report Total bills paid 22,742 11,236 9,585 Total bills paid within target 19,307 9,088 9,131 Percentage of bills paid within target 84.90% 80.88% 95.26%

The Trust has received no complaints regarding failure to pay on time, and has incurred no charges under The Late Payment of Commercial Debts (Interest) Act 1998.

Signed: Jackie Daniel, Chief Executive Date: August 2002

Signed: A. Robinson, Finance Director Date: August 2002

Auditors Report on the Summary Financial Statements I have examined the summary financial statements set out on pages 16 to 19. Respective responsibilities of directors and auditors The directors are responsible for preparing the Annual Report. My responsibility is to report to you my opinion on the consistency of the summary financial statements with the statutory financial statements. I also read the other information contained in the Annual Report and consider the implications for my report if I become aware of any misstatements or material inconsistencies with the summary financial statements. Basis of opionion I conducted my work in accordance with Bulletin 1999/6 “The auditor’s statement on the summary financial statements” issued by the Auditing Practices Board for use in the United Kingdom. In forming our opinion, I have considered the adequacy of the disclosures made on page 16 of the financial statements concerning the uncertainty as to the ability of the Trust to meet its statutory financial obligations and consequently on its ability to continue to operate in its current configuration. In view of the significance of this uncertainty I consider that it should be drawn to your attention but our opinion is not qualified in this respect. Opinion In my opinion the summary financial statements are consistent with the full financial statements of the Trust for the year ended 31st March 2002 on which we have issued an unqualified opinion.

Signed: Date: August 2002 Andrew Laird 1 Friars Gate, 2nd Floor, 1011 Stratford Road, Solihull, B90 4EB

The Board acknowledges and accepts its responsibility for maintaining a sound system of internal control including risk management, and for reviewing its effectiveness. As part of the NHS Controls Assurance Project, I as Chief Executive confirm that the year ending 31st March 2002, and in accordance with NHS Executive circulars HSC 2001/005 and HSC 1999/123 and supporting guidance, the Board has reviewed and endorsed an action plan resulting from an organisation wide self assessment against relevant risk management and organisational control standards produced by the NHS Executive. The Board will oversee implementation of the action plan.

D S EO U ÆD AM ANTE ÆD Signed: Chief Executive Date: August 2002 Annual Report 2001/02 20 Statement of Internal Control

The board is accountable for internal control. As Accountable Officer, and Chief Executive Officer of this Board, I have the responsibility for maintaining a sound system of internal control that supports the achievement of the organisation’s objectives, and for reviewing its effectiveness. The system of internal control is designed to manage rather than eliminate the risk of failure to achieve these objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing risk management process designed to identify the principal risks to the achievement of the organisation’s objectives; to evaluate the nature and extent of those risks; and to manage them efficiently, effectively and economically. The system of internal control is underpinned by compliance with the requirements of the core Controls Assurance standards:

• Governance Internal Control • Financial Management • Risk Management (Risk Management System standard for 2001/2002) I plan to have the necessary procedures in place by the beginning of the financial year 2003/2004 necessary to meet the Treasury guidance. This takes into account the time needed to fully embed the processes into the organisation that the Board has agreed. The actions taken so far include: • The organisation has undertaken a self-assessment exercise against the core Controls Assurance standards (Governance, Financial Management and Risk Management). • An action plan has been developed and will be implemented to meet gaps in Core Controls Assurance Standards. • The NHSLA have assessed the Trust against the new Risk Pooling Scheme for Trusts Risk Management standard and the Clinical Negligence Scheme for Trusts. The Trust was awarded level 2 in CNST. In addition to the action outlined above, in the coming year it is planned to further develop strategies to improve governance and internal control. This will include: • Review of management and committee structure to improve accountability at all levels in the organisation. • Develop robust links with PCT/Strategic Health Authority and integrate their requirements into Trust Objectives. • Review accountability to strengthen internal financial controls. • Review the incident reporting and investigation procedure and implement appropriate changes. • Risk awareness training for all levels of staff, covering Risk and Financial aspects of Governance. • Introduction of a single risk-grading tool linked to the requirement of the National Patients Safety Agency.

As Accountable Officer, I also have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control has taken account of the work of the executive management team within the organisation who have responsibility for the development and maintenance of the internal control framework, and the work of the internal auditors. I have also taken account of comments made by external auditors and other review bodies in their reports.

Signed: Jackie Daniel, Chief Executive Officer Date: August 2002

(On behalf of the board)

D S EO U ÆD AM ANTE ÆD

Annual Report 2001/02 D S EO U ÆD AM ANTE ÆD

The Robert Jones & Agnes Hunt Orthopaedic & District Hospital NHS Trust

Oswestry, Shropshire SY10 7AG Tel: 01691 404000 Fax: 01691 404050 Website: www.rjah.nhs.uk