Annual Report and Accounts 2011/12
Bolton NHS Foundation Trust Annual Report and Accounts 2011/12
Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) of the National Health Service Act 2006
Contents
1 Foreword 7
2 Directors’ Report 11
3 Remuneration report 18
4 Disclosures for NHS Foundation Trust Code of Governance 21
5 Quality Report 33
6 Staff Survey 92
7 Regulatory Ratings 96
8 Other Public Interest Disclosures 97
9 Statement of Accounting Officer’s Responsibilities 105
10 Annual Governance Statement 106
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Bolton NHS Foundation Trust Annual Report and Accounts 2011/12
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Bolton NHS Foundation Trust Annual Report and Accounts 2011/12 1 Foreword
1.1 Chairman’s Welcome
The year 2011/2012 saw a considerable change to us as an organisation as in July 2011 we welcomed staff and services based in the community to our Trust. This integration has been a major undertaking, occupying a great deal of time in planning and implementation. We are now beginning to see benefits for both staff and patients as we are able to reduce “barriers” and offer more streamlined care.
The hard work and innovation of our staff was recognised locally, nationally and internationally throughout the year with a string of finalists and winners in a range of awards. In particular the use of our Bolton Improving Care System (BICS) to bring increased quality at the same as reducing inefficiencies has attracted a great deal of positive attention. Our staff have demonstrated that they truly care for our patients, constantly seeking to bring improvements for them in particular by reducing mortality rates and improve their experiences of health services.
On the other hand there can be no denying that we failed to meet two key targets, notably the target for admitting, discharging or transferring 95% of patients at A and E within four hours, and also the 18 week inpatient target for referral to treatment. As a result of this, and not being able to assure Monitor that our remedial actions were timely or that our Board oversight was robust enough. In April 2012 we were found in significant breach of our authorisation as a Foundation Trust. This is something the Board took and continues to take extremely seriously. We are aiming that by the time this report is presented at our annual meeting in September we will be well back on track and sustaining an improved performance.
This report therefore shows the highs and lows of the very busy year we had.
Finally, I would like to take the opportunity to thank our staff, Governors, Board and indeed our patients and all our partners for the support they have shown the Trust.
I would particularly like to thank Roger McMullen who retired as a Non‐Executive Director at the end of March 2012 and Yaseer Ahmed who retired at the end of October 2011 for the time and attention they gave to Trust matters.
Cliff Morris Chairman Bolton NHS foundation Trust
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Bolton NHS Foundation Trust Annual Report and Accounts 2011/12 Page 1 Foreword
1.2 Chief Executive’s Welcome
2011/12 was my first full year as Chief Executive of the Trust and it was certainly a year of challenge and change.
As the Chairman has observed, the most serious part came right at the end of the year when, having failed to meet important patient waiting time targets, we were unable to assure Monitor, our regulator of the Board’s timely focus on performance and Board governance and we were found to be in significant breach of our authorisation as a Foundation Trust. When we identified the likelihood of missing the targets we put into place a series of measures to strengthen both the Trust’s performance and the Board’s governance arrangements but this should have happened much sooner. Further measures, such as the appointment of KPMG to review governance have been put in place since we were found in significant breach. As is their standard practice, Monitor has kept us at a red rating until we can demonstrate that both performance and governance meet the expectations and standards of our licence to be a Foundation Trust. The Board and I are determined to do this.
In April further issues arose regarding our year end accounts which also put in question the robustness of the reporting to the Board on financial issues this has significant implications to the financial stability within the organisation and at the time of writing this report we have identified a year end deficit of £1.9 million rather than forecasted surplus. Again the Board will ensure an external review and a turnaround plan is immediately put in place.
Missing targets for A and E waits and for the 18 week inpatient referral to treatment are failures of important patient guarantees and lead to a poor patient experience. There are, however, other areas where the Trust did well, particularly in improving safety and quality of care. In particular in reducing mortality rates, falls and pressure sores and in infection control and, as the Chairman has said in his introduction, the high number of awards Trust staff won in the year is testament to a commitment to improve and innovate and have high calibre staff working here.
I’d like to pay tribute to all our staff. They worked hard caring for high numbers of sick patients against a background of national change in the NHS and the integration of community and hospital services last summer. On top of this there were changes in organisational structure and changes in location for many. As well as integrating with our community services in a major project we welcomed staff from Salford and Bury as part of the Making It Better programme which has seen us become a major centre for maternity and children’s services.
It is a credit to the staff, their team leaders and managers, and to our corporate team that at a time of such change the Trust had its best ever results in the national staff survey.
The results of this and other surveys, and information on our performance can be found in the pages of this annual report.
Lesley Doherty Chief Executive 31st May 2012
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Bolton NHS Foundation Trust Annual Report and Accounts 2011/12 Page 1 Foreword
1.3 Trust Profile Bolton NHS Foundation Trust became an integrated care organisation on 1st July 2011. We provide patient care in the community at health centres and clinics as well as services such as school nursing, district nursing and health visiting. We also provide services at the Royal Bolton Hospital. Our vision is to develop the organisation and aim to match the best integrated care organisations internationally for the quality and efficiency of our services by 2016. Our renewed focus will give us three fundamental aims:‐ • Best care for better health (for our patients and our community). • Responsible use of resources (for the taxpayer). • Valued, respected and proud (for our staff, patients and public). Our strategic direction will be to address:‐ • Meeting the health needs of our population. • Improving the safety and quality of care. • Improving the patient’s experience. • Making our services more efficient. • Serving the population of Bolton (around 263,000) and many patients choose to come here from other locations. Facts and figures • RBH is one of the busiest hospitals in the North West for emergency admissions. • RBH has 622 inpatient beds, 36 day case beds and 15 endoscopy (gastrointestinal exploration) beds. • We employ around 5,700 staff. Mental health services are provided on the Royal Bolton Hospital site but are managed by Greater Manchester West Mental Health NHS Foundation Trust. Renal dialysis is provided and managed by Salford Royal NHS Foundation Trust at a dedicated unit at the Royal Bolton Hospital. Making it Better In 2011, the Royal Bolton Hospital became a regional 'supercentre' for the care of women, children and babies with a £20 million investment in services. We have expanded and improved our facilities to create a centre of excellence in maternity, paediatric and neonatal care. Work includes an improved maternity unit, a new children's ward and a new neonatal critical care unit. We have also invested in around 400 extra members of staff to provide the very best care for our patients.
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Bolton NHS Foundation Trust Annual Report and Accounts 2011/12 Page 1 Foreword
1.4 Achievements
Our departments and staff hold a wide range of awards and achievements. These include:
• Excellence in HRM Award 2011 ‐ Healthcare People Management Association. • Clinical Leader of the Year 2011 ‐ British Medical Journal Group Awards. • Nurse of the Year 2011 ‐ Nursing Standard Awards. • North West Clinical Leader of the Year ‐ NHS North West Awards. • Best Process Improvement Project in Service & Transaction 2011 ‐ National Process Excellence Awards. • Hospital Catering Award 2010 ‐ Health Business Awards. • Diamond Care Award for Best Care ‐ NHS Bolton. • Patient Safety in Surgery ‐ National Patient Safety Awards 2011. • Apprentice of the Year 2011‐ NHS North West. • Working in Partnership to Narrow the Gap in Health Inequalities ‐ Community Empowerment Awards 2011.
1.5 Quality Governance
The Directors used Monitor’s Quality Governance Framework to assess its processes and gain assurance that it has and will keep in place effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients.
Further details on quality can be found within the quality section (page 34) and in the Annual Governance Report (page 107)
Although the Trust was found to be in significant breach of its terms of authorisation in March 2012, the Board at all times were assured with regard to the quality and safety of care provided to patients. This view is supported by information provided by the Care Quality Commission and other information on serious untoward incidents, complaints and patient safety.
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2.1 Business Review – 2011/12
Introduction The review which follows considers the financial performance of the Trust for 2011/12. The Accounts included within this report have been prepared under a Direction issued by Monitor. Main Sources of Income Bolton NHS Foundation Trust, in common with all NHS Hospital Trusts receives by far the majority of its income from providing patient care services. These are paid for by Primary Care Trusts who receive an allocation of funds directly from the Department of Health. Table one below provides an analysis of income in 2011/12 and compares this to 2010/11 financial year. The major difference between 2011/12 and 2010/11 is that in 2011/12 the Trust acquired community services worth £64m in a full year (from July 2011 = 75% of full year income and costs), in September 2011 became a level 3 neonatal intensive care unit (full year extra cost = £5.3m) and in February 2012 has transferred to Bolton on a proportion of the maternity services from Fairfield hospital in Bury (full year cost circa £2.3m):
Table 1 2011/12 2011/12 2010/11 2010/11 £m % £m % Patient Services income * 252.7 89.3 187.5 88.9 Other income 30.4 10.7 23.5 11.1 Total 283.1 100.0 211.0 100.0
* Monitor requires Trusts to ensure that the proportion of private patient income as a percentage of total patient services income does not exceed a Trust‐specific agreed percentage. In Bolton NHS FT’s case, the maximum percentage is 0.11% and in 2011/12 private patient income was £257k or 0.10% of total patient income, which was below the threshold. Income derived from NHS Bolton, the Trust’s main commissioner, was £186.3m, being 74% of the Trust’s patient services income figure of £252.7m. As the lead commissioner, NHS Bolton works closely with the Trust to manage finances and ensure that all national and local standards and targets are met.
Financial Performance in 2011/12 The Trust set out to make recurring revenue savings of £13.1m in 2011/12 which would enable the following to be achieved: • £1.7m surplus • £12.2m EBITDA • FRR of 3 • £8m cash at 31st March Until late in the financial year reports to the Finance and Investment Committee and Board showed that the Trust would achieve £11.4m savings of which £11.1m were assessed to be recurring. The shortfall of £1.7m in 2011/12 was to be covered by £1.7m CQUINS achieved by the Trust but not allocated for any other purpose.
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However, following production of the final accounts it became clear that the Trust had not achieved the financial plans and in fact the financial position was drastically different from the reports that the Board had received, as follows: • £2m deficit • £8.1m EBITDA • FRR of 2 • £7.6m cash This is a significant variance from the reported position and puts the Trust in a bad starting position in 2012/13. Given the scale of the failure to report the true position of the Trust an external review and investigation has been commissioned by the Board which is due to start at the beginning of June 2012 with a timescale to report their findings as soon as possible thereafter. Last year I was able to report that the Trust had been successful in achieving its savings target, which meant that there was no overhang of savings to be brought forward into 2011/12 and therefore represented a sound platform from which to start that financial year. Based on the initial findings from a limited internal investigation of what went wrong in 2011/12, it appears that the Trust, if it took no mitigating action above and beyond the £15.5m savings already planned, would be in deficit by £4.6m at the end of March 2013. Clearly this cannot be allowed to happen and so during the latter part of May and early June 2012 additional plans will have to be developed to enable the Trust to recover the position. Clearly the Trust’s financial position is currently poor and radical action will be required if the organisation is to recover.
Operational performance (relevant to finances) In 2011/12 the Trust agreed to new contracting arrangements with NHS Bolton, our main commissioner, that were designed to manage the financial risks to both parties in a way that would maintain financial control. The Trust agreed a block contract for non elective activity and community services, meaning that the same amount would be paid to the Trust by NHS Bolton regardless of activity levels (it should be noted that activity above the 2008/9 non elective level through national policy are reimbursed at 30% of the full tariff rate). The activity level was set in relation to the forecasted 2010/11 outturn position (which was consistent with the levels achieved in the previous three years) and the idea was to give the Trust an incentive to reduce non elective admissions and keep the resulting savings to be able to reinvest in admission avoidance initiatives. The idea was to generate benefits from the integration of hospital and community services as quickly as possible. A subsequent rise in activity during the last quarter of 2010/11 was attributed to the flu outbreak in that winter and the block contract was not adjusted to take account of the increase. The Trust also agreed to a financially capped contract for elective services based on the forecasted 2010/11 outturn position. The control here was to ensure that the Trust did not undertake a level of activity above what could be afforded by commissioners. If activity levels needed to be higher, the Trust had the opportunity to convince commissioners and obtain 100% funding for the extra activity. If the Trust could not convince commissioners, the most that commissioners would be required to pay was 50% of tariff.
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In addition to the contract for patient services, the Trust and NHS Bolton also concluded a Business Transfer Agreement (BTA) in relation to the transfer of Community services in July 2011 and one of the provisions within this was that if our joint activity assumptions turned out to be significantly out of line with plans, activity levels could be re‐negotiated. Table 2 below shows the activity outturn for elective and non elective services:
Table 2 Plan Actual Difference Diff (%)
Elective activity 28,919 29,760 841 2.9
Non elective activity - Adult Acute 7,866 7,533 ‐333 ‐4.2 - Elective Care 16,891 16,916 25 0.1 - Family Health Services 19,483 21,697 2,214 11.4 Sub total non elective 44,240 46,146 1,906 4.3
Grand total 73,159 75,906 2,747 3.8
Table 3 below shows the position on outpatients, A&E and diagnostic imaging services:
Table 3 Plan Actual Difference Diff (%) New outpatient 81,732 80,429 ‐1,303 ‐1.6 attendances Follow up attendances 137,154 154,719 17,565 12.8 Outpatient procedures 31,521 42,729 11,208 35.6 Total outpatients 250,407 277,877 27,470 11.0
A&E attendances 111,273 110,720 ‐553 ‐0.5
The tables show that non elective activity was significantly above plan, primarily within Family Health Services and here paediatrics was the major contributor. Overall, and taking into account the various conditions attached to the block contract, including beneficial ones, the Trust was correctly paid for non‐elective activity. However, the Trust did not recover the full amount of income for outpatient services (£1.1m) and did not fully recover £0.5m for A&E services, where activity was in line plans, but the casemix of patients seen was higher than planned. For elective activity the original plan, which did not include the additional non recurring activity approved by NHS Bolton, was exceeded by 2.9%, but once the additional activity agreed by the PCT in December 2011 is included in the figures, the variance is virtually nil. The Trust has been paid for the activity performed on the elective inpatient/daycase side of the business. NHS Bolton agreed to the additional activity because it was realised, as it turned out too late in the year, that the Trust would not be able to achieve the national requirements for 18 week GP referral to treatments times (18 week RTT). The Trust has been unable to convince commissioners of the need for extra activity to treat a backlog of people waiting too long that had built up during Q4 of the previous financial year and had not been cleared during 2011. ‐ 13 ‐
Bolton NHS Foundation Trust Annual Report and Accounts 2011/12 Page 2 Directors’ Report
Also, in the first four months of 2011/12 GP referrals had actually been lower than in the previous year, so it was not surprising that the Trust’s requests for extra funding were not convincing. The Trust also found it difficult to provide the necessary information required by commissioners, because it had had difficulty in recreating the necessary reports when the new data warehouse was implemented in September 2011. When the required information was available in November 2011, this enabled the necessary agreements to be concluded between the Trust and the Bolton commissioners. The additional activity enabled the Trust to deliver the 18 week RTT from April 2012, but it was not successful in achieving the target by the end of March 2012 and therefore incurred a £250k penalty.
Looking forward The main risk for the Trust going forward is clearly the unplanned and unexpected position reached in 2011/12. At the time of writing this business review the new, revised plans for 2012/13 had not been developed. They are expected to be submitted to the Board of Directors and Monitor at the end of June 2012. However, there are some significant changes to the contract with commissioners that are nevertheless worthy of note for the coming year: • NHS Bolton CCG has agreed that the elective part of the contract will be paid at full tariff in 2012/13, which means that should there be any difficulties in meeting the 18 week RTT, there should be no delay in being able to marshal the financial resources required to deal with any problems. • Although a block contract for non elective activity is still in place, commissioners have agreed that the level at which the contract is set will be revised to take account of actual outturn levels in 2011/12. • There is an extra 1% or £2.7m worth of CQUINS available to earn in 2012/13, should the Trust be able to achieve the required quality standards. • The national readmission policy is likely to reduce income by around £2.5m and this has had to be provided for in the plans. • Commissioning intentions that reduce activity in the Trust and therefore income have been kept to relatively low levels. • The impact of the implementation of ’Any Qualified Provider’ (AQP) is not yet known. The 2012/13 savings programme was originally planned on the basis of a £13.5m requirements (circa 5%) that was subsequently increased to £15.5m or 5.7% when it was known towards the end of 2011/12 that up to £2m of savings made in 2011/12 were not recurring. The Trust developed a savings programme that sought to limit the impact on front line patient treatment and care and medical and nursing staffing levels, particularly at ward level, were protected. This was based on some benchmarking the Trust undertook with McKinsey Consulting which showed that the biggest savings opportunities were within scientific and therapy staffing, administration and clerical staffing and certain non pay budgets. The percentage savings for medical staffing were set at 1%, nursing at 3.2%, scientific and therapy staffing at 7% and administration and clerical staffing (and management) and non pay at 8% for 2012/13.
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Bolton NHS Foundation Trust Annual Report and Accounts 2011/12 Page 2 Directors’ Report
Going Concern Opinion Given the financial problems identified after the end of the financial year and the consequential substantial shortfall that this creates in 2012/13, there is a need within this business review to include the relevant parts of the going concern opinion considered by the Audit Committee and Board of Directors. ‘Going concern’ is an underlying assumption that the business entity (Trust) will continue in operational existence for the foreseeable future and that the entity has neither the intention nor the need to liquidate or curtail materially the scale of its operations. As part of its consideration of the assumption that the Trust remains a going concern, the Board has considered a report that can be summarised as follows: • 12 month cash flow forecasts – which demonstrate that current plans, excluding any further mitigation to cover the impact of the Trust’s financial deterioration, will deliver the following cash position quarter by quarter (without any mitigating action the Trust would go into deficit in month 6):
Q1 Q2 Q3 Q4 30th June 2012 30th September 31st December 31st March 2012 2012 2013 £1.6m ‐£1.2m ‐£2.5m ‐£3.1m
• Mitigation plans are being considered by the Board and revised plans will be in place by the end of June 2012. In the meantime, the Trust is seeking approval from its Bank to utilise its working capital facility (confirmation meeting to be held on 12th June 2012). • Commissioners still require the Trust to provide the full range of services currently provided and will seek to change the portfolio only under extant national guidance, such as any qualified provider (the current contract increases activity above 2011/12 levels). They would seek to make more fundamental changes only as part of a strategic change process, which would allow the Trust the time to make the required changes. • Benchmarking (undertaken by McKinsey Consulting) of the Trust’s costs suggest that if the Trust were able to achieve the levels of efficiency achieved in our peer organisations, up to £18m could be saved if we moved from our current quartile to the next level of performance and £30m could be saved if we moved to the top quartile of performance. If the Trust were to achieve the levels of cost efficiency achieved by some of our peers, it is possible to recover from the current difficult financial position while maintaining the quality of services. • All receipt of loans, repayments of loan principal and interest, payments of Public Dividend Capital, capital expenditure, as well as income and expenditure items have been included in the cash forecasts. Overall, while the Trust is clearly in a difficult financial position, it is in the process of developing further plans to mitigate the impact of the reported year end deterioration in finances and the Board’s view is that the Trust can remain a going concern, provided that effective mitigating action can be achieved. ‐ 15 ‐
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Summary With the emerging picture on the year end outturn for 2011/12 becoming clearer, it looks certain that the Trust finished the year nearly £4m worse than planned and this has significant implications for the start if the new financial year (2012/13). In particular, there will be around £5m less for capital in 2012/13 compared to our original plan of £7.6m. Radical mitigation and additional savings plans will be required in order to turnaround the revenue financial position of the Trust and these will be the subject of detailed work over the coming weeks in May and June 2012. A further update on the plans is required for the end of June that will be subject to Board of Directors’ approval and discussions with key stakeholders, including Governors and commissioners.
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2.2 Statement as to disclosure to Auditors Each of the Directors at the date of approval of this report confirm that: So far as the Director is aware, there is no relevant audit information of which the NHS Foundation Trust’s Auditor is unaware; and The Directors have taken all the steps that they ought to have taken as Directors in order to make themselves aware of any relevant audit information and to establish that the NHS Foundation Trust’s auditor is aware of that information.
2.3 Additional disclosures Pensions Disclosure The accounting policies for pensions and other retirement benefits are set out in note 1.3 to the accounts and details of senior employees’ remuneration can be found in the remuneration report on page 19.
Statement of accounts preparation The accounts have been prepared under direction issues by Monitor, the independent regulator for Foundation Trusts, as required by paragraphs 24 and 25 of Schedule 7 to the National Health Service Act and in accordance with the NHS Foundation Trust Annual Reporting Manual 2011/12.
Statement of register of interests The Trust Secretary maintains a register of other significant interests held by Directors and Governors which may conflict with their responsibilities. Access to the register can be obtained by submitting a written request to the Trust Secretary
2.4 Going concern After making appropriate enquiries, the Directors have a reasonable expectation that the NHS Foundation Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts.
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Bolton NHS Foundation Trust Annual Report and Accounts 2011/12 Page 3 Remuneration Report
3.1 Remuneration Report The remuneration report has been prepared in compliance with the relevant elements of sections 420 to 422 of the Companies Act 2006, Regulation 11 and Schedule 8 of the Large and Medium‐sized Companies and Groups (Accounts and Reports) Regulations 2001 and elements of the NHS Foundation Trust Code of Governance.
3.2 Nomination and Remuneration committee The remuneration and conditions of service of the Chief Executive and Executive Directors are determined by a Nomination and Remuneration Committee, comprising membership as below. Chair – Cliff Morris, Chairman Margaret Blenkinsop, Senior Independent Director Arthur Rawlinson, Non‐Executive Director Roger McMullan, Non‐Executive Director Yaseer Ahmed, Non‐Executive Director (1st April 2011 – 30th November 2011) Carol Davies, Non Executive Director Ebrahim Adia, Non Executive Director The Nomination and Remuneration Committee met twice during the reporting period to consider the performance and the remuneration of the Executive Directors. The Chief Executive and Director of Workforce and Organisational Development attended meetings other than when matters being discussed would have meant a conflict of interest. Minutes of meetings were recorded by the Trust Secretary. In considering the Executive Directors’ remuneration, the Committee take into account the national inflationary uplifts recommended for other NHS staff, any variation in or change to the responsibility of Executive Directors and relevant benchmarking with other NHS and public sector posts. The performance of Executive Directors and the Chief Executive is discussed at the Remuneration Committee. Executive Directors are subject to annual appraisal by the Chief Executive who is herself appraised by the Chairman. The contracts of employment of all Executive Directors, including the Chief Executive, are permanent and are subject to six months notice of termination. No performance‐related pay scheme (e.g. pay progression or bonuses) is currently in operation within the Trust and there are no special provisions regarding early termination of employment. Associate Directors of Operations and General Managers are employed on a local payscale agreed by the Remuneration Committee. All of their other Terms and Conditions mirror Agenda for Change. All other senior managers are subject to Agenda for Change pay rates, terms and conditions of service, which are determined nationally. There are two exceptions to this in that there are two managers who chose to remain on local terms and conditions when Agenda for Change was introduced. These individuals do not receive any inflationary pay uplift. There is also a Governors’ Nomination and Remuneration Committee. This Committee has met on three occasions during the reporting period and successfully appointed a new Non‐ Executive Director. ‐ 18 ‐
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Pension arrangements for the Chief Executive and all Executive Directors are in accordance with the NHS Pension Scheme. The accounting policies for pensions and other relevant benefits are set out in Note 1.8 to the accounts. Name and Title 2011/12 2010/11 Salary Other Taxable Salary (Bands Other Taxable (Bands of Remuneration Benefit of of £5,000) Remuneration Benefit of £5,000) (Bands of Lease Car (Bands of Lease Car £5,000) £5,000) £000 £000 £ £000 £000 £ Executive Directors L Doherty Acting Chief Executive (from 1st 140 – 145 ‐ ‐ 125‐130 ‐ ‐ May 2010) B Andrew Director of Assurance and 95 – 100 ‐ ‐ 95‐100 ‐ ‐ Engagement G Raphael 110 – 115 ‐ ‐ 110‐115 ‐ ‐ Director of Finance A Schenk Director of Strategy and 85 – 90 ‐ ‐ 85‐90 ‐ ‐ Improvement J Bene 45‐50 130 ‐ 135 ‐ 50 ‐ 55 125‐130 ‐ Medical Director N Ingham Director of Workforce and 85 – 90 ‐ ‐ 85‐90 ‐ ‐ Organisational Development A Cogan (from 3rd May 2010) 85 – 90 ‐ ‐ 85‐90 ‐ ‐ Director of Operations D Sissons Director of Patient Safety and Experience /Chief 80 – 85 ‐ ‐ ‐ ‐ ‐ nurse(from 3rd May 2011
A Bennett (acting Director of 5 ‐ 10 ‐ ‐ ‐ ‐ ‐ Finance 1st – 31st March 2012 M Sinfield (from 1st May 2010 – 30th April 2011) 5 ‐ 10 ‐ ‐ 55‐60 ‐ ‐ Acting Director of Nursing Non Executive Directors C Morris Chairman 40 ‐ 45 ‐ ‐ 40‐45 ‐ ‐
M Blenkinsop 10 – 15 ‐ ‐ 10‐15 ‐ ‐
Y Ahmed (until 30th November 5 ‐ 10 ‐ ‐ 10‐15 ‐ ‐ 2011)
A Rawlinson 10 – 15 ‐ ‐ 10‐15 ‐ ‐
R McMullan 10 ‐ 15 ‐ ‐ 10‐15 ‐ ‐
C Davies (from 1st September 10 ‐ 15 ‐ ‐ 5‐10 ‐ ‐ 2010)
E Adia (from 30th November 10 ‐ 15 ‐ ‐ 0‐5 ‐ ‐ 2010)
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Name and Title Real Real Total Lump sum Cash Cash Real increase increase in accrued at age 60 Equivalent Equivalent Increase in in lump sum pension at related to Transfer Transfer Cash pension at age 60 age 60 at accrued Value at 31 Value at 31 Equivalent sum at at 31 31 March pension at March March Transfer age 60 March 2012 31 March 2012 2011 Value 2012 2012 funded by Employer (bands of (bands of (bands of (bands of £2500) £2500) £2500) £2500) £000 £000 £000 £000 £000 £000 £000
L Doherty 167.5‐ 5.0‐7.5 15.0‐17.5 55.0‐57.5 1,080 869 190 Chief Executive 170.0
B Andrew 132.5‐ Director of Assurance and 0‐2.5 2.5‐5.0 42.5‐45.0 855 746 90 Engagement 135.0
G Raphael 130.0‐ 0‐2.5 2.5‐5.0 42.5‐45.0 828 712 98 Director of Finance 132.5
A Schenk 107.5‐ Director of Strategy and 0‐2.5 2.5‐5.0 35.0‐37.5 742 665 60 Improvement 110.0
J Bene 100.0‐ 0‐2.5 0‐2.5 32.5‐35.0 560 463 85 Medical Director 102.5
N Ingham Director of Workforce and 0‐2.5 2.5‐5.0 15‐17.5 47.5‐50.0 231 169 57 Organisational Development
D Sissons Director of Patient 107.5‐ Safety and Experience /Chief 0‐2.5 0‐2.5 35.0‐37.5 720 612 93 nurse(from 3rd May 2011) 110.0
A Cogan (from 3rd May 2010) 0‐2.5 0‐2.5 25.0‐27.5 75.0‐77.5 415 346 61 Director of Operations
M Sinfield (01/05/10 – 30/04/11) 0‐2.5 2.5‐5.0 20.0‐22.5 62.5‐65.0 392 330 53 Acting Director of Nursing
A Bennett (acting Director of st st 0‐2.5 0‐2.5 5.0‐7.5 15.0‐17.5 87 57 29 Finance 1 – 31 March 2012
Pension arrangements for the Chief Executive and all Executive Directors are in accordance with the NHS Pension Scheme. The accounting policies for pensions and other relevant benefits are set out in Note 1.8 to the accounts.
The median salary of the Trust at 31 March 2012 is £25,528. The the ratio of the median salary to the highest paid salary is 5:28.
31st May 2012
Lesley Doherty, Chief Executive ‐ 20 ‐
Bolton NHS Foundation Trust Annual Report and Accounts 2011/12 Page 4 Code of Governance Disclosures
4.1 Statement of Compliance with the Code The Trust Secretary reviews our compliance with the NHS Foundation Trust Code of Governance and prepares a report for the Audit Committee. The Audit Committee considered this report at its meeting on February 14th 2012 and agreed that Bolton NHS Foundation Trust complied with the main and supporting principles of the Code of Governance. The Code is implemented through key governance documents, policies and procedures of the Trust, including but not limited to: The Constitution Standing Orders Standing Financial Instructions Scheme of Delegation Code of Conduct (for Directors, for Governors and for Senior managers) Staff Handbook Governor Handbook Standards for Behaviour and Attitude at Work.
4.2 The Council of Governors As set out in the constitution, the Council of Governors consists of 23 publicly elected Governors, seven staff Governors (to return to six staff Governors on 1st April 2012) and eleven appointed partner Governors. The Council of Governors meets in public four times a year. The statutory duties of the Governors are to: Set the terms and conditions of Non‐Executive Directors Approve the appointment of future Chief Executives Appoint or remove the Trust’s external auditor Consider the annual accounts, annual report and auditor’s report Be consulted by the Board of Directors on the forward plans for the Trust. The Board of Directors and the Council of Governors enjoy a strong and developing working relationship. Mr Cliff Morris, Trust Chairman, chairs both and acts as a link between the two. Each is kept advised of the other’s progress through a number of systems, including informal updates via the Chairman, ad hoc briefings, exchange of meeting minutes and attendance of the Board of Directors at the Council of Governors and by individual Directors at Council of Governors sub‐committees.
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Elected Governors ‐ Public Constituency End of period Attendance Committee/Sub Involved in other Name Area Date Elected term of office (4 held) Group Membership groups Mohammed Ayub Great Lever Oct 10 Sept 13 1st 1
Ann Bain Breightmet Oct10 Sept 13 1st 4 PEAT inspection
Denise Baldwin Rest of England Oct 09 Sept 12 1st 2 P 100 voices
Derek Burrows Kearsley Oct 10 Sept 13 2nd 4 P Making it Better Kate Cowpe Rest of England Oct 10 Sept 13 2nd 4 P Safety express
Hanif Darvesh Crompton Oct 10 Sept 13 1st 3
Margaret Evans Hulton Oct 11 Oct 14 1st 2/2 P Heaton and Ken Hahlo Lostock Oct 09 Sept 12 1st 3 M,P, H Mortality Little Lever and Eric Hyde Darcy Lever Oct 10 Sept 13 2nd 3 P,M Divisional quality Westhoughton 100 voices, safety Pauline Lee and Chew Moor Oct 09 Sept 12 2nd 2 P express
Paul McCarthy Farnworth Oct 09 Sept 12 1st 3 M,P, H Westhoughton Helen McSorley South Oct 09 Sept 12 2nd 1 P Geoffrey Auditor Minshull Bromley Cross Oct 10 Sept 13 2nd 2 A appointment Ronald Parkinson Rumworth Oct 10 Sept 13 1st 4 H
Mike Phillips Rest of England Dec 10 Sept 13 1st 3 H Pt exp., workforce, Jack Ramsay Bradshaw Oct 10 Sept 13 2nd 3 M,P,N Clin Gov.
Barbara Ronson Horwich NE Oct 08 Sept 12 1st 2 P green issues Horwich and Isabel Seddon Blackrod Oct 08 March 12 3 P 100 voices Tonge with the Jim Sherrington Haulgh Oct 10 Sept 13 2nd 4 P,N, H Patient experience
Lynne Siddall Astley Bridge Oct 10 Sept 13 1st 3
John Taylor Smithills Oct 10 Sept 14 2nd 3 M,P, H Divisional Board
Victor Williams Halliwell Oct 10 Sept 13 1st 3
Barbara Winder Hulton Oct 08 Sept 11 1/2 M,P Key: A: Audit. N: Nomination and remuneration. M: Membership and member communications. P: Patient, staff and visitor experience, H – More than a Hospital ‐ 22 ‐
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Elected Governors – Staff Constituency End of Period of Attendance Committee and Sub Name Area Date Elected term Office (4 held) Group Membership Doctors and Yousouf Adenwala Dentists Oct 11 Sept 14 1st 1/2 Nurses and Carol Bernstein Midwives Oct 09 Sept 12 1st 3 P
Jean Cummings All other staff Oct 08 Sept 11 2/2 P
David Hamer AHP and scientists Oct 08 Sept 13 1st 3/4 N
Peter Hindle All other staff Oct 11 Sept 14 1st 2/2 Doctors and Simon Kelly Dentists Oct 08 Sept 11 1/2 P
Wendy Pickard Community Staff July 11 March 12 1 only 2/2 Nurses and Janet Roberts Midwives Dec 10 Sept 13 1st 3/4 P
Chris Tinsley All other staff Oct 10 Sept 13 1st 3/4 P, H
Appointed Governors Attendance (4 Committee and Sub Name Representing Date Appointed held) Group Membership
Tim Evans NHS Bolton Oct 08 – Dec 11 0/3
Jack Firth Bolton LINk Dec 10 3/4 Bolton Council For Voluntary Geoffrey Hargreaves Services Oct 08 3/4 P
Dr. Liaqat Natha Bolton Local Medical Committee Jan 10 3/4 P, M
Robert Nettleton Bolton University Dec 09 1/4 Bolton Connexions (Youth Farhan Patel Governor) July 09 – Dec 11 0/3 M
Dr. Aarya Prabhakaran Bolton Local Medical Committee Jan 10 3/4 Bolton Council For Voluntary Thaira Qureshi Services Oct 08 3/4 P Bolton Metropolitan Borough Linda Thomas Council April 10 ‐ 1/4 Bolton Metropolitan Borough John Walsh Council Oct 08 1/4 N
Jill Wild Salford University Oct 08 2/4 P
Key: A: Audit. N: Nomination and remuneration. M: Membership and member communications. P: Patient, staff and visitor experience, H – More than a Hospital ‐ 23 ‐
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4.3 Elections to the Council of Governors Elections to the Council of Governors were held according to the constitution in September 2011. Results were as reported below.
Seat Turnout Governor elected Bradshaw uncontested Jack Ramsay Little Lever and Darcy Lever uncontested Eric Hyde Out of Area uncontested Kate Cowpe Smithills uncontested John Taylor Doctors and Dentists uncontested Yousouf Adenwala Bromley Cross 45.7% Geoffrey Minshull Horwich NE 46.3% Barbara Ronson Hulton 27.5% Margaret Evans All other staff 19% Peter Hindle
4.4 Directors’ and Governors’ Register of Interests A register is kept of Directors’ and Governors’ interests. Access to the register can be gained either by contacting the Trust Secretary or from the Trust website.
4.5 Developing understanding The Board of Directors has taken steps to ensure that Members of the Board, and in particular the Non‐Executive Directors, develop an understanding of the views of Governors and members about their NHS Foundation Trust. Mr Cliff Morris chairs both the Board of Directors and the Council of Governors and with the assistance of the Trust Secretary is the link between the two bodies. The full Council of Governors meets a minimum of four times a year and these meetings are attended by representatives of the Executive Directors, the Senior Independent Director and representatives of the Non‐Executive Directors. The Governors’ meetings provide the opportunity for the Governors to express their views and raise any issues so that the Executive Directors can respond. Minutes of the meeting are shared with the Board of Directors so they can pick up and respond to any issues raised. The Governors have two formal sub‐committees dealing with Auditor appointment, and nomination and remuneration. These are attended by the Chair of Audit and Director of Finance (Auditor appointment) and by the Senior Independent Director (nomination and remuneration). The Governors also have three sub‐groups, each chaired by a Governor nominated by the group. The chairs of the sub‐groups meet with the Chairman on a regular basis, these groups are also attended by the Trust Secretary. The Director of Assurance and Engagement, and other members of Trust staff also attend appropriate sub group meetings as required. ‐ 24 ‐
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The Trust recognises the importance of being accessible to members. Council of Governors meetings are held in public and publicised on the Trust website, member newsletters and notices around the hospital. The Governors representing the electoral wards of Bolton attend the local area forums run by Bolton Council to meet individual FT members and members of the public and hear their views.
4.6 Board of Directors The Board of Directors comprises the Chairman, Chief Executive, Senior Independent Director, five independent Non‐Executive Directors, five voting Executive Directors and three non‐ voting Corporate Directors. (The composition of the Board has changed over the period of the report – the number of Non Executive Directors was reduced from six to five at the end of Yaseer Ahmed’s term of office on 30th November 2011. This was a planned reduction following the increase in 2010/11 to provide expertise on community services prior to integration). The Board meets in private on the last Tuesday of each month and a summary of the minutes is published on the public website. The Directors have collective responsibility for setting strategic direction and providing leadership and governance. The Scheme of Delegation which is included in the Trust’s standing orders, sets out the decisions which are the responsibility of the Board of Directors and those which have been delegated to a sub‐committee of the Board. The Trust has an Executive Board which consists of the Executive Directors and other senior clinicians and managers within the Trust. The Executive Board meets monthly and is chaired by the Chief Executive. Its remit is to consider the operational management and the day to day business of the Trust.
4.7 Balance, Completeness and Appropriateness There is a clear separation of the roles of the Chairman and the Chief Executive, which has been set out in writing and agreed by the Board. The Chairman has responsibility for the running of the Board, setting the agenda for the Trust and for ensuring that all Directors are fully informed of matters relevant to their roles. The Chief Executive has responsibility for implementing the strategies agreed by the Board and for managing the day to day business of the Trust. All of the Non‐Executive Directors are considered to be independent in accordance with the NHS Foundation Trust Code of Governance. Whilst on appointment the Chairman has to meet the Code’s ‘test of independence’, it does not apply to this role thereafter. The Board considers that the Non‐Executive Directors bring a wide range of business, commercial, financial and other knowledge required for the successful direction of the Trust. The Executive Directors are experienced and were collectively responsible for drafting the various strategies which formed the Trust’s application for Foundation Trust status. These strategies were agreed by the whole Board and now form the basis of the relationship with the Regulator. All Directors are equally accountable for the proper management of the Trust’s affairs. ‐ 25 ‐
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All Directors are subject to an annual review of their performance and contribution to the management and leadership of the Trust. During the Foundation Trust application process, the Board used external facilitators to work with the Directors on Board development. At the present time the Board is satisfied as to its balance, completeness and appropriateness, but will keep these matters under review.
4.8 Our Directors Cliff Morris Chairman (Appointed November 2008 for four years, appointment extended till November 2013 at the October 2011 Council of Governor meeting) A former Bolton Mayor, Cliff is Leader of the ruling Labour Group on Bolton Council and the Chair of Social Services. Cliff was appointed Chairman in 2003.
Lesley Doherty Chief Executive (October 2010 to present day) Acting Chief Executive (June 2010 – October 2010) Director of Nursing and Performance improvement (2003 to June 2010), Lesley joined the NHS in 1976 and is a qualified nurse and midwife with varied clinical and operational experience across health care provision, including regional and national roles. She joined Bolton in 2003 as Director of Nursing, moving to include the day to day management of the Trust in 2005. In October 2010 she was appointed Chief Executive.
Gary Raphael Director of Finance, Information and Procurement Gary is a qualified Chartered Institute of Public Finance and Accountancy (CIPFA) accountant and has held a number of senior finance posts in both London and the North West. Gary joined the Trust in 2009.
Jackie Bene Medical Director Jackie’s primary responsibilities are patient safety and quality improvement and ensuring the good medical practice of all doctors working in the Trust. Jackie was appointed Medical Director in 2008 having been a consultant in Elderly Medicine at the Trust since 1998.
Beverley Andrew Director of Assurance and Public Engagement As Director of Assurance and Public Engagement Beverley is responsible for corporate governance and public engagement, risk management including emergency planning and estates strategy. Beverley started her NHS career in Bolton in 1978.
Dee Sissons Director of Patient Safety and Experience/Chief Nurse Dee is responsible for maintaining high standards in the care of all patients, leading in ensuring high quality and safe care. Dee was appointed in March 2011 having previously been Director of Nursing and Quality at NHS Nottingham City.
Ann Schenk Director of Strategy and Improvement ‐ 26 ‐
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As Director of Strategy and Improvement, Ann is responsible for strategic and business planning, service improvement through the development of the Bolton Improving Care System (BICS) and Information Technology. She has worked in a variety of NHS planning and business management posts since 1979.
Nicky Ingham – Director of Workforce and Organisational Development Nicky is responsible for the Workforce and Organisational Development requirements of the Trust, including staff health and wellbeing, staff engagement, skills development, provision of HR advice and employee services. Nicky joined the Trust in 2005.
Andrew Cogan Director of Operations Andrew is responsible for the day to day running of the Trust’s operational services. Andrew has worked for a number of acute hospitals in Greater Manchester and Merseyside since 1989 and joined the Trust in 2005 initially as Divisional Manager for Diagnostics and Therapies and then as Divisional Manager for Surgery. Andrew commenced in his current role in January 2011.
Non Executive Directors Margaret Blenkinsop: (Deputy Chair/Senior Independent Director) appointed April 2009 for four years Margaret’s career was spent in education, retiring as a Director of Bolton’s Children's Services in 2006. She serves the Board as Deputy‐Chair and is the Non‐Executive Director lead for safeguarding and whistleblowing. Margaret is also Chair of Bolton’s Octagon Theatre, she joined the Trust in 2005.
Yaseer Ahmed: (April 2003 – November 2011) Yaseer became a Non‐Executive Director in 2003 and completed his eight year tenure with the Trust in November 2011.
Arthur Rawlinson: appointed April 2009 for four years Arthur's background is in information technology, retiring as UK General Manager for Data Centres within Fujitsu Services in 2002. He is a member of the Audit, Finance, IT and Clinical Governance Committees and Chair of the Hospital's Charitable Trust Fund. Arthur joined the Trust in 2005.
Roger McMullan: April 2008 – March 2012 Roger, as well as having been Director and Company Secretary at Warburtons Ltd. set up Bolton Business Ventures in the 1980s, one of the first enterprise agencies in the UK. Roger stood down from the Board at the end of his first tenure on 31st March 2012
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Carol Davies (Chair of Audit Committee) appointed September 1st 2010 for three years Carol is currently Director of Finance and Resources at Mount St Joseph Business and Enterprise College. She has also held senior finance positions in a number of other organisations, including Bolton Council and Trafford Health Authority. She is a qualified accountant with the Chartered Institute of Management Accountants.
Ebrahim Adia appointed November 30th 2010 for three years Dr Ebrahim Adia is a senior lecturer in Education at the University of Central Lancashire (UCLan) and is a former joint Vice‐Chair of NHS Bolton. He is a member of the Trust’s Audit Committee.
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Attendance at meetings
Board of Audit Council of Remuneration Directors Committee Governors Committee (11 meetings) (5 meetings) (4 meetings) (2 meetings) Cliff Morris 11 3 2
Lesley Doherty 10 3 Gary Raphael 11 4
Jackie Bene 8 2 Beverley 11 4 Andrew Dee Sissons 7/9 2
Andrew Cogan 9 2
Ann Schenk 10 3
Nicky Ingham 9 3 Margaret 11 5 3 2 Blenkinsop Yaseer Ahmed 5/8 0/3 0/3 0/2 Roger 9 5 4 2 McMullan Arthur 10 5 4 2 Rawlinson Carol Davies 10 5 3 2 Ebrahim Adia 10 5 3 2
n/a = not applicable ‐ attendance not required at this committee ‐ 29 ‐
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4.9 Audit Committee At its meeting on April 27th 2011 the Council of Governors approved the appointment of the Audit Commission as its external auditors. Following changes leading to the demise of the Audit Commission, the Governor sub‐committee for Auditor appointment has been reconvened to appoint a new external Auditor The Audit Committee met on five occasions during the period April 1st 2011 and March 31st 2012 and at its February meeting conducted a self assessment of the effectiveness of the committee. The purpose of the Audit Committee is to provide the independent assurance to the Board that there are effective systems of governance, risk management and internal control for all matters relating to corporate and financial governance and risk management. Key activities during the period April 1st 2011 and March 31st 2012 were: • Reviewing the Board Assurance Framework and Risk Register • Reviewing financial statements • Receiving reports from the internal and external auditor • Receiving internal reports. On occasion the Trust may decide to request additional services from the Audit Commission. The Council of Governors delegated specific authority for commissioning additional services to the Trust’s Audit Committee subject to an overall policy cap on directly attributable fees which should not exceed 50% in aggregate of the approved annual statutory audit fee in any twelve month period. This would be on the understanding that the Audit Committee takes responsibility for agreeing any specific areas of additional work to be undertaken and, in doing so, considers whether the external auditor or any other organisation is best placed to provide the service i.e. based on relevant experience, expertise in that particular area and value for money.
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4.10 Membership Every member of the public over the age of 16 can become an FT member of Bolton NHS Foundation Trust and give their views on how they think we should develop our services. Through our members, we can really get to know what the public wants and, more importantly, act on that as our services evolve.
Membership strategy We are committed to building a membership that is representative of and reflects the local communities we serve in terms of disability, age, gender, socio‐economics, sexuality, ethnic background and faith. Public members Membership of the Trust is open to anyone who resides in England although we would expect the majority of our members to reside in Bolton and the surrounding areas of Salford, Wigan, Bury and South Lancashire. There is a lower age limit of 16 but no upper age limit. There are no limits on the number of people who can register as members. Public members are placed in constituencies based on where they live. There are 20 constituencies representing the electoral wards of Bolton and one to represent “out of area” members. Staff members We have elected to adopt an opt out arrangement in respect of staff membership. Under this arrangement, staff will automatically be registered as a member of the Trust unless they have completed the opt out form which was circulated with payslips prior to authorisation as a Foundation Trust. New members of eligible staff are provided with information and a form at induction. Staff membership is open to everyone who is employed by the Trust full or part time on a contract with no fixed term or those staff on fixed term contracts of 12 months or more. Membership is also available to those bank staff who have an agreement to work for the Trust and have done for 12 months or more. Staff working for the Trust’s contractor for portering and domestic services are also eligible for staff membership if they meet the above criteria. Staff membership ceases at the point that the member leaves the service of the Trust, but individuals can then choose to become a public member.
Benefits of membership Although there are no financial benefits to FT membership, there are also no costs. There is, however, much satisfaction in being in a position which can help local people and local services. There are no benefits to members in terms of access to services. During 11/12 we held two Medicine for Members events. These informal and informative talks were well attended and well received. There will be a continuing programme of these events which will be publicised through the members’ newsletter and the Trust website. We will use our members as a valuable resource calling on those who have expressed a willingness to participate in surveys and focus groups to gain a snapshot view of the user’s perspective. ‐ 31 ‐
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Membership recruitment We aim to continue recruiting new members and are using a variety of methods to ensure we reach as many people as possible. People wishing to join can do so by registering online at www.boltonft.nhs.uk or by calling 01204 390654. Alternatively application forms are available throughout the hospital.
Contact procedures for members that wish to communicate with Governors and/or Directors Members who wish to communicate with Governors may do so by email to [email protected] or by post c/o the Trust Secretary. To communicate with Directors contact [email protected] Membership Statistics
Public Constituency Last Year Next year (estimated) 2011/12 2012/13 At year start (1 April) 4589 4863 New members 378 350 Members leaving 104 120 At year end (31 March) 4863 5093 Staff Constituency Last Year Next year (estimated) At year start (1 April) 3640 5229 At year end (31 March) 5229 5100
Analysis of current public membership
Public Constituency Number of members Eligible membership Age 0 ‐ 15 16 ‐ 22 372 15597 22+ 4491 241844 Ethnicity White 3693 232343 Mixed 67 2602 Asian or Asian British 755 23619 Black or Black British 145 1654 Other 203 869 Socio‐economic groupings ABC1 2396 94931 C2 1168 31850 D 701 41712 E 598 33489 Gender Male 2351 126943 Female 2512 133764
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INTRODUCTION I am delighted to share with you our fourth Quality Report. This covers the aspect of our service which matters most to all of us ‐ the quality of care we offer to our patients. Looking back at previous reports it is clear that we have made a real difference in improving the quality of care we provide to our patients. Mortality rates have fallen year on year and we have continued to reduce the incidence of hospital acquired infection. We have, however, in 2011/12 not met important patient waiting time targets for 18 week referral from GP to treatment and out A&E target of ensuring patients are seen, treated and either admitted or discharged within 4 hours. This has led the Trust being found in significant breach of our authorisation with our regulator Monitor for failing to achieve and provide adequate Board oversight of these important patient experiences. These will be in our top priorities for 2012/13 and further information is provided within this report. In July 2011 we formally integrated acute and community services to form a new integrated care organisation. Over the coming year we will continue to work on integrating care pathways to bring further improvements to the quality of care we provide. We have worked closely with our stakeholders particularly, our Governors, to consider the priorities for inclusion in this report. With so many important areas of work limiting this to just five was difficult but after much deliberation it was agreed that the Quality Report priorities for 2012/13 are:
• To continue to focus on improving mortality. • To ensure that patients who attend our Accident and Emergency Department are seen, treated and either discharged or admitted within four hours. • To ensure patients who require elective procedures are seen within 18 weeks of referral. • To continue our programme to improve appraisals and development for our staff. • To improve patient safety through the Safety Express programme.
This Quality Report describes in detail why our priorities are important to us, how we will measure our performance and what we are going to do. The Board of Directors is committed to this and will closely monitor progress and support this at every level. Limiting the number of priorities means that many areas which are important to us are not included in this report. We recognise that stakeholders may also wish to receive information on areas such as care of stroke patients and care of dementia patients in out next quality account will include this in our review of performance in 2012/13. During the course of 2012/13 we plan to meet regularly with our LINk, our governors and other stakeholders to discuss and agree indicators to include in our review of 2012/13. This will also give us an opportunity to provide regular updates on the priorities we have agreed for this year.
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We will continue to use the Bolton Improving Care System (BICS) as the quality improvement method of seeing our processes through the users’ eyes and engaging staff in solving problems which cause frustration to staff and patients. I hope that this report gives a clear indication about our progress and where we want to be. We have committed and dedicated staff whose focus on improving patient care and experience will continue. The Trust Board has received and endorsed the details set out in the Quality Report.
Lesley Doherty Chief Executive
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STATEMENT OF DIRECTORS’ RESPONSIBILITIES IN RESPECT OF THE QUALITY REPORT The Directors are required, under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010, to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual Quality Reports (which incorporate the above legal requirements) and on the arrangements that foundation trust boards should put in place to support the data quality for the preparation of the Quality Report.
In preparing the Quality Report, directors are required to take steps to satisfy themselves that: • the content of the Quality Report meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2011‐12; • the content of the Quality Report is not inconsistent with internal and external sources of information including: • Board minutes and papers for the period April 2011 to April 2012 • Papers relating to quality reported to the Board over the period April 2011 to April 2012 • Feedback from the commissioners 18th May 2012 • Feedback from Governors dated 02/02/2012 and 11/04/2012 • The annual report on complaints reviewed by the Board May 2012.
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• The 2011 national patient survey (published April 2012) • The 2011 national staff survey (published March 2012) • The Head of Internal Audit annual opinion over the trust’s control environment dated May 2012 • Monthly CQC quality and risk profiles. • The Quality Report presents a balanced picture of the NHS foundation trust’s performance over the period covered; • The performance information reported in the Quality Report is reliable and accurate; • There are proper internal controls over the collection and reporting of the measures of performance included in the Quality Report, and these controls are subject to review to confirm that they are working effectively in practice; • The data underpinning the measures of performance reported in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review; and the Quality Report has been prepared in accordance with Monitor’s annual reporting guidance (which incorporates the Quality Accounts regulations) (published at www.monitornhsft.gov.uk/annualreportingmanual) as well as the standards to support data quality for the preparation of the Quality Report (available at www.monitornhsft.gov.uk/annualreportingmanual). The Directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Report. By order of the Board 29th May 2012
Chairman Chief Executive
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Overseeing Quality The Trust has made arrangements for promoting, overseeing and monitoring the quality of care which we deliver. It is a central part of our planning and performance review cycle, through ensuring quality is a key responsibility of every member of staff, and is reflected in their personal objectives, personal development and appraisal. Although good progress has been made, staff appraisal continues to be one of our key experience priorities in 2012/13. This is in view of the clear evidence that regular appraisal has a direct and positive impact on both organisational performance and patient care. At a corporate level, the Executive Board and Board of Directors receive routine reporting on indicators of quality. Our suite of reports provide regular updates on key patient safety and experience measures, and provide one of the ways in which the Trust routinely monitors performance on the elements in the Quality Report. Divisional performance is formally reviewed by the Executive Directors through a series of performance review meetings. Externally, the Trust is also accountable through contracts with the commissioners. A local quality framework is in place, with key performance targets which are regularly monitored by commissioners and which may be subject to penalties for underperformance. In addition, the CQUIN (Contracting for Quality, Improvement and Innovation) set of indicators provides an opportunity for the Trust to attract payment for achievement of ‘stretch’ quality targets. The Care Quality Commission (CQC) produces an ongoing quality and risk profile for each Trust which determines the level of inspection undertaken. The Trust is currently registered without conditions by the CQC. The independent FT regulator Monitor also holds the Trust to account and monitors performance by way of the annual plan and quarterly compliance declarations as part of the Compliance Framework. As an FT, our Governors also act as a check and balance to the Board of Directors and receive regular feedback on the Trust’s performance over a range of indicators. The Governors’ Patient, Staff and Visitor Sub‐committee takes a particular interest in patient safety and experience, and has been actively involved in agreeing priorities for inclusion in this report Finally, the Trust uses internal and external auditors to assist the Board in understanding strengths and weaknesses of specific systems, providing a level of external assurance which underpins a good understanding of how the Trust is performing.
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What is BICS? Improving what we do – The Bolton Improving Care System (BICS) The Bolton Improving Care System (BICS) is the Trust’s system for ensuring continued quality improvement. It embraces practical day to day methods of problem solving, redesigning services to deliver better care, involving patients in improving what we do, and involving all staff in the continuous pursuit of best possible care. It is at the heart of our plans for driving safety, quality and productivity. The problem solving approaches in BICS use “lean” methods, borrowed initially from the manufacturing industry, but adapted and applied to healthcare. Although, at first glance, it may seem that healthcare has little in common with manufacturing, our own experience and the experience of many other organisations has demonstrated that a focus on improving processes, removing waste and improving quality is very relevant to tackling the biggest challenges faced by this hospital and by healthcare in general. We have a vision that the Trust will be an organisation where the whole workforce is involved every day in making our processes better. The starting point of this approach is seeing “waste” and removing it from the way we work. Staff and patients see waste all too often in our everyday work – wasted effort because things are in the wrong place, wasted supplies, wasted time duplicating work or doing unnecessary tasks or just waiting for things to be done, waste in sometimes having to put right things that weren’t right first time and wasted talent of people who are over‐burdened or distracted from what they really come to work to do – deliver good care. We fundamentally believe that removing waste reduces defects, improves quality of care, improves the experience of patients and staff and reduces costs. After five years of using lean methods, the Trust has seen some marked benefits (in clinical outcomes, workforce engagement, efficiency and patient experience) but we recognise that we are still at the beginning of our journey of transformational change.
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PRIORITY ONE: Reducing the Trust’s mortality rate
Why this is important to us The Trust’s risk adjusted mortality rate has been high for a number of years, although concentrated work on improving patient pathways displaying high mortality rates has achieved significant reductions and especially so in the last year. There are various ways of calculating the hospital mortality rate and the Trust will be working over the next year with an organisation called CHKS using a measure called the RAMI (Risk Adjusted Mortality Indicator). Previously the Trust worked with Dr Foster who use a measure called the HSMR (Hospital Standardised Mortality Rate). Furthermore, the Department of Health has been developing a new metric, the SHMI (Standardised Hospital Mortality Indicator) to be used universally across England by all providers. This is now the national risk adjusted mortality metric. The HSMR and RAMI are risk‐weighted measures which are calculated by assessing the number of actual deaths in comparison to the number of “expected” deaths. Whether death is “expected” is based on clinical coding, which describes the severity of a patient’s illness, and their contributory medical problems, when they are admitted to hospital. In April 2010 the Trust’s HSMR was 116 but had dropped to 104 by March 2011. The hospital switched from Dr Foster to CHKS in September last year so the Trust risk adjusted mortality indicator is now the RAMI which was at 89.9 in April 2011 and is currently at 73. The Trust was one of the fastest improving hospitals in the North West through 2011/12 and whilst we are still improving there is further work to do in order for the Trust to achieve its goal of being in the top 50% of hospitals in England in the next year.
How we propose to measure our performance We will track our improvement by measuring:
i) RAMI (Risk Adjusted Mortality Indicator).
ii) Changes in the hospital’s crude (unadjusted) death rate for specific conditions, and across the Trust as a whole.
iii) SHMI (Summary Hospital Mortality Indicator).
Where do we start from?
The Trust has seen a steady decline in its RAMI over the last three years, falling to 91 at the end of March 2010; 85.1 at the end of March 2011; and 73 as of Feb 2012.
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Over the last four years we have also experienced a consistent reduction in the unadjusted mortality rate (actual deaths), which fell by 0.1% again in the last year but has fallen over 1% since 2005.
The Summary Hospital Mortality Indicator was first published in October 2011 for the April 2010 to March 2011 period. The Trusts SHMI at this time was 1.05 which although 5% greater than the national average is within the “expected range” when compared with a national peer group. It was republished in April 2012 for the period October 2010 to September 2011 and it had fallen slightly further to 1.04 which is still “as expected”.
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What are we aiming for in the year ahead?
We aim to achieve: − A RAMI for the twelve months April 2012 to March 2013 of less than 75. − At least a 0.2 % reduction in unadjusted mortality, compared to 2011. − A 0.5% reduction in SHMI.
What we will do The Trust has a five point mortality plan, which is overseen by the Mortality Reduction Group, chaired by the Medical Director and representatives from clinical services from across the Trust. The progress of the project is reported monthly to the Board of Directors together with the most up‐to‐date trends in mortality. The five work streams were reset by the Mortality Reduction Group in February 2012 and are:
1. The reduction of deaths associated with respiratory disease, especially chronic obstructive pulmonary disease.
2. The reduction of deaths due to heart failure.
3. The provision of better pathways of care for patients at the end of life, so that such patients do not spend their final days in hospital if this can be avoided.
4. The use of risk assessments in patients on elective and non‐elective surgical pathways.
5. The management of sepsis in all clinical areas in accordance with the Sepsis 6 Care Bundle.
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PRIORITY TWO: To ensure that patients who attend our Accident and Emergency Department are seen, treated and either discharged or admitted within four hours. Why it is important We recognise that improvement in urgent care patient pathways and, through that, achievement of the four hour target, is essential to improving the quality and safety of care in the hospital. In the last five years, the Trust has failed to achieve the A&E standard for admission, discharge or transfer in four hours in at least one quarter. It has been proven that having effective management of emergency care patients is a key factor for performance throughout the whole hospital. Not only can it produce better outcomes for patients, it is proven to give reduced length of stay, enabling more patients to be admitted.
Where we start from Urgent care performance in the second half of 2011/12 was very poor, the A&E target was not consistently achieved and many electives operations were cancelled as a result of there not being a bed available. The table below shows A&E performance for the four quarters of the year both in the hospital A & E department and for the Bolton health economy (includes patients seen at the walk in centre)
Hospital A & E performance Month Total <4 Hours >4 Hours % Q1 27,696 26,124 1,572 94.3 Q2 27,278 25,892 1,386 94.9 Q3 27,250 25,065 2,185 92.0 Q4 28,509 25,933 2,576 91.0 Total 110,733 103,014 7,719 93.0
Health Economy A&E performance Month Total <4 Hours >4 Hours % Q1 40,477 38,905 1,572 96.1 Q2 39,083 37,697 1,386 96.5 Q3 39,311 37,126 2,185 94.4 Q4 38,345 35,769 2,576 93.3 Total 157,216 149,497 7,719 95.1
The table below shows performance in previous years:
2007/08 2008/09 2009/10 2010/2011 Trust 96 95% 97 94.4 Health 97.2 96.7% 98 96.4 Economy
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What we are aiming for in the year ahead In order to achieve our urgent care target we have agreed the following: • Achieve and sustain at least 95% type 1 A&E performance for each quarter. • Increase medical specialty bed capacity by 24 for the whole year and add a further 24 beds from November to March 2013 and a further 12 in January/February 2013. Plan staffing levels to enable more to be available in the winter than in the summer. • Implement a Clinical Decision Unit (CDU), comprising 18 high quality trolleys from November 2012 in order to expedite specialty assessments and support direct admissions to specialty wards. • Improve the pathways for urgent care and ensure that the benefits from integration are realised through the development of intermediate care and case management. • Work with primary care to identify practices with high levels of attendances, referrals and frequent attenders in order to develop deflection plans. • Design and plan for the implementation of seven day working • Consume all urgent care pressures so that there is no impact on surgical services, allowing all surgery to be undertaken as and when it is planned.
How we will achieve this
The milestones we have agreed in order to achieve the urgent care target are: • From March 2012 to increase operational control of A&E/departmental performance and ensure that at least 95% type 1 performance is achieved each week/quarter. Responsible manager – Associate Director of Operations/Head of Division.
• From 1st April 2012, keep ward B2 open to accommodate medical specialty patients. • By October 2012, to have refurbished ward B1 so that it is fit for use for adult services from early November and enable 24 “winter” beds to come into play. Responsible manager – Director of Operations. • From the first week in January 2013, to have opened a further 12 beds for medical specialties, by swinging part of a surgical ward to medical specialty use. Responsible manager – Associate Director of Operations. • To have agreed how to staff the planned additional capacity by July 2012 so that any recruitment can be undertaken and staff in place by October 2012. Responsible manager – Director of Patient Safety and Experience. • By the end of May 2012 to have completed the outline designs for a CDU and by the end of May 2012 to have begun the building and engineering work with an estimated completion date of mid October 2012, ready for use from early November 2012. Responsible manager – Director of Operations. • By the end of Q1 to have designed and agreed the pathways and protocols necessary to underpin the operation of a CDU. Responsible manager – Medical Director.
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• By October 2012 to have in place all the resources necessary to run the CDU. Responsible manager – Director of Operations. • By the end of Q1 to have demonstrated how improvements to community and mental health services can assist in managing urgent care pressures during the winter and to be implemented from September 2012. Responsible manager – Associate Director of Operations/Head of Division. • By the 31st July 2012 to have consulted on changes to job plans for the relevant consultants to enable seven day working to be achieved when resources are available. Responsible manager – Associate Director of Operations/Head of Division.
• By 30th June 2012 to have concluded discussions with commissioners on how any extra resources may become available to support implementation of this aim for seven day working. Responsible manager – Director of Finance • By the end of Q1 2012/13 to have assurance on capacity and redesign to support closure of walk‐in centre in Q2. Responsible manager – Director of Operations. • By the end of May 2012 each ward to have daily discharge targets in place to allow performance management of discharge pathways. Responsible manager – Associate Director of Operations/Head of Division.
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PRIORITY THREE: To ensure patients who require elective procedures are seen within 18 weeks of referral
Why this is important to us Ensuring patients get the most appropriate treatment in timely way. Patients should be able to receive excellent care without any unnecessary delays.
Our work so far Although the Trust was an early achiever of 18 weeks and continued to achieve the target in 2008/09 and 2009/10, we missed the target in quarter four of 2010/11. At the time this was put down to a large number of cancellations (circa 400) during the exceptionally bad weather and protection of intensive care bed capacity, the latter being a nationally required response to the flu outbreak. The high number of cancellations led to a backlog being built up in quarter four of 2010/11, which led to problems in getting back on track during quarter one of 2011/12. Treating a significant number of patients who had already breached the 18 week referral to treatment (RTT) in quarter one of 2011/12 meant that the 18 week RTT could not be met.
Objectives The 18 week RTT requirements are 90% for admitted patients, 95% for non‐admitted patients and 92% for incomplete spells. We aim to meet these requirements from April 2012 and sustain them for the whole year, noting that early review and reassessments will be required by GPs. Referrals will be closely monitored as part of a Bolton health economy access policy and contingency plans developed should referrals increase.
How we will achieve this We will take the following steps to achieve and sustain the 18 week target: • From early May 2012 we will protect surgical specialty beds to enable elective capacity to be effectively planned and matched more closely to demand. • We will adopt a zero tolerance of hospital cancelled operations. • We will flex consultant, theatre and other capacity to meet demand for elective services and enable the 18 week RTT to be sustained. • We will improve the scheduling of patient operating lists, improve efficiency and effectiveness of the operating process and improve analytical and reporting processes.
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PRIORITY FOUR: Improving the appraisal and development of staff
Why it is important Appraisal has a direct impact upon quality of patient care, including vital elements such as mortality. Appraisal has direct links to staff engagement, motivation and performance. In previous Quality Reports we have reported the results of our focus on the number of appraisals undertaken. Last year we undertook to also improve the quality of appraisal and to ensure that our colleagues joining us from the PCT and from Salford and Bury as part of the MiB development, also receive high quality appraisal. In 2012/13 we intend to continue this work.
How we propose to measure our performance There is a Trust target of a minimum of 80% appraisals completed. This was achieved in 2010/11 but in 2011/12 fell slightly to 74%. Now that all staff have transferred we wish to achieve and maintain 80%. Recent staff survey results show that 40% staff had a well structured appraisal in the last 12 months. This puts the Trust in the highest 20% of acute trusts and is an improvement on last year’s results. However we want to seek improvements to this by focussing on appraisal quality and process.
Where we start from Staff survey results – the 2011 results for Bolton NHS FT show an improvement of 6% from the 2010 survey. This puts the Trust in the highest 20% of all acute Trusts for having a well‐ structured appraisal in the last 12 months. 81% of staff who responded to the survey had been appraised with a personal development plan (PDP) in the last 12 months.
What we are aiming for in the year ahead Continued improvement in the number of appraisals undertaken alongside improvements in the quality of the appraisals undertaken. Work will also continue on aligning the impact of appraisal on other key workforce performance indicators such as overall staff satisfaction, attendance, productivity and the reputation of the Trust as a good place to work and be cared for as a patient.
What we will do • Continue to measure uptake of appraisal in line with Trust minimum target of 80%. • Reinforce the value of quality appraisal and its relationship with an improved staff and patient experience (cultural) • Support the development of materials to promote a quality appraisal – e.g. local DVD. • Continue organisational development and learning targeted interventions to areas
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• Ensure a link to the exemplar programme to support clinical areas • Continue to use staff survey results as a key indicator for appraisal The following table shows our progress against these measures and the actions we will take in 2012/13 to support this priority.
Measure Action taken to date Further actions planned Continue to measure uptake Appraisal performance reporting has In liaison with HR Business Managers of appraisal in line with Trust stabilised as a result of integration and carry out action plan to support areas minimum target of 80% based winter/service pressures. The current who are not achieving 80% compliance. on new FT. rate is 75%. An action is in plan in place Hold a number of appraisal surgeries to for both acute and community staff. support introduction of new documentation and target hotspot areas Reporting on appraisal performance has for attendance. improved significantly addressing the Continue to provide quality of appraisal challenges of integrating data from reporting information. other external systems. Continue work on ensuring integrity of community appraisal data. Reinforce the value of quality Audits using survey monkey on the Following launch of updated appraisal and its relationship quality of appraisals established, documentation in April 2012, audit with an improved staff and subsequently areas have been identified quality of appraisal six months after patient experience (cultural). for concentrated support. implementation. Review of appraisal documentation completed with Best Employers Group, Ensure introduction of values into updated documentation incorporating paperwork is promoted in Divisions and values of organisation drafted. Directorates. Support the development of The Appraisal DVD was completed. New DVD will be developed to materials to promote a quality Rework required to incorporate new incorporate best practice and reflect the appraisal – e.g. local DVD. documentation. requirements in the new Training updated to reflect quality documentation. approach to appraisal (using previous Finalise and action feedback on documentation). appraisal documentation. Introduction of 60 minute manager Ensure launch of new documentation session – using a coaching approach to alongside Trust values in April 2012. appraisal. To further update training materials incorporating values. E learning options to be explored. Continue organisational Action plan in place both for acute and Continue to work with HR Business development and learning community staff. Managers to share diagnostics on areas targeted interventions to struggling with appraisal and provide a areas requiring support joint approach to supporting areas. Ensure a link to the exemplar Established link with exemplar Continue to support lead and areas as programme to support clinical programme lead and sharing of part of exemplar process. areas. appraisal data. Appraisal support given to areas in the process of exemplar status. Continue to use staff survey Examine results of 2012 staff survey for Consider improvements from 2012 staff results as a key indicator for improvements related to appraisal. survey and implement where necessary. appraisal.
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PRIORITY FIVE: Harm Free Care
In our Quality Report for 2010/11 we stated that one of our priorities for the year would be the Safety Express Programme. The Safety Express Programme is a national improvement programme that aims to reduce harm from pressure ulcers, falls, catheter acquired urinary tract infections (CAUTI) and venous thromboembolism (VTE) ‐ the collective name for deep vein thrombosis (DVT) and pulmonary embolism (PE) These four areas were selected because: • They are avoidable • They impact negatively on patient experience and outcome • They rely on the whole system getting it right • They are applicable to all care settings. The programme involves staff who are at the forefront of care both in the hospital and in the community. It sets ambitious improvement goals to increase the proportion of patients who complete their journey of care without experiencing any one of the four areas of harm. We intend to continue our focus on the reduction of harm in 2012/13. Our progress in 2011/12 is reported on page 70 of this report.
What is harm? Harm is defined in many ways but a widely accepted definition is that harm is “unintended injury resulting from, or contributed to, by clinical care that requires additional monitoring, treatment or extended stay in hospital”. Simply, this is a something the patient experiences either because of something we should have done but didn’t, or something we didn’t do but should have.
Why the programme is important to us We want to see a significant reduction in all four harms to ensure that at least 95% of our patients do not suffer any of the four avoidable harms. The focus for the programme is on rapid acceleration and spread therefore, using BICS methodology, front line teams (direct care givers) are pivotal in designing and testing changes aimed at reducing harm so we can realise the benefits across the health economy. The benefits of working in collaboration with other organizations will help us share and learn together and to move together at a pace and scale which is previously unprecedented.
How we propose to measure our performance We will track progress through measuring each of the harms across the integrated organisation. We will also be measuring the number of patients who have none of the four harms. The purpose of such close measurement is for teams to understand that harm is not one person’s ‘fault’ but to see harm as the responsibility of the system and amenable to changes in the systems and processes
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What we are aiming for: Reduce Category III and IV pressure ulcers by 75% in hospital Reduce Category III and IV pressure ulcers by 25% in community Reduce Catheter acquired urinary tract infection by 50% Reduce serious injury from falls by 50% Reduce VTE by 50% All of the above targets were set at the beginning of the Safety Express Programme with an end point of December 2012. For 2012/13 further targets in all of the above areas have been set as part of the CQUINS quality incentive scheme relating to Harm Free Care. These targets are aiming for further reductions in the incidence of falls, VTE, catheter‐associated UTI and pressure ulcers, together with achieving 95% compliance in a range of care indicators such as pressure ulcer and falls risk assessments and care plans. A Harm Free Care Delivery Plan has been developed to support the delivery of the CQUINS indicators and baseline measures have begun.
What we will do
Four working groups were established during 2011/12 to focus improvements in each of these areas to achieve rapid improvement across the integrated organisation. This will include involvement of frontline teams to engage patients and their families in the quest for safe care. The groups are supported by a steering group. Representatives of our Council of Governors sit on each of the groups and on the main steering group. The work of these groups will be continued in 2012/13.
Further information from on Safety Express is on page 70 of this report
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Review of services During 2011/12 Bolton NHS Foundation Trust provided and/or sub‐contracted seven regulated activities (as defined by the CQC) across 38 specialities (as per schedule two of the Terms of Authorisation). Bolton NHS Foundation Trust has reviewed all the data available to them on the quality of care in these NHS services. The income generated by the NHS services reviewed in 2011/12 represents 100% of the total income generated from the provision of NHS services by Bolton NHS foundation Trust in 2011/12
Information on Clinical Audit and National Confidential Enquires During 2011/12 40 national clinical audits and four national confidential enquires covered NHS services that Bolton NHS Foundation Trust provides. During 2011/12 Bolton NHS Foundation Trust participated in 88% of national clinical audits and 100% national confidential enquires of those which it was eligible to participate in. The national clinical audits and confidential enquires that Bolton NHS Foundation Trust was eligible to participate in and the national clinical audits and confidential enquires that Bolton NHS Foundation Trust participated in during 2011/2012 are as follows in the tables below. The national clinical audits and national confidential enquires that Bolton NHS FT participated in, and for which data collection was completed during 2011/2012 are listed below (alongside the number of cases required by the terms of that audit or enquiry).
National Confidential Enquiries
Eligible Participated % submitted Status Bariatric surgery* Yes Yes 100 complete Cardiac arrest Yes Yes 100 complete Peri‐operative Yes Yes 100 complete care Surgery in Yes Yes 100 complete children
*Although bariatric surgery is not carried out at the organisation the Trust did participate in the questionnaire and provided the information required with regard to facilities and equipment available for bariatric patients.
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National Audit Participation ‐Snap Shot National Audits
Name of Audit Participated Audit requirements Number of cases submitted and percentage provided where appropriate (%) Emergency use of Y All patients on a given ward who are The Trust audited 422 patients oxygen (British Thoracic on oxygen therapy. across 19 wards , of which 49 Society) (It is permissible to audit the first ten patients were on oxygen patients in any one ward provided therapy. there is no bias in the selection of patients) Pleural procedures Y Minimum of 19 cases, split between The Trust audited 20 cases across (British Thoracic Society) various procedures over a two month various procedures (over 100%). period.
Severe sepsis & septic Y 30 cases. 30 cases submitted (100%). shock (College of Emergency Medicine) Adult critical care (Case Y All cases. The Trust submitted 203 cases Mix Programme – (100%). ICNARC CMP) Seizure management N Did not participate. Closing date had already passed (National Audit of when Trust was informed this Seizure Management) audit was part of the Quality Report audit requirements. National Comparative Y 40 cases. 40 submitted (100%). Audit of Blood :Bedside Transfusion Paediatric pneumonia Y All applicable cases during audit 61 cases out of 64 submitted (British Thoracic Society) period. (95%). Paediatric asthma Y Where possible, all cases admitted 38 cases‐ 100%. (British Thoracic Society) for asthma during the audit period should be added to the audit tool. Where it is not possible to record all cases (for example when the number of cases admitted during the audit period is very large (over 100), it is recommended that at least 20 consecutive cases should be audited. Pain management in Y 50 cases. 50 cases submitted (100%). Children (College of Emergency Medicine) Epilepsy 12 audit Y 40 40 cases submitted (100%). (Childhood Epilepsy)
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Diabetes (Paediatric) Y No numbers specified by terms of the 89 cases submitted‐ (100%‐ all (PNDA) audit. cases). Care of dying in hospital Y 30 cases. 51 cases submitted‐ (over 100%). (NCDAH) Risk factors (National Y 100 cases. 95 cases (95 %) unable to submit Health Promotion in final five cases due to problems Hospitals Audit) with the national database Heavy menstrual Y The national organisers estimated 224 questionnaires were bleeding (HMB) 492 questionnaires to be returned by returned by patients (46%). patients. National pain database Y‐ i) organisational audit The Trust was unable to organisation participate in patient ii) Distribute patient questionnaires al (09/10) questionnaire part of the audit in pain clinic. due to resource limitations in N‐ patient pain clinic and the requirement questionnai‐ to consent patients. res Inflammatory bowel Y 40 cases. 40 cases‐ 100%. disease (IBD) Audit
Parkinson's disease N N/A did not participate. This audit became applicable to (National Parkinson's the Trust following integration Audit) between the provider and community services, by which point the Trust was unable to register for the audit. Adult asthma (British Y Where possible, all cases admitted 20 cases submitted (100%). Thoracic Society) for asthma during the audit period should be added to the audit tool. Where it is not possible to record all cases (for example when the number of cases admitted during the audit period is very large (e.g. over 100)), it is recommended that at least 20 consecutive cases should be audited. Bronchiectasis (British Y Where possible, all cases attending Six Cases submitted (30%). Thoracic Society) for an out‐patient appointment for bronchiectasis during the audit period should be added to the audit tool. Where it is not possible to record all cases (for example when the number of cases admitted during the audit period is very large (over 100)), it is recommended that at least 20 consecutive cases should be audited.
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Adult community Y‐Planning Where possible, all cases admitted Data collection for 11/12 acquired pneumonia for community acquired currently in planning stage‐ (British Thoracic Society) pneumonia during the audit period deadline for audit 31st May should be added to the audit tool. 2012. Non invasive ventilation N N/A Deadline 31st May 2012‐ no ‐adults (British Thoracic plans to participate in this round Society) of the audit.
National Clinical Audit‐ Ongoing Clinical Audits (please note some deadlines for data collection fall in 12/13)
Name of Audit Participated Details
National Cardiac Arrest Audit Y‐ From February All applicable cardiac arrests are required to 2012 be submitted to the audit. There have been 15 cardiac arrests in 11/12 that fit the audit criteria since the Trust registered for the audit in February 2012. All these have been submitted to the national database. National Comparative Audit of Y Data Collection in progress. Blood : Medical use of blood Lung cancer (NLCA) Y 220 cases estimated by the national organisers, 181 cases submitted so far and data collection ongoing. Bowel cancer (NBOCAP) Y 147 cases estimated by national organisers, 194 cases submitted so far and data collection ongoing. Head and neck oncology Y No case assertion data provided by the (DAHNO) national organisers, 26 cases submitted so far and data collection ongoing. Oesophago‐gastric cancer Y 60 cases estimated by national organisers, 29 (NAOGC) cases submitted so far and data collection ongoing. Acute coronary syndrome or Y National audit organisers request the Trust Acute myocardial infarction submit as many cases as possible‐ for 11/12 (MINAP) the Trust submitted 430 cases (100%). Hip fracture database (NHFD) Y The Trust was expected to submit 350 cases to the audit. In total 371 hip fractures were submitted to the national database in 11/12 (100%).
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Name of Audit Participated Details
Cardiac arrhythmia (HRM) Y All cases required for the audit. 203 cases submitted to the audit. Data collection for 11/12 is still ongoing and processes in place to capture 100% of patients. Perinatal mortality (MBRRACE‐ Y All cases required, for 11/12 Bolton NHS FT UK) submitted 35 still births and 13 early neonatal deaths (100%). Neonatal intensive and special Y All applicable cases required for the audit. For care (NNAP) 11/12 the Trust submitted all 523 applicable cases (100%). Stroke Improvement Y National organisers state as many as possible National Audit Programme but a minimum of 20 per month. Bolton NHS (SINAP) ‐ FT submitted 385 cases (over 100%). Heart failure (NHF) N The Trust has continually audited heart failure patients through the North West Advancing Quality scheme and has undertaken further local audit around the use of the heart failure care bundles and heart failure mortality. Trust is registered to participate in national audit for 12/13. Carotid interventions audit Y The national audit requires all cases are (CIA) submitted for the audit. The Trust submitted all 43 applicable cases (100%). National Joint Registry (NJR) Y The national audit requires all cases to be submitted. The Trust has submitted 417/418 cases so far (99.8%). Elective surgery (National Y 421 applicable cases. 238 pre op PROMs Programme) questionnaires were returned by patients (56.5%). The national average was 68.4%. Peripheral vascular surgery Y All cases are required for the audit and (VSGBI Vascular Surgery processes are in place to ensure that all Database) patients are audited. Data collection for 11/12 is still ongoing. Potential donor audit (NHS Y All cases are required for the audit and the Blood & Transplant) Trust submitted all 189 applicable cases (100%).
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National Audit Action Plans The reports of 21 national clinical audits were reviewed by the provider in 2011/12 and Bolton NHS FT intends to take the following actions to improve the quality of health care provided: National Heart Failure Audit‐ Following review of the national report the Trust has set up systems to participate in this audit. A rapid improvement event facilitated by the Bolton Improving Care Systems team is underway focusing on audit recommendation 6.2.1 – ‘All secondary care service providers should streamline the heart failure care pathway to ensure all patients, regardless of admission ward, have access to recommended medication in line with NICE guidelines (16) and that treatment is managed by specialist staff.’ National Joint Registry‐ Following metal on metal hip replacement alert – Each consultant is made responsible for establishing their own database of metal‐on‐metal resurfacings of hip replacements. The department is reviewing all patients and setting up extra clinics as needed. National Hip Fracture Database‐ The team reviewed hip fracture mortality cases and hold monthly mortality meetings for hip fracture. The team is working to improve cover and has recently employed a new orthogeriatrician as lead and a hip fracture advanced nurse practitioner. The Trust is currently reviewing use of the Nottingham Hip fracture scores for mortality. National Intensive and Special Care (NNAP) – There was a dramatic drop in neonatal mortality from 2005. Local audits have taken place to improve some of the poorer performing measures, notably retinopathy of prematurity assessment and involvement of senior staff. Since the report a purple sheet has been introduced into the patients’ notes to increase recording of senior review. There were concerns that activity was not reflected in the report due to poor recording and gaps in data completeness. Junior doctors now enter the medical information on the database and all discharges are completed online before a child is discharged/transferred. National Lung Cancer Audit ‐ The data for the time period was incomplete and not reflective of activity or practice. Since then data completeness had increased and it is likely this data is more reflective of practice. Inflammatory Bowel Disease (IBD) Audit ‐ Bolton met the majority of standards and areas of concern are being addressed. The team is exploring ways of providing all patients with a written care plan, management plans will be incorporated into all patients’ clinic letters at outpatient reviews and patients will receive a copy. National Mastectomy and Breast Reconstruction Audit ‐Data reported annually since 2008 showed consistently high levels of performance and any surgical complications were acted on. The earlier report showed Bolton patients had limited reconstruction and a length of stay of around 6 days. By the 2011 report the average length of stay had reduced to two days and reconstruction was offered to more patients than in any other hospital across the Cancer Network. Surgeons have continued to audit their own performance locally. National Audit of Falls and Bone Health‐ The work done under the Safety Express quality improvement programme will focus on actions around falls reduction and safety. The National Dementia Audit‐ The dementia pathway is in development this will be re‐audited in April 2012. Carotid Intervention Audit ‐ Actions have been taken to focus on reducing the time between
assessment and surgery. The availability of duplex and MR angiograms has improved (within ‐ 55
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24‐48 hours) and consultants continue to explore opportunities to reduce any delays in the surgical process. Further work around a Transient Ischaemic Attack (TIA) clinic is progressing. Stroke Improvement National Audit Programme (SINAP) – A Trust monitored action plan is in place to improve quality and weekly reporting of direct admissions has been introduced. National Head and Neck Cancer Audit‐ The report highlighted Bolton’s performance as average but the clinical lead was cautious about any interpretation of the results because DAHNO data completeness is limited. These weaknesses of data which were not unique to Bolton were nationally recognised and it is hoped will improve in the longer term with greater use of the Somerset system. College of Emergency Medicine: Renal Colic‐ Actions agreed following the audit were the re‐ education of junior doctors/ registrars focusing on the need for appropriate investigations. This will be re‐audited in 2012/13. College of Emergency Medicine: Feverish Children‐ Further training will be provided for paediatric triage staff around measuring and recording observations. Health Promotion Audit‐ The results were used in further planning of health promotion pathways within clinical settings and as evidence in contributing towards CQUIN targets. Perinatal mortality (MBRRACE‐UK) ‐ A validated proforma will be used for rigorous assessment of stillbirth cases. Adult Asthma (British Thoracic Society) – An integrated asthma care bundle will be developed to address issues with inhaler technique and discharge planning. The care bundle will be developed in an easy to use format. We are looking at the potential use of stickers that can be placed in the medical notes to guide healthcare professional in ensuring all relevant steps are completed. A written asthma action plan will be produced as a sticker that will be fixed into the peak flow diary. Diabetes (Paediatric) (PNDA) The Trust’s admissions trend has been coming down from 2006. Bolton is much better than the North West average for the number of admissions and also compares favourably to most regions in the country ICNARC ‐ reports are discussed six monthly at the “adult critical care strategic group”. Recent themes include ‐ relatively high pre‐unit cardiac arrest rate. This is being actioned via the Trust’s mortality group cardiac arrest root cause analysis. National Care of the Dying Audit – Actions include a Liverpool Care Pathway (LCP) Facilitator to support education and training and the provision of supportive written information. National Comparative Audit of Blood: Bedside Transfusion‐ The Trust has a high compliance for transfusion observations start/stop times but not 100%. Actions will be taken to raise awareness and this will be re‐audited in 2012.
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Local Clinical Audits There is a comprehensive clinical audit programme taking place across Bolton NHS FT. Over 250 local, regional and national audits were registered with the Trust in 2011/12 all at various stages in the clinical audit cycle. An audit isn’t considered complete until an action plan is returned to the Clinical Effectiveness Department. The reports of 43 local clinical audits were reviewed by the provider in 2011/12 and Bolton NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided:
Family Care Actions planned or Implemented Tubal ectopic pregnancy ‐ Review consent form for diagnostic procedures. laparoscopic (RCOG consent Patient leaflet implemented. standards) FDIU induction ‐ use of two Adopt new misoprostol dosing regime. misoprostol dosing regime (intra‐ Re‐audit one year after updating guideline. uterine foetal death) Anaemia management in Education of GP & Community staff regards protocols. pregnancy Possible development of PGD for iron supplements. Education to improve recognition of anaemia. Multiple pregnancies Departmental teaching session to include review of guideline. management New patient information leaflets. Consolidate proforma & guideline. Enforce scan protocol. Document initial scan diagnosis of multiple pregnancies. Teenage pregnancy outcome Continue dedicated teenage pregnancy clinic with extra support. Promote LARC & sex education. Induction of labour for postdate Offer membrane sweep to all eligible pregnant women ‐ pregnancy increase awareness in community. Improve on documentation of Bishop Score ‐ use of Bishop Score sticker in the community setting. Introduce membrane sweep database. Pregnancy of unknown location Introduction of new coding system for PUL. Appropriate classification / management pathway Re‐audit in 12 months. Essure Re‐audit when 100 procedures completed.
Menorrhagia management (HMB) Documentation of counselling of management options &
reasons for acceptance / non‐acceptance of particular option
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Family Care Actions planned or Implemented (proforma in development). Documentation of outpatient endometrial ablation ‐ creating database for outpatients procedures. Postnatal Readmission Rate Improve hand hygiene. Conduct of prospective audit. Record Keeping in Acute Incorporation of the latest audit report into induction session Paediatrics for junior doctors on ‘Defensible Documentation’ feedback to junior and nursing staff on recent audit report and in particular areas to improve. Introduce specific teaching session on documentation in the wider framework of clinical governance teaching to the department. Feedback to nursing and ward support staff to the results including ‘Condition of Record’ and the importance of correct filing. Record Keeping in Community Trial system of providing a form on the back of appointment Paediatrics letters for demographic details, address, etc to be completed and handed in by the family when they come to the
appointment. Stamp to be provided for each clinician, with name, designation and GMC number. All clinicians to record place of intervention and check all pages are clearly identified with patient detail. All clinicians to record growth measurements or reason or, if not recorded, reason why. All clinicians to check immunisation status. Clinicians to ask secretaries to record demographic details of children (e.g. sticky label), with investigations requested and check when results returned. Database as above to be kept. Target of GP letter sent within 48 hours of clinic attendance. Early Warning Score ‐ Paediatrics Doctor to document exact time patient was seen despite the retrospective documentation by doctor/ recorded by nursing staff (tick box if seen within 30mins).
Re‐audit.
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Family Care Actions planned or Implemented CAMHS pathway for Psychosis & Introduce standard audit proformas to be completed in each at risk mental state new case on the psychosis pathway to test whether a move to a real time audit process is possible. Due to the relatively small numbers of young people on this particular pathway, this methodology may be feasible. Consider whether a CAMHS Specific SOP re: lithium and / or mood stabilisers with associated treatment proformas and side effects monitoring tools is necessary. At present the number of young people treated with lithium is minimal. Further standardise the assessment process including standard information for young people and families, looking to what extent we would be able to incorporate PANS & CARMS. Paediatric asthma ‐ discharge Introduction of an asthma discharge ‘sticker’ into medical notes planning to be used by both nursing and medical staff. Education of nursing staff re: current asthma guidelines including documentation of inhaler technique, use of written guidelines etc. Education of medical staff re use of ‘sticker’ and need to assess interval symptoms and consider starting preventer treatment.
Elective Care Division Actions planned or Implemented Use of Prothrombin Complex Provide more guidance on use of Octaplex. Concentrate (Octaplex) Provide regular anti‐coagulant education/training. Ensure scientific staff guide appropriate use of Octaplex and refer inappropriate requests to senior haematologist. Audit of Strict Glycaemic Control Focus on BMs within first 24 hours ‐ Raise awareness – in critical care education. More detailed data collection – in particular how quickly BMs controlled within first 24 hrs ‐ RE‐Audit 2012. Longer duration – first 24 hours ‐ Re‐Audit 2012 4) Review response to BMs >8.4 in regards to guidelines ‐ Raise awareness education. North West Regional Issue: To decrease waiting time for elective Ureteroscopy < four Urology(NWRU) Ureteroscopy & weeks ‐ Action: appointment of a consultant urologist with PCNL Audit stone Interest Issue: Image intensifier available for stone cases in theatre. Action: arrival of image intensifier in theatre in next two weeks. Testicular & Penile cancer (NW Issue: specialist nurses should be involved in counselling. This is Urological cancer Audit) difficult as CSN are not available but these patients can been now seen in any of the six urology clinics running each week for
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Elective Care Division Actions planned or Implemented the patient who require counselling. Issue: Written information on orchiectomy Action: within our leaflet on scrotal surgery, there is a section on orchiectomy. We would like a separate patient leaflet on radical orchiectomy. NWRU Prostate Cancer Audit Development of new clinical guidelines discussed and agreed from the results of the audit. Management of Osteoarthritis Recommendations include the greater use of non surgical treatment of osteoarthritis through better communications with GP. This audit has been forwarded to PCT to help with further management. Transfer times from Royal Bolton Separate register of patients who require neurosurgical to Salford Royal for neurosurgical intervention should be held at Royal Bolton Hospital as interim intervention measure. Introduction of a “Head Injury Pathway” with clearly documented times and discussions/decisions. Re‐audit after changes to allow proper evaluation of the timeliness of transfers. Review of patient with fractured Introduction of A to Z of anaesthetic pre‐optimisation for hip neck of femur who are deemed fracture patients. medically unfit for an operation • pilot document • feedback issues • will be made available on the intranet. Warfarin reversal protocol (Trust Guidelines on management of peri‐operative anticoagulation). Neonatal TPN All actions on the plan discussed at pharmacy meetings. Recommendations agreed but not yet implemented. Prolonged Hospital Stays in Improvement of post‐operative pain control through teaching. Surgery Increase physician input on surgical wards by regular physician on surgical ward rounds, greater involvement of surgical team in
discharge planning/MDT. Currently implementation in discussion with matrons and surgeons. To review progress October 2012. Routine Antenatal Anti‐D Share data with Obstetrics & Gynaecology re patients who did Prophylaxis (RAADP) Uptake Re‐ not receive RAADP when eligible. Audit Determine root cause of non‐uptake. Continue RAADP 'opt‐out' system and monitor. Re‐audit Nov 2012. Audit of Protective compliance in PRVC to be default ventilation mode for all patients when Critical Care initially ventilated. This has become a `to consider` rather than
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Elective Care Division Actions planned or Implemented Improved education (nursing and juniors) ‐ education session at unit development day 2011. Titration of oxygen to SpO2 monitoring ‐ Cultural change in progress. Daily targets sticker ‐ Included in newly developed daily medical review proforma. Interim analysis of intracuff The audit in question was presented by a trainee in the March pressures of LMA during audit meeting in anaesthetic. The results are that the cuff anaesthesia inflation pressures do increase and there was discussion of whether that was important or does any action need to take place. The consensus was that it probably wasn't significantly important and more work may need to be done. DVT Prophylaxis (orthopaedics) Re‐audit to include G3 and TSU as well as A4 and G4 in six months. Mechanical prophylaxis and stop the clot booklet need to be given to patient and as well tick in the wardex if they are given. Action: Need to educate staff, not only nursing staff but also junior doctors who clerk the patients in. Education of the nursing staff and junior doctors when to give dalteparin prior to or after surgery ‐ Action: Need to be part of induction programme. Involvement of ward‐based staffs, including pharmacists and junior doctors based in the wards to review new admissions and check risk assessments. Action: Need to remind the new staff coming in to check the risk assessment. Reduction of length of stay after Early involvement of multidisciplinary team for rehabilitation protective beds introduced on programme ‐ Already implemented where nursing staffs are 15/08/11 usually very good in facilitating the involvement of physiotherapist, occupational therapist, and social worker to
aim for early discharge of the patient. No Action. Re‐audit after further implementation of the protective beds for one year to have a better comparable figures of each month. ‐ Action still in progress as after it was implemented from 15/8/11 to 18/11/11, the trial was lifted and it was implemented and lifted again afterwards due to the shortage of beds around the hospital. Re‐audit to include A4 and G4 if protective beds can be introduced in both wards respectively as well ‐ Action still in progress as after it was implemented from 15/8/11 to 18/11/11, the trial was lifted and it was implemented and lifted again afterwards due to the shortage of beds around the hospital. Transfusion sample and request Maintain awareness of sample acceptance criteria amongst
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Elective Care Division Actions planned or Implemented errors detected at the pre testing laboratory staff. stage Dissemination across Trust to consider further actions. Monitor NPSA competency assessment compliance Continue transfusion sample zero tolerance i.e. all incorrect samples are discarded. Retraining and re‐assessment of all phlebotomy staff Podiatry Documentation Audit ‐ Standards that have not been achieved will be reviewed at Dec 2011 professional meetings. Re‐audit in 12 months
Acute Adult Care Division Actions planned or Implemented Most common reason for blood Revision of laboratory practice‐ To devise multi choice film referral. Are appropriate questions based on actual blood films to form part of initial blood films being made? training. Lung Cancer patient experience Ensure information given includes psychological support. And information on help and self help groups. Ensure patient is offered a copy of information prescriptions. Readmission Audit in Elderly More communication with the patient’s GP and hospital was required. Increased roles in active case management with more support at home. Effective discharge planning to carry out geriatric assessment prior to discharge.
Corporate/ Trust Wide/ Part of Actions planned or Implemented Quality Improvement work streams Advancing Quality Towards the end of the year an improvement model of live data collection was developed using BICS methods. This will support clinicians on wards and departments involved in AQ by ensuring documentation of measures is recorded appropriately in health records. Improved performance data will show the effect of this in 2012‐2013.
Re‐audit of pneumonia care Elements to be completed in A&E. bundle Education for nursing staff in A&E and junior doctors on induction. More awareness and visibility of care bundle posters.
Bereavement Team and SPCT Provision of quality end of life care and education to all staff ‐ 62
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input ‐ care of the dying patient Trust wide. Mckinley Syringe Driver Re‐audit Improvement in practice since last audit. The audit highlighted some issues around training and actions are being implemented to improve this including dissemination of information packs to ‘train the trainers’. NICE clinical guideline 50: Audit of Increased ward level accountability and responsibility (e.g. compliance in critical care highlighting on observations charts non‐compliant observation). admissions 2011 Continued emphasis on education. Various Hospital Acquired VTE Trust wide action plan in force and work being taken forward via audits and completion of VTE risk Trust improvement workstreams. assessments Sepsis Care Bundle Audit Awareness raising and training around sepsis six care bundles is continuing across the Trust alongside improvement work. Audit of Heart Failure care Themes raised from audit to be discussed further with the acute bundles physician teams. Review clerking proforma to support the work. Heart failure workstream to commence in 2012/13
Information on clinical research The number of patients receiving NHS services provided or sub‐contracted by Bolton NHS Foundation Trust that were recruited during the period to participate in research approved by a research ethics committee was 474. The Greater Manchester and Cheshire Cancer Network target was exceeded, with 164 patients recruited to trials. The target was 97.
Goals agreed with commissioners A proportion of Bolton NHS Foundation Trust’s income in 2011/12 was conditional upon achieving quality improvement and innovation goals agreed between the Trust and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework. Further details of the agreed goals for 2011/12 and for the following 12 month period are available on request from the Trust.
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Care Quality Commission Registration The Care Quality Commission (CQC) is the independent regulator of health and adult social care services in England. This means that as well as checking individual services, they look at how well the two sectors work together. There are many people who need to use both health and social care services and it’s important that their care is as ‘joined up’ as possible. The CQC do this by: • Driving improvement across health and social care. • Putting people first and championing their rights. • Acting swiftly to remedy bad practice. • Gathering and using knowledge and expertise, and working with others. The CQC registration system for health and adult social care aims to ensure that people can expect services to meet essential standards of quality and safety that respect their dignity and protect their rights. The system is focused on outcomes rather than systems and processes, and places the views and experiences of people who use services at its centre. If the CQC have concerns that a provider is not meeting essential standards of quality and safety, they aim to act quickly, working closely with commissioners and others, and using their enforcement powers. The Trust is required to register with the Care Quality Commission and its current registration status is registered without conditions. The Care Quality Commission has not taken enforcement action against the Trust during 2011/12. There are 16 standards of essential quality & safety that cover the following areas: • Respecting and involving people who use service • Consent to care and treatment • Care and welfare of services users • Meeting nutritional needs • Cooperating with other providers • Safeguarding people from abuse • Cleanliness and infection control • Management of medicines • Safety and suitability of premises • Safety, availability and suitability of equipment • Requirements relating to workers • Staffing • Supporting workers • Assessing and monitoring the quality of service provision
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• Records The Trust has not participated in any special reviews or investigations by the Care Quality Commission during the reporting period. CQC have undertaken the following inspections in the period covered by the report: Inspection 1: Planned Review of all 16 of the Essential Standards of Quality & Safety, conducted on the 13th April 2011. During this inspection the CQC visited wards • B3 Complex Care (Female) • B4 Complex Care (Male) • E3 Surgical (Male) • D1 Medical Assessment Unit • M2 (post natal) • M4 (antenatal). Inspection 2: The CQC the undertook a follow up review against all of the 16 of the Essential Standards of Quality & Safety this was conducted on the 13th October 2011. During this inspection the CQC visited • Bolton Breast Unit • B3 Complex Care (Female) • B4 Complex Care (Male) • D1 Medical Assessment Unit. All 16 of the standards were assessed under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, and the Trust was found to be compliant overall with all 16 standards. However during the follow up inspection on the 13th October 2011 the CQC did suggest three areas which would benefit from improvement actions. Minor Concerns were identified in: Outcome 01 ‐ Respecting and involving people who use services Outcome 05 ‐ Meeting nutritional needs No concerns identified in: Outcome 04 ‐ Care and welfare of people who use services. Moderate concerns were identified in: Outcome 21 – Records. Improvement actions are actions a provider should take so that they maintain continuous compliance with essential standards.
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Inspection 3: As part of a national review of the regulations for termination of pregnancy the trust was inspected on 20th March 2012 to review the documentation processes for termination of pregnancy. The CQC inspector took copies of five HSA1 forms during this inspection. At the time of writing this report the Trust has had a follow up unannounced visit by the CQC who found the Trust compliant in all the areas of concern identified above. The Trust continues to welcome all suggestions made by the CQC, and robust action plans and responses are developed in response to all visits and inspection from the CQC. This is overseen by the Director of Patient Safety & Experience / Chief Nurse to ensure that each area for improvement is addressed. The action plans are received and monitored through the Trust`s Clinical Governance & Assurance Committee which reports exceptions and areas of significant risk to the Risk & Assurance Committee, a formal sub‐committee of the Board.
Data Quality The Trust submitted records during the period Apr‐Feb 2011/12 to the Secondary Uses Service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data: which included the patient's valid NHS Number was: • 99.7% for admitted patient care; • 99.8% for outpatient care; and • 99.0% for accident and emergency care. which included the patient's valid General Practitioner Registration Code was: • 100% for admitted patient care; • 100% for outpatient care; and • 100% for accident and emergency care.
Bolton NHS Foundation Trust Information Governance Assessment Report overall score for 2011/12 was 62% and was graded amber from the IGT Grading Scheme
Bolton NHS Foundation Trust was not subject to the Payment by Results clinical coding audit during the reporting period by the Audit Commission.
Bolton NHS Foundation Trust will be taking the following actions to improve data quality: Production of the Data Quality Dashboard. This is produced monthly and presented to the Information Quality Assurance Group, which reports to the Information Management and Technology (IM and T) Committee a sub‐committee of the Board. The Data Quality Dashboard is presented directly to the IM and T Committee on a quarterly basis. The data quality
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dashboard includes data quality metrics including NHS number coverage, demographic coverage and data completeness. The Trust also completes monthly data quality audits on patient data, comparing case notes to data recorded on the Patient Administration System. Results of the audits and actions arising from the audits are discussed at the Information Quality Assurance Group which reports to the IM and T Committee (sub‐committee of the Board).
Bolton NHS Foundation Trust has a Data Quality Policy the purpose of which is to improve data quality within the Trust, by formalising the procedure for accountability for data quality. On a daily basis the Trust has routines to check data recorded on the Patient Administration System for duplicate and missing data on data items such as GP details, patient address details and NHS numbers.
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Our performance for safety and quality in 2011/12 This section of our report is provided to give an overview of the quality of care offered by Bolton NHS Foundation Trust in 2011/12. The indicators included were selected by the Board in consultation with stakeholders.
For Patient Safety • Reducing the Trust’s mortality rate (please refer to page 40) • Preventing harm by using Safety Express • Infection Control
For Effectiveness • Improving patient communication and discharge planning • Reducing the number of people who do not attend their outpatient appointments • Reducing waiting times for patients referred for admission for elective procedures (please see page 46)
For Patient Experience • Reducing the waiting time in our A & E department (please see page 43) • “100 voices” – patient experience feedback • Improving the appraisal and development of staff (please refer to page 47)
Earlier in this report we set out our priorities for the coming year. These were agreed following consultation with stakeholders who were keen to see us continue work on some of the priorities agreed in the previous year. The priorities identified for 2012/13 are discussed in detail in the first section of this report, therefore to avoid repetition they have not all been included in this section. The other indicators remain important to the Trust and although not selected as key priorities in this report will continue to be monitored in the coming year.
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Using Safety Express to Reduce Harm to Patients Update and Progress
The Safety Express Steering Group has met regularly to oversee a programme of work aimed at reducing the four harms: • Pressure Ulcers • Falls • Cather Acquired UTI • VTE Four sub‐groups undertake the detailed work to ensure delivery of each work stream element. Each sub‐group is tasked with overseeing the following aspects contributing to improvements in their particular area of harm. • Policy Development and Review • Development and delivery of education and training programmes • Development and review of clinical practice interventions and care bundles • Development and review of risk assessment and care planning documents • Review of data‐incidents, themes, trends, root cause analysis
Pressure Ulcers The pressure ulcer work stream is led by a tissue viability specialist nurse and involves clinical staff across both hospital and community sites. A new care plan has been piloted and launched in trial areas. A key focus in the next few months will be on rapid spread of improvement work to embed and sustain the use of the care plan in all clinical areas. This will be crucial in order to achieve the very challenging CQUINS targets for 2012/13. Validation and Root Cause Analysis (RCA) for all reported pressure ulcers graded two and above is undertaken across hospital and community sites. This is to help us to understand the reasons why pressure ulcers are occurring so that we can take remedial action. Themes from RCA are used to help to develop tailored training programmes for staff which have been well received. Two programmes of training have been commissioned from external providers during 2011/12. The link nurse programme was relaunched in 2011‐for every ward and speciality, supported by a dedicated training programme. The programme was opened up to band 7 community nurses in 2012. Objectives have been set for each nurse within their appraisals to take forward the elements of good practice in their own areas of responsibility.
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The Safety Express target for 2011/12 was to: Reduce Category III and IV pressure ulcers by 75% in hospital and to Reduce Category III and IV pressure ulcers by 25% in community
The four charts below demonstrate that the target has been achieved for hospital-acquired pressure ulcers.
Category 3 Hospital Acquired Pressure Ulcers 4
3
2
1
0
Fiscal 2010/2011 Fiscal 2011/2012
Total Category 3 Hospital Acquired Pressure Ulcers
20 18
15
10
5 1 0
Fiscal 2010/2011 Fiscal 2011/2012
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Category 4 Hospital Acquired Pressure Ulcers 4
3
2
1
0
Fiscal 2010/2011 Fiscal 2011/2012
Total Category 4 Hospital Acquired Pressure Ulcers 5 4 4
3
2 1 1
0
Fiscal 2010/2011 Fiscal 2011/2012
With regard to community‐acquired pressure ulcers a lower target of 25% reduction was set in recognition of the highly complex nature of community care, where community nurses are often delivering an element of care alongside other agencies and in partnership with residential care homes, families and carers. All community–acquired pressure ulcers are reported as clinical incidents in line with NICE guidance. A root cause analysis is then completed and submitted to the Tissue Viability Service for further analysis and attribution i.e. a judgement is made as to whether the pressure ulcer developed as a consequence of a deficiency of the care provided. Work has recently been completed on integrating the acute and community incident reporting systems ‐ this should greatly assist in the ‘tracking’ of patients with pressure ulcers across the health economy.
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Falls The falls workstream is led by the Senior Nurse for Older People. Improvement work has focussed on the undertaking of falls risk assessments, development of falls care plans for those at risk and ensuring that care plans are fully implemented in practice. As for pressure ulcers, the focus in the next few months will be on the rapid spread of improvement work to embed and sustain the work across all areas. In 2010/11 there were 413 falls reported to have resulted in moderate or severe harm. In 2011/12 there were 193 falls reported to have resulted in moderate or severe harm. This is a reduction of 53.3% falls 450 400 350 300 falls
of 250
200 150 number 100 50 0 2010/11 2011/12
The CQUINs for 2012/13 will require the trust to undertake a root cause analysis for all falls involving moderate or severe harm‐themes and trends will be reported on a quarterly basis. Mini‐RCA has already been introduced to pilot wards as part of Safety Express. These wards have also delivered intensive training to staff on the Falls Policy. Further work will need to be done in 2012/13 to improve compliance with use of the Falls Care Plan and to demonstrate implementation of all the identified interventions in the care plan that are considered to be of likely benefit to the patient.
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VTE VTE risk assessment has been a particular challenge for the Trust in terms of accurate data capture. From February 1st 2012 the method of data capture was changed from collection by clinical coders from patient notes after discharge to electronic data collection at time of admission on the ward or department. This change was made following an internal audit review of the VTE data collection process, which found that the process of data capture was not robust enough to be an accurate reflection of the practice. When the new system of data capture was introduced each clinical area was asked to develop a standard operating procedure to ensure that the VTE risk assessment is completed and recorded on the LE2.2 system. The aim was to be able to demonstrate by the end of March 2012 that the risk assessments have been undertaken on at least 90% of patients at the time of admission. It has taken some considerable time to embed the new process and iron out technical difficulties and although we did not achieve the target during the reporting year, in March 2012 we achieved over 90%.
VTE Achievement 100% 90% 80% 70% 60% 50%
Achievement 40% 30% VTE 20% 10% 0%
As for pressure ulcers, a root cause analysis is undertaken for any cases of hospital‐acquired VTE and the themes from RCA are presented to the Thrombosis Committee. Case note audit for all cases of VTE commenced in August 2010. From August to December 2010 a total of 116 case notes were reviewed. 33 cases of hospital‐acquired thrombosis cases were identified, of which ten were fatal and 23 non‐fatal. From January 2011 until December 2011 a total of 141 case notes were reviewed. 37 hospital‐acquired thrombosis cases were identified, of which 6 were fatal and 31 non‐fatal. The CQUIN for Harm Free Care for 2012/13 will require a 95% coverage of VTE risk assessment, together with a 30% minimum reduction in adult VTE incidences.
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Catheter-Associated Urinary Tract Infection The Catheter‐Associated Urinary Tract Infection work stream is led by the urology specialist nurse. Improvement work has involved developing a new catheter care and observation chart and a training package to support its implementation. A baseline audit of catheter‐associated UTIs was undertaken in October 2010 in an attempt to establish the local position. A review of all casenotes of patients with a positive catheter specimen of urine (CSU) in the first week of October 2010 was undertaken, using an audit tool approved by the consultant microbiologist. 29 patients were initially identified as having a positive result from a CSU; of these, 16 met the criteria to be included in the audit. Four of these were considered to have a catheter‐related urinary tract infection. This would give a CAUTI rate of 25%. However, it would not be wise to use such a small sample of patients to determine a baseline for improvement work. There are no nationally agreed criteria for a catheter‐associated urinary tract infection. It is considered that the safety thermometer data collection method will be used as the measure of this particular harm as we move into 2012/13‐this measure gathers evidence of antibiotic use linked with signs and symptoms of urine infection in a catheterised patient.
Safety Thermometer Although each of the four harms is measured on an ongoing basis through incident reporting procedures, the Trust has piloted the use of the ‘Safety Thermometer’ tool to measure the total harm present in the whole organisation at a specific point in time. The aim is to be able to demonstrate from safety thermometer measurements that at least 95% of patients receive care in Bolton NHS FT without suffering any of the four harms. Initial measurement took place in September 2011, when a total of 1169 patients were included in the audit. A second audit was undertaken in December 2011 with a total of 842 patients being audited. To date, the data collected is not considered to be sufficiently robust to be an accurate measure of harm. As the tool is refined and staff are trained in the correct use of the tool it is anticipated that we will be able to use the tool to demonstrate year‐on‐ year improvements in patient safety. One of the Harm Free Care CQUINs for 2012/13 requires the use of the Safety Thermometer on a monthly basis to capture the prevalence of harm. This will take place from April 2012 onwards.
Transparency Project
The Trust is one of a number of North West organisations participating in a pilot project to publish data relating to the number of falls and pressure ulcers that have occurred to patients whilst under our care. The project involves gathering data on the number of pressure ulcers and falls that occur and then going to the clinical areas concerned to ask a set of questions relating to both patient and staff experience.
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The first month’s data was published in January and the publication was timed to coincide with a national launch of the project at the Chief Nursing Officer’s business meeting in Leeds.
Phase two of the project is about to be launched and will involve more organisations‐it is considered that it is likely to become a contractual requirement to publish such data in the future.
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Infection Control What is infection control? Infection prevention and control is about protecting patients, workers and others from the identifiable risks of acquiring a healthcare‐associated infection (HCAI). Examples of HCAIs are clostridium difficile (CDT) and meticillin‐resistant staphylococcus aureus (MRSA).
Why is infection control important? Anyone can get an infection, but some people are more at risk because their immune systems are weak. In a hospital those vulnerable people may be at additional risk because they have had a procedure that, while it is an important part of their treatment, may increase their risk of infection. It is especially important to prevent infections to help patients recover quickly and stay as healthy as possible. Performance
Number of cases of post 48 hour MRSA 35 31 30
25
20 15 15 10 10 4 5 3
0 2007/08 2008/09 2009/10 2010/11 2011/12
Number of cases of post 72 hour C.difficile 350 294 300 250 200 176 150 100 46 50 34 22 0 2007/08 2008/09 2009/10 2010/11 2011/12
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What Have We Been Doing To Prevent Infections? We have concentrated on those key areas that we know are critical to the prevention of infection, these include; • Stringent hand hygiene practices • High standards of decontamination and cleaning • Environmental cleanliness • The controlled use of antibiotics. These elements are incorporated into everyday clinical practice. This is underpinned by ongoing education and training of staff to ensure excellent practice. A robust programme of audit and surveillance is in place so that these key elements are monitored on a regular basis. Compliance with a range of metrics has remained high, such as hand hygiene and cleanliness of the environment. These audits also monitor the number of staff who are trained in aseptic non touch technique and Blood Culture sampling, which are all reported monthly. Root Cause Analysis is carried out for all cases of MRSA and C. difficile. This ensures there is learning and any themes that may require actions to be taken to address issues can be identified. A process to monitor and report wider infections has been established. These infections now also result in a root cause analysis and being followed up by clinical teams and microbiology.
Sustaining and Growing
• Continue with Screening and Decolonisation Strategy. • Identification of high risk patients so interventions can be taken to minimise risk of infection. • Careful monitoring of any invasive devices being used. • Safety Express Group looking specifically at improving management of catheters and catheter associated urinary tract infections. • Education campaign to recognise and put into place necessary interventions to protect high risk groups.
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Improving clinical correspondence
Why this is important to us Successive annual NHS inpatient surveys have highlighted the importance to our patients of good discharge planning and clear communication. This is an area on which the Trust’s performance in the patient survey has been relatively poor. We also know from the patient diaries and interviews carried out as part of our “patient experience‐based design” work, that shortcomings in discharge arrangements can cause clinical, practical and emotional problems for patients. The Trust has been working hard over the last year to improve our performance in notifying GPs of their patient’s discharge from both inpatient care and from outpatient appointments. This notification process is important because GPs need to know what has happened in hospital so they can continue to care for patients in the longer term.
In last year’s Quality Report we set the objective that by the end of March 2012 we would send at least 95% of inpatient discharge information to GPs within 24 hours and 99% within two days. We also set ourselves the objective to send 99% of all outpatient discharge letters within five days.
Digital Dictation Digital dictation is now live in all departments across the hospital and in use for creating outpatient clinical correspondence and also for clinicians and managers who wish to use it for non‐clinical letters. It allows authors to dictate letters which are then saved as an audio file and if a SpeechMike handset has been used then these files are immediately available on the network for typing. If a digital pocket memo (the portable device) is used for the dictation then the files created become available for secretaries to access on the network once the handset has been docked at a PC and the files have been downloaded. The quality of the sound on digital recordings is higher than the sound quality of analogue machines and tapes, especially if a SpeechMike is used at a PC and the digital devices cut down on the background noise recorded. When clinicians dictate in clinic between patients, the fast transfer of the audio files on to the network means that secretaries are able to type real‐time whilst the clinic is taking place. For some secretaries this may not always be possible due to working hours and other work commitments but a secretarial problem solving event was held on 27/07/11 which looked at some of the changes which could be implemented to improve work processes. Clinicians are also able to prioritise work enabling urgent letters to be typed first. This has been of real benefit to secretaries as they do not have to scroll through tapes to find urgent dictations as they automatically appear at the top of their work list and they can also filter their work lists to find specific files. The advantages of digital dictation from a system administration point of view are that work can easily be redirected if necessary when, for example, a secretary is on annual or sick leave. Files which need typing can be picked up by other secretaries, preventing unnecessary delays in correspondence being sent out. The G2 system administration also provides an improved
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audit trail if there are any queries about the status of a file, where a file has been sent or who has accessed it. Consultant led services in the previous provider services will also use digital dictation in the near future. Adult Elective Care Division Update Clinical correspondence over the last year has seen an improvement in both discharge correspondence as well as clinic letters produced. In April 2011, specialties across the Division created a letter for 66.2% of discharges with 50.2% created within 24 hours. As at February 2012 performance had improved to 78.2% of discharges having a letter created with 72.6% created within 24 hours. Despite this significant improvement this is still below the expected performance. The Division is now beginning to target individual patient level for those who have no letter created to understand and action the reasons for under achievement. With regards to clinic letters, performance has improved from 77.4% of letters sent to GPs within five working days in April 2011, to 83.4% sent within five days in February 2012. Once again the individual patient level detail of those having a clinic appointment with no letter created is being reviewed to understand the reasons and take appropriate action.
Family Care Division Inpatient clinical correspondence for March 2012 was as follows Service 24 hour target 48 hour target Letters created Paediatrics 79.5% 83.9% 88.1% Gynaecology 76.6% 86.1% 88.3%
Although this is not included in the forward look section of our Quality Report it remains a key priority on which the Trust will be monitored by its commissioners.
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Reducing the number of people who do not attend their outpatient appointments
Why it is important When a patient does not attend (DNA) a booked appointment it wastes valuable capacity, incurs unnecessary cost and, in effect, prevents another patient having access to an earlier appointment. Waiting times have reduced significantly over recent years and many more patients are now involved in choosing the date and time of their appointments. This was a priority in our Quality Report last year and although it has not been included in the forward look of this year’s report it still remains a priority for the Trust and particularly for our Council of Governors.
Where we start from In our Quality Report for 2011/12 we set ourselves the objective of reducing the DNA rate to no more than 6% for new patients and 8% for follow‐up patients.
DNA Rate 2008/09 2009/2010 2010/2011 2011/2012 New patients 9.0% 8.8% 9.5% 8.8% Follow‐up 11.0% 11.3% 10.9% 10.1% Outpatients
Adult Elective Care Division Update Several initiatives have been implemented with the aim of reducing the DNA rates for both first and follow‐up appointments. Whilst progress has been made, the Trust is yet to see the level of reduction that it was looking for. In January 2011, as part of our BICS improvement work the booking team held an event around slot utilisation. At 60 days a 45% reduction in wasted new patient slots for surgical clinics in general outpatients had been realised with an approximate financial gain of £66,000 to the Trust. This event has had a positive impact on DNA rates as a result of the telephone access team confirming appointments. By March 2011 vascular clinic DNA rates had fallen from 8% to 5% and general surgery from 9% to 6% overall. Expansion of this work is planned for 2011/12 which should have a further positive impact on reducing the Trust’s DNA rates. We recognise that one of the contributory factors to patients not attending appointments is when we make changes to existing appointments. There is also a programme of work to reduce this which we recognise is a source of frustration for our patients. In December 2011 the specialties participating in the telephone call reminder service changed to include urology services delivered within GOPD, pain services and cardiology. Some services chose to exit from the pilot and all are now evaluating the effect of the call reminder service both in terms of its effect on DNA rates and our ability to backfill appointments cancelled or changed in terms of guaranteeing the Trust’s expected income. Urology has seen a significant fall in DNA rates from 11.4% in December 2011 to 6.0% in February 2012 for new patients.
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As part of a BICS event to be held in May, the cardiology team is undertaking a bespoke piece of work looking at the reasons why patients DNA outpatient appointments and will share findings with the wider audience. The Trust access policy has been rewritten and is currently out for first stage consultation. GP colleagues have expressed an interest in being involved in the wider consultation and application of this policy which will help us manage our DNA rates more effectively in partnership.
Family Care Division Update Acute services Outpatient DNA rates between April 2011 and February 2012
Service New patients Follow up Total
Paediatrics 11.2% 19.6% 16.8%
Obstetrics 8.2% 13.2% 11.2%
Gynaecology 6.8% 9.3% 8.4%
DNA rates continue to be a cause for concern and subject to further work. A BICS event is planned for week commencing 16th April 2012 to consider a new way of delivering paediatric outpatient appointments in community settings. It is anticipated that this work will have a positive impact on the reduction in DNAs by providing this care closer to home to avoid the need to attend the hospital site for new and follow up appointments. It is also planned to consider the use of text messaging technology / telephone reminders to provide reasonably timed reminders and offers to rearrange inconvenient appointments. Obstetric services have been subject to major change this year with the transfer of services from Salford and Bury sites as part of the Making it Better (MIB) programme. Work is planned post MIB to look at ways of achieving improvements in new and follow‐up DNAs. Gynaecology services have demonstrated a reduction in DNAs in year for both new (8.9 to 7.1%) and follow‐up appointments (11.7 to 11.2%) however these rates remain unacceptably high and will be subject to further work in 2012/13. The use of telephone reminder systems is in place in this service currently. It may be possible to look to provide gynaecology clinics in community settings to try to bring care closer to home for patients. This will also be explored in the coming year.
Community Services Community services have demonstrated considerable success in DNA reduction with current levels as follows.
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Service DNA rate at April 2012. Health Visiting 5% School Nursing 1% Special School Nursing 0% Paediatric Speech & Language Therapy 5% Paediatric Occupational Therapy 5% Paediatric Physiotherapy 5% Paediatric Dietetics 5% Paediatric Learning Disabilities 2% Parallel 0% Youth Offending Team 0% Paediatric Acute Nursing Team 11% Paediatric Continuing Care 11% Paediatric Respiratory 9% Newborn Hearing screening 1% Paediatric Audiology 20% Paediatric Consultants 13% ADHD 0%
Many of these services have seen considerable reductions in DNA levels. Screening services nationally have higher levels of DNAs than treatment services so the achievements of the newborn hearing team are commendable in this context. Further work is needed with those services currently above 5% and this will be ongoing in 2012/13.
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100 Voices – Patient Experience Feedback Background The 100 voices audits seek to listen to as many patients as possible each month about their experience of care. Managers are encouraged to support this initiative by releasing non‐ward based staff for one hour per month to take part. This initiative includes key questions taken from a number of sources including: • CQUINS • DH delivering same sex accommodation • 2010 National Inpatient Survey where the organisation scored in the bottom 20%. The questions are set out using the following categories: • Respect, Privacy and Dignity • Being Involved and Safe • Cleanliness and Hygiene • Confidence, Care and Compassion The template is now being revised to update the elements from the 2011 inpatient survey, as well as making links with the transparency pilot; the organisation is a part of. Patients are also asked if they have any other comments they would wish to make. These have been themed against each of the above areas and are summarised at the end of each section.
Respect, Privacy and Dignity The questions relating to same sex accommodation ask a patient, if when they were first admitted they shared sleeping accommodation with a person of the opposite sex. 10% of patients asked, believed that they had, though it was apparent that some areas the person identified as where this occurred, were in fact same sex areas. The next question in relation to same sex accommodation is to determine if patients were moved to another ward, that they then shared sleeping accommodation with a person of the opposite sex. Whilst the majority indicated that they had not, 17 patients believed that they had. Of all patients who were asked if they had ever shared bathroom facilities with a person of the opposite sex, 4% said they had. Overall 3% of patients sharing sleeping accommodation said they minded. The numbers believing they had shared sleeping accommodation does not correlate with reports from areas with mixed sex accommodation. Nor did it always match with the ward areas identified as a person being on. It is clear that the question causes a lot of confusion, as such; focused work will be carried out to do more awareness‐raising for both patients and staff, about the delivery of same sex accommodation. Without a true reflection of actual numbers it is difficult to plan how we might improve this area. The wording to this question has also been changed to make it clearer what is meant.
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Positive Comments Negative Comments
Uncomfortable with some patients in close proximity Confused lady in male shower Staff behaved as though I was wasting their time, and I was in agony Shower could do with improvement
Being Involved/Communication The majority of patients (92%) felt that they were ‘definitely’ and ‘to some extent’ involved in the decisions about their care and treatment. 95% of patients felt they were given enough privacy and dignity when discussing their treatment. For those who said that this was not the case, the following comments were given: “Having your own room would be better” Five patients identified that only curtains separated each bed space, so people can overhear conversations.
Positive Comments Negative Comments
Very Good No communication Have had the opportunity to discuss Not happy with staff The doctors explained everything Would like more information about what is happening with my care Long delay between ward round directions and action Not informed what was happening
Feeling Safe and Comfortable Patients were asked if they had somewhere to lock personal belongings and if this was important to them. This was only important to 13% of patients. 87% of patients did not mind or think that this was important. Whilst the majority (95%) of patients, did not feel threatened by other patients or visitors, 5% had at some time felt threatened. 79% of patients were not bothered by noise at night by staff. Of the 21% who were bothered, they highlighted staff hand‐over periods and disturbance when patients were admitted to wards (largely acute admission areas) as the main reasons for this. Whilst this year’s data did not identify rubbish bins to be a problem as it had in previous years, it was mentioned in the
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additional comments when patients were asked for any other comments overall. As a response, quiet bins have been purchased, but this has not extended to all areas as yet.
Positive Comments Negative Comments
A very nice ward, the nurses are lovely Threatened by a confused patient, but Food lovely (two comments) moved Looked after well, staff good People smoking outside can be unpleasant Not answering call bell, Noisy patients, excellent staff answered straight away at night Enjoyed food Lockers not well designed, too small, Food excellent, improved greatly drugs drawer too big Noise levels high. Bin, patient bedside lockers, folders closed make a lot of noise, tea trolley wheels, nurses speaking loudly during handover Not enough salt in food, only given sachet Foot pedals on bins noisy Not much variety on halal menu
Cleanliness and Hygiene 97% of patients felt the ward was either very clean or fairly clean. Only one patient out of a total of 445 thought the hospital was not clean at all. A large percentage of patients observed nurses and doctors washing their hands although in some cases, it was not noticed and not known if it had happened.
Positive Comments Negative Comments
Very good at dealing with spillages I feel the bathroom should be cleaned Very clean ward, lovely hard working staff more or better‐ the ward should be mopped more Cleanliness improved, excellent, staff fantastic Washbowl in washrooms too small Delivery suite very clean Toilets not always clean bathrooms not very clean Cutlery has food remains on them
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Confidence, Care and Compassion The next section contains some of the most important questions that capture a person’s experience, and are a key indication of whether we have met their expectations. When asked if a person felt that if on reflection they had got the care that mattered to them, 69% of patients said they got this ‘at all times’ 22% felt that this was done ‘most of the time’ and out of the 444 responses to this question, three people said ‘never’
Positive Comments Negative Comments
Wonderful, very happy Staff very busy Dr X is the best consultant I have ever had All people who have had surgery need a treating me quiet place to rest Nurses who came to see me where nicer Sometimes would like someone to talk to than last time I was in hospital one to one Nurses are very good More staff at night Been very good The care and attention has been very good It’s been nice at Bolton Hospital Marvellous staff Couldn’t have had better care Excellent Very happy with courtesy and treatment of nurses Have been excellently treated in here, only too helpful Nothing I can fault at all and I am a retired nurse with 40 years experience
Patients were asked to rate on a scale from one to ten, with one being the lowest and 10 the highest, of whether they would recommend the hospital to a friend or relative revealed that 154 scored this as a ten, and at the other end of the scale, four patients gave this a one.
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I would recommend this hospital to a friend or relative (1 is lowest 10 is highest)
180 154 160 140 120 102 100 76 80 60 40 20 9 20 4 1 4 2 7 0 12345678910
If patients scored eight or below, they were asked why, which is set out below:
Reasons for scoring eight and below
Food ok, clean, nurses and doctors good Based on consultant treatment Because it seems to me when it comes near to weekend they hurry up and try and get you out even if you are not better Because of previous surgery and came out with an infection , required four ops to correct it, which have failed, face major surgery Having not been in many times, hard to say First admission Slow attention/noise from staff Not aware of success rate going by personal experience and lack of info regarding stats Always room for improvement
Summary and Recommendations Overall the results were very positive. Where issues or concerns were identified these were taken to, dealt with and resolved immediately by the ward manager/sister of the relevant area. The process for capturing the 100 voices is under review to increase the numbers of staff participating.
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Monitor’s Compliance Framework Performance against key measures, April 2011 ‐ March 2012
Target threshold Achieved RAG
C difficile year on year reduction (to fit the trajectory for the year, as 32 22 agreed with PCT (post 72 hours)
Maintaining the annual number of MRSA bloodstream infections (post 4 3 48 hours)
Maximum waiting time of four hours in A&E from arrival to admission, 95.0% 95.1% R transfer or discharge
Although the Trust achieved the A&E target for the year this target was not achieved in quarter three or four. The Trust is currently in significant breach of the terms of authorisation for governance failings, leading and failure of healthcare targets
Maximum waiting time of 31 days from diagnosis to treatment of all 94% 98.6% cancers ‐ surgery
Maximum waiting time of 31 days from diagnosis to treatment of all 98% 100% cancers – anti cancer drug treatments
Maximum waiting time of 62 days from urgent referral to treatment for 85% 85.9% all cancers ‐ from urgent GP referral to treatment
Maximum waiting time of 62 days from urgent referral to treatment for 90% 93% all cancers ‐ from consultant screening service referral
Cancer: two week wait from referral to first seen, all cancers 93% 98.3%
Cancer: two week wait from referral to first seen, symptomatic breast 93% 98% patients (cancer not initially suspected)
Referral to Waiting Times ‐ Admitted (95th percentile) 23 weeks 24.1 weeks R
Referral to Waiting Times ‐ Non Admitted (95th percentile) 18.3 weeks 16.4 weeks
Certification against compliance with requirements regarding access to Yes yes healthcare for people with a learning disability.
Screening all elective in patients for MRSA 100% 100%
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Response from Bolton LINk The Quality Report was presented to Bolton LINk on 14th May 2012. Arrangements have been made to hold four forums during the course of 2012/13 to discuss progress on the priorities agreed in the account. These forums will be open to the public and will be publicised by LINk and the Trust. Following the presentation the Trust received the statement below from LINk
Bolton LINk is supportive of the priorities that Bolton NHS Foundation Trust have included in their quality account and the actions that are being taken to improve on performance in these areas. The LINk are also keen to support the development of forums where the Trust can have a wider opportunity to liaise with members of the public, giving more of the community an opportunity to hear about the work that is being undertaken and share their experiences and views first hand with Bolton NHS FT Directors and staff.
In the last financial year, Bolton LINk Authorised Representatives have undertaken three enter and view visits to various areas of the Royal Bolton Hospital and are appreciative of the progressively detailed action plans developed from feedback provided in the reports, reflecting the snapshot of service users views gained during each visit. Bolton LINk are keen to continue to develop their relationship with Bolton NHS FT via quarterly meetings outside of the proposed forums giving us an additional opportunity to share information with each other.
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Response from the Council of Governors The Governors of Bolton NHS Foundation Trust are involved in the production of the Quality Report through the course of the year. Having agreed the priorities for 2011/12 Governors were provided with updates on progress to achieve these targets at their regular quarterly meetings and in the additional sub‐committee meetings. At the full Governor meeting on 2nd February 2012 Governors discussed and agreed the priorities for inclusion in the Quality Report. At this stage the decision was made to continue with the priorities chosen in 2011/12. At an additional Governor meeting on 11th April 2012; Governors agreed that in light of the failure to achieve the A & E and 18 week targets these should be included as priorities. Governors were keen to ensure that although no clinical correspondence and did not attends will be included in the stated priorities they will continue to be a priority for the Trust and progress would still be reported in the review of 2012/13 when the next Quality Report is published. The following statement was provided by the governors in support of the Trust:
As Foundation Trust Governors we have worked closely with the Directors of the Trust and will continue to do so during 2012/13. We remain very concerned about the Trust’s current position in significant breach of its terms of authorisation and we will continue to work with the Board to ensure this position is rectified. We welcome the publication of the Quality Report and congratulate the Trust on the results achieved particularly with regard to mortality and infection control. We hope that the same effort and determination will bring the required results in Accident and Emergency and 18 weeks.
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Response from NHS Bolton
NHS Bolton Clinical Commissioning Group’s response to Bolton NHS Foundation Trust’s Quality Account for 2011/12
1. As the developing Clinical Commissioning Group for Bolton, we have made it clear in our contract with Bolton NHS Foundation Trust for 2012/13 that we are commissioning for outcomes and quality.
2. We feel the improved level of clinical involvement from the respective organisations will make a significant difference to the care of our population. The establishment of the Joint Clinical Group, which has agreed priority areas for quality improvement, and regularly monitors progress on these, will add to improving quality of care for the population of Bolton.
3. We are pleased to see that Bolton NHS Foundation Trust have been transparent and open in their Quality Account about the level of scrutiny they are under from their regulator, Monitor. We intend to work very closely with Bolton NHS Foundation Trust to ensure the required improvements to performance to patient care are achieved.
4. We recognise the changes made by Bolton NHS Foundation Trust to their Quality Account following discussions with the CCG Board on an early draft and are grateful that so many of the comments were listened to and reflected in the final report.
5. The CCG’s high priority is to improve patient experience and acknowledge the high profile this has been given in the Trust’s Quality Report. We intend to work together to improve this monitoring going forward.
6. The CCG’s preference would have been for the Trust to have retained HCAI as one of the key outcomes, due to its high profile with the public in all surveys and engagement, but recognise the difficult choices to be made when the maximum number of outcomes expected is 5.
7. The CCG also suggested to Bolton NHS Foundation Trust that monitoring of stroke quality indicators is retained in the Quality Accounts and are pleased that commitment has been given that this monitoring will continue.
Whilst there is a significant amount of work yet to be done, we do feel that the level of cooperation between the CCG and Trust during the past year has improved significantly and that we now have a shared agenda to benefit Bolton people.
We look forward to working with Bolton NHS Foundation Trust in 2012/13 and beyond.
Wirin Bhatiani Susan Long Chair Interim Accountable Officer
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Results from the 2011 Staff Survey
The results from the staff survey show a position of significant improvement from 2010. The Trust is recording highest/best 20% performance in 31 of the 38 key factors, average in five key factors and below average in just two key factors. An action plan to focus on sustaining and achieving improvements across all 38 key factors will be put in place and monitored by the Trust Best Employer Group.
6.1 Overall Response Rate
2010 2011 Trust improvement or deterioration Trust National Trust National Average Average Response Rate 50% 50% 54% 53% Increase of 4% from the 2010 survey, but better than average for acute Trusts
Staff 3.66 3.62 3.69 3.62 Improvement from 2010 and above Engagement the national average in 2011
6.2 Top Four Ranking Questions
Top Four Ranking 2009/10 Top Four Ranking 2010/11 Trust improvement or Scores Trust National Scores Trust National deterioration Average Average Question KF14 KF9 % of staff 69% 61% 8% above the national % of staff appraised 80% 66% using flexible working average with personal options development plans in the last 12 months Question KF12 KF14 % of staff 81% 68% Improvement from PCT % of staff appraised 90% 78% appraised with perspective, 13% better in the last 12 personal development than the national average) months plans
Question KF17 KF17 % of staff 11% 16% Improvement from PCT % of staff suffering 12% 16% suffering work‐related perspective, 5% lower than from work‐related injury in the last 12 the national average injury in the last 12 months months Question KF3 KF3 % of staff 81% 76% 5% better than above the % of staff feeling 81% 76% feeling valued by their national average valued by their work colleagues work colleagues
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6.3 Lowest Four Ranking Questions
Bottom Four 2009/10 Bottom Four Ranking 20010/11 Trust improvement Ranking Scores Trust National Scores Trust National or deterioration Average Average Question KF23 KF36 % of staff 35% 48% 18% worse than % of staff experiencing 11% 8% having E&D training national average. E physical violence from learning solutions for patients/relatives in 12/13 should correct the last 12 months this Question KF24 KF28 Impact of 1.59 1.56 Decrease from last % of staff experiencing 2% 1% health and wellbeing on year, 0.03 difference physical violence from ability to perform work from the national staff in the last 12 or daily activities average, worse in months Elective care and highest in Scientific and Technical group Survey questions focus on the following aspects Q36 difficulty in carrying out work and daily life in the last four weeks due to physical health problems ‐ 1% below median Q37 % of staff who in the last four weeks are saying personal and emotional problems kept them from doing work or daily activities – 2% below the median
Question KF21 KF20 % of staff 35% 34% Improvement from % of staff reporting 93% 95% witnessing potentially last year, 1% worse errors, near misses or harmful errors, near than national average incidents witnessed in misses or incidents the last month Question KF20 40% 37% KF37 % of staff 89% 90% 1% worse than % of staff witnessing believing that the Trust national average‐ potentially harmful provides equal particularly those who errors, near misses or opportunities for career are part time staff and incidents witnessed in progression or in surgical services the last month promotion
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Summary of local actions undertaken in the year: • 2010 Staff Survey action plan implemented with successful outcomes • Action plan progress monitored monthly by the Best Employer Group • Development of the Staff Temperature Check in electronic and paper versions to measure engagement on a quarterly basis
6.3 Learning and Development
During the year the Organisational Development and Learning Department has been strengthened through integration with the PCT Learning and Development Team. We continue to make improvements in the ways we support our integrated workforce in learning and continuous development, which we believe are key to delivering patient centred care across the Trust. Once again improving the uptake of appraisal has been a central theme and we continue to work towards the target of 80% appraisals in the integrated Trust. We are also continuing to audit the quality of the appraisals that have taken place. Mandatory training is also a key target and there has been a complete review of mandatory training, resulting in an updated policy which meets the requirements of NHSLA level 2. Ensuring full recording of training information and the integrity of data on ESR across the integrated Trust has been another challenge for the department. We continue to work towards records that reflect the range of training activity and attendance. This information is shared with managers to enable compliance with mandatory training and appraisal targets. The appointment of an E Learning Manager has assisted in the development of programmes which allow staff to complete training requirements in a more timely and convenient way, allowing us to work towards a blended approach to learning. We have been able to offer a range of education, training and development opportunities that underpin workforce and organisational development. These opportunities are available to all staff groups often in partnership with universities, colleges and other education providers. Our Practice Education team works closely with the universities and in practice, to ensure a high quality learning experience for student nurses. We are still committed to the Skills Pledge – a voluntary public commitment to ensure we work towards having a fully qualified workforce. We have supported the introduction of apprentices into our workforce and provided learning opportunities for our future workforce through collaboration with our local colleges and schools. Our management development programme has been particularly successful this year, with coaching as the key theme running through every programme, some of our programmes are accredited with the Institute of Leadership and Management. Through our Management Forum and Masterclasses, we have provided opportunities for managers to network and learn together. We continue to deliver the ‘Engaging Manager’ programme linking to the engagement events held within the Trust. The Trust has maintained strong links with the North West Leadership Academy, accessing its range of leadership development programmes.
Staff have access to a range of excellent education facilities. The Education Centre has a
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complete with video conferencing and touch pad interactive systems. There is a well stocked library and an information technology suite based in the main part of the hospital. Through collaboration with the Sports and Social Club, we now have a training facility and office accommodation for the Mandatory Training and Practice Education Teams. As a result of integration, staff can now access training facilities across Bolton. E‐learning is increasingly being used as a learning methodology and we will be opening a small e‐learning facility at Pikes Lane in the near future.
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Regulatory Ratings Monitor awards NHS foundation trusts regulatory ratings based on self‐certification received from trusts in their annual plan, in‐year quarterly submissions and any exception reports, including any reports from third parties such as the Care Quality Commission (CQC). These ratings for Bolton NHS Foundation Trust over the last two years are summarised in the tables below. The ratings awarded at the start of each year are based on expected performance at the time of the annual risk assessment in our annual plan. The quarterly ratings are based on actual performance reported to Monitor via the quarterly in‐year submissions.
Annual Plan Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11 2010/11 Financial risk 3 3 3 3 3 rating
Governance risk amber‐ amber‐ green green green rating green green
Mandatory green green green green green services
The table above outlines the ratings received during 2010/11. The mandatory services rating relates to provision of services in line with our terms of Authorisation, the governance risk rating relates to ongoing compliance with healthcare targets and indicators.
Annual Plan Q1 2011/12 Q2 2011/12 Q3 2011/12 Q4 2011/12 2011/12 Financial risk 3 3 3 3 3 rating
Governance risk Amber Amber Amber red red red rating green green
Mandatory green green green green green services
The financial risk rating was as planned throughout 2010/11. In 2011/12 the Trust received amber green rating for the first two quarters of the year, this was as a result of failing to meet the 18 week target for admitted patients. In quarter three the Trust was rated red for governance following a continued failure of the 18 week target, failure of the A&E four hour target and failure of the cancer target for waiting time from consultant screening service. As a result of the failure to meet the 18 weeks admitted target and the four hour A&E target the Trust was placed in significant breach of its terms of authorisation in April 2012.
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8.1 Actions taken by Bolton NHS Foundation Trust to maintain or develop the provision of information to, and consultation with employees Over the last 12 months the Trust has continued its pursuit of an engagement culture in order to underpin the Trust’s reputation as an integrated provider of: • Safe, high quality healthcare • Employer of choice. Workforce related activity to support this has been to utilise our “engagement” methodology aligned to our BICS approach in order to increase staff satisfaction and involvement in continuously improving our services. In 2011 the Trust was awarded the HPMA Excellence award for its work on Staff Engagement and in 2012 the Trust reported significant improvements in the 2011 annual NHS Staff Survey, achieving best 20% of performance levels in 31 of the 38 Key Factors. To support Transforming Community Services (TCS) a further series of “conversation” events were held with over 200 community staff, including staff side representatives. The views of staff contributed significantly in to shaping the new organisations values, which were launched in March 2012. To support ongoing cultural transformation the values have been integrated into the appraisal documentation and throughout 2012‐13 the values will be integrated with many other aspects of organisational life, such as recruitment and performance management. This activity will supported by a values sustainability plan and impact assessment. The following tables represent the diversity of the workforce of the Trust (31st March 2012)
Age Ethnicity 16-20 16 White 4463 21-25 336 Mixed 37 26-30 495 Asian/Asian British 335 31-35 552 Black/Black British 46 36-40 682 Chinese 15 41-45 821 Any Other Ethnic Group 36 46-50 905 Not Stated 297 51-55 724 56-60 453 Religious Belief 61-65 210 Atheism 184 66+ 35 Buddhism 6 Christianity 2215 Gender Hinduism 70 Female 4445 Not disclosed/not known 2458 Male 784 Islam 99 Other 197 Disability No 2778 Sexual Orientation Not known 2299 Bisexual 6 Yes 152 Gay 11 Heterosexual 2480 Total 5229 Not disclosed 2722 Lesbian 10
N.B. Discrepancies in the totals in this table are as a result of not all staff and members declaring data for ethnicity and diversity monitoring. ‐ 97
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8.2 Bolton NHS Foundation Trust policies in relation to disabled employees and equal opportunities The Trust is committed to providing first class services that are equally accessible to all who use them. We aim for our services to be provided by staff who reflect the Bolton Community. It is important that staff recognise and value the diverse needs of different values and cultures.
Training Strategy The Trust has an Equality and Diversity Strategy for staff training in conjunction with 5 Boroughs. There are four levels of training provided linked to the Knowledge and Skills Framework (KSF). The Trust now has commissioned an e‐learning package to support the delivery of Equality and Diversity basic and intermediate modules. This is in addition to the bespoke training that will be delivered based on identified need. In October 2010, the Equality Act came into effect, prior to this time there had been over 100 pieces of legislation covering equalities protection and alongside them there are three associated public duties for race, gender and disability. The Equality Act has nine protected characteristics defined as: • Age • Disability • Gender • Gender Reassignment • Marriage and Civil Partnership • Pregnancy and Maternity • Religion or belief ‐ this includes lack of belief • Sexual Orientation • Ethnicity/Race. As such when we are writing or making any changes to Policies, services or functions, we complete an EIA form this helps us to consider the impact any changes have on different groups and what can be done to reduce discrimination and increase equality. Equality Delivery System All organisations must undertake a self assessment of their performance against the Equality Delivery System (EDS) which is a toolkit structured around four goals. Bolton NHS Foundation Trust undertook an original self‐assessment using the Equality Performance Improvement Toolkit (EPIT 2), this was replaced by the Equality Delivery System (EDS) and from these pieces of work we consider ourselves to be developing across the eighteen outcomes and four overarching goals a summary of which is set out on the following page:
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GOAL No of Outcomes Progress
Goal 1‐ Better health 5 Developing the five outcomes outcomes for all
Goal 2‐ Improve 4 Developing the four outcomes patient access and experience
Goal 3 empowered, 6 Developing one and Achieving engaged and well five supported staff
Goal 4 Inclusive 3 Achieving three leadership at all levels
From this self assessment using the EPIT2 toolkit, actions have been identified which also relates to the Single Equality Scheme. We have used a traffic light system using a category of Green, Amber and Red to identify the position of each required action. Information will be published each year to help the public and our patients use our services and find information they may need.
What are we doing next? As part of its actions identified from the EDS, Bolton NHS Foundation Trust will be working to improve the way in which people from different groups are treated as service users, carers and employees. This Trust has a range of legal responsibilities to support Equality and Diversity and our aims are to: • Improve partnership working across the Bolton family, to improve the health and well being of people living in Bolton through the One Bolton Campaign • Ensure the workforce reflects the diverse backgrounds, beliefs and values of the local community • Improve the quality and quantity of patient related information with regard to equality and diversity • Ensure our services are sensitive to and designed around the diverse needs of the local population.
Our objective for 2012/13 We have agreed to focus efforts on improving our handling of complaints and or concerns from patients and carers, from protected groups, to ensure that they are handled respectfully and efficiently. We will be collecting and analysing data to compare how we do this in comparison to how we handle complaints and subsequent redress for patients and carers as a whole. We plan to revisit our processes and identify any gaps to be able to set out what
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for protected groups through the mainstream process. We are planning to undertake engagement exercises with key disadvantaged groups to begin this work.
8.3 Workplace Health and Wellbeing The Workplace Health and Wellbeing department is dedicated to ensuring a provision for staff which is targeted, proactive and accredited. The approach is holistic and provides staff with a “wrap around” service which covers both physical and mental wellbeing. Supporting staff to be healthy in work benefits the patients they treat and the organisation as a whole. Following is a selection of health and wellbeing initiatives and interventions which are provided for staff within the Trust:‐ • Staff health clinics • Mental wellbeing drop‐in sessions • Counselling • Fast track physiotherapy • Flu vaccination • Stress risk assessments and follow up • Pre employment checks • Workplace assessments • Healthy walks • Gym and zumba • Healthy fruit and vegetable van There are still areas for improvement and further work is ongoing to review the correlation between our wellbeing interventions and staff attendance management.
8.6 Sickness Absence Data We work hard to ensure our staff are healthy and enjoy work and to see a year‐on‐year improvement in attendance. We have a comprehensive attendance management policy and encourage staff to seek professional medical support through our extensive occupational health services if needed. The following table highlights the levels of absence against a Trust wide target of 4.0%. There has been an overall improvement in attendance across the Trust with the exception of Quarter 4 which saw a rise in absence of 0.4% for the months of January, February and March 2012. There are still areas of improvement which are being implemented across the organisation to support the attainment of the Trust target of 4.0%.
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Sickness Absence Data 2011/12 Apr‐10 4.74% Apr‐11 4.54% May‐10 4.55% May‐11 4.49% Jun‐10 4.65% Jun‐11 4.24% Quarter 1 4.65% Quarter 1 4.42%
Jul‐10 4.44% Jul‐11 4.23% Aug‐10 4.47% Aug‐11 4.48% Sep‐10 4.71% Sep‐11 4.60% Quarter 2 4.54% Quarter 2 4.46%
Oct‐10 5.06% Oct‐11 5.28% Nov‐10 4.97% Nov‐11 5.09% Dec‐10 5.42% Dec‐11 4.89% Quarter 3 5.15% Quarter 3 5.08%
Jan‐11 4.99% Jan‐12 5.18% Feb‐11 4.26% Feb‐12 4.70% Mar‐11 4.17% Mar‐12 4.75% Quarter 4 Quarter 4 4.48% 4.88% Total Total
It is a Treasury FReM requirement that public bodies must report sickness absence data. The data must be consistent to permit aggregation across the NHS and with similar data for the core Department. The figures below are for the calendar year January 2011 – December 2011 from the ESR national data warehouse. Underlying figures have been converted to the “Cabinet Office” measurement base by applying a factor of 225/365 to adjust for the different base years.
Average of 12 Months (2010 Average FTE FTE‐Days FTE‐Days Lost to Average Sick Days Calendar Year) 2010 Available Sickness Absence per FTE
4.5% 3,400 765,000 34,461 10.1
8.5 Health and Safety Performance There have been no prosecutions or Health and Safety Executive (HSE) enforcement notices issued to the Trust during the reporting period.
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The Trust has had one HSE advisory visit during the period in regard to an accident investigation when scaffolding blew over in high winds on the contractor’s site during the demolition of L block. The contractor and not the Trust received a caution from the HSE. The total number of accidents reportable to the Health and Safety Executive reduced again from 23 in 2010/11 to 17 in 2011/12. This represents a 56% reduction over the past three years and is significantly lower than similar NHS reporting organisations.
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8.6 Information on policies and procedures with respect to countering fraud and corruption The Trust has a Counter Fraud and Corruption Policy in place. A counter fraud work plan is agreed with the Director of Finance and approved by the Audit Committee. The local counter fraud specialist is a regular attendee at Audit Committee meetings to provide an update on the ongoing programme of pro‐active work to prevent any potential fraud and investigatory work into reported and suspected incidents of fraud.
8.7 Better payment practice code The Trust is expected to pay 95% of all creditor invoices within 30 days of goods being received or a valid invoice (whichever is the later) unless other payment terms have been agreed with the supplier. The table below shows performance against this target in 2010/11 and 2011/12.
Year ended 31 March 2012 Year ended 31 March 2011 Number £'000 Number £'000 Total non‐NHS trade invoices paid within the target 38,861 46,463 45,027 55,008 Total non‐NHS trade invoices paid in the period 53,872 68,616 49,378 60,946 Percentage of non‐NHS trade invoices paid within the target 72.1% 67.7% 91.2% 90.3% Total NHS trade invoices paid within the target 1,270 15,878 1,338 16,735 Total NHS trade invoices paid in the period 2,041 22,037 1,569 18,441 Percentage of NHS trade invoices paid within the target 62.2% 72.1% 85.3% 90.7% 8.8 Consultations There were no formal consultations during 2011/12.
8.9 Disclosures in relation to “other income” The “other income” figure in the accounts is not considered significant.
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8.10 Cost allocation and charging requirements The Trust remains compliant with cost allocation and charging requirements laid down by HM Treasury and the Office of Public Sector Information.
8.9 Details of Serious Untoward Incidents (SUIs) involving data loss or confidentiality breach The Trust had one Serious Untoward Incident (SUI) involving data loss – the details of this are declared in our Annual Governance Statement on page 107.
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Statement of the Chief Executive's responsibilities as the accounting officer of Bolton NHS Foundation Trust
The NHS Act 2006 states that the Chief Executive is the Accounting Officer of the NHS Foundation Trust. The relevant responsibilities of the accounting officer, including their responsibility for the propriety and regularity of public finances for which they are answerable, and for the keeping of proper accounts, are set out in the NHS Foundation Trust Accounting Officer Memorandum issued by the Independent Regulator of NHS Foundation Trusts (“Monitor”). Under the NHS Act 2006, Monitor has directed Bolton NHS Foundation Trust to prepare for each financial year a statement of accounts in the form and on the basis set out in the Accounts Direction. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of Bolton NHS Foundation Trust and of its income and expenditure, total recognised gains and losses and cash flows for the financial year. In preparing the accounts, the Accounting Officer is required to comply with the requirements of the NHS Foundation Trust Annual Reporting Manual and in particular to: • observe the Accounts Direction issued by Monitor, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis; • make judgements and estimates on a reasonable basis; • state whether applicable accounting standards as set out in the NHS Foundation Trust Annual Reporting Manual have been followed, and disclose and explain any material departures in the financial statements; and • prepare the financial statements on a going concern basis. The Accounting Officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the NHS foundation trust and to enable him/her to ensure that the accounts comply with requirements outlined in the above mentioned Act. The Accounting Officer is also responsible for safeguarding the assets of the NHS Foundation Trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities.
To the best of my knowledge and belief, I have properly discharged the responsibilities set out in Monitor's NHS Foundation Trust Accounting Officer Memorandum.
Signed Date…31st May 2012………………………………. Lesley Doherty Chief Executive
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st st Annual Governance Statement – 1 April 2011 – 31 March 2012 1. Scope of responsibility As Accounting Officer and Chief Executive of this Board I have responsibility for maintaining a sound system of internal control that supports the achievement of the NHS Foundation Trust’s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the NHS Foundation Trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum.
2. The purpose of the system of internal control The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of Bolton NHS Foundation Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place in Bolton NHS Foundation Trust for the year ended 31 March 2012 and up to the date of approval of the annual report and accounts.
3. Capacity to handle risk 3.1 Leadership Responsibility of the Chief Executive The Chief Executive has overall responsibility and accountability for leading risk management arrangements on behalf of the Board. The Chief Executive holds each line manager accountable for setting objectives, relevant to the Board’s corporate objectives for their own staff. The Chief Executive is a member of the Risk and Assurance Committee and the Finance and Investment Committee and attends other trust wide committees. The Chief Executive is also personally involved in the management of complaints against the Trust. Responsibility of the Director of Assurance and Public Engagement The Director of Assurance and Public Engagement has managerial responsibility for the Risk and Assurance department. The Director of Assurance and Public Engagement attends the Audit Committee and is a member of the Risk and Assurance Committee and the Finance and Investment Committee. The Director of Assurance and Public Engagement is the Chair of the Clinical Governance and Assurance Committee and the Health and Safety Committee. Responsibility of the Director of Patient Safety and Experience/Chief Nurse The Director of Patient Safety and Experience is operationally responsible for the quality of clinical services within the Trust through the divisions. This includes the achievement of key performance indicators patients, quality or experience and patient safety. The role also includes the professional leadership of nurses and midwives and providing advice to the Board on nursing and midwifery issues in addition to representing Allied Health Professionals and healthcare scientists at Board level. The Director of Patient Safety and Experience is also managerially responsible for estates and facilities and sits on the Risk and Assurance Committee and Clinical Governance and Assurance Committee. ‐ 106
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Responsibility of the Medical Director The Medical Director provides professional leadership for clinical governance within the Trust. The Medical Director chairs the Clinical Safety and Quality Improvement Committee, sits on the Risk and Assurance Committee and the Clinical Governance and Assurance Committee. The Medical Director also provides medical advice to the Board and is managerially and professionally responsible for the clinical effectiveness department, audit, research and development and medical education. The Medical Director is supported by the Heads of Division and the Clinical Leads for clinical effectiveness, patient safety and post graduate education Responsibility of the Director of Finance, Information and Procurement The Director of Finance is the responsible officer for managing financial risk in the Trust and is also responsible for performance reporting, information and procurement. The Director of Finance provides professional financial advice to the Board. The Director of Finance attends the Audit Committee and sits on the Finance and Investment Committee and the Risk and Assurance Committee. Responsibility of Director of Strategy and Improvement The Director of Strategy and Improvement is responsible for service planning, objective setting, Information Governance and IM and T issues. The Director of Strategy and Improvement is the Senior Information Risk Owner (SIRO) for the Trust and is responsible for ensuring that organisational information risk is properly identified, managed and that appropriate assurance mechanisms exist. The Director of Strategy and Improvement sits on the Risk and Assurance Committee and Chairs the IM&T Committee. Director of Operations The Director of Operations is responsible for the day to day operational management of the Trust and the achievement of key performance targets relating to patient access. The Director of Operations attends the Risk and Assurance Committee and the Finance and Investment Committee and chairs the Operational Board. The Director of Operations is supported by three Associate Directors of Operations who lead the three divisions. Responsibility of Director of Workforce and Organisational Development
The Director of Workforce and Organisational Development is responsible for ensuring operational effectiveness through workforce strategy to achieve a skilled efficient, cost effective motivated and flexible workforce. The Director of Workforce and Organisational Development sits on the Risk and Assurance Committee, Chairs the Workforce Committee and is the Board Champion for workplace health and wellbeing and staff engagement.
3.2 Committees The Board of Directors has overall responsibility for risk management in the Trust. The following formal Board sub committees and Trust wide committees provide additional assurance to the Board having explored relevant key issues in greater depth: Sub committees • Audit Committee • Risk and Assurance Committee • Remuneration and Nomination Committee • Finance and Investment Committee
• Charitable funds Committee ‐ 107
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Two additional Board level sub‐committees have recently been established to provide additional governance assurance and oversight to the urgent care and elective programmes; these are both chaired by the Chief Executive and have Non Executive Director membership. Minutes of these two committees are received by the Board. All Executive Directors and three Non Executive Directors are members of the Risk and Assurance Committee which receives reports from the following assurance providing committees: • IM and T committee • Workforce Committee • Health and Safety Committee • Clinical Governance and Assurance Committee The Audit Committee continues to provide assurance and to review the establishment and maintenance of an effective system of integrated governance and internal control across the whole of the Trust’s activities both clinical and non clinical. In addition one or two Non‐Executive Directors are attached to each Trust wide Committee. The executive team is supported by a divisional management structure consisting of three divisions*. Each division has a clinical Head of Division and an Associate Director of Operations who are jointly responsible for the delivery of key objectives in their areas. Each division is supported by a professional lead who has specific responsibility for delivering on patient safety, quality and the governance agenda. The remainder of the Trust’s business is managed by the following functional Directorates: • Finance Information and Procurement • Workforce and Organisational Development • Assurance and Public Engagement • Patient Safety and Experience • Strategy and Improvement • Medical Performance monitoring reports are provided to the Executive Board and Board of Directors on a monthly basis and, in addition to this the, Executive Directors undertake bi annual performance reviews. The minutes of all the Trust wide committees are also seen by the Executive Board. The Risk and Assurance Committee received the Board Assurance Framework (BAF) and Risk Register at each of its six meetings during 2011/12 and the Audit Committee received the Board Assurance Framework and the Trust Risk Register twice in this period. The Board of Directors received the BAF and Risk Register twice and also received quarterly Complaints, Litigation, Incidents and PALS (CLIP) reports The Finance and Investment Committee meets monthly and monitors the Trust’s operational budget position, cash balances and progress against the Trust’s investment, capital programme and savings plan. The Finance and Investment Committee also monitors and agrees any changes to the Trust’s capital programme. The minutes of the Finance and Investment Committee are received by the full Board of Directors. As Accounting Officer I have overall accountability for internal control. To support this role there are clear systems of accountability within the organisation with each Executive Director having specific areas of responsibility
* The Divisional structure was reviewed on integration and on 1st July 2011 changed from four to three divisions ‐ 108
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Arrangements are in place for the reporting of serious untoward incidents to the Strategic Health Authority (SHA) and other stakeholders through the Trust’s Incident Reporting Policy. The Trust also links to the National Reporting and Learning System (NRLS) of the National Patient Safety Agency.
3.3 Processes in place by which we work with partner organisations. As a result of significant changes in the NHS, there have been key changes in partner organisations over the course of the reporting year. On 1st July 2011 the services previously provided by NHS Bolton were integrated into the services provided by the Royal Bolton Hospital NHS FT to form a new integrated care organisation. In readiness for the abolition of PCTs and the move to clinical commissioning groups the accountability for commissioning was transferred to the Greater Manchester PCT cluster, the Trust has worked with the Greater Manchester Cluster and also with the newly established Clinical Commissioning Group (CCG) for Bolton during the year. Overarching partnership structures, embracing local authority, NHS and non statutory sector organisations provide a framework for borough wide strategic development and the Trust is an active member of the Vision Steering group and its partnership boards including the Children’s Trust, Health and Care Together, Local Safeguarding Children’s Board and local safeguarding adults board.
3.4 Training To ensure the successful achievement of the Risk Management Strategy and implementation of the Risk Management Policy staff at all levels are provided with appropriate training in carrying out risk assessments and the reporting of incidents. The ongoing programme of training within the trust also includes: training such as managing safely, risk register training, fire safety training, manual handling, Safeguarding training, major incident training and conflict resolution training Medicine management training is delivered at doctors’ induction programmes and during educational and developmental sessions. Medication error reports are brought to the Clinical Governance and Quality Committee and disseminated to the divisions through their Divisional Quality Boards. Support and advice on medicine management is also provided at ward and departmental level by the Chief Pharmacist and link pharmacists. Risks and safety in respect of clinical equipment and devices is discussed and disseminated by the Medical Devices and Equipment Management Committee on which all divisions are represented and which also has a training sub group and each ward has a link nurse. General awareness raising on risk management issues is achieved through staff briefings, team brief, safety bulletins, induction and the intranet. The Trust has a Patient Experience group which is chaired by the Associate Director of Professional Standards and Patient Experience and includes the Customer Relations Co‐ordinator, PALS Officer, Quality Managers, Foundation Trust Governors, lay members and matrons. The purpose of the group is to identify themes from complaints and PALS issues on a monthly basis and to agree lessons to be learnt and actions to be taken to improve patient experience and ensure this information is shared across the organisation. Work is also undertaken on audits including 100 voices (for more detail see page 84 within the annual report) or particular issues such as protected meal times, mixed sex accommodation, nutritional assessments, patient records and infection control.
4. The risk and control framework The risk management policy outlines the responsibilities of the following executives:
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• Director of Assurance and Public Engagement • Director of Finance • Director of Patient Safety and Experience/chief Nurse Directors and Associate Directors of Operations are accountable for ensuring that risks are identified and managed in their own areas of responsibility and escalated as appropriate and that their staff are appropriately trained. Responsibility for risk management for all levels of staff is fully outlined in the Trust’s General Safety and Risk Management Policy. A Board endorsed risk management strategy is in place and describes the following: • Board Statement • aims • strategic objectives • philosophy of risk management • risk controls • risk management structure • risk management responsibilities • process of evaluating and prioritising risk • risk register • performance management • monitoring and review • risk management training and support • fair blame culture The risk management strategy also links to other Trust policies, e.g. risk management policy and protocols, e.g. accident/incident reporting and investigation and root cause analysis. The strategy is available to staff in all wards and departments via the Trust intranet. The risk management strategy was reviewed and approved in June 2010 to reflect the organisational structure and to meet the requirements of the new NHSLA Risk Management Standards and the revised governance arrangements
4.1 Risk management is embedded in the trust Risk management is embedded within the Trust through key committees: • Audit Committee • Finance and Investment Committee • Risk and Assurance Committee • Clinical Governance and Assurance Committee • IM and T Committee • Workforce Committee • Health and Safety Committee
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Minutes of these groups are exchanged and made available to staff through the intranet, meetings and bulletins. Other groups which cover risk issues include: • Radiation Protection Committee • Medical Devices and Equipment Management Committee • Divisional Quality Boards • Infection Control Committee (reports to Clinical Safety and Quality Improvement Committee) • Local Security Management Committee • Fire Safety Committee • Emergency Preparedness Steering Group The implementation of the Trust’s policies and procedures is the responsibility of Directors, associate directors, heads of service and departmental managers.
4.2 Board assurance framework A Board approved assurance framework was in place for the period 1st April 2011 – 31st March 2012. The framework: • covers all of the Trust’s main activities • identifies the corporate objectives and targets the Trust is striving to achieve and covers the core standards on which the Trust is required to declare its compliance during 2011/12 • identifies risks to achievement of these objectives and targets • identifies the system of internal control in place to manage the risks • identifies and reviews the assurance mechanisms which relate to the effectiveness of the system of internal control The Board also receives updates on high/significant risks and risks are documented in the Trust Risk Register. The Risk and Assurance Committee consider high and significant risks and recommends their inclusion on the Trust Risk Register. The Trust Risk Register and Assurance Framework go to The Risk and Assurance Committee six times a year, to the Audit Committee twice a year, to the Board twice a year relevant sections are considered by the Executive Board members and other Trust wide committees on a regular basis. Risk prioritisation and action planning is informed by the corporate objectives of the Trust, incident reports, litigation claims, audit information, complaints, individual issues from divisions, Directorates and national requirements/guidance. Action plans are developed for unresolved risks and the scoring of risks is adapted from the Australian/New Zealand Risk Management scoring system. Lead managers and Directors are identified to deal with gaps in control and assurance and are responsible for developing action plans to address the gaps. The most significant issues on the Board Assurance Framework for 2011/12 were: • Failure to sustain A&E targets • Failure to sustain 18 weeks • Clinical Correspondence • Failure to achieve CNST level 2
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• Failure to engage staff • Failure to maintain mandatory training compliance The Board received a significant assurance opinion from internal audit for its Board assurance process in 2011/12
4.3 Quality Governance Arrangements The Quality Governance Framework has been developed by Monitor as an assessment tool for Trusts to use to benchmark their arrangements for effective quality governance in four categories: • Strategy • Capabilities and Culture • Process and Structure • Measurement In the annual plan submission, the Board signed the approved declaration to state that it was “satisfied that, to the best of its knowledge and using its own processes and having had regard to Monitor’s Quality Governance Framework (supported by Care Quality Commission information, its own information on serious incidents, patterns of complaints, and including any further metrics it chooses to adopt), its NHS foundation trust has, and will keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients.” In preparation for signing this statement the Board reviewed a matrix outlining the position of the Trust for each of the four areas of the Quality Governance Framework and the evidence available to support this: 4.3.1 Strategy ‐ Quality is embedded in the Trust’s overall strategy, the safety and effectiveness of care and the experience of patients are at the heart of all that we do. The Bolton Improving Care System is an internationally recognised improvement programme which uses lean methodology to achieve improvements. Annual objectives reflecting local and national priorities are agreed in consultation with internal and external stakeholders and reflect quality objectives. The achievement of the Trust’s annual objectives is monitored through policy deployment with specific measureable and time bound measurements included in the L1 The Annual Quality Report includes priorities which are identified in consultation with internal and external stakeholders including FT governors. Each Board agenda includes items relating to quality, performance is tracked at the board through the suite of performance reports. The Trust has in place an exemplar programme – a rigorous framework for setting, achieving and monitoring a range of essential standards for continuous quality improvement. 4.3.2 Capabilities and Culture ‐ The Board is assured that quality governance is subject to rigorous challenge with full NED engagement in the Audit Committee and NED involvement in the assurance providing committees. Board members attend regular training and development sessions and the Board committees conduct regular self assessments to test effectiveness. 360º appraisals are conducted for all Board members – these include assessment of leadership skills and capabilities. 4.3.3 Process and Structure ‐ The Corporate Governance Structure was reviewed in 2010 with reference to the Audit Commission publication “Taking it on Trust” A revised Corporate Governance Handbook was published in line with this review. The Corporate Governance Handbook was updated in July and September 2011 following integration. The Trust has clear process in place for:
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• Whistle blowing • Complaints • Management of SUIs Action plans are put in place to address issues arising from these processes 4.3.4 Measurement ‐ A full suite of performance reports is provided for the Board of Directors, Executive Board and Council of Governors meetings. When necessary the metrics included in the reports are challenged by board members. The Trust uses information to monitor performance with targets, to compare with previous performance and to benchmark with other providers. Internal Audit reviews are commissioned to provide assurance of the robustness of quality information. The clinical audit programme is linked to the Board Assurance Framework. Action plans from audits are reviewed and re‐audits are undertaken where appropriate to assess improvement. In line with Monitor requirements the Trust commissioned a review of the 2010/11 Quality Account. Recommendations in the report were followed up by the Audit Committee. 4.4 Information governance controls In March 2010, the Trust adopted a new and overarching Information Risk Management Policy, setting out key principles, the legislative and good practice framework, revised information governance structures, and roles and responsibilities, including the concept of Information Asset Owners. The Trust’s IT security policy has been revised and approved to take into account new requirements. It is mandated that all new bulk flows of data must be registered with the Information Governance Group. Other flows of personal data have been documented and mapped as per the requirements of the Department of Health. The Trust has encrypted all laptops and desktop PCs. Centralised storage has been rolled out across the Trust to ensure that all critical and sensitive data is held securely, not on local equipment. All portable devices such as memory sticks that are plugged into PC’s and laptops have enforced encryption. Email encryption software has been procured which allows the encryption of emails containing sensitive information. An updated Email and Internet Access policy has been approved to reflect the capabilities that new security applications now give the Trust. Staff have been reminded that email should not be used to send personally identifiable data, unless it is encrypted or NHSmail is used and messages remain within the NHS. The Trust reported one breach of information governance when a handover sheet was found outside the Trust by a member of public. The hand over sheet contained the details of nineteen in‐patients which included: names, bed number, clinical information and some had social circumstances but there were no addresses or telephone numbers. A SUI investigation was conducted and the resulting actions were addressed.
4.4 Public involvement The Trust engages with the public in a number of ways in relation to risk management. There is lay representation, in most cases through Foundation Trust Governors on the Clinical Governance and Assurance committee, the Ethics Committee, Emergency planning group, Patient Experience Group, Mortality group, Workforce Committee, Divisional Quality Boards and PEAT visits. Council of Governor meetings are held in public and publicised in the local media, performance reports are shared at these meetings and Governors and the Public are invited to discuss corporate objectives and performance.
4.5 Care Quality Commission
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Bolton NHS foundation Trust is fully compliant with the requirements of registration with the Care Quality Commission. The Trust had three visits by the CQC in 2011/12. See page 65 in the quality account for further details.
4.6 CNST/NHSLA Standards In February 2011 the Trust was re‐ assessed against the general NHSLA risk management standards and was successful at level 2. The Trust has level 1 against the maternity CNST standards and is aiming for accreditation at level 2 in 2012/13. The Trust has to be assess at level 2 again against the general standards in 2012/13 following integration.
4.7 As an employer with staff entitled to membership of the NHS Pension Scheme control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employee’s contributions and payments into the scheme are in accordance with the scheme rules and that member pension scheme records are accurately updated in accordance with the timescales detailed in the regulations. Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with. The Trust has undertaken risk assessments and is working with the Carbon Trust to ensure Carbon Reduction Delivery Plans are in place in accordance with UKCIP 2009 and to ensure that this organisation’s obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with. The Trust employs a Head of Emergency Planning who is responsible for ensuring compliance with emergency preparedness and civil contingency requirements. Policies are in place to deal with a major incident; in addition the Trust has a number of other plans including CBRN plan, a heatwave plan and a flood plan. Plans are tested and an exercise was held which met the definition for a live exercise as part of the three yearly requirement.
5. Review of economy, efficiency and effectiveness of the use of resources The Trust regularly reviews the economic, efficient and effective use of resources with robust arrangements in place for setting objectives and targets on a strategic and annual basis. These arrangements include: • ensuring the financial strategy is affordable • Scrutiny of cost savings plans • Co‐ordination of individual and departmental objectives with corporate objectives using lean methodology. Performance against objectives is monitored and actions identified through a number of channels • Approval of the annual budgets by the Board of Directors • at Executive Director meetings • Quarterly reporting to the council of Governors • Monthly reporting to the Board of Directors and the Executive Board on key performance indicators • Monthly review of financial targets by the Finance and Investment Committee
• Quarterly reporting to Monitor and compliance with terms of authorisation. ‐ 114
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The Trust also participates in initiatives to ensure value for money for example: • The Trust uses lean methodology as its quality improvement approach to optimise the efficient and effective use or resources whilst enhancing the patient experience and care. • Procurement of goods and services is undertaken thorough professional procurement staff and through working with neighbouring organisations within a procurement hub. • In year cost pressures are rigorously reviewed and challenged, and alternatives for avoiding cost pressures are always considered.
6. Annual Quality Report The Directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual Quality Reports which incorporate the above legal requirements in the NHS Foundation Trust Annual Reporting Manual. In producing its Quality Account in 2011, the Trust identified key areas for improvement under the three headings of patient safety, clinical effectiveness and experience. To ensure a balanced view, the Board worked with Governors and other internal stakeholders to select the priorities on which the Trust would be reporting in 2011/12. The process for identifying priorities for 2012/13 included the Board, our Council of Governors, staff and other stakeholders. The final short list of priorities for inclusion in the report was agreed between the Non Executive Directors and the Council of Governors We have used existing performance management arrangements to track progress throughout the year on the targets selected and have reported at year end on these to the Board. An External Audit report on our 2010/11 Quality Account provided assurance that the Trust has arrangements to ensure the accuracy of data.
7. Review of effectiveness As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, and the executive managers within the NHS foundation trust who have responsibility for the development and maintenance of the internal control framework. I have drawn on the content of the quality report attached to this annual report and other performance information available to me. My review is also informed by comments made by the external auditors in their management letter and other reports. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the board, the audit committee and the risk and assurance committee, and a plan to address weaknesses and ensure continuous improvement of the system is in place. The Assurance Framework itself provides me with evidence that the effectiveness of controls that manage the risks to the organisation achieving its principal objectives have been reviewed. My review has also been informed by o The Head of internal audit overall significant opinion on the system of internal control. o The Head of Internal Audit overall significant opinion on the Board Assurance Framework. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by: • The Board who receive monthly performance reports covering the Trust’s objectives and quarterly Reports on complaints, litigation, incident reporting, Serious Untoward Incidents and Patient Advice and Liaison Service (PALS) issues.
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• The Audit Committee who receive and review the Board Assurance Framework and Trust Risk Register twice a year, and also monitor progress and action taken in relation to external audit and internal audit reports. • The Finance and Investment Committee who monitor the organisations financial performance, review progress against the organisation’s investment, improvement and savings plan and recommend a capital programme to the Board and monitor and approve in year amendments. • The Risk and Assurance Committee who review and monitor the Board Assurance Framework and Risk Register, monitor progress on SUI action plans and receive formal reports on issues identified by the Board as requiring further assurance. Since Q3 the Risk and Assurance Committee has focused on the failure to achieve the A&E four hour target and the 18 week target for elective patients as well as other high or significant risks. In 2012/13 the Risk and Assurance Committee has increased its frequency from bi‐monthly to monthly to ensure more focus on mitigation plans, and action plan progress on high and significant risks. • The Clinical Governance and Assurance Committee who review aspects of patient safety, patient experience and clinical effectiveness and clinical audit. The Committee review the Complaints, Litigation, Incidents and PALS report (CLIP). • Executive Directors ‐ I have regular meetings with my Executive Directors, who advise me of actions they have taken to review the effectiveness of the system of internal control in their areas of responsibility.
8. Conclusion 8.1 Significant Control Issues 8.1.1 Data Loss During the reporting year 2011/12 the Board had one breach of information governance relating to data loss – described in section 4.4.
8.1.2 Significant Breach of the Terms of authorisation During 2011/12 the trust failed to meet the A&E target in quarter three and quarter four and the 18 week RTT for all four quarters as a result of this the Trust was red rated for governance and on 17th April 2012 were found by the regulator Monitor to be in significant breach of the Terms of Authorisation. This is in relation to:
• concerns about Board Governance • performance against the A&E four hour target • performance with regard to the 18 week target for admitted patients
An external review has already been commissioned from KPMG to review Board governance and to report on any gaps in Board performance, Board reporting and assurance processes and recommend actions to drive improvements to ensure full Board compliance with the required standards. The Trust will be on monthly monitoring from Monitor until these actions are completed.
8.1.2 Limited Assurance Reports During 2011/12 the Trust received limited assurance reports relating to:
• Data quality VTE • Cash management • Incident reporting ‐ 116
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• Attendance management
Action plans have been put in place to address the recommendations in these reports; these will be monitored through the Audit Committee.
8.1.2 Lapse in Financial Control In April 2012 it became apparent that the Trust would not achieve its planned surplus. External assurance has been commissioned to understand this unexpected variation from plan.
Signed
Date 31st May 2012
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12 Annual Accounts
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Page‐ Data entered below will be used throughout the workbook:
Trust name: BOLTON NHS FOUNDATION TRUST This year: 2011/12 Last year: 2010/11 This year ended: For the year ended 31 March 2012 Last year ended: For the year ended 31 March 2011 This year commencing: 1 April 2011
Intro BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
FOREWORD TO THE ACCOUNTS
BOLTON NHS FOUNDATION TRUST
These accounts for the year ended 31 March 2012 have been prepared by Bolton NHS Foundation Trust under Schedule 7, sections 24 and 25, of the National Health Service Act 2006.
Signed ……..…………………………………………….
L Doherty Chief Executive
Date 7 June 2012 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
STATEMENT OF COMPREHENSIVE INCOME FOR THE YEAR ENDED 31 MARCH 2012
Restated
For the year For the year ended 31 ended 31 March 2012 March 2011 NOTE £000 £000 Revenue Operating revenue from continuing operations (patient care) 5 252,710 187,519 Other operating revenue 7 30,419 23,516 Operating expenses 9 (291,060) (214,086) Operating surplus (deficit) (7,931) (3,051) Finance costs: Finance Income 14 33 56 Finance costs 15 (791) (381) Finance expense - unwinding of discount on provisions (9) (11) Public dividend capital dividends payable (3,625) (3,859) NET FINANCE COSTS (4,392) (4,195)
Surplus/(Deficit) from continuing operations (12,323) (7,246)
Other comprehensive income Revaluation gains/(losses) and impairment losses property, plant and equipment 212 3,484 Other recognised gains and losses Total comprehensive income for the year (12,111) (3,762)
The notes on pages 6 to 39 form part of these accounts.
The Trust's reported deficit from continuing operations of £12,323k comprises a trading deficit of £1,877k, offset by a non cash impairment of £10,446k (see note 18.5) on revaluation of land and buildings.
Page 1 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
STATEMENT OF FINANCIAL POSITION AS AT 31 MARCH 2012
Restated Restated
For the year For the year For the year ended 31 ended 31 ended 31 March 2012 March 2011 March 2010 NOTE £000 £000 £000 Non-current assets Intangible assets 19 424 602 724 Property, plant and equipment 18 126,137 128,095 120,667 Trade and other receivables 22 1,129 1,138 1,039 Total non-current assets 127,690 129,835 122,430 Current assets Inventories 21 1,253 1,094 1,160 Trade and other receivables 22 10,301 6,733 7,245 Cash and cash equivalents 23 7,639 7,643 6,191 Total current assets 19,193 15,470 14,596 Total assets 146,883 145,305 137,026
Current liabilities Trade and other payables 24 (18,940) (14,035) (9,453) Borrowings 25 (1,851) (545) (82) Provisions 28 (82) (576) (565) Total current liabilities (20,873) (15,156) (10,100)
Total assets less current liabilities 126,010 130,149 126,926
Non-current liabilities Borrowings 25 (21,527) (13,550) (6,535) Provisions 28 (307) (312) (341) Total non-current liabilities (21,834) (13,862) (6,876)
Total assets employed 104,176 116,287 120,050
Financed by taxpayers' equity: Public dividend capital 75,711 75,711 75,711 Revaluation reserve 29 29,774 30,170 29,379 Retained earnings (1,309) 10,406 14,960 Total Taxpayers' Equity 104,176 116,287 120,050
The financial statements on pages 1 to 5 were approved by the Board on 7 June 2012 and signed on its behalf by:
Signed: ……………………………… (Chief Executive) Date: 7 June 2012
Page 2 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
STATEMENT OF CHANGES IN TAXPAYERS' EQUITY (Restated)
Public Revaluation Donated Income & Total dividend reserve asset Expenditure capital reserve reserve (PDC) £000 £000 £000 £000 £000 Balance at 1 April 2010 As previously stated 75,711 28,875 1,093 14,371 120,050 Prior Period Adjustment 504 (1,093) 589 0 Restated balance 75,711 29,379 0 14,960 120,050
Changes in taxpayers’ equity for 2010/11 Total Comprehensive Income for the year Retained surplus/(deficit) for the year (7,246) (7,246) Revaluation gains/(losses) and impairment losses property, plant and equipment 3,484 3,484 Other recorecognisedgnised ggainsains and losses 0 New PDC received 0 PDC repaid in year 0 Other reserve movements in year (2,693) 2,692 (1) Balance at 31 March 2011 75,711 30,170 0 10,406 116,287
Page 3 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
STATEMENT OF CHANGES IN TAXPAYERS' EQUITY
Public Revaluation Donated Income & Total dividend reserve asset Expenditure capital reserve reserve (PDC) £000 £000 £000 £000 £000 Balance at 1 April 2011 As previously stated 75,711 30,170 0 10,406 116,287 Prior Period Adjustment 0 Restated balance 75,711 30,170 0 10,406 116,287
Changes in taxpayers’ equity for 2011/12 Total Comprehensive Income for the year Retained surplus/(deficit) for the year (12,323) (12,323) Revaluation gains/(losses) and impairment losses property, plant and equipment 212 212 Other recognisedrecognised ggainsains and losses (5) 5 0 New PDC received PDC repaid in year Other reserve movements in year (603) 603 0 Balance at 31 March 2012 75,711 29,774 0 (1,309) 104,176
Page 4 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
STATEMENT OF CASH FLOWS FOR THE YEAR ENDED 31 MARCH 2012
For the year For the year ended 31 ended 31 March 2011 March 2012 (Restated) £000 £000 Cash flows from operating activities Operating surplus/(deficit) from continuing operations (7,931) (3,051)
Non-cash income and expense: Depreciation and amortisation 5,535 5,183 Impairments 10,446 9,106 Interest accrued and not paid 0 0 (Increase)/Decrease in trade and other receivables (3,559) 413 (Increase)/Decrease in inventories (159) 66 Increase/(Decrease) in trade and other payables 4,905 4,582 Increase/(Decrease) in provisions (499) (18) Tax (paid)/received 0 0 Other movements in operating cash flows (240) (1,445) Net cash generated from/(used in) operations 8,498 14,836
Cash flows from investing activities Interest received 32 56 (Payments) for Intangible Assets 0 0 (Payments) for property, plant and equipment (12,756) (15,654) Sales of property, plant and equipment 0 6 Net cash generated from/(used in) investing activities (12,724) (15,592)
Cash flows from financing activities Loans received from the DH 9,194 6,997 Interest paid (521) (228) CapitalCapital element of finance leases and PFI ((633)633) ((547)547) Interest element of finance lease (112) (53) Dividends paid (3,706) (3,961) Net cash generated from/(used in) financing activities 4,222 2,208
Increase/(decrease) in cash and cash equivalents (4) 1,452
Cash and cash equivalents at 1 April 2011 7,643 6,191 Cash and cash equivalents at 31 March 2012 7,639 7,643
Page 5 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
NOTES TO THE ACCOUNTS
1. ACCOUNTING POLICIES
Monitor has directed that the financial statements of Bolton NHS Foundation Trust shall meet the accounting requirements of the NHS Foundation Trust Financial Reporting Manual which shall be agreed with HM Treasury. Consequently, the following financial statements have been prepared in accordance with the 2011/12 NHS Foundation Trust Financial Reporting Manual issued by Monitor. The accounting policies contained in that manual follow International Financial Reporting Standards (IFRS) and HM Treasury’s Financial Reporting Manual to the extent that they are meaningful and appropriate to NHS Foundation Trusts. The accounting policies have been applied consistently in dealing with items considered material in relation to the accounts.
1.1 Accounting conventions
These accounts have been prepared under the historical cost convention modified to account for the revaluation of fixed assets at their value to the business by reference to their current costs. NHS Foundation Trusts are not required to provide a reconciliation between current cost and historical cost surpluses and deficits.
1.2 Acquisitions and discontinued operations
Activities are considered to be 'acquired' only if they are acquired from outside the public sector. Activities are considered to be 'discontinued' only if they cease entirely. They are not considered to be 'discontinued' if they transfer from one NHS body to another.
1.3 Critical accounting judgements and key sources of estimation uncertainty
InIn th thee app applicationlication ofof thethe TrustTrust accountingaccounting policiespolicies, managementmanagement isis requiredrequired toto makemake judgementsjudgements, estimates and assumptions about the carrying amounts of assets and liabilities that are not readily apparent from other sources. The estimates and associated assumptions are based on historical experience and other factors that are considered to be relevant. Actual results may differ from those estimates. The estimates and underlying assumptions are continually reviewed. Revisions to accounting estimates are recognised in the period in which the estimate is revised if the revision affects only that period, or in the period of the revision and future periods if the revision affects both current and future periods.
1.4 Critical judgements in applying accounting policies
Critical judgements, apart from those involving estimations (see below), management has made in the process of applying the entity’s accounting policies and that have the most significant effect on the amounts recognised in the financial statements.
1.5 Key sources of estimation uncertainty
The following are the key assumptions concerning the future, and other key sources of estimation uncertainty at the Statement of Financial Position date, that have a significant risk of causing a material adjustment to the carrying amounts of assets and liabilities within the next financial year:
Holiday pay accrual Incomplete spells (see revenue recognition note at 1.6) Depreciation (asset lives) Asset revaluations, impairments Provisions
Page 6 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
NOTES TO THE ACCOUNTS
1. ACCOUNTING POLICIES (CONTINUED)
1.6 Revenue recognition
Revenue in respect of services provided is recognised when, and to the extent that, performance occurs and is measured at the fair value of the consideration receivable. The main source of income for the Foundation Trust is contracts with commissioners in respect of healthcare services.
Where revenue is received for a specific activity which is to be delivered in the following financial year, that revenue is deferred.
Under Application Note G of FRS 5 and UITF 40, the Foundation Trust is entitled to recognise revenue for partially completed spells of activity at 31 March 2012. As the individual National Tariff price and procedure code is not known for partially completed spells, the Foundation Trust has based its calculation of such income on the average length of stay and the cumulative activity and price of individual specialties.
Revenue from the sale of non-current assets is recognised only when all material conditions of sale have been met, and is measured as the sums due under the sale contract.
The Foundation Trust receives income under the NHS Injury Cost Recovery Scheme, designed to reclaim the cost of treating injured individuals to whom personal injury compensation has subsequently been paid e.g. by an insurer. The Foundation Trust recognises the income when it receives notification from the Department for Work and Pensions' Compensation Recovery Unit that the individual has lodged a compensation claim. The income is measured at the agreed tariff for the treatments provided to the injured individual, less a provision for unsuccessful compensation claims and doubtful debts.
1.7 Employee benefits
Salaries, wages and employment related payments are recognised in the period in which the service is received from employees. The cost of annual leave entitlement earned but not taken by employees at the end of the period is recognised in the financial statements to the extent that employees are permitted to carry forward leave into the following period.
1.8 Pension costs
NHS Pension Scheme
Past and present employees are covered by the provisions of the NHS Pensions Scheme. The scheme is an unfunded, defined benefit scheme that covers NHS employers, general practices and other bodies, allowed under the direction of Secretary of State, in England and Wales. It is not possible for the NHS Foundation Trust to identify its share of the underlying scheme liabilities. Therefore, the scheme is accounted for as a defined contribution scheme.
Employer's pension cost contributions are charged to operating expenses as and when they become due
Additional pension liabilities arising from early retirements are not funded by the scheme except where the retirement is due to ill-health. The full amount of the liability for the additional costs is charged to the operating expenses at the time the Foundation Trust commits itself to the retirement, regardless of the method of payment.
1.9 Expenditure on other goods and services
Expenditure on goods and services is recognised when, and to the extent that they have been received, and is measured at the fair value of those goods and services. Expenditure is recognised in operating expenses except where it results in the creation of a non-current asset such as property, plant and equipment.
Page 7 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
NOTES TO THE ACCOUNTS
1. ACCOUNTING POLICIES (CONTINUED)
1.10 Property, plant and equipment
Recognition
Property, plant and equipment is capitalised where:
• it is held for use in delivering services or for administrative purposes; • it is probable that future economic benefits will flow to, or service potential be provided to, the Foundation Trust; • it is expected to be used for more than one financial year; and • the cost of the item can be measured reliably; and individually has a cost of at least £5,000; or • collectively have a cost of at least £5,000 and individually have a cost of more than £250, where the assets are functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under single managerial control; or • items form part of the initial equipping and setting-up cost of a new building, ward or unit irrespective of their individual or collective cost. Where a large asset, for example a building, includes a number of components with significantly different asset lives e.g. plant and equipment, then these components are treated as separate assets and depreciated over their own useful economic lives.
Measurement
Valuation
All property, plant and equipment assets are measured initially at cost, representing the costs directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of ooperatingperating in the manner intended bbyy management.management. All assets are measured subsesubsequentlyquently at fair value.
Subsequent expenditure
Where subsequent expenditure enhances an asset beyond its original specification, the directly attributable cost is added to the asset’s carrying value. Where subsequent expenditure is simply restoring the asset to the specification assumed by its economic useful life then the expenditure is charged to operating expenses.
Depreciation
Freehold land, properties under construction, and assets held for sale are not depreciated
Items of property, plant and equipment are depreciated over their remaining useful economic lives in a manner consistent with the consumption of economic or service delivery benefits. Freehold land is considered to have an infinite life and is not depreciated.
Property, plant and equipment which has been reclassified as ‘Held for Sale’ ceases to be depreciated upon the reclassification. Assets in the course of construction and residual interests in off-Statement of Financial Position PFI contract assets are not depreciated until the asset is brought into use or reverts to the Foundation Trust, respectively.
Otherwise, depreciation and amortisation are charged to write off the costs or valuation of property, plant and equipment and intangible non-current assets, less any residual value, over their estimated useful lives, in a manner that reflects the consumption of economic benefits or service potential of the assets. The estimated useful life of an asset is the period over which the Trust expects to obtain economic benefits or service potential from the asset. This is specific to the Trust and may be shorter than the physical life of the asset itself. Estimated useful lives and residual values are reviewed each year end, with the effect of any changes recognised on a prospective basis. Assets held under finance leases are depreciated over their estimated useful lives.
Page 8 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
NOTES TO THE ACCOUNTS
1. ACCOUNTING POLICIES (CONTINUED)
Revaluation and impairment
Increases in asset values arising from revaluations are recognised in the revaluation reserve, except where, and to the extent that, they reverse an impairment previously recognised in operating expenses, in which case they are recognised in operating income.
Decreases in asset values and impairments are charged to the revaluation reserve to the extent that there is an available balance for the asset concerned, and thereafter are charged to operating expenses.
Gains and losses recognised in the revaluation reserve are reported in the Statement of Comprehensive Income as an item of ‘other comprehensive income’.
De-recognition
Assets intended for disposal are reclassified as ‘Held for Sale’ once all of the following criteria are met:
• the asset is available for immediate sale in its present condition subject only to terms which are usual and customary for such sales; • the sale must be highly probable i.e.: - management are committed to a plan to sell the asset; - an active programme has begun to find a buyer and complete the sale; - the asset is being actively marketed at a reasonable price; - the sale is expected to be completed within 12 months of the date of classification as ‘Held for Sale’; and - the actions needed to complete the plan indicate it is unlikely that the plan will be dropped or significant changes made to it.
Following reclassification, the assets are measured at the lower of their existing carrying amount and their ‘fair value less costs to sell’. Depreciation ceases to be charged and the assets are not revalued, except where the ‘fair value less costs to sell’ falls below the carrying amount. Assets are de-recognised when all material sale contract conditions have been met.
Property, plant and equipment which is to be scrapped or demolished does not qualify for recognition as ‘Held for Sale’ and instead is retained as an operational asset and the asset’s economic life is adjusted. The asset is de- recognised when scrapping or demolition occurs.
1.11 Intangible fixed assets
Recognition
Intangible assets are non-monetary assets without physical substance which are capable of being sold separately from the rest of the Foundation Trust’s business or which arise from contractual or other legal rights. They are recognised only where it is probable that future economic benefits will flow to, or service potential be provided to, the Foundation Trust and where the cost of the asset can be measured reliably.
Page 9 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
NOTES TO THE ACCOUNTS
1. ACCOUNTING POLICIES (CONTINUED)
Internally generated intangible assets
Internally generated goodwill, brands, mastheads, publishing titles, customer lists and similar items are not capitalised as intangible assets.
Expenditure on research is not capitalised.
Expenditure on development is capitalised only where all of the following can be demonstrated:
• the project is technically feasible to the point of completion and will result in an intangible asset for sale or use; • the Foundation Trust intends to complete the asset and sell or use it; • the Foundation Trust has the ability to sell or use the asset; • how the intangible asset will generate probable future economic or service delivery benefits e.g. the presence of a market for it or its output, or where it is to be used for internal use, the usefulness of the asset; • adequate financial, technical and other resources are available to the Foundation Trust to complete the development and sell or use the asset; and • the Foundation Trust can measure reliably the expenses attributable to the asset during development. Software
Software which is integral to the operation of hardware, e.g. an operating system, is capitalised as part of the relevant item of property, plant and equipment. Software which is not integral to the operation of hardware, e.g. application software, is capitalised as an intangible asset.
Measurement
Intangible assets are recognised initially at cost, comprising all directly attributable costs needed to create, produce and prepare the asset to the point that it is capable of operating in the manner intended by management.
Subsequently intangible assets are measured at fair value. Increases in asset values arising from revaluations are recognised in the revaluation reserve, except where, and to the extent that, they reverse an impairment previously recognised in operating expenses, in which case they are recognised in operating income. Decreases in asset values and impairments are charged to the revaluation reserve to the extent that there is an available balance for the asset concerned, and thereafter are charged to operating expenses. Gains and losses recognised in the revaluation reserve are reported in the Statement of Comprehensive Income as an item of ‘other comprehensive income’.
Intangible assets held for sale are measured at the lower of their carrying amount or ‘fair value less costs to sell’.
Amortisation
Intangible assets are amortised over their expected useful economic lives in a manner consistent with the consumption of economic or service delivery benefits.
Page 10 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
NOTES TO THE ACCOUNTS
1. ACCOUNTING POLICIES (CONTINUED)
1.12 Donated fixed assets
Donated and grant funded fixed assets are capitalised at their fair value on receipt. The donation/grant is credited to income at the same time, unless the donor has imposed a condition that the future economic benefits embodied in the grant are to be consumed in a manner specified by the donor, in which case the donation/grant is deferred within liabilities and is carried forward to future financial years to the extent that the condition has not yet been met.
The donated and grant funded assets are subsequently accounted for in the same manner as other items of property, plant and equipment.
This is a change in policy for 2011/12 and a prior period adjustment has been made to the comparative figures.
1.13 Leases
Leases are classified as finance leases when substantially all the risks and rewards of ownership are transferred to the lessee. All other leases are classified as operating leases.
Finance leases
Where substantially all risks and rewards of ownership of a leased asset are borne by the NHS Foundation Trust, the asset is recorded as property, plant and equipment and a corresponding liability is recorded. The value at which both are recognised is the lower of the fair value of the asset or the present value of the minimum lease payments, discounted using the interest rate implicit in the lease. The implicit interest rate is that which produces a constant periodic rate of interest on the outstanding liability.
The asset and liability are recognised at the inception of the lease, and are de-recognised when the liability is discharged, cancelled or expires. The annual rental is split between the repayment of the liability and a finance cost. The annual finance cost is calculated by applying the implicit interest rate to the outstanding liability and is charged to Finance Costs in the Statement of Comprehensive Income.
Operating leases
Other leases are regarded as operating leases and the rentals are charged to operating expenses on a straight-line basis over the term of the lease. Operating lease incentives received are added to the lease rentals and charged to operating expenses over the life of the lease.
Leases of land and buildings
Where a lease is for land and buildings, the land component is separated from the building component and the classification for each is assessed separately. Leased land is treated as an operating lease.
The Foundation Trust as lessor
Rental income from operating leases is recognised on a straight-line basis over the term of the lease. Initial direct costs incurred in negotiating and arranging an operating lease are added to the carrying amount of the leased asset and recognised on a straight-line basis over the lease term.
Page 11 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
NOTES TO THE ACCOUNTS
1. ACCOUNTING POLICIES (CONTINUED)
1.14 Inventories
Inventories are valued at the lower of cost and net realisable value using the weighted average cost formula. This is considered to be a reasonable approximation to fair value due to the high turnover of stocks.
1.15 Cash and cash equivalents
Cash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than 24 hours. Cash equivalents are investments that mature in 3 months or less from the date of acquisition and that are readily convertible to known amounts of cash with insignificant risk of change in value.
In the Statement of Cash Flows, cash and cash equivalents are shown net of bank overdrafts that are repayable on demand and that form an integral part of the Foundation Trust’s cash management.
1.16 Provisions
The NHS Foundation Trust provides for legal or constructive obligations that are of uncertain timing or amount at the Statement of Financial Position date on the basis of the best estimate of the expenditure required to settle the obligation. Where the effect of the time value of money is significant, the estimated risk-adjusted cash flows are discounted using HM Treasury’s discount rate of 2.2% in real terms.
1.17 Clinical negligence costs
The NHS Litigation Authority (NHSLA) operates a risk pooling scheme under which the NHS Foundation Trust pays an annuall contribution t ib ti to t the th NHSLA, NHSLA which, hi h in i return, t settles ttl all ll clinical li i l negligence li claims. l i Although Alth h the th NHSLA is administratively responsible for all clinical negligence cases, the legal liability remains with the NHS Foundation Trust. The total value of clinical negligence provisions carried by the NHSLA on behalf of the NHS Foundation Trust is disclosed at note 28.
1.18 Non-clinical risk pooling
The NHS Foundation Trust participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the Foundation Trust pays an annual contribution to the NHS Litigation Authority and in return receives assistance with the costs of claims arising. The annual membership contributions, and any ‘excesses’ payable in respect of particular claims, are charged to operating expenses when the liability arises.
1.19 Contingent liabilities
Contingent liabilities are not recognised, but are disclosed in Note 30, unless the probability of a transfer of economic benefits is remote.
Contingent liabilities are defined as:
• possible obligations arising from past events whose existence will be confirmed only by the occurrence of one or more uncertain future events not wholly within the entity’s control; or • present obligations arising from past events but for which it is not probable that a transfer of economic benefits will arise or for which the amount of the obligation cannot be measured with sufficient reliability.
Page 12 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
NOTES TO THE ACCOUNTS
1. ACCOUNTING POLICIES (CONTINUED)
1.20 Financial assets
Financial assets are recognised on the balance sheet when the Foundation Trust becomes party to the financial instrument contract or, in the case of trade receivables, when the goods or services have been delivered. Financial assets are de-recognised when the contractual rights have expired or the asset has been transferred. Financial assets are initially recognised at fair value.
Financial assets are classified into the following categories: financial assets ‘at fair value through profit and loss’; ‘held to maturity investments’; ‘available for sale’ financial assets; and ‘loans and receivables’. The classification depends on the nature and purpose of the financial assets and is determined at the time of initial recognition.
Financial assets at fair value through profit and loss
Embedded derivatives that have different risks and characteristics to their host contracts, and contracts with embedded derivatives whose separate value cannot be ascertained, are treated as financial assets at fair value through profit and loss. They are held at fair value, with any resultant gain or loss recognised in the income statement. The net gain or loss incorporates any interest earned on the financial asset.
Loans and receivables
Loans and receivables are non-derivative financial assets with fixed or determinable payments which are not quoted in an active market. After initial recognition, they are measured at amortised cost using the effective interest method, less any impairment. Interest is recognised using the effective interest method. Fair value is determined by reference to quoted market prices where possible, otherwise by valuation techniques.
The effective interest rate is the rate that exactly discounts estimated future cash receipts through the expected life of the financial asset, to the net carrying amount of the financial asset.
At the balance sheet date, the Foundation Trust assesses whether any financial assets, other than those held at ‘fair value through profit and loss’ are impaired. Financial assets are impaired and impairment losses recognised if there is objective evidence of impairment as a result of one or more events which occurred after the initial recognition of the asset and which has an impact on the estimated future cash flows of the asset.
For financial assets carried at amortised cost, the amount of the impairment loss is measured as the difference between the asset’s carrying amount and the present value of the revised future cash flows discounted at the asset’s original effective interest rate. The loss is recognised in the income statement and the carrying amount of the asset is reduced directly, or through a provision for impairment of receivables.
If, in a subsequent period, the amount of the impairment loss decreases and the decrease can be related objectively to an event occurring after the impairment was recognised, the previously recognised impairment loss is reversed through the income statement to the extent that the carrying amount of the receivable at the date of the impairment is reversed does not exceed what the amortised cost would have been had the impairment not been recognised.
Page 13 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
NOTES TO THE ACCOUNTS
1. ACCOUNTING POLICIES (CONTINUED)
1.21 Financial liabilities
Financial liabilities are recognised on the balance sheet when the Foundation Trust becomes party to the contractual provisions of the financial instrument or, in the case of trade payables, when the goods or services have been received. Financial liabilities are de-recognised when the liability has been discharged, that is, the liability has been paid or has expired.
Loans from the Department of Health are recognised at historical cost. Otherwise, financial liabilities are initially recognised at fair value.
Financial liabilities are classified as either financial liabilities ‘at fair value through profit and loss’ or other financial liabilities.
Financial liabilities at fair value through profit and loss
Embedded derivatives that have different risks and characteristics to their host contracts, and contracts with embedded derivatives whose separate value cannot be ascertained, are treated as financial liabilities at fair value through profit and loss. They are held at fair value, with any resultant gain or loss recognised in the income statement. The net gain or loss incorporates any interest earned on the financial asset.
Other financial liabilities
After initial recognition, all other financial liabilities are measured at amortised cost using the effective interest method. The effective interest rate is the rate that exactly discounts estimated future cash payments through the life of the asset, to the net carrying amount of the financial liability. Interest is recognised using the effective interest method.
1.22 Value Added Tax
Most of the activities of the Foundation Trust are outside the scope of VAT and, in general, output tax does not apply and input tax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT.
1.23 Foreign exchange
The functional and presentational currencies of the Foundation Trust are sterling.
A transaction which is denominated in a foreign currency is translated into the functional currency at the spot exchange rate on the date of the transaction.
Where the Foundation Trust has assets or liabilities denominated in a foreign currency at the balance sheet date: • monetary items (other than financial instruments measured at ‘fair value through income and expenditure’) are translated at the spot exchange rate on 31 March; • non-monetary assets and liabilities measured at historical cost are translated using the spot exchange rate at the date of the transaction; and • non-monetary assets and liabilities measured at fair value are translated using the spot exchange rate at the date the fair value was determined.
Exchange gains or losses on monetary items (arising on settlement of the transaction or on re-translation at the balance sheet date) are recognised in income or expense in the period in which they arise.
Exchange gains or losses on non-monetary assets and liabilities are recognised in the same manner as other gains and losses on these items.
Page 14 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
NOTES TO THE ACCOUNTS
1. ACCOUNTING POLICIES (CONTINUED)
1.24 Third party assets
Assets belonging to third parties (such as money held on behalf of patients) are not recognised in the accounts since the NHS Foundation Trust has no beneficial interest in them. Details of third party assets are disclosed in Note 33 to the accounts.
1.25 Public dividend capital (PDC) and PDC dividend
Public dividend capital (PDC) is a type of public sector equity finance based on the excess of assets over liabilities at the time of establishment of the predecessor NHS Trust. HM Treasury has determined that PDC is not a financial instrument within the meaning of IAS 32.
A charge, reflecting the forecast cost of capital utilised by the NHS Foundation Trust, is paid over as public dividend capital dividend. The charge is calculated at the rate set by HM Treasury (currently 3.5%) on the average relevant net assets of the NHS Foundation Trust.
Relevant net assets are calculated as the value of all assets less the value of all liabilities, except for donated assets and cash held with the Office of the Paymaster General. Average relevant net assets are calculated as a simple means of opening and closing relevant net assets.
1.26 Losses and special payments
Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way each individual case is handled.
Losses and special payments are charged to the relevant functional headings in the Income and Expenditure Account on an accruals basis, including losses which would have been made good through insurance cover had NHS Foundation Trusts not been bearing their own risks (with insurance premiums then being included as normal revenue expenditure).
1.27 Accounting standards
No accounting standards have been adopted early.
1.28 Corporation tax
Bolton NHS Foundation Trust is regarded as a Health Service body within the meaning of the Income and Corporation Tax Act (ICTA) 1988 and accordingly is exempt from taxation on its income and capital gains within categories covered by this. There is a power for the Treasury to disapply this exemption in relation to the specified activities of a Foundation Trust. Accordingly, Royal Bolton NHS Foundation Trust is potentially within the scope of corporation tax in respect of activities which are not related to, or ancillary to, the provision of healthcare and where the profits therefrom exceed £50,000 p.a.
There is no corporation tax liability for this financial period.
Activities such as staff and patient car parking and sales of food are considered to be ancillary to the core healthcare objectives of the Foundation Trust and therefore not subject to corporation tax.
Page 15 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
NOTES TO THE ACCOUNTS
1. ACCOUNTING POLICIES (CONTINUED)
1.29Accounting standards that have been issued but have not yet been adopted
The Treasury FReM does not require the following Standards and Interpretations to be applied in 2011-12. The application of the Standards as revised would not have a material impact on the accounts for 2011-12, were they applied in that year:
IAS 1 Presentation of financial statements (Other Comprehensive Income) - subject to consultation IAS 12 - Income Taxes (amendment) - subject to consultation IAS 19 Post-employment benefits (pensions) - subject to consultation IAS 27 Separate Financial Statements - subject to consultation IAS 28 Investments in Associates and Joint Ventures - subject to consultation IFRS 7 - Financial Instruments: Disclosures (annual improvements) - effective 2012-13 IFRS 9 Financial Instruments - subject to consultation IFRS 10 Consolidated Financial Statements - subject to consultation IFRS 11 Joint Arrangements - subject to consultation IFRS 12 Disclosure of Interests in Other Entities - subject to consultation IFRS 13 Fair Value Measurement - subject to consultation
2. OPERATING SEGMENTS
All activity for Bolton NHS Foundation Trust is healthcare related. As the operating segments have similar characteristics there is no requirement to report segmentally.
3 MERGER
In July 2011 Royal Bolton Hospital NHS Foundation Trust merger with NHS Bolton Provider Arm Services to become Bolton NHS Foundation Trust, an integrated care provider for Bolton. This transaction saw the annual turnover of Bolton NHS Foundation Trust increase by £17m for 2011/12 for Apr '12 to Jun '12. Full merger accounting is not applicable due to a disdispensationpensation from treasurtreasury.y.
In November 2011 as part of the Greater Manchester wide reconfiguration of Neonatal and Maternity Services, the services formally provided in these areas at Salford Royal NHS Foundation Trust merged with the services provided at Bolton NHS Foundation Trust. This transaction saw the annual turnover of Bolton NHS Foundation Trust increase by £6.5m (£4.3m prior transfer)
In March 2012 as part of the Greater Manchester wide reconfiguration of Neonatal and Maternity Services, the services formally provided in these areas at Pennine Acute NHS Trust merged with the services provided at Bolton NHS Foundation Trust. This transaction saw the annual turnover of Bolton NHS Foundation Trust increase by £4.2m (£2.3m prior transfer)
Merger accounting has been applied to account for the transfer of these services. The impact of merger accounting can be seen in the table below
Bolton FT Provider Arm Salford Bury Maternity Final Position (Including (B) Maternity and Services (D) to be Reported Integrated Neonatal Provider Arm Services (C) from Jul ’11) (A) 2011-12 (Income) £4m £2m £283m £260m £17m Adjust for Apr – Adjust for Apr – Oct Feb 2010-11 comparatives (Income) £201m No adjustment £7m £3m £211m 2011-12 (Expenditure) £4m £2m £268m £17m Adjust for Apr – Adjust for Apr – £291m Oct Feb 2010-11 comparatives (Expenditure) £204m No adjustment £7m £3m £214m
Page 16 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
NOTES TO THE ACCOUNTS
4. INCOME GENERATION ACTIVITIES
The Trust undertakes income generation activities with an aim of achieving profit. The total income generation for the year ended 31 March 2012 was £70k. This is included within other income.
5. OPERATING INCOME FROM CONTINUING OPERATIONS
5.1. Revenue from patient care activities - by point of delivery 2011/12 2010/11 (Restated) £000 £000
Acute Trusts Elective income 31,966 31,788 Non elective income 80,489 80,759 Outpatient income 32,284 31,342 A&E income 10,456 9,361 Other NHS clinical income 95,562 32,404
All Trusts Private patient income 257 140 Other non-protected clinical income 1,696 1,725 Total income from activities 252,710 187,519
55.2.2 Revenue from ppatientatient care activities - byby source 2011/12 2010/11 (Restated) £000 £000
NHS Foundation Trusts 641 459 NHS Trusts 254 230 Strategic Health Authorities 237 0 Primary Care Trusts 249,586 182,522 Local Authorities 28 0 Department of Health - Other 11 665 NHS Other 0 1,778 Non-NHS: Private patients 115 131 Overseas patients (non-reciprocal) 142 9 Injury costs recovery 1,512 1,717 Other 184 8 252,710 187,519
Injury cost recovery income is subject to a provision for impairment of receivables of 10.5% to reflect expected rates of collection. 5.3 Revenue from patient care activities - mandatory and non- 2011/12 2010/11 mandatory (Restated) £000 £000
Revenue from mandatory patient care activities 250,757 185,654 Revenue from non-mandatory patient care activities 1,953 1,865 252,710 187,519
Page 17 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
NOTES TO THE ACCOUNTS
6. PRIVATE PATIENT INCOME
Section 44 of the 2006 Act requires that the proportion of private patient income to the total patient related income of NHS Foundation Trusts should not exceed its proportion whilst the body was an NHS Trust in 2002/03 (the Private Patient Cap).
2011/12 2010/11 2002/03 (Restated) (Base Year) £000 £000 £000 Private patient income 257 140 126 Total patient related income 252,710 187,519 118,421 Proportion as a percentage 0.10% 0.07% 0.11%
7. OTHER OPERATING REVENUE 2011/12 2010/11 (Restated) £000 £000
Education, training and research 9,147 7,552 Charitable and other contributions to expenditure 0 0 Non-patient care services to other bodies 5,475 5,876 Other revenue 15,797 10,088 30,419 23,516
2011/12 2010/11 Other Revenue (Restated) £000 £000
Car parking 883 864 Estates recharges 283 319 Rental revenue from operating leases 0 166 Staff recharges 3,608 2,304 IT recharges 544 54 Pharmacy sales 1,719 1,884 Staff accommodation rentals 100 100 Clinical excellence awards 0 0 Catering 331 326 Property rentals 203 166 Other 8,126 3,905 Total 15,797 10,088
8. REVENUE
Revenue is almost totally from the supply of services. Revenue from the sale of goods is immaterial.
Page 18 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
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9. OPERATING EXPENDITURE
9.1 Operating expenses 2011/12 2010/11 (Restated) £000 £000 Services from Foundation Trusts 2,158 1,492 Services from other NHS Trusts 322 400 Services from PCTs 3,766 1,079 Services from other NHS bodies 164 70 Purchase of healthcare from non-NHS bodies 266 157 Employee expense - Executive directors 1,122 846 Employee expense - Non-executive directors 123 116 Employee expense - Staff costs 199,599 141,854 Drug costs 13,936 11,154 Supplies and services - clinical (excluding drug costs) 18,823 17,069 Supplies and services - general 7,286 6,593 Establishment 3,147 1,420 Research and development 0 0 Transport 427 227 Premises 11,422 7,619 Increase/(Decrease) in bad debt provision 32 71 Depreciation on property, plant and equipment 5,267 4,938 Amortisation on intangible assets 268 245 Impairments of property, plant and equipment 10,446 9,106 Audit fees auditaudit serv servicesices - s statutorytatutory au auditdit 46 54 audit services - regulatory reporting 9 35 Other auditors' remuneration other services 0 18 Clinical negligence premium 6,637 5,903 Loss on disposal of land and buildings 0 40 Loss on disposal of other property, plant and equipment 45 14 Legal fees 133 174 Consultancy costs 661 732 Training, courses and conferences 699 492 Patient travel 42 49 Insurance 193 86 Losses, ex gratia & special payments 130 75 Other 3,891 1,958 291,060 214,086
9.2 Audit remuneration 2011/12 2010/11 £000 £000 Other services: Board Review Other services: IFRS Review 018 0 18
Page 19 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
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10. OPERATING LEASES
10.1 As lessee
Operating lease payments include £236k for leased vehicles and £49k for equipment leases. The contracts for equipment leases are taken out for between 5 and 10 years, whilst vehicle leases are taken out for 3 years.
Payments recognised as an expense 2011/12 2010/11 £000 £000
Minimum lease payments 285 213 Contingent rents 0 0 285 213
Future minimum lease payments due: 2011/12 2010/11 £000 £000
Buildings - not later than one year 0 0 - later than one year and not later than five years 0 0 - later than five years 0 0 0 0
Other - not later than one year 153 119 - later than one year and not later than five years 136 140 - later than five years 0 0 289 259
Total 289 259
10.2 As lessor
Rental revenue 2011/12 2010/11 £000 £000
Contingent rent 180 171 Other 0 0 Total rental revenue 180 171
Total future minimum lease payments receivable 2011/12 2010/11 £000 £000
Buildings - not later than one year 180 171 - later than one year and not later than five years 443 683 - later than five years 151 196 774 1,050
Total 774 1,050
The £180k received in rental revenue includes rentals received from: - the WRVS for the use of rooms within the hospital for providing shops; - HighmeadowsHighmeadows nursery;
Page 20 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
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11. EMPLOYEE COSTS AND NUMBERS
Restated 11.1 Employee costs 2011/12 2011/12 2011/12 2010/11 Total Permanent Other Total
£000 £000 £000 £000
Salaries and wages 163,454 155,155 8,299 115,955 Social Security costs 11,785 11,785 0 8,608 Pension costs - defined contribution plans Employer's contributions to NHS Pensions 18,543 18,543 0 13,240 Agency/contract staff 6,939 0 6,939 4,897 Total gross staff costs 200,721 185,483 15,238 142,700
11.2 Average number of people employed 2011/12 2011/12 2011/12 2010/11 Total Permanent Other Total Number Number Number Number
Medical and dental 663 342 321 385 Administration and estates 1,568 1,565 3 775 Healthcare assistants and other support staff 950 950 0 629 Nursing, midwifery and health visiting staff 2,139 2,136 3 1,205 Nursing, midwifery and health visiting learners 9900 Scientific, therapeutic and technical staff 847 847 0 370 Bank & agency staff 215 0 215 188 Other 55021 TotalTotal 6, 396 5, 854 542 3, 573
11.3 Directors' remuneration 2011/12 2010/11 £'000 £'000
Directors' remuneration 1,245 962 Employer contribution to a pension scheme in respect of directors 117 125 Number Number The total number of directors to whom benefits are accruing under defined benefit schemes 10 9
11.4 Analysis of termination benefits 2011/12 2010/11
Number of terminations 33 0 Value of terminations (£' 000) 748 0
11.5 The number of exist packages paid for the year 2011/12 is 33 (0 2010/11). Further detail is given in the table below
Exit package cost band Number of Number of other Total number of compulsory departures exit packages by redundancies agreed cost band
<£10,000 3 11 14 £10,00 - £25,000 1 5 6 £25001 - £50,000 2 7 9 £50,001 – £100,000 0 4 4
11.6 Key management remuneration
Keyyg management is defined as the executive and non-executive directors of the Foundation Trust. Further details of their remuneration can be found in the 2011/12 remuneration report published as part of the Foundation Trust's annual report.
Page 21 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
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12. PENSION COSTS
Past and present employees are covered by the provisions of the NHS Pensions Scheme. Details of the benefits payable under these provisions can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions. The scheme is an unfunded, defined benefit scheme that covers NHS employers, GP practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The scheme is not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS Body of participating in the scheme is taken as equal to the contributions payable to the scheme for the accounting period.
The scheme is subject to a full actuarial valuation every four years (until 2004, every five years) and an accounting valuation every year. An outline of these follows:
a) Full actuarial (funding) valuation The purpose of this valuation is to assess the level of liability in respect of the benefits due under the scheme (taking into account its recent demographic experience), and to recommend the contribution rates to be paid by employers and scheme members. The last such valuation, which determined current contribution rates was undertaken as at 31 March 2004 and covered the period from 1 April 1999 to that date. The conclusion from the 2004 valuation was that the scheme had accumulated a notional deficit of £3.3 billion against the notional assets as at 31 March 2004.
In order to defray the costs of benefits, employers pay contributions at 14% of pensionable pay and most employees had up to April 2008 paid 6%, with manual staff paying 5%.
Following the full actuarial review by the Government Actuary undertaken as at 31 March 2004, and after consideration of changes to the NHS Pension Scheme taking effect from 1 April 2008, his Valuation report recommended that employer contributions could continue at the existing rate of 14% of pensionable pay, from 1 April 2008,2008, following the introduction of employee contributions on a tiered scale from 5% up to 8.5%8.5% of their pensionable pay depending on total earnings.
On advice from the scheme actuary, scheme contributions may be varied from time to time to reflect changes in the scheme’s liabilities.
b) Accounting valuation A valuation of the scheme liability is carried out annually by the scheme actuary as at the end of the reporting period by updating the results of the full actuarial valuation.
Between the full actuarial valuations at a two-year midpoint, a full and detailed member data-set is provided to the scheme actuary. At this point the assumptions regarding the composition of the scheme membership are updated to allow the scheme liability to be valued.
The valuation of the scheme liability as at 31 March 2012, is based on detailed membership data as at 31 March 2008 (the latest midpoint) updated to 31 March 2012 with summary global member and accounting data.
The latest assessment of the liabilities of the scheme is contained in the scheme actuary report, which forms part of the annual NHS Pension Scheme (England and Wales) Resource Account, published annually. These accounts can be viewed on the NHS Pensions website. Copies can also be obtained from The Stationery Office.
Page 22 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
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12. PENSION COSTS (CONTINUED)
c) Scheme provisions
The NHS Pension Scheme provided defined benefits, which are summarised below. This list is an illustrative guide only, and is not intended to detail all the benefits provided by the Scheme or the specific conditions that must be met before these benefits can be obtained:
The Scheme is a “final salary” scheme. Annual pensions are normally based on 1/80th for the 1995 section and of the best of the last three years' pensionable pay for each year of service, and 1/60th for the 2008 section of reckonable pay per year of membership. Members who are practitioners as defined by the Scheme Regulations have their annual pensions based upon total pensionable earnings over the relevant pensionable service.
With effect from 1 April 2008 members can choose to give up some of their annual pension for an additional tax free lump sum, up to a maximum amount permitted under HMRC rules. This new provision is known as “pension commutation”.
Annual increases are applied to pension payments at rates defined by the Pensions (Increase) Act 1971, and are based on changes in retail prices in the twelve months ending 30 September in the previous calendar year.
Early payment of a pension, with enhancement, is available to members of the scheme who are permanently incapable of fulfilling their duties effectively through illness or infirmity. A death gratuity of twice final year’s pensionable pay for death in service, and five times their annual pension for death after retirement is payable.
For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the liability for the additional costs is charged to the statement of comprehensive income at the time the trust commits itself to the retirement, regardless of the method of payment.
Members can pypurchase additional service in the NHS Scheme and contribute to money purchasep AVCs run byy the Scheme’s approved providers or by other Free Standing Additional Voluntary Contributions (FSAVC) providers.
Page 23 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
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13. RETIREMENTS DUE TO ILL-HEALTH
During 2011/12 there were 5 (2010/11, 10) early retirements from the NHS Trust agreed on the grounds of ill- health. The estimated additional pension liabilities of these ill-health retirements will be £524,615 (2010/11: £903,316). The cost of these ill-health retirements will be borne by the NHS Business Services Authority - Pensions Division.
14. FINANCE INCOME 2011/12 2010/11 £000 £000
Interest on loans and receivables 33 56 Interest on held-to-maturity financial assets 0 0 Total 33 56
15. FINANCE COSTS - INTEREST EXPENSE 2011/12 2010/11 £000 £000
Loans from the Foundation Trust Financing Facility 676 328 Interest on loans 0 0 Interest on obligations under finance leases 112 53 Other interest costs 3 Total interest expense 791 381 Other finance costs 0 0 Total 791 381
16. THE LATE PAYMENT OF COMMERCIAL DEBTS (INTEREST) ACT 1998 2011/12 2010/11 £000 £000
Amounts included in finance costs from claims made under this legislation 0 0 Compensation paid to cover debt recovery costs under this legislation 0 0 Total 00
17. OTHER GAINS AND LOSSES 2011/12 2010/11 £000 £000
Gain/(loss) on disposal of property, plant and equipment (45) (54)
Page 24 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
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18.1 PROPERTY, PLANT AND EQUIPMENT Land Buildings Dwellings Assets under Plant and Transport Information Furniture & Total excluding construction machinery equipment technology fittings dwellings 2011/12: £000 £000 £000 £000 £000 £000 £000 £000 £000
Cost or valuation at 1 April 2011 23,273 110,562 1,058 11,187 18,669 138 5,068 423 170,378 Additions purchased 2,418 7,494 0 1,596 1,882 0 0 0 13,390 Additions donated 0 52 0 0 146 0 0 0 198 Reclassifications 0 11,187 0 (11,187) 0 0 0 0 0 Revaluations 0 232 (20) 0 0 0 0 0 212 Impairments 0 0 0 0 0 0 0 0 0 Disposals 0 0 0 0 (784) 0 0 0 (784) At 31 March 2012 25,691 129,527 1,038 1,596 19,913 138 5,068 423 183,394
Depreciation at 1 April 2011 183 26,049 197 0 12,107 110 3,436 201 42,283 Disposals 0 0 0 0 (739) 0 0 0 (739) Impairments 468 9,974 4 0 0 0 0 0 10,446 Provided during the year 0 3,144 34 0 1,572 5 471 41 5,267 Depreciation at 31 March 2012 651 39,167 235 0 12,940 115 3,907 242 57,257
Net book value NBV - Owned at 31 March 2011 23,090 84,095 815 11,187 4,891 28 1,632 217 125,955 NBV - Finance lease at 31 March 2011 0 0 0 0 1,107 0 0 0 1,107 NBV - Donated at 31 March 2011 0 418 46 0 564 0 0 5 1,033 Total at 31 March 2011 23,090 84,513 861 11,187 6,562 28 1,632 222 128,095
Net book value NBV - Owned at 31 March 2012 25,040 89,695 803 1,596 4,995 23 1,161 181 123,494 NBV - Finance lease at 31 March 2012 0 0 0 0 1,590 0 0 0 1,590 NBV - Donated at 31 March 2012 0 665 0 0 388 0 0 0 1,053 Total at 31 March 2012 25,040 90,360 803 1,596 6,973 23 1,161 181 126,137
18.2 Analysis of property, plant and equipment at 31 March 2012
Net book value NBV - Protected assets at 31 March 2012 24,830 89,256 803 0 0 0 0 0 114,889 NBV - Unprotected assets at 31 March 2012 210 1,104 0 1,596 6,973 23 1,161 181 11,248 Total at 31 March 2012 25,040 90,360 803 1,596 6,973 23 1,161 181 126,137
18.3 Net book value of property, plant and equipment in revaluation reserve
2011/12 2010/11 £'000 £'000
Carrying value at 1 April 30,170 29,379 Movement in year (396) 791 CiCarrying value lt31Mh at 31 March 2929,77 7744 3030,170 170
Page 25 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
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18.4 PROPERTY, PLANT AND EQUIPMENT (CONTINUED) Land Buildings Dwellings Assets under Plant and Transport Information Furniture & Total excluding construction machinery equipment technology fittings dwellings Prior year: 2010/11 £000 £000 £000 £000 £000 £000 £000 £000 £000
Cost or valuation at 1 April 2010 23,273 96,891 1,881 5,670 17,220 138 4,817 414 150,304 Additions purchased 0 14,913 8 9,378 2,867 0 251 9 27,426 Additions donated 0 0 0 0 0 0 0 0 0 Reclassifications 0 (4,663) (854) (3,861) 0 0 0 0 (9,378) Revaluations 0 3,461 23 0 0 0 0 0 3,484 Impairments 0 0 0 0 0 0 0 0 0 Disposals 0 (40) 0 0 (1,418) 0 0 0 (1,458) At 31 March 2011 23,273 110,562 1,058 11,187 18,669 138 5,068 423 170,378
Depreciation at 1 April 2010 183 13,833 165 0 12,213 104 2,978 161 29,637 ` Disposals 0 0 0 0 (1,398) 0 0 0 (1,398) Impairments 0 9,106 0 0 0 0 0 0 9,106 Provided during the year 0 3,110 32 0 1,292 6 458 40 4,938 Depreciation at 31 March 2011 183 26,049 197 0 12,107 110 3,436 201 42,283
Net book value NBV - Owned at 31 March 2010 23,090 82,566 1,716 5,670 4,208 34 1,839 253 119,376 NBV - Finance Lease at 31 March 2010 0 0 0 0 198 0 0 0 198 NBV - Donated at 31 March 2010 0 492 0 0 601 0 0 0 1,093 NBV total at 31 March 2010 23,090 83,058 1,716 5,670 5,007 34 1,839 253 120,667
Net book value NBV - Purchased at 31 March 2011 23,090 84,095 815 11,187 4,891 28 1,632 217 125,955 NBV - Finance Lease at 31 March 2011 0 0 0 0 1,107 0 0 0 1,107 NBV - Donated at 31 March 2011 0 418 46 0 564 0 0 5 1,033 NBV total at 31 March 2011 23,090 84,513 861 11,187 6,562 28 1,632 222 128,095
18.5 Analysis of property, plant and equipment 31 March 2011
Net book value NBV - Protected assets at 31 March 2011 22,880 82,403 851 0 0 0 0 0 106,134 NBV - Unprotected assets at 31 March 2011 210 2,110 10 11,187 6,562 28 1,632 222 21,961 Total at 31 March 2011 23,090 84,513 861 11,187 6,562 28 1,632 222 128,095
Page 26 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
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18.6 PROPERTY, PLANT AND EQUIPMENT (CONTINUED)
Assets totalling £198k have been donated by Bolton NHS Charitable Fund. These are:
£'000 Specimen Cabinet 58 Vestibular & Oculometer System 31 Vivid Ultrasound Machine 24 Biopsy Device 12 2 MP30 Monitors 11 2 Specialist Hoists 10 AMD Room Building Works 52
Assets are depreciated evenly over the estimated life given in the table below:
Life (Years)
Software Licences 2 - 5 Buildings excluding dwellings 1 - 79 Dwellings 13 - 43 Plant & Machinery 3 - 15 Transport Equipment 7 Information Technology 2 - 15 Furniture and Fittings 7 - 10
At 31 March 2012 no land, buildings or dwellings were valued at open market value.
The date of the latest revaluation of land and buildings was 1 January 2012. This was carried out by the District ValuerValuer andand thethe valuationvaluation was basedbased on "modernmodern equivalentequivalent asse assetsts".
The overall effect of the revaluation is a reduction in value of Land and Buildings of £10,246k.
The revaluation resulted in an impairment of £9,633k during the year.
In addition, the Trust has revalued buildings which are not part of the Trust's long term strategy and are planned for demolition within the next year. This has resulted in an impairment of £813k on these buildings.
Page 27 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
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19. INTANGIBLE ASSETS Computer Total software - 2011/12: purchased
£000 £000
Gross cost at 1 April 2011 1,423 1,423 Additions purchased 90 90 Gross cost at 31 March 2012 1,513 1,513
Amortisation at 1 April 2011 821 821 Provided during the year 268 268 Amortisation at 31 March 2012 1,089 1,089
Net book value Purchased 602 602 Donated 0 0 Total at 31 March 2011 602 602
Net book value Purchased 424 424 Donated 0 0 Total at 31 March 2012 424 424
Prior year: ComputerComputer TotalTotal software - 2010/11: purchased
£000 £000
Gross cost at 1 April 2010 1,300 1,300 Additions purchased 123 123 Gross cost at 31 March 2011 1,423 1,423
Amortisation at 1 April 2010 576 576 Provided during the year 245 245 Amortisation at 31 March 2011 821 821
Net book value Purchased 602 602 Donated 0 0 Total at 31 March 2011 602 602
Page 28 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
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20. CAPITAL COMMITMENTS
Contracted capital commitments at 31 March not otherwise included in these financial statements:
2011/12 2010/11 £000 £000
Property, plant and equipment 226 502 Intangible assets 0 0 Total 226 502
21. INVENTORIES
2011/12 2010/11 £000 £000
Drugs 612 501 Consumables 241 189 Energy 104 125 Other 296 279 Total 1,253 1,094 of which held at net realisable value: 1,253 1,094
The Foundation Trust does not have any non-current inventories.
21.1 INVENTORIES RECOGNISED IN EXPENSES 2011/12 2010/11 £000 £000
Inventories recognised in expenses 11,572 10,163 Write-down of inventories recognised as an expense 0 7 Reversal of write down of inventories recognised as a reduction in expense 0 0 TOTAL Inventories recognised in expenses 11,572 10,170
Page 29 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
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22. TRADE AND OTHER RECEIVABLES
22.1 Trade and other receivables Current Non-current 2011/12 2010/11 2011/12 2010/11 £000 £000 £000 £000
NHS receivables - revenue 1,071 1,040 0 0 NHS receivables - capital 0 0 0 0 Other receivables with related parties - Revenue 29 12 0 0 Provision for the impairment of receivables (167) (141) (88) (121) Deposits and advances 0 1 0 0 Prepayments - other 1,050 909 0 0 Accrued income 5,548 2,638 0 0 Interest receivable 0 0 0 0 Operating lease receivables 0 0 0 0 PDC receivable 183 102 0 0 VAT receivable 278 416 0 0 Other receivables 2,309 1,756 1,217 1,259 Other receivables - capital 0 0 0 0 Total 10,301 6,733 1,129 1,138
91% of trade is with Primary Care Trusts, as commissioners for NHS patient care services. As Primary Care Trusts are funded by Government to buy NHS patient care services, no credit scoring of them is considered necessary.
22.2 Analysis of impaired receivables 2011/12 2010/11 £000 £000
0-30 days 732 168 30-60 days 336 37 60-90 days 396 4 90-180 days 131 9 180-360 days 142 10 1,737 228
Page 30 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
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22.3 Provision for impairment of receivables 2011/12 2010/11 £000 £000
Balance at 1 April 262 190 Amount recovered during the year 0 0 (Increase)/decrease in receivables impaired (6) 72 Balance at 31 March 256 262
Receivables impaired during the period relate to the movement in the provision for bad debt on the injury cost recovery scheme.
Page 31 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
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23. CASH AND CASH EQUIVALENTS 2011/12 2010/11 £000 £000 Balance at 1 April 7,643 6,191 Net change in year (4) 1,452 Balance at 31 March 7,639 7,643
Made up of Cash with the Government Banking Service 7,592 7,611 Commercial banks and cash in hand 47 32 Current investments 0 0 Cash and cash equivalents as in statement of financial position 7,639 7,643 Bank overdraft - Government banking service 0 0 Bank overdraft - Commercial banks 0 0 Cash and cash equivalents as in statement of cash flows 7,639 7,643
Third party assets held by the foundation trust 2011/12 2011/12 2010/11 2010/11 Monery on Monery on Bank balances deposit Bank balances deposit £000 £000 £000 £000
Balance at 1 April 49 0 53 0 Gross inflows 31 0 27 0 Gross outflows (28) 0 (31) 0 Balance at 31 March 52 0 49 0
Page 32 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
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24. TRADE AND OTHER PAYABLES Current Non-current 2011/12 2010/11 2011/12 2010/11 £000 £000 £000 £000
Receipts in advance 0 0 0 0 NHS payables - capital 0 0 0 0 NHS payables - revenue 3,855 2,580 0 0 Other trade payables - capital 1,252 2,868 0 0 Other trade payables - revenue 6,321 1,942 0 0 Social security costs 0 0 0 0 VAT payable 0 0 0 0 Other taxes payable 4,012 2,338 0 0 Other payables 2,346 3,160 0 0 Accruals 1,154 1,147 0 0 PDC dividend payable 0 0 0 0 Total 18,940 14,035 0 0
Other payables include: There are 5 (10 2010/11) cases at a total of £525k (£903k 2010/11) of payments due in future years under arrangements to buy out the liability of early retirements over 5 years; and £2,310,508 (£1,574,567 2010/11) outstanding pension Pension contributions are paid a month in arrears.
25. BORROWINGS Current Non-current 2011/12 2010/11 2011/12 2010/11 £000 £000 £000 £000
Loans from: Foundation Trust FinancingFinancing FacilityFacility 11,368,368 0 2121,230,230 13,40413,404 Finance lease liabilities 483 545 297 146 Total 1,851 545 21,527 13,550
The Foundation Trust has two loans with the Department of Health which total £22,598k. £19,998k- To fund "Making it Better" developments within Women's and Children's. The loan has a fixed rate of 3.75% and has been taken out over a 20 year term and is due to be fully repaid by October 2029. £2,600k- To fund the purchase of land for a Car Park. The loan has a fixed rate of 1.26% and has been taken out over a 10 year term and is due to be fully repaid by December 2022.
Page 33 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
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26. PRUDENTIAL BORROWING LIMIT
The Foundation Trust is required to comply and remain within a prudential borrowing limit.
This is made up of two elements:
• the maximum cumulative amount of long-term borrowing. This is set by reference to the five ratio tests set out in Monitor’s Prudential Borrowing Code. The financial risk rating set under Monitor’s Compliance Framework determines one of the ratios and therefore can impact on the long term borrowing limit; and • the amount of any working capital facility approved by Monitor. Further information on the NHS Foundation Trust Prudential Borrowing Code and Compliance Framework can be found on the website of Monitor, the Independent Regulator of Foundation Trusts. The Foundation Trust has a prudential borrowing limit of £78,800k in 2011/12.
Approved Actual Ratios Ratios Actual Ratios Approved For the Year to For the Year Ratios Ended 31 31 March Ended 31 to March 2012 2012 March 2011 31 March 2011
Minimum dividend cover 2.0 >1x 2.8 >1x Minimum interest cover 8.3 >3x 28.13 >3x Minimum debt service cover 4.6 >2x 11.62 >2x Maximum debt service to revenue 0.5% <2.5% 0.5% <2.5%
The Foundation Trust has an actual committed working capital (bank overdraft) facility of £17,500k within its approved limit of £78,800k. The amount borrowed in the year was £9,283k, balance outstanding being £23,378k.
The Foundation Trust has not drawn down on its working capital facility at 31 March 2012. This facility expires on 30 September 2012.
27. FINANCE LEASE OBLIGATIONS Finance leases are generally for medical equipment used within the Trust. The largest of these is for a Managed Facilities Service in radiology that commenced in July 2010. The capital value of the assets provided to date under this facility is £1,590,662. The facility is for a 15 year term. Other finance leases are taken out over 5 or 7 years; these include an automated haematology analyser used within pathology. This had a capital value of £310k when taken out in 2006.
Amounts payable under finance leases: Minimum lease payments Present value of minimum lease payments 2011/12 2010/11 2011/12 2010/11 £000 £000 £000 £000
Within one year 575 592 575 592 Between one and five years 332 156 332 156 After five years Less future finance charges (127) (57) (127) (57) Present value of minimum lease payments 780 691 780 691
Included in: Current borrowings 483 545 483 545 Non-current borrowings 297 146 297 146 780 691 780 691
Page 34 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2011/12
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28. PROVISIONS Current Non-current 2011/12 2010/11 2011/12 2010/11 £000 £000 £000 £000
Pensions relating to former directors 0 0 0 0 Pensions relating to other staff 2 2 59 62 Legal claims 80 143 248 250 Other 0 431 0 0 Total 82 576 307 312
Pensions Legal Agenda for Other Total relating to claims Change other staff
£000 £000 £000 £000 £000
At 1 April 2011 64 393 0 431 888 Change in the discount rate 0 3 0 0 3 Arising during the year 0 106 0 0 106 Utilised during the year (5) (135) 0 (294) (434) Reversed unused 0 (46) 0 (137) (183) Unwinding of discount 2 7 0 0 9 At 31 March 2012 61 328 0 0 389
Expected timing of cash flows: - not later than one year; 280 0 0 82 - later than one year and not later than five years; 948 0 0 57 - later than five years. 50 200 0 0 250 TOTAL 61 328 0 0 389
£25,226,705 is included in the provisions of the NHS Litigation Authority at 31 March 2012 in respect of clinical negligence liabilities of the Trust (31 March 2011: £24,042,520).
Legal Claims include £67,208 for Employer's and Occupiers' Liability cases and £260,382 for Permanent Injury Benefits. The items shown for Employer's and Occupiers' Liability cases relate to cases that have more than a 50% chance of being settled. Claims that have a remote chance of being settled are classed as contingent liabilities and disclosed in note 30.
In January 2009 the Trust signed an agreement with the NHSLA that in the event of the Trust (i) choosing to leave the CNST voluntarily and (ii) in the event of insolvency, the Trust would be required to compensate the NHSLA for all outstanding clinical negligence claims i.e. lump sum liability.
29. MOVEMENTS ON REVALUATION RESERVE
Movements on reserves comprised the following: Revaluation Reserve £000
Revaluation reserve at 1 April 2011 30,170
Impairments 0 Revaluations 212 Transfers to other reserves 0 Asset disposals (5) Other recognised gains and losses 0 Other reserve movements (603) Revaluation reserve at 31 March 2012 29,774
Restated Revaluation Reserve £000
Revaluation reserve at 1 April 2010 29,379
Impairments 0 Revaluations 3,484 Transfers to other reserves 0 Asset disposals 0 Other recogggnised gains and losses 0 Other reserve movements (2,693) Revaluation reserve at 31 March 2011 30,170
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NOTES TO THE ACCOUNTS
30. CONTINGENT LIABILITIES
2011/12 2010/11 £000 £000
Equal pay cases 0 0 Amounts recoverable against liabilities 0 0 Other (Employer's and Occupiers' legal claims) (36) (68) Total (36) (68)
31. FINANCIAL INSTRUMENTS
31.1 Financial assets
At 31 March 2012, £7,639 of the Foundation Trust's financial assets were held at a floating rate.
31.2 Financial liabilities
At 31 March 2012, none of the Foundation Trust's financial liabilities are carried at a floating rate.
31.3 Financial assets by category At fair value Loans and Available Total through receivables for sale Income and Expenditure £000 £000 £000 £000
Receivables 0 6,440 0 6,440 Cash at bank and in hand 0 7,642 0 7,642 Total at 31 March 2011 0 14,082 0 14,082
Receivables 0 9,912 0 9,912 Cash at bank and in hand 0 7,639 0 7,639 Total at 31 March 2012 0 17,551 0 17,551
31.4 Financial liabilities by category At fair value Other Total through Income and Expenditure £000 £000 £000
Payables 0 7,578 7,578 Finance lease obligations 0 691 691 Other borrowings 0 13,404 13,404 Provisions under contract 0 263 263 Total at 31 March 2011 0 21,936 21,936
Payables 0 11,771 11,771 Finance lease obligations 0 780 780 Other borrowings 0 22,598 22,598 b Provisions under contract 0 260 260 Total at 31 March 2012 0 35,409 35,409 a
Notes a Fair value is not significantly different from book value since, in the calculation of book value, the expected cash flows have been discounted by the Treasury discount rate of 2.8% in real terms. b Borrowings from the Department of Health's NHS Foundation Trust Financing Facility where it is expected that book value will equal fair value.
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NOTES TO THE ACCOUNTS
31.5 Financial risk management
Financial Reporting Standard IFRS 7 requires disclosure of the role that financial instruments have had during the period in creating or changing the risks a body faces in undertaking its activities. Because of the continuing service provider relationship that the NHS Trust has with Primary Care Trusts and the way those Primary Care Trusts are financed, the NHS Trust is not exposed to the degree of financial risk faced by business entities. Also financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which the financial reporting standards mainly apply. The NHS Trust has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the NHS Trust in undertaking its activities.
The Trust’s treasury management operations are carried out by the finance department, within parameters defined formally within the Trust’s standing financial instructions and policies agreed by the Board of Directors. Trust treasury activity is subject to review by the Trust’s internal auditors.
Currency risk
The Trust is principally a domestic organisation with the great majority of transactions, assets and liabilities being in the UK and sterling based. The Trust has no overseas operations. The Trust therefore has low exposure to currency rate fluctuations.
Interest rate risk
The Trust borrows from Government for capital expenditure, subject to affordability as confirmed by the Strategic Health Authority. The borrowings are for 1 – 25 years, in line with the life of the associated assets, and interest is charged at the National Loans Fund rate, fixed for the life of the loan. The Trust therefore has low exposure to interest rate fluctuations.
Credit risk
Because the majority of the Trust’s income comes from contracts with other public sector bodies, the Trust has low exposure to credit risk. The maximum exposures as at 31 March 2012 are in receivables from customers, as disclosed in the Trade and other receivables note.
Liquidity risk
The Trust’s operating costs are incurred under contracts with Primary Care Trusts, which are financed from resources voted annually by Parliament. The Trust funds its capital expenditure from funds obtained within its prudential borrowing limit. The Trust is not, therefore, exposed to significant liquidity risks.
32. EVENTS AFTER THE REPORTING PERIOD
There are no events after the reporting period.
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NOTES TO THE ACCOUNTS
33. RELATED PARTY TRANSACTIONS
Details of related party transactions with individuals are as follows:
Payments to Receipts from Amounts Amounts due Related Party Related Party owed to from Related Related Party Party £ '000 £ '000 £ '000 £ '000 Bolton MBC - The Chairman of the Foundation Trust is Leader of the Council 3,180 1,564 0 0
The Department of Health is regarded as a related party. During the period, Bolton NHS Foundation Trust has had a significant number of material transactions with the Department, and with other entities for which the Department is regarded as the parent Department. These entities are listed below:
£ '000 £ '000 £ '000 £ '000 Department of Health 0 12
Bolton Primary Care Trust 4,930 205,361 2,457 3,385 Ashton, Leigh & Wigan Primary Care Trust 71 19,752 4 403 East Lancashire Primary Care Trust 0 576 0 121 Manchester Primary Care Trust 0 4,504 368 Salford Primary Care Trust 64 16,679 47 408 Bury Primary Care Trust 0 7,281 0 571 Other Primary Care Trusts 47 5,606 94 676
Greater Manchester West Mental Health NHS Foundation Trust 1 2,734 53 97 Other Foundation Trusts 3,383 1,857 951 478
Other NHS Trusts
Strategic Health Authorities 19 8,982 8 7
In addition, the Foundation Trust has had a number of material transactions with other Government Departments and other central and local Government bodies. Most of these transactions have been with the NHS Pension Scheme and the National Insurance Fund in respect of employee contributions. These entries are listed below:
£ '000 £ '000 £ '000 £ '000 NHS Blood & Transplant 1,211 113 29 0 NHS Litigation Authority 6,665 0 28 0 NHS Purchasing and Supply 3040 NHS Pensions Agency 24,886000 Other WGA 230 3 0 30
The Foundation Trust has received revenue and capital benefit from purchases made by Bolton NHS Charitable Fund. The transactions are summarised below. The separate Trustees' Report and Accounts for Bolton NHS Charitable Fund are available on request.
Purchases made from Purchases Charitable made from Funds relating Charitable to capital Revenue Capital Funds relating assets Payments to Payments to to revenue transferred to Charitable Charitable items the Trust Funds Funds £ '000 £ '000 £ '000 £ '000
Bolton NHS Charitable Fund 48 146
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NOTES TO THE ACCOUNTS
34. THIRD PARTY ASSETS
The Trust held £52,575 cash and cash equivalents at 31 March 2012 (£49,769 at 31 March 2011) which relates to monies held by the NHS Trust on behalf of the SHO Induction Fund and patients. This has been excluded from the cash and cash equivalents figure reported in the accounts.
35. ANALYSIS OF INTER WHOLE OF GOVERNMENT BALANCES
Current Income Current Expenditure receivables Transactions payables transactions £000 £000 £000 £000
English NHS Foundation Trusts 575 4,591 1,004 3,384 English NHS Trusts 104 890 180 622 Department of Health 0 12 0 0 English Strategic Health Authorities 7 8,982 8 19 English Primary Care Trusts 5,932 259,759 2,602 5,112 RAB Special Health Authorities 0 0 0 0 NHS WGA bodies 1 113 61 7,879 NHS CGA bodies 0 3 0 0 Total NHS Receivable/Payables 6,619 274,350 3,855 17,016 Other WGA bodies - Local Government 0 1,564 0 3,180 Other WGA bodies - Central Government 29 2,341 0 59,137 Total WGA Receivables/Payables at 31 March 2012 6,648 278,255 3,855 79,333
36. LOSSES AND SPECIAL PAYMENTS
There were 70 cases of losses and special payments (2010/11: 76 cases) totalling £162, 147 (2010/11: £145,370) paid during 2011/12.
There were no cases exceeding £250,000. These amounts have been prepared on an accruals basis but exclude provisions for future losses.
37. LIMITATION ON AUDITORS' LIABILITY
There is no specified limitation in the Trust’s contract with its external auditors, the Audit Commission, that provides for limitation of the auditors' liability.
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