Council of Governors
Board Room, The Royal Marsden Hospital, London Wednesday 14th May 2014, 11am - 1pm followed by lunch
1 Welcome from the Chairman
2 Minutes of the meeting held on 5th March 2014 (enclosed) (Chairman)
3 Presentation: ‘Sutton for Life’ (enclosed) (Director of Projects and Estates)
4 Governor update 4.1. Members Event held on 28th April 2014 (enclosed) (Governor Maggie Harkness) 4.2. FTGA Spring Development Day held on 26th March 2014 (enclosed) (Governor Peter Lewins) 4.3. Deloitte: ‘Evolving governance requirements’ held on 31st March 2014 (enclosed) (Governor Duncan Campbell)
5 Corporate Governance 5.1. NED Appointment – for decision (enclosed) 5.2. Governor elections – for information (enclosed) (Chairman)
5.3. Progress report on Governor Working Groups – for information (enclosed) 5.4. Evaluation of the Council– for decision (enclosed) (Assistant Director of Organisation Development)
6 Update on the Royal Brompton Estate 6.1. Progress report on the Royal Brompton Estate (enclosed) (Chief Executive / Director of Projects and Estates)
6.2. Communications Strategy (enclosed) (Director of Marketing and Communications)
7 Finance Report 7.1. Operational Plan 2014-16 (enclosed) 7.2. Financial Report 2013/14 (enclosed) (Director of Finance)
8 Quality and Performance 8.1. Key Performance Indicators Q4 (enclosed) (Director of Performance and Strategy Implementation)
8.2. Quality Accounts for March 2014 (enclosed) 8.3. Annual Quality Accounts for 2013 / 14 (enclosed) (Chief Nurse)
8.4. Update on Outpatient Waiting Times (Chief Operating Officer) (enclosed)
9 Equality Strategy (Assistant Director of Organisation Development) (enclosed)
10 Audit and Finance Committee 10.1. Annual Report for 2013 / 14 (enclosed) 10.2. Highlight Report from meeting held on 9th April 2014 (enclosed) 10.3. Tendering of the external auditor (enclosed) (Ian Farmer, Chair of Audit and Finance Committee)
11 Any Other Business
Date of next meeting: Tuesday 16th September 2014, 11 am - 1 pm Board Room, Chelsea
Page 2 of 2
Council of Governors
Board Room, The Royal Marsden Hospital, Chelsea Wednesday 5th March 2014 11:00am – 13:00pm
Minutes
Present:- R. Ian Molson (Chairman) Governors as per attached attendance list In attendance Cally Palmer (Chief Executive) Nancy Hallett (Non-Executive Director) Dr Liz Bishop (Chief Operating Officer) Alan Goldsman (Director of Finance) Dr Shelley Dolan (Chief Nurse) Professor Martin Gore (Medical Director) Nicky Browne (Director of Performance & Strategy Implementation) Maggie Gairdner (Divisional Director of Sutton and Merton Community Services) Syma Dawson (Head of Corporate Governance) Samantha Greenhouse (Assistant Director of Organisational Development)
MEETING BUSINESS 1 Apologies Vikki Orvice (Governor) Cllr Stephen Alambritis (Governor) Dr Claire Dearden (Governor) Bernadette Knight (Governor) Robert Shearer (Governor) Sarah Clarke (Divisional Director of Cancer Services)
2 Minutes of meeting held on the 3rd December 2013 The minutes of meeting held on the 3rd December 2013 were approved subject to minor amendments.
3 Corporate Governance 3.1. Senior Independent Director The Chairman noted the Board’s decision to appoint Nancy Hallett, Non-Executive Director as the Senior Independent Director.
3.2. Proposed Framework for Governor Engagement and Involvement The Assistant Director of Organisational Development presented the proposed framework to the Council and highlighted the following key matters: • Ensuring the safety, quality and effectiveness of patient care through the proposed Patient and Carer Quality Group • Refreshing of the Membership and Communications group to help recruit new members and further engage with existing members • Information which is accessible to the public, including Board meetings
Fiona Stewart requested clarification in terms of the impact of the proposed framework on the role of PCAG. In response, the Chief Nurse recognised the important work of PCAG and explained that she was due to attend the next PCAG meeting to discuss the proposal, which will still involve the work of PCAG and aim to improve current arrangements for the benefit of the Trust.
Page 1 of 7 In response to a query raised by Duncan Campbell, the Chief Nurse explained that the Trust wanted to avoid having too many groups and both she and the Chair of PCAG are considering what can be done altogether.
The Chairman asked the Council to reflect on the proposal over the coming weeks and to send feedback to the Head of Corporate Governance. It was agreed that an update will be brought back to the next Council of Governor meeting.
3.3. NED Appointments The Chairman provided an update to the Council of Governors with regard to the recruitment of two NED’s to replace departing NEDs Greg Andrews, Chair of the Audit and Finance Committee and Colin Clark. • Chair of the Audit and Finance Committee and Non-Executive Director The Chairman informed the Council that a candidate, Ian Farmer, has been successfully identified for the position of Chair of the Audit and Finance Committee. The Chairman gave an overview of the selection and recruitment process which had been followed and how those who have met the candidate in question fully endorse the recommendation of the appointment. Duncan Campbell and Fiona Stewart added how impressed they were by the candidate’s commitment and enthusiasm for the role and Trust.
The Chairman confirmed that although the candidate may occupy another role elsewhere in future, the candidate would make the necessary time available for the role.
The Council approved the appointment of Ian Farmer to Non-Executive Director position and Chair of the Audit and Finance Committee for a period of three years, commencing 1st April 2014.
• Non-Executive Director Sir John Craven The Chairman noted that the current term of office for NED Sir John Craven was due to expire and therefore, the Council is required function with regard to his reappointment. It was noted how Sir John has expressed a keen interest in remaining a member of the Board and has requested reappointment on an annual basis should the Council approve.
Fiona Stewart queried whether the Trust ought to plan in terms of succession planning. In response, the Chief Executive confirmed that the Trust will plan accordingly and seek a replacement when the need arises.
The Council approved the reappointment of Sir John Craven which will commence on the 1st April 2014 and is subject to annual review by the Council.
3.4. Feedback from Governors Awareness Session Carol Joseph reported that an Awareness Session was held for Governors, which was delivered by Ray Tarling from DAC Beachcroft. A key focus of this session was how Governors can add value to the organisation, particularly in accordance with their new responsibilities under the Health and Social Care Act 2012.
Carol Joseph queried the Board’s approach in terms of having Board Seminars. In response, the Chief Executive explained that the Board requires the ability to prepare and discuss strategic issues in confidence before it is presented to the Council. The Board Seminar’s will therefore provide such a forum and ensure the Board can effectively function in such a way.
Carol Joseph requested a financial seminar to help the Governors understanding in this area, to which the Director of Finance agreed to facilitate.
4 Presentation: Opening of West Wing Clinical Research Centre
The Chief Executive introduced Rachel Turner, Clinical Research Business Manager and Angela Little, Matron, to present on the new West Wing Clinical Research Centre in Sutton.
Page 2 of 7 Rachel Turner explained Clinical Research at The Royal Marsden, including its background, context and how the West Wing Clinical Research Centre will have a positive effect in improving patient care. The Charity’s contribution and support to the Centre was emphasised and how the West Wing Clinical Research Centre is an MDU in a research setting. The layout of the facilities was illustrated via imaging and a virtual tour alongside a discussion about the selection of clinical trials and review of clinical research protocols.
Kate Law queried whether there had been any contention with the opening of the Centre with other partners. In response, Rachel Turner explained how the site appeases both academic and commercially sponsored partners given its portfolio.
The Chairman queried the amount of prospective trials which have been declined because they have not complied with the requirements of a protocol. The Medical Director assured the Chairman and Council that this is a rare occasion as some can be very specific and designed with a particular hospital in mind. The Chief Operating Officer highlighted the following: 1) A trial set-up meeting has been established and is Chaired by the Associate Director of Clinical Research 2) A structured process of leadership has also been established so that each tumour group has a research lead
The Chief Operating Officer invited Governors to have tours of the Centre should they wish and recognised the excellent contribution of Rachel Turner, Angela Little and other staff in the opening of the Centre.
In response to a query raised by Ann Curtis as to whether the Trust was sharing outcomes with other hospitals, the Medical Director added that hospitals generally share lessons learnt and in this case, the same approach will be taken.
Duncan Campbell asked whether there is any contention between research protocol and patient care. The Medical Director informed the Council that a basic rule of clinical research is that a patient’s needs always take precedence over the research protocol.
The Chairman recognised the growing totality of research within The Royal Marsden and the Board’s responsibility to ensure the Trust operates the highest possible standards which are embedded in the organisation.
5 Presentation: Patient Public Involvement in Research
The Chief Executive welcomed the BRC Assistant Director, Rowena Sharpe to present on Patient Public Involvement (PPI) in Research, with reference to PPI for the BRC in the enclosed paper.
Rowena Sharpe explained the background of the BRC to the Council and how this benefits The Royal Marsden as the only established Cancer BRC. It was noted that the Trust has a leading role in this respect and must consider how it influences PPI at the strategic level and project level. The structure within the Trust was outlined as well as the patient representation on the BRC Steering Committee which allocates funding accordingly. The Council were informed about the lifecycle of a clinical study and the various ways in which the Trust ensures PPI in Research.
The Chairman emphasised the importance of the BRC status for the Trust and noted how standards rise and requirements change at the reapplication stage every 5 years. The Chairman also noted that the Board has considered whether the Trust will meet all of the relevant criteria in order to be successful in its application in 2016. The Chairman urged Governors to think about how they can participate in the process. Rowena Sharpe agreed to cascade relevant information to Governors with regard to PPI in Research.
In response to a query raised by Kate Law regarding how the patient representative on the BRC Steering Group relates to the West Wing group, Rowena Sharpe explained that the BRC was an internal grant funding body which funds research that may or may not be carried out on the West Wing Clinical Research Facility, but any funding decision made by the BRC Steering Committee would certainly want input from the West Wing Protocol Review Group. Page 3 of 7
Kate Law also queried whether the web portal for patients to submit proposals is in working order to which Rowena Sharpe confirmed it was. Rowena Sharpe concluded that she is keen to see how many proposals, which are submitted by patients, are then taken forward and translated into studies.
6 Heads of Agreement with Imperial Academic Health Science Centre
The Chief Executive described the Trust’s current position as one which hoped to explore research and service models with Imperial AHSC through the work of a Cancer Board over the coming months; a position which is reflected in the signed Heads of Agreement.
In response to a query raised by Carol Joseph about how this relates to the work of the London Cancer Alliance (LCA), the Chief Executive explained that the LCA is a quality and accreditation group and therefore, both the Trust and Imperial would continue to operate as a member of the LCA in this regard.
Robert Freeman asked whether this was considered a significant transaction to which the Chairman confirmed this was not. The Chairman explained that the Trust is still in the process of discussing the needs of each party and faces the challenge of achieving such precision. It was noted how the Board is less concerned with aspirations but rather, more concerned about establishing a meaningful agreement which brings a tangible benefit to patients. In response, Robert Freeman asked that the Board be mindful of Imperial’s performance in it’s delivery of cancer services and their ability to commit necessary funding to improving this. The Chairman assured the Council that the Board shares those concerns and is clear that it will delineate any proposed arrangement in the interest of The Royal Marsden.
7 Financial Plan 2014-16 The Director of Finance presented the Financial plan 2014-16 to the Council and highlighted that for the first time the Trust is required to submit a two-year operational plan to Monitor on 4th April 2014. The Council of Governors have previously provided comment on the strategic plan for 2014 – 19 which must be submitted to Monitor by 30th June 2014.
The Director of Finance explained that the financial plan is designed to achieve a low-risk profile; measured against Continuity of Services Risk Rating (COSRR) score of 4 (the lowest risk category). The trust requires an annual operating revenue surplus (at current prices) of at least £20m to deliver its 10 year capital replacement programme and maintain sufficient cash headroom to meet its working capital needs (assumed to be at least £10m at current turnover).
It was reported that in the short term, this 2-year operational plan will provide sufficient cash and capital to meet the minimum requirements for sustaining operational performance and service quality; but does not, yet, provide the financial headroom required to commit to longer term investments such as new IT solutions and major building and site upgrades.
The Trust’s approach is to deliver improvements in three key areas: 1) Service portfolios 2) Access policy to establish a balance between NHS activity and private activity 3) Surgical strategy to ensure this area operates efficiently
The Director of Finance expressed his concern with regard to engaging with Commissioner’s and the ongoing work in contract negotiation for Sutton and Merton Community Services (SMCS). The degree of risk was noted in the event contracts are not agreed on time.
Kate Law questioned whether the Trust was reducing its surgical activity to enable more private activity. In response, the Chief Executive explained this was not the case but rather, the Trust is assessing where it can add the most value to patient care, for example, cases where the Trust has accepted long distance patients for common cancers whereby
Page 4 of 7 their local cancer provider is able to deliver the same service. The Council agreed the importance of managing the expectations of patients and clinicians.
In response to a query raised by Duncan Campbell regarding the utilisation of theatres in Sutton, the Chief Operating Officer explained this is on the Board’s balance scorecard and highlighted the following three issues: 1) The Trust recognises that utilisation is low but the unit is staffed for this level of activity 2) The breast unit are the highest users of Sutton Theatres and the management team are ensuring optimal utilisation and management of their lists 3) There is a problem with delayed start times, which are being addressed.
The Chairman informed the Council that the Trust is in the process of re-examining its surgical strategy as it is a duty of the Board to ensure the best use of resources. The Chairman assured the Council that this would be shared with Governors once a definitive conclusion had been reached at the Board.
Richard Keane queried whether the Trust was close to resolving the issue regarding Cyberknife and Specialist Commissioning. In response, the Chief Nurse explained that this remained a difficult issue but noted how the LCA has joined together in taking a professional and educated lobbying approach. The Chief Executive added that the issue of radiotherapy and understanding how new technology such as Cyberknife can be cost- effective was back on the national agenda.
8 Performance
8.1 Key Performance Indicators Q3 The Director of Performance and Strategy Implementation presented the KPI’s to the Council and highlighted the following: • The Trust reported 11 cases of C.Diff on target with two months remaining to reach the target. Recent guidance from NHS England details the targets in 2014 and and recommends that contractual penalties will no longer exist • Section 4.6. Research; the Trust has made significant improvement in its compliance for the 70 day target. The Chief Executive praised Professor Cunningham, Liz Bishop and staff for their success in this area, which is receiving national recognition. The Chief Operating Officer anticipates an inspection of this at some point but confirmed the Trust had the evidence to support reported performance.
8.2. Proposed CQUINS 2014/14 (Commissioning for Quality and Innovation Payments) The Director of Performance and Strategy Implementation explained the background and purpose of CQUINs and how the Trust receives an amount of funding as a result, for example, £3million for 2012/13 and approx £750k for SMCS. The following points were noted: • The significant work of the palliative care team who had over four year period continuously achieved 100% compliance with CQUIN targets • Chemotherapy waiting times CQUIN; performance in this area has substantially improved. However, in outpatients improvements in waiting times has been more challenging and the Trust is reviewing current facilities and busy clinics to determine where further improvements can be made. This issue is reported quarterly to the Integrated Risk Management Committee. • Community CQUIN for district nursing where patients have had a pressure ulcer risk assessment within the first contact; it was reported that the Trust is currently on track to reach the 90% target. • 90 prevention of admissions by 30 September; the Trust achieved this target in Q3 • 2% reduction in attendances aged 0-17; it was noted that this target is outside the Trust’s control and more dependent on access to GPs 9 Quality Account
9.1. The Chief Nurse invited comments from the Governors on the proposed Quality Accounts (QA) and noted the due diligence process that must be followed to ensure a full consultation has occurred. The Chief Nurse thanked Governors for their previous Page 5 of 7 contributions in improving the Quality Accounts (QA) each year.
The Chief Nurse highlighted the responsibility of Governor’s, staff and Commissioner’s to establish the right goals for improvement as outlined in part 2 of the enclosed paper; some of the listed priorities are mandatory and some the Trust may choose.
The Chairman queried whether there were any themes or areas which give rise to concern. In response, the Chief Nurse and Chief Operating Officer highlighted the following areas: • Chemotherapy waiting times in MDU which has always been a long-standing concern, but these had improved with the changes in scheduling patients • Pressure Ulcers which are regularly reviewed at QAR and Board continue to be a challenge in Community Services and the team are constantly reviewing measures to improve the care • Delayed discharge and waiting for medication to take home is a recognised problem but is a CQUIN for 2014-15 so this should help drive improvements • Long outpatient waiting times because of its volume and complexity; RM has over 300 different types of clinics across both sites and there are problems with the size and complexity of clinics in addition to the workforce and clinic estate; improvements in waiting times is a CQUIN for 2014-15 so this should help drive improvements.
However, both the Chief Nurse and Chief Operating Officer assured the Chairman and Council that any causes for concern are appropriately documented in the QA in an open and transparent way. The Chairman requested that a report regarding Pharmacy be brought to the Board’s attention for further inspection and scrutiny to which the Chief Nurse agreed.
In response to a query raised by Ann Curtis regarding whether chemotherapy is delivered on-site, the Chief Operating Officer explained this was a combination of on-site and off- site where the Trust may outsource for business reasons and in cases of a complex nature.
Richard Keane queried the progress towards telephone follow-up calls. In response, the Chief Nurse explained this was a large ongoing piece of work which the Trust is considering in relevant models.
10 Any other business
No other business was raised.
Date of next meeting:
14th May 2014, 11am – 1pm, Board Room, Chelsea
SIGNED…………………………………………………………………………..
DATED……………………………………………………
Page 6 of 7
Council of Governors Attendance List 5th March 2014
Elected Governors Constituency Signature
Maggie Harkness Kensington & Chelsea and Sutton & Merton Joyce Herve Kensington & Chelsea and Sutton & Merton Apologies Colin Peel Kensington & Chelsea and Sutton & Merton
Fiona Stewart Elsewhere in London Dr Peter Lewins Elsewhere in London
Vikki Orvice Elsewhere in England Apologies Simon Spevack Elsewhere in England
Lesley-Ann Gooden Carer Duncan Campbell Carer
Public Governors Dr Carol Joseph Kensington and Chelsea Janet Mountford Sutton & Merton Ann Curtis Elsewhere in England Robert Shearer Elsewhere in England Apologies
Staff Governors Bernadette Knight Corporate Support Services Apologies Richard Keane Clinical Professionals Vacant Clinical Support Staff Dr Claire Drearden Doctor Apologies Maureen Carruthers Nurse
Nominated Governors
Cathy Scivier Institute of Cancer Research Robert Freeman Local Authority: Borough of Kensington & Chelsea Kate Law Cancer Research UK (Charity) Cllr Stephen Alambritis Local Authority: Boroughs of Sutton & Merton Apologies Vacant Clinical Commissioning Group Vacant Clinical Commissioning Group
Page 7 of 7
COUNCIL OF GOVERNORS PAPER SUMMARY SHEET
Date of Meeting: Agenda item
14th May 2014 Item 3
Title of Document: To be presented by
Presentation: “Sutton for Life” Sunil Vyas, Director of Projects and Estates Executive Summary
Sunil Vyas, Director of Projects and Estates, will deliver a presentation on “Sutton for Life”
Author: Contact Number or Date: E-mail: Sunil Vyas, Director of Projects and 8th May 2014 Estates 8135 PA
SUTTON FOR LIFE Our Vision & Why We Are Here
“Sutton For Life will be a world-leading, life-science enterprise campus specialising in cancer research, diagnosis, treatment, 192,000+ Sqm education and biotech commercialisation.”
9,000 Additional direct jobs
£890m direct GVA pa
Redefining the Golden Triangle SUTTON FOR LIFE Immediate Priority: Site Ownership Transition
7.2 ha
Realises the full vision
JV SUTTON FOR LIFE Opportunity Sutton
The Sutton for Life is part of the Opportunity Sutton programme. Since its inception just one year ago it has delivered: • 1,640 additional jobs • £322m direct investment in Sutton • 939 new businesses in Sutton
Sutton for Life Governance
LBS Potential Funding ICR RMH Opportunity Sutton Organisations Board Board Board
Collaboration Agreement Sutton for Life Partnership Board
Programme Delivery Team
Joint Venture Campus Master Land Assembly Funding BIds Arrangement Plan SUTTON FOR LIFE World Class (spatial study indicative phasing - 1) 2016
20,000+ 650 Life Additional Science Sqm Direct jobs Incubator SUTTON FOR LIFE Immediate Priority: Cancer Drug Discovery Centre
20,000+ Sqm
650+ Additional jobs
£50m For building one
+£150m Income from IP
Planning permission in place SUTTON FOR LIFE World Class (spatial study indicative phasing - 2)
20,000+390+ HomesSqm SUTTON FOR LIFE World Class (spatial study indicative phasing - 3)
390+ Homes SUTTON FOR LIFE World Class (spatial study indicative phasing - 4) 2018
50,000+ 2,500 390+ Additional Sqm Direct jobs Homes SUTTON FOR LIFE World Class (spatial study indicative phasing – 7) 2025
100,000+ 5,200 330+ Additional Sqm Direct jobs Homes SUTTON FOR LIFE World Class (spatial study indicative phasing - 9) 2030+
192,000+ 9,000 £890m Sqm Additional Ecosystem Direct jobs GVA pa SUTTON FOR LIFE Opportunity: Tramlink (improving public transport)
Potential 11,000 daily LSC users
Sutton and Merton offering £45m
Reducing CO2
£460m annual GVA SUTTON FOR LIFE Sutton for Life
• The site presents a once-in-a-lifetime opportunity to expand and diversify the Sutton cluster • We will create an Enterprise Campus of international importance
9,000 Increased 192,000+ £890m Additional research Sqm GVA pa direct jobs income
We want to partner with the LEP and GLA to accelerate the project deliver rapid enterprise growth through: 1. Investment to facilitate land assembly 2. £25m seed funding for Drug Discovery Centre 3. Enterprise support mechanisms, for example Enterprise Zone 4. Support for the Tram to open up transport capacity 5. Links into Life Science support networks such as Med City
COUNCIL OF GOVERNORS PAPER SUMMARY SHEET
Date of Meeting: Agenda item
14th May 2014 Item 4.1
Title of Document: To be presented by
Members Event held on 28th April 2014 Maggie Harkness, Patient Governor: Kensington & Chelsea and Sutton & Merton
Background
The Trust holds approximately three members’ events each year in which Public and Patient members are invited to attend. Events are a useful means by which Governors can engage with members and therefore fulfil their statutory duty to represent the views of members and the public.
Executive Summary
The paper informs the Council on the Trust’s most recent Members’ Event: Journey of a Tumour Sample which was held on the 28th April 2014 in the Centre for Molecular Pathology (CMP) Building in Sutton.
Conclusion
The Corporate Governance team will continue to update the Council on future Members Events, which will be supported by the Membership and Communications working group.
Author: Contact Number or Date: E-mail: Syma Dawson, Head of Corporate 8th May 2014 Governance 8856 Rebecca Hudson, Member and Governor Lead
Members’ Event: Journey of a Tumour Sample
1. Purpose
The purpose of the paper is to inform the Council of Governors on the most recent Members’ Event: Journey of a Tumour Sample which was held on the 28th April 2014 in the Centre for Molecular Pathology (CMP) Building in Sutton.
2. Introduction
The Trust holds approximately three members’ events each year; attendance to these events varies between 50 – 90 members. Events are a useful means by which Governors can engage with members and therefore fulfil their statutory duty to represent the views of members and public.
3. Members Event: Journey of a Tumour Sample
The member’s event ‘Journey of a Tumour Sample’ took place on Monday 28 April 2014 and was held in the Centre for Molecular Pathology (CMP) building in Sutton. With 60 members on the guest list, the event had reached its maximum capacity in terms of the building and logistics.
The aim of the event was for members to learn what happens once a tumour sample has been taken from a patient and then follow its journey on a behind the scenes tour.
The event began with the following three presentations:
• Introduction on the NIHR Biomedical Research Centre (BRC) and why it’s important, Dr Rowena Sharpe, Assistant Director RM/ICR NIHR Biomedical Research Centre
• Philosophy of the Centre for Molecular Pathology, Professor Mitch Dowsett, Head of CMP and /Head of Academic Biochemistry
• Journey of a tumour sample, Dr Lisa Thompson, Molecular Diagnostics Laboratory Manager/ Senior Clinical Scientist
Following this, members were split into groups of 10 and toured the following laboratories: • Molecular Diagnostics • Histopathology • Immunophenotyping • Flurescence In Situ Hybridisation (FISH) and; • The ICR drug discovery laboratories
The Corporate Governance team would like to take this opportunity to thank Governors Maggie Harkness, Colin Peel, Carol Joseph, Fiona Stewart and Duncan Campbell for their much needed help and support on the day.
The Trust is pleased to report that the event was an incredible success as feedback forms showed an 82.6% ‘excellent’ rating and 17.4% as ‘good’.
3. Conclusion
The Corporate Governance team will continue to keep the Council informed on future Members Events, which will be supported by the Membership and Communications working group.
14.5.14 COUNCIL OF GOVERNORS 1
COUNCIL OF GOVERNORS PAPER SUMMARY SHEET
Date of Meeting: Agenda item
14th May 2014 Item 4.2
Title of Document: To be presented by
FT GA Spring Development Day held on 26th March 2014 Peter Lewins, Patient Governor: Elsewhere in London
Background
Executive Summary
The purpose of this paper is to update the Council of Governors on key issues discussed at the Foundation Trust Governor Association Development Day.
Conclusion
The Council is asked to note the paper.
Author: Contact Number or Date: E-mail: Governor, Peter Lewins 8th May 2014
Notes from the Foundation Trust Governors’ Association (FTGA) Development Day on 26th March 2014
FT Membership
• One of the weaknesses of FTs is their low membership, which affects accountability. • The group discussed different approaches to increasing membership which we will relay to the Membership and Communications sub-group.
COG Committees & relationship with the Board
• There was general support for formal Committees of the COG. One FT had a Finance & Strategic Planning Committee which met monthly, and the more usual Committees on Hospital Environment, Membership & Community, Patient Experience and Quality & Safety. The Finance and Strategic planning committee was a way of engaging a representative group of governors at all stages of strategy development and implementation. These governors had access to the commercially sensitive data available to the board (often having entered into confidentiality agreements). • The Committees were chaired by a Governor with NEDs and execs invited. In some FTs the relevant execs acted as secretary to the group providing admin support and attending each meeting. There was a view that NEDs should be closely involved with these COG committees as this would build a relationship and assist in their appraisal. • There were wide ranging discussions about the role of lead governor. The role varied in FTs from the bare minimum defined by Monitor to being part of a triumvirate of lead governor, chairman and CEO. In one FT, the Chairman had fortnightly meetings with the Lead Governor which covered forward planning of the work of the Committees. There was agreement that whatever the role of the lead governor this should be determined and agreed by the COG. • One FT had set-up Governors’ breakfast meetings on the last Friday of the month. Execs were invited on a rotational basis to give informal briefings of key issues.
Significant transactions
• Monitor was revising the way in which these were reviewed in the light of the Competition Commission case. New guidance was expected in Q2. • Monitor would like to engage with FTs at the point of a Strategic Options Case which involved any significant or material transaction. There would be an informal review to identify any potential competition issues. Clearance of competition issues would be given at the Outline Business Case stage. • A significant transaction involved more than 25% of the FT’s assets or income. A material transaction involved between 10% and 25%. These figures have become indicative rather than absolute as a number of other factors were considered such as leverage and quality of management in arriving at an overall risk assessment. • Monitor’s risk assessment result would be given on the Final Business Case which was the point at which formal COG approval would be needed. There was agreement that governors should be involved much earlier in the process as by the formal final stage there was very little scope for changes. • The COG of one FT took the approach of identifying significant transactions from the operating plan. These were based on factors other than just the size of the transaction.
Urgent and Emergency Care
• The presentation was remarkably positive and gave a clear vision and implementation plan of changes to improve urgent and emergency care across the NHS. • Although the Marsden doesn’t have an A&E there are implications that will affect revenue and also an opportunity to extend “hospital” services into the community.
Duncan Campbell
Peter Lewins
COUNCIL OF GOVERNORS PAPER SUMMARY SHEET
Date of Meeting: Agenda item
14th May 2014 Item 4.3
Title of Document: To be presented by
Deloitte event: ‘Evolving governance requirements’ held Duncan Campbell, Patient on 31st March 2014 Governor: Carer
Background
The Trust’s external auditors Deloitte host several events in which Governors are invited to attend.
Executive Summary
The paper informs the Council of the details of the session held on 31st March which considered the following: • Current key issues for the Foundation Trust sector, and a discussion of concerns Governors may have that could affect 2013/14 audits; • Findings from the survey of Trusts on evolving governance requirements and practice particularly in light of the Code of Governance changes effective from 1 January 2014.
Conclusion
The Council is asked to note the report.
Author: Contact Number or Date: E-mail: Governor, Duncan Campbell 8th May 2014
DELOITTE – GOVERNORS WORKING LUNCH – 31 March 2014
Around 20 FT Governors attended this session run by three Deloitte partners. It started with some scene setting of general issues across the health sector. Margins were deteriorating, due principally to an increase in agency spend. Post-Francis there was a tension between improving quality and reducing cost. Nearly 20% of FTs were not achieving their Cost Improvement Plans.
The session focussed on governance themes ahead of the quality accounts. Risk management was emphasised and there was discussion of the involvement of Governors in audit committees. This was viewed as a growing trend but current practice was very varied. In one FT, Governors met with the chairman of the audit committee and the Senior Independent Director before a board meeting. Another FT commented that there was a general lack of awareness and interest among their Governors in financial matters.
Other FTs commented that more learning and insight was needed on costs. When one FT examined the profitability of its heart and cancer activities this had led to a restructuring.
There was a general view that Governors should have an earlier involvement in assessing merger proposals and be more closely involved in strategic planning. Governors in one example were able to bring to the Board’s attention the potential impact of a new US funded hospital in their area.
Duncan Campbell
COUNCIL OF GOVERNORS PAPER SUMMARY SHEET
Date of Meeting: Agenda item
14th May 2014 Item 5.1.
Title of Document: To be presented by
Non-Executive Director Appointment Chairman
Background In September 2013 the Council of Governors agreed that the NED term of Colin Clark would end on 31st March 2014 and that the incoming NED will come from a Clinical / Academic speciality in order to enhance the balance of the Board in terms of its skill, knowledge and experience. As a result, the Nominations Committee has functioned in accordance with its Terms of Reference. Executive Summary
A recruitment company was hired to assist the Trust in the search for suitable candidates for the vacant NED position. There was a two-stage interview process whereby the Chairman and Chief Executive interviewed the three shortlisted candidates followed by interviews with Governors Robert Shearer and Mo Carruthers. The outcome of these interviews was shared with the full Nominations Committee to allow a unanimous recommendation made to the Council of Governors. Conclusion • The Nominations Committee recommend the appointment of Professor Dame Janet Husband as an NED. This is a unanimous recommendation from the Nominations Committee. • The Council is asked to approve the appointment of Professor Dame Janet Husband as Non-Executive Director, with responsibility for being a member of the Audit and Finance Committee and Quality, Assurance and Risk Committee for a three year term from 1st June 2014. Author: Contact Number or Date: E-mail: Syma Dawson, Head of Corporate 8.5.14 Governance 8856
Non-Executive Director Appointment
1. Purpose of Report The purpose of the report is to present the recommendation of the Nominations Committee with regard to the appointment of a Non-Executive Director (NED), replacing former NED Colin Clark, to the Council of Governors. 2. Background In September 2013 the Council of Governors agreed that the NED term of Colin Clark would end on 31st March 2014 and that the incoming NED will come from a Clinical / Academic speciality in order to enhance the balance of the Board in terms of its skill, knowledge and experience. As a result, the Nominations Committee has functioned in accordance with its Terms of Reference.
3. Appointment of Non-Executive Directors 3.1. Recruitment Process A recruitment company was hired to assist the Trust in the search for suitable candidates for the vacant NED position. Four candidates were shortlisted however one candidate withdrew their application because of time commitment concerns. There was a two-stage interview process whereby the Chairman and Chief Executive interviewed the three shortlisted candidates followed by interviews with Governors Robert Shearer and Mo Carruthers. The outcome of these interviews was shared with the full Nominations Committee to allow a unanimous recommendation made to the Council of Governors.
3.2. Recommendation of the Nominations Committee The Nominations Committee would like to recommend the appointment of Professor Dame Janet Husband to the role of Non-Executive Director with effect from 1st June 2014 for a three year term of office. Janet was a Consultant Radiologist and Professor of Diagnostic Radiology at The Royal Marsden and Institute of Cancer Research (ICR) as well as former Medical Director of the Trust from 2003 to 2006. As a result, Janet has a good understanding of the importance of a close working relationship between the Hospital and the Institute in ensuring effective translation of basic scientific research to improving patient care. Until 2013, Janet was Chair of the National Cancer Research Institute, the national partnership of funders set up to add value to cancer research for patient benefit through coordination, collaboration, facilitation and better communication between funders and researchers.
Current appointments: • Co-operation and Competition Panel of Monitor, Panel Member, 2009- (1 day per month, appointment nearing the end of tenure) • Nuada Medical Group, Non-Executive Director Specialist Imaging Centre, 2009- (1 day per month) • Health Honours Committee, Member 2009- International Cancer Imaging Society, Founder and Trustee 2000- • Emeritus Professor of Radiology Institute of Cancer Research, University of London 2007-
Monitor’s Code of Governance states that a Non-Executive Director may be ‘independent’ if they have not been an employee of the Trust within the last five years. As Janet left the Trust in 2007, she may be considered an independent Non-Executive Director.
1 4. Recommendations
4.1. The Nominations Committee recommend the appointment of Professor Dame Janet Husband as an NED. This is a unanimous recommendation from the Nominations Committee. 4.2. The Council is asked to approve the appointment of Professor Dame Janet Husband as Non-Executive Director, with responsibility for being a member of the Audit and Finance Committee and Quality, Assurance and Risk Committee for a three year term from 1st June 2014.
2
COUNCIL OF GOVERNORS PAPER SUMMARY SHEET
Date of Meeting: Agenda item
14th May 2014 Item 5.2
Title of Document: To be presented by
Governor elections – for information Chairman
Executive Summary
The purpose of this paper is to inform the Council on: • Recently appointed Governors • Current elections • The Clinical Support Staff constituency
Conclusion
The Council is asked to note the report for information only.
Author: Contact Number or Date: E-mail: Syma Dawson, Head of Corporate 8th May 2014 Governance 8856 Rebecca Hudson, Member and Governor Lead
THE ROYAL MARSDEN NHS FOUNDATION TRUST
Governor Appointments and Elections
1. Purpose
The purpose of the paper is to inform the Council of Governors (CoG) on:
• Recently appointed Governors • Current elections • The Clinical Support Staff constituency
2. Recently appointed Governors
The revision of the Constitution in 2013 reconfigured the Council and established two Clinical Commissioning Group (CCG) constituencies. As such, the following individuals have been nominated to fill these positions:
• Dr Chris Elliott, Chief Clinical Officer, Sutton Clinical Commissioning Group Chris has been a GP in Sutton for thirty years and has held a large number of positions within the NHS including Chair of the Nelson Commissioning Group, Joint Chair of The Federation and a member of NHS Sutton & Merton Professional Executive Committee.
Chris chairs the Clinical Quality Review Group for Epsom & St. Helier NHS Trust and has successfully completed the Accountable Officer’s assessment process developed by the NHS Commissioning Board.
• Dr Phillip Mackney, West London Clinical Commissioning Group Awaiting profile information.
3. Current Elections
Two elections are currently being facilitated by the Independent Electoral Reform Services (ERS) for the following seats:
• Public Governor, Kensington and Chelsea The seat is currently occupied by Dr Carol Joseph who will have served 3 years of her first term of office at the end of June 2014. Carol has expressed an interest in re-standing.
• Staff Governor, Corporate and Support Services The seat had recently become vacant due to Ms Bernadette Knight’s resignation from the Trust in April 2014.
The following timetable outlines the key dates in the election process;
Date Action Thursday 17 April 2014 Formal Notice of Election Tuesday 20 May 2014 Nominations Deadline Wednesday 21 May 2014 Publish summary of nominated candidates Thursday 12 June 2014 Voting packs despatched Monday 7 July 2014 Voting closes Tuesday 8 July 2014 Results announced
14.5.14 COUNCIL OF GOVERNORS 1 4. Vacant Governor Seat
Following the reconfiguration of the Council in April 2013, the Clinical Support Staff constituency has remained vacant. The Trust has held two elections in an attempt to fill the seat but unfortunately, no candidates have put themselves forward.
The Trust will continue its efforts to fill the vacant seat; however the Council may be required to function on this matter at its next meeting on 16 September 2014.
5. Conclusion
The Council of Governors is asked to note;
• The newly appointed Governors • Current elections taking place • That the Council may be asked to function on the Clinical Support Staff seat at its next meeting on 16 September 2014.
14.5.14 COUNCIL OF GOVERNORS 2
COUNCIL OF GOVERNORS PAPER SUMMARY SHEET
Date of Meeting: Agenda item
14th May 2014 Item 5.3
Title of Document: To be presented by
Progress report on Governor Working Groups – for Samantha Greenhouse, information Assistant Director of Organisational Development
Background
The ‘Proposed Framework for Governor Engagement and Involvement’ discussed at the Council’s February 2014 meeting aims to ensure that Governors not only fulfil their statutory duties but continue to add value to The Royal Marsden through their advisory, governance and strategic roles.
Executive Summary
This paper provides the Council of Governors with an update on the implementation of the ‘Framework for Governor Engagement and Involvement’ as requested at the last meeting.
The framework proposed the establishment of two Governor Working Groups: • Patient and Carer Quality Group • Membership and Communications
Further development sessions are also being planned for Governors to take place over the summer.
Conclusion
The Trust is satisfied that the working groups will enhance Governors’ ability to fulfil their statutory duties whilst continuing to add value to The Royal Marsden.
Author: Contact Number or Date: E-mail: Syma Dawson, Head of Corporate 8th May 2014 Governance and; 8856 Samantha Greenhouse, Assistant Director of Organisational Development
Progress report on Governor Working Groups
1.0. Introduction
The Council of Governor’s received at its previous meeting on the 5th March 2014 a ‘Proposed Framework for Governor Engagement and Involvement’. The aim of the proposed framework was to ensure that Governors not only fulfil their statutory duties but continue to add value to The Royal Marsden through their advisory, governance and strategic roles.
The purpose of this paper is to provide the Council of Governors an update on the implementation of the framework as requested at the last meeting.
2.0. Proposed Framework for Governor Engagement and Involvement
2.1. Advisory – Patient and Carer Quality Group The Trust recognises the pivotal role that Governors play in supporting the Board to ensure that the safety, effectiveness and experience of patient care remains at the centre of the Trust’s strategy. The establishment of the Patient and Carer Quality Group will enable Governors to advise the Trust in such a way and ensure patient needs and concerns are understood at Council and Board level.
The Chief Nurse is working closely with key leads through a task and finish group, including representatives of the Patient and Carer Advisory Group, to ensure the Patient and Carer Quality Group is as efficient and effective as possible. It is important to note that whilst discussions take place, both the Patient and Carer Advisory Group and Patient Experience Quality Account Group continue to function in order to ensure the important work of both groups is not affected as a result.
The Trust expects to come back to Governors regarding the membership and meeting of the new group before August 2014.
2.2. Governance – Membership and Communications Group A statutory duty of Governors is to represent the interests of the members as a whole and interests of the public. In order for Governors to add value in this way, it was agreed that the Membership and Communications sub-group is refreshed so that the group is jointly led by Governors and the Trust’s Head of PR and Communications with support from the Corporate Governance team.
The following Governors will form the Membership and Communications Group: • Maggie Harkness, Patient Governor • Fiona Stewart, Patient Governor • Dr Peter Lewins, Patient Governor • Dr Carol Joseph, Public Governor • Ann Curtis, Public Governor • Janet Mountford, Public Governor
The Trust is currently in the process of scheduling the first Membership and Communications meeting and expects this will be before August 2014.
2.3. Strategic – Council of Governor meetings and Governor development The Council of Governor Meetings are a key mechanism in ensuring Governors fulfil their statutory duty in holding Non-Executive Directors to account for the performance of the Board. These meetings enable Governors to receive and discuss strategic and performance related information which relates to the work of the Board, for example, Annual Plan, Board Committee reports.
14.5.14 Council of Governors 1 Further development sessions are also being planned for Governors. The aim of these sessions is to further understanding in areas such as Finance, Audit and Key Performance Indicators. These sessions will take place over the summer 2014 and will supplement the training programme which Governors are accessing through the Foundation Trust Network.
3.0. Conclusion
The Trust is satisfied that it is fulfilling its statutory duty in ensuring that Governors are ‘equipped with the skills and knowledge they require in their capacity as such’1.
The Trust is also satisfied that the working groups will enhance Governors ability to fulfil their statutory duties whilst continuing to add value to The Royal Marsden.
1 Health and Social Care Act 2012, Part 4, s151 (5)
14.5.14 Council of Governors 2
COUNCIL OF GOVERNORS PAPER SUMMARY SHEET
Date of Meeting: Agenda item
14th May 2014 Item 5.4
Title of Document: To be presented by
Evaluation of the Council– for decision Samantha Greenhouse, Assistant Director of Organisational Development
Background
Monitor’s Code of Governance states that the Council of Governors should periodically assess their collective performance.
Executive Summary
As part of the periodic performance review, Governors are asked to complete this self- assessment appraisal. The responses will be presented in a summary report to the Council of Governors to set the objectives for the coming year and the programme of development.
Author: Contact Number or Date: E-mail: Corporate Governance 8th May 2014 8856
Review of Collective Performance of the Council of Governors
Monitor’s Code of Governance states that the Council of Governors should periodically assess their collective performance.
As part of the periodic performance review, Governors are asked to complete this self-assessment appraisal. The responses will be presented in a summary report to the Council of Governors to set the objectives for the coming year and the programme of development.
Please note that all answers given or comments made will be treated in confidence.
Name: ______
Statement Comments (please continue on a separate sheet if
necessary)
Strongly Strongly agree Agree Disagree Strongly disagree N/A
1. I understand my statutory responsibilities
2. I constructively challenge and contribute to discussions at Council of Governor meetings
3. As a Governor I am clear about my role, and the differences between that and those of the Executive and Non-Executive directors
4. I am satisfied that I have been appropriately trained and have the skills to carry out my role as Governor
5. I am happy with the information provided to me and feel I have sufficient knowledge to fulfil my duties
1
Statement Comments (please continue on a separate sheet if
necessary)
Strongly Strongly agree Agree Disagree Strongly disagree N/A
6. I communicate well with and represent the views of my members as best to my knowledge and ability
7. I contribute to the recruitment of new members
8. There is an appropriate number of Members’ Events per year (3 times a year)
9. I understand the priorities for the coming year as stated in the annual forward plan
10. I get sufficient support from the Corporate Governance Office
11. I am happy with the Council of Governor composition in terms of its skills, knowledge and experience
12. I feel the Council works well as a collective unit and also with staff of the Trust
2 What objectives would you suggest the Council of Governors should set for itself for 2014/15?
Do you feel you have any training requirements that will assist you in your role as Governor?
Any other comments:
Thank you for taking the time to complete this appraisal.
Number of meetings attended during the year ………………………
Signed ……………………………………………………………
3
Governors Briefing
Date of Meeting: Agenda item
14th May 2014 Item 6.1
Title of Document: To be presented by
The Brompton Estate in Chelsea Sunil Vyas – Director of Projects and Estates
Background
The Royal Brompton & Harefield Trust have announced plans to sell a considerable amount of land in Chelsea to fund the redevelopment of their Sydney Street site. This includes the Fulham Wing (South Block) which is located on the Fulham Road between the ICR and the Royal Marsden. A draft Supplementary Planning Document (SPD) has been issued by RBKC for consultation.
The consultation process was due to last for 6 weeks ending on the 10th April, but on the 14th April was extended to the 30th April. During this period we have been engaging residents associations and relevant key stakeholders such as the Kensington Society and the Chelsea Society. In general feedback has been positive and the community at large clearly support our aspiration to expand into the Fulham Wing rather than see it changed into luxury residential accommodation.
If this SPD is adopted it sits alongside the Councils core policy and would pave the way for a residential planning application of the Fulham Wing. If residential planning permission were to be granted the value of the property would increase substantially from its value as a healthcare premises. We have requested the SPD process be withdrawn to allow time for further discussions between the two hospitals. RBKC have refused to withdraw the SPD or delay the timetable for its adoption which is currently scheduled for June 14 after the Council elections.
Attached are some aerial photographs plus the following which went into our SPD Objection:
• A memorandum to the Trust Board from the Medical Director and Chief Nurse. • The Royal Marsden’s proposals for the Fulham Wing submitted to RBKC for Pre-application advise Dec 13. • Current set of proposed drawings for the Fulham Wing.
1 Summary Briefing Note Whilst we have responded to the SPD our covering letter to RBKC reiterates our view that the SPD if adopted is unlawful. The Trust believes the Council should have followed the more onerous consultation process of a Local Plan Document rather than the shorter SPD process. Also if the SPD is adopted it is liable to being quashed by the Court on an application for judicial review.
The Trust has also written to the Secretary of State for Local Government, the Rt Hon Eric Pickles MP, to review the SPD and if determined to be unsatisfactory, exercise his powers and issue a direction requiring its modification. A further letter was sent to the Secretary of State for Health, The Rt Hon Jeremy Hunt MP requesting his intervention in order that a solution can be found that meets the aspirations of both hospitals. A reply has been received from the Secretary of State saying that the matter will need to be resolved at a local level.
We are carrying out independent valuations of the Brompton’s proposed hospital build, the SPD is predicated on a claim that the Brompton require £563m to build their new hospital and refurbish the existing Sydney street wing. Our professional advisors early estimate for this work is £430m. The Trust are carrying out further estimates on the private residential value of the Fulham Wing. RBHT have reported that this is £140m, our professional advisors early estimate is considerably lower.
Further work will need to be developed on these estimates before they can be shared in full with RBKC and the Brompton as the Brompton’s main argument for requiring full residential value for the majority of their land is that they still have an £89m shortfall to build the required £563m modern hospital.
The Council’s planning department has indicated it is unlikely to withdraw the SPD, and the Trust has successfully completed a petition in line with RBKC’s constitution so we can insist on a full Council debate about withdrawing the SPD.
If RMH successfully stops the change of use, RMH will resume negotiations with RBHT to consider selling its interest in the Fulham Wing. RBHT have indicated the Fulham Wing will be vacated in 2025 subject to the full development of their Sydney Street site, so if successful our development will follow that date. Author: Contact Number or Date: E-mail: Sunil Vyas Director of Projects and Estates [email protected] 29th April 2014
2
The Royal Marsden: Proposal for development of The Royal Brompton Fulham Road Wing
December 2013
PRIVATE AND CONFIDENTIAL
1 Who we are
The Royal Marsden NHS Foundation We also provide Sutton and Merton Trust is a world-leading cancer centre Community Services. Since April 2011 specialising in cancer diagnosis, The Royal Marsden has managed treatment, research and education. a range of community services, and together we are ensuring that Our academic partnership with treatment and care is of the highest The Institute of Cancer Research (ICR) quality and seamless between makes us the largest comprehensive hospital and home environments. cancer centre in Europe with a combined staff of 4,300. Through this The Royal Marsden was founded in partnership, we undertake ground- 1851 by William Marsden. His vision breaking research into new cancer was to create a pioneering cancer drug therapies and treatments. We hospital dedicated to excellence in the have two hospitals: one in Chelsea, study, treatment and care of people London, and another in Sutton, Surrey. with cancer. Also in Surrey, we have a Medical Today we continue to build on this Day Unit at Kingston Hospital and legacy, constantly raising standards an academic partnership with the to improve the lives of the 50,000 Mount Vernon Cancer Centre. This cancer patients from across the UK partnership enhances our research and abroad that we see each year. programmes and our contribution to the NHS in finding new and better ways to treat patients diagnosed with cancer.
3 Summary
1. The Royal Brompton has been in discussions The Royal Brompton Fulham Road Wing is in with The Royal Borough of Kensington and a Conservation Area and therefore there is a Chelsea regarding its development proposals, preference for the current building to be retained. with the intention of remaining in the borough; The Royal Marsden proposes to retain the façade this involves allowing some of the existing Royal of the building thereby avoiding the need for Brompton estate, including the Fulham Road demolition and maintaining the look and feel Wing, to be sold. Their current consultation of the classic style of architecture within the document offers the sole option of development borough. of this building into residential use. The Royal Marsden has expressed an interest in purchasing The Royal Marsden proposal takes place against the Fulham Road Wing to extend their facilities. a background of rising incidence of cancer This would benefit Kensington and Chelsea in the UK, however we can no longer expand residents by providing high-quality healthcare our services because of our estate capacity and jobs for the local community. constraints. The incidence of cancer in the UK is reported to have grown by 25% in the 30 years The Royal Marsden has a successful track record between 1977 and 2006 (Cancer Research UK). of delivering high quality NHS/Private Care and The UK’s cancer incidence can be expected to clinical research within a Victorian building, increase by almost two per cent per year, or an which has been refurbished internally to a aggregate of 20% over the 10-year period from high-quality specification. The Royal Marsden 2010 to 2021. This projection means the UK will is committed to remaining within The Royal face 383,000 new cancer cases in 2021, equating Borough of Kensington and Chelsea; this can to an incidence rate of one case per 175 people. be evidenced by significant investment in our Chelsea site (£100m over the last five years).
Projected numbers of newly diagnosed cases of cancer 2. (excluding non-melanoma skin cancers), UK 2010-2021
1. Rapid Diagnostic and Assessment Centre Fast and accurate diagnosis contributes to better outcomes for patients. 2. CyberKnife First in the NHS to provide the very lastest in cancer technology and treatments. 3. Translational Research Together with the ICR we take drug discovery through in to clinical trials for the benefits of 3. cancer patients nationwide. Source: Cancer Research UK 5 Professor David Cunningham, Director of Clinical Research and Consultant Medical Oncologist at The Royal Marsden
A significant number of these patients will need –– Drop off/low volume parking for patients surgery or chemotherapy at some point in their –– Low volume parking for key clinical personnel cancer pathway. Improved survival rates and new drug technology coupled with an increase –– Walkway/tunnel connection to the main Royal of around 60% in the amount of chemotherapy Marsden site to facilitate patient transfer e.g. delivered is putting cancer chemotherapy services to/from the Critical Care Unit under increasing pressure in order to provide a This will enable expansion on the main Royal safe and effective service with limited resources Marsden site to include the following: and space. Space is now critically constrained on The Royal Marsden site, in particular for surgical –– Freeing up of current Private inpatient inpatients, ambulatory clinical research and facilities for NHS patients chemotherapy and day surgery. –– Increased NHS inpatient bed provision
In the UK one in every five cancer patients is –– Translational clinical research delivery involved in research, representing 42,000 cancer (ambulatory) and research patients, the highest level in the world. Together –– Clinical Assessment Unit care with its academic partner, The Institute of Cancer Research (ICR) situated adjacent to the –– More efficient use of theatres/Critical Care Fulham Road Wing, The Royal Marsden recruits Unit and NHS Day Surgery Units more patients on to clinical trials than any other Throughout each of these areas of focus, the early similar hospital in the UK. However, the absence design principles and approaches have been of dedicated clinical research facilities within centred on delivering world-class care in the most the Chelsea site severely restricts the potential modern, effective and efficient way continually number of clinical trials that could be undertaken ensuring the delivery of an improved patient at The Royal Marsden in Chelsea, thereby experience. It is therefore envisaged that through reducing the associated research grant income capital cost development these facilities will be and, more critically, the ability to run more trials world-leading in both design and function and the to a wider population of cancer sufferers. delivery of healthcare and clinical research. Through a process of options appraisal with key A number of other major UK centres have clinical and non-clinical teams, and in line with embarked on ambitious expansion plans in the the strategic review of The Royal Marsden team, field of clinical research and the development it was agreed that The Royal Brompton Fulham of new models of cancer care delivery, some of Road Wing should be developed to function in which are already operational, e.g. The Christie the following key areas of care delivery: and University Hospital College London NHS –– Inpatient beds Foundation Trusts. The Kings Health Partners –– Three operating theatres and a supporting Cancer Centre at Guy’s Hospital business Day Surgery Unit case was approved at the February 2013 board meeting and the development commenced on –– Medical Day Unit care site on 18 February 2013. This expansion –– Patient outpatient and rapid assessment at The Royal Marsden would mirror services developments at other large centres and ensure we can retain our place as the –– Diagnostic and imaging facilities country’s leading provider of cancer research, –– Clinical Research Centre treatment and care.
7 Our proposal
It is proposed that The Royal Brompton Fulham The current Royal Brompton Fulham Road Wing, Road Wing will be developed alongside three key following development by The Royal Marsden, principles and strategies: would be comprised of seven floors and would include: –– The Royal Brompton Fulham Road Wing will 1. be redeveloped with the intention of replacing –– Basement – may include underground tired estate and facilities to provide a hybrid parking; a tunnel connection to the main of healthcare service and provision including Royal Marsden building and imaging/ NHS service, Private Care, and delivery of diagnostic (CT/MRI scanners) and world-leading clinical research. mechanical and electrical engineering services –– This will free up other space to ensure the development and substantial growth in world- –– Ground floor – will include Outpatients class translational clinical trial and research (incorporating the Rapid Diagnostic and facilities on The Royal Marsden’s Chelsea site. Assessment Centre - RDAC) and some retail space including pharmacy –– The provision of flexible and efficient services across two co-located buildings which contain –– First floor (Mezzanine) – Medical Day high-end facilities, yet retain the external Unit (MDU). (Growth in activity over the appearance of both buildings inkeeping with last two years has been around 7.5% for all the local conservation area. chemotherapy day activity) –– Second floor – Three operating theatres and a supporting Day Surgery Unit –– Third floor – Inpatient bed facility (all single en-suite rooms) –– Fourth floor – Inpatient bed facility (total c 65 beds across the first, third and fourth floors combined) –– Fifth floor – Clinical Research Centre
2.
1. CCU The only level 3 critical care unit in the UK dedicated to the needs of cancer patients. 2. Theatres Constantly pushing the boundaries of surgical innovation. 3. Ellis Ward Our newly refurbished 3. female ward. 9 The proposed design principles of the –– Medical Day Unit (MDU): Patients will departments are as follows: have high-quality accommodation that meets the expectations of our patients and –– Rapid Diagnostic and Assessment Centre insurers. The unit will be future proofed (RDAC): The department has been designed allowing for expansion and the flexibility to include the associated imaging within to manage changes to treatment regimens. the department and reduces the need for Consulting rooms are available in the unit to patients to move between departments provide the on treat consultation for patients during a single pathway of care. The RDAC prior to treatment. Relocating the on treat clusters ensure that facilities are provided consultations to the unit allows for a speedier for a range of diagnostic and consultation management of the patient without the need requirements so that patients may be seen, to go to the main outpatient department as screened, diagnosed, treated or discharged part of their treatment. rapidly without the need for multiple hospital –– Day Surgery Unit: The day surgery unit will visits in a confidential and patient friendly allow rapid turnover and early discharge by environment. co-locating the operating theatre with the –– Outpatients (OPD): Patients will have admissions, recovery and discharge areas. high-quality accommodation that meets the –– Clinical Research Centre: The dedicated expectations of our patients and insurers; the Clinical Research Centre will consolidate all outpatient department will be operationally clinical research development and delivery and physically integrated with RDAC and staff in one area which is co-located to will manage those patients that have begun clinical space. This will be high-end business treatment for cancer and require follow up space to promote collaborations with the by the consultant, a clinical nurse specialist pharmaceutical industry in the development or associated healthcare professional as of clinical research and will facilitate the part of their treatment plan. The outpatient management of the trial documentation department is designed to be flexible and efficiently without leaving the new facility. manage large and small clinics within the clusters. Co-location of these services will ensure a more efficient way of working through the sharing of physical facilities and the distribution of staff.
Our newly installed MRI scanners will maximise patient comfort and provide clinical excellence and translational research. 11
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Stair Clinical Staff Lift Rest Storage Theatre Refuge Riser Staff Stores Meeting D.T. Change 1 Room Procedures Scrub D.T. Change 2 Room Theatre Room 1 Prep' D.T. Change 3 Esc' Stairs D.T. Change 4 Nurse Admin' Dirty Base Utility Stair D.T. Change 5 Admin' Anaes' Operating Waiting Day Surgery Unit Day Theatres 1 2 3 4 Area Clean Utility Theatre Support Nurse Dirty Anaes' WC's Recovery Recep Anaes' Base Lifts Lobby Utility Area Dirty Utility Staff Reception Theatre 3 St Staff Change (Day) Change Day Consult / Consult / Consult / Prep' Nurse Theatre Wc Wc Prep' Theatre Theatre Exam 1 Exam 2 Exam 3 Base Support Support Room 2 Staff Room Admin Admin Scrub Office Office Scrub
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Refuge Riser Bath Bath Room 8 Room 2 Bath Bath Bath Bath Room 3 Room 9
Bath Bath Esc' Stairs Room 4 Room 10 Room 9 Room 3
Bath Stair Bath Treatment Hand- St Room over Bath Clnr Sister Linen Room 12 Room 13 Room 12 Room 13 Inter- Room 5 Nurse Nurse view Room 4 Office Room 5 Bay Bay Lifts Lobby Bath Bath Bath Bath Bath Room 6 Bath 13 Bed Ward 13 Bed Ward Reception Bath Bath Wc Wc Wc Wc Clnr El Clean Dirty Equip Equip Dirty Clean Linen Staff Staff Bath Utility Utility Store Store Utility Utility Bath Bath Bath Bath Room 6 Admin Admin Room 7 Room 7 Room 11 Office Office Room 11 Room 10 Meet Meet
Clinical Departments Admin, Staff Facilities, Research Circluation Plant Line of existing New facade REV P01 DATE 02/04/14 DRAWN / CHECKED / APPROVED RF / CS / CS Retail & Catering facade First Issue
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Refuge Riser Bath Bath Room 8 Room 2 Bath Bath Bath Bath Room 3 Room 9
Bath Bath Esc' Stairs Room 4 Room 10 Room 9 Room 3
Bath Stair Bath Treatment Hand- St Room over Bath Clnr Sister Linen Inter- view Room 12 Room 13 Room 12 Room 13 Room 5 Nurse Nurse Room 4 Office Room 5 Bay Bay Lifts Lobby Bath Bath Office Bath Bath Bath Room 6 Bath 13 Bed Ward 13 Bed Ward Reception Bath Bath Wc Wc Wc Wc Clnr El Clean Dirty Dirty Clean Linen Equip Equip Bath Utility Utility Staff Staff Bath Store Store Utility Utility Bath Bath Bath Room 6 Admin Admin Room 7 Room 7 Room 11 Office Office Room 11 Room 10 Meet Meet
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Riser Refuge Stair Lift
Refuge Riser AHU Room 1
AHU Room 4
AHU Room 2 AHU Room 3 Esc' Stairs
Stair
Research Group 2 Research Group 3 Seminar WC's WC's Plant Plant Room Lifts Lobby
Office Office Office Office Office Office Office Admin Office Research Group 1 Research Group 4
Meeting Rooms 1-3
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COUNCIL OF GOVERNORS PAPER SUMMARY SHEET
Date of Meeting: Agenda item
14th May 2014 Item 6.2
Title of Document: To be presented by
Update on the Royal Brompton Estate: Communications Rachael Reeve, Director of Strategy Marketing and Communications
NOT FOR WIDER CIRCULATION
Background As Governors are aware, the Royal Brompton is planning to sell part of its estate to fund a redevelopment of its Sydney Street site. One of these buildings is the Fulham Road Wing which The Royal Marsden has had a long held interest in and is looking to purchase.
Executive Summary
The enclosed paper notes the Trust’s Strategic Direction, Objectives, and Grassroots Strategy from a Communications perspective. Governors should note that the enclosed paper is not for wider circulation.
Conclusion
Communication will continue with both local and central government in particular, at appropriate times taking into consideration the upcoming elections and the council ‘purdah’.
We will also be continuing to update our other stakeholders, including Resident’s Associations, Governors and staff throughout the planning process, at key points, particularly when action is required.
Author: Contact Number or Date: E-mail: Rachael Reeve, Director of Marketing 8th May 2014 and Communications 8024 PA
Council of Govenors
NOT FOR WIDER CIRCULATION: COUNCIL OF GOVERNORS ONLY
14 May 2014 Board room, The Royal Marsden, Chelsea
Sale of the Royal Brompton estate
PR, Communications and Stakeholder Strategy - update
Rachael Reeve, Director of Marketing and Communications
1. Background The Royal Brompton is planning to sell part of its estate to fund a redevelopment of its Sydney Street site. One of these buildings is the Fulham Road Wing which The Royal Marsden has had a long held interest in and is looking to purchase.
We are currently operating at maximum capacity and have no more room to expand our Chelsea site for further world class research, clinical trials and patient care. The Fulham Road Wing is situated between The Royal Marsden and our academic partner, The Institute of Cancer Research, and will allow us to increase both our NHS and Private Care provision and expand research capacity to cope with current and future demand. Being co-located in this way is a once-in-a-lifetime opportunity that we do not want to miss.
It is the view of The Royal Marsden that such a precious healthcare resource in this location should not be lost to residential use and we want to ensure that this opportunity to secure our long-term future is not missed.
We believe there is a way forward which takes the needs of both The Royal Marsden and the Royal Brompton into account and which will not adversely affect the Royal Brompton’s aspirations for their redevelopment. We have been working with both the Royal Brompton and the Royal Borough of Kensington and Chelsea (RBKC) to achieve a suitable outcome for all parties.
We are working with Cavendish Communications on a PR, communications and stakeholder engagement strategy.
2. Strategic direction We propose two specific strategies which we believe complement each other and have the same aim – to establish The Royal Marsden as the preferred purchaser of the Fulham Road wing site in the eyes of local residents and ultimately the Council. These two strategies are:
• A top-level strategy targeted at senior decision makers and influencers to persuade them that The Royal Marsden is a serious and credible purchaser of the Fulham Road wing site.
• A grassroots strategy involving local Residents Associations, other local personalities and supporters of The Royal Marsden to urge the Council to allow for sufficient time to consider The Royal Marsden’s interest in the Fulham Road wing site and to urge the Council that continued healthcare provision is preferable to luxury residential development.
These two core strategies are supported by a media campaign at selected points throughout the process to ensure maximum exposure at the most appropriate moments.
3. Objectives a) To establish The Royal Marsden as the preferred purchaser in the eyes of the Council. b) To convince senior Councillors and decision makers that a continued healthcare facility is preferable to residential development. c) To demonstrate to the Council that The Royal Marsden has sufficient funding to purchase the site without negatively impacting on the Brompton’s redevelopment plans.
In support of the objectives, messaging will focus on the following themes: • The historic legacy of The Royal Marsden in the Borough • The need to prioritise world class cancer research • Why the Fulham Road wing site is critical to the Royal Marsden’s expansion plans
A number of RBKC, London and National political figures have been identified, that we believe will (or have the potential to) shape the planning process and for whom engagement should be a priority:
4. Grassroots strategy Our key objectives going forward will be: a) To achieve a delay in the Council accepting residential use on the Fulham Road Wing site to give The Royal Marsden additional time to impress upon the Council that it is a serious potential purchaser for the Fulham Road wing site. b) To ensure that local Residents Associations make the case that the Fulham Road wing site should continue to be used for healthcare and that more luxury residential development risks turning Chelsea into a residential ghetto. c) To effectively harness local opposition to the Royal Brompton’s plans contrast this lack of support with the goodwill locally for The Royal Marsden.
In support of the objectives, messaging will focus on the following themes: • The Council must not rush into adopting the SPD or granting the change of use application • The Fulham Road wing site is better suited for continued healthcare rather than luxury residential development • The Royal Marsden has the interests of the local population at heart
To implement the Grassroots Strategy we will engage with the following groups: • Local groups well respected by RBKC council including Chelsea Society, Kensington Society, Kings Road Association of Chelsea Residents (KRACR) • Leading stakeholders around The Royal Marsden – both residents and businesses. • Residents Associations close to The Royal Marsden including Dovehouse Street, Astell Street, Chelsea Square, Sydney Street, Onslow Neighbourhood Association, Milner Street, the Boltons Association, Queens Gate Gardens Committee and Christchurch Residents Association. • Key internal stakeholders including Governors and members, staff and patients.
5. Communications summary (as of 30 April 2014)
To date, we have liaised with the following stakeholder groups: • Central Government • Greater London Authority • Local MP, Greg Hands • Local Government (All councillors, RBKC)
• Residents Associations: Regular briefings and communications with all the key residents associations including the Chelsea Society, Kings Road Association of Chelsea Residents and Sydney Street Residents Association. • Governors: Briefing documents emailed to all governors for distribution to their members; further communication regarding petition distributed in late April. N.B. All communication with Governors to be co-ordinated via Corporate Governance office as opposed to Directors themselves. • Staff: Message included in Chief Executive trust wide email distributed in early April; further communication regarding petition distributed via directors in late April • Friends of The Royal Marsden, Chelsea: Briefing documents emailed to Chair of Friends, Chelsea for distribution to their members • Media: Articles in Kensington and Chelsea Chronicle, Evening Standard and Health Service Journal outlining Royal Marsden position
Petition In order to prompt a full council debate on this issue, we initiated a petition both online and in person (within the hospital), to achieve the required 1500 signatures. After communication through social media, governors, The Friends of The Royal Marsden and staff, we have achieved over 6000 signatures of support. This has now been submitted to the Council.
6. Conclusion The Royal Marsden’s message has, so far, been communicated to all the key stakeholders who have shown a huge amount of support for our campaign.
Communication will continue with both local and central government in particular, at appropriate times taking into consideration the upcoming elections and the council ‘purdah’.
We will also be continuing to update our other stakeholders, including Resident’s Associations, Governors and staff throughout the planning process, at key points, particularly when action is required.
COUNCIL OF GOVERNORS PAPER SUMMARY SHEET
Date of Meeting: Agenda item
14th May 2014 Item 7.1
Title of Document: To be presented by
Operational Plan 2014-16 Alan Goldsman, Director of Finance Executive Summary
The Trust is required to submit its two-year operational plan to Monitor on 4th April 2014.
This paper summarises the two-year operational plan for 2014 – 16 using assumptions agreed by the Board in 2013.
Recommendations
The Council is asked to note and discuss the Operational Plan 2014-16.
Author: Contact Number or Date: E-mail: Alan Goldsman, Director of Finance 8th May 2014 2151 PA
ROYAL MARSDEN NHS FOUNDATION TRUST BOARD
Operational plan – 2014 – 16 and Board declarations
1) Introduction
The Trust is required to submit its two-year operational plan to Monitor on 4th April 2014. A strategic plan for 2014 – 19 must be submitted to Monitor by 30th June 2014.
This paper summarises the two-year operational plan for 2014 – 16 (attached) using assumptions agreed by the Board in 2013. It should be read in conjunction with the Board declarations (appendix 1); which were considered by the Audit and Finance and Quality, Assurance and Risk committees at their last meeting.
The Council is asked to approve the operational plan and declarations (in section 4 below and in appendix 1); and to note the contract risk in the current position.
2) Operational plan
There are three key drivers of the operational plan;
2.1) Financial sustainability
The Board has previously functioned on its requirement to remain financially sustainable over a longer period of at least 10 years. This is set out in more detail in the Strategic Plan 2014 – 19 and requires annual operating revenue surplus (at current prices) of at least £20m to deliver its 10 year capital replacement programme and maintain sufficient cash headroom to meet its working capital needs (assumed to be at least £10m at current turnover). In this scenario new investment is funded either through loan or similar facilities based on revenue positive business cases; or where appropriate through charitable grants (for non-core NHS activities).
In the short term, and taking into account the risks outlined below, this 2-year operational plan provides sufficient cash and capital to meet the minimum requirements for sustaining operational performance and service quality; but does not provide the financial headroom required to commit to longer term investments such as new IT solutions and major building and site upgrades.
2.2) Clinical sustainability
This 2-year operational plan is built on delivering improvements across three key initiatives:
Service Portfolios
Services are managed by tumour type and differentiated according to whether they are provided to NHS patients, private patients or for research; creating portfolios of activity. The service line objective is to achieve a positive contribution across the portfolio. This task is supported by service line reporting and patient level costing systems in order to understand the impact of cancer tariffs and clinical decision making on the underlying service.
Access policy
Revision to the access policy will involve realigning capacity and hospital resource allocation to achieve a more clinically sustainable level of service provision.
Surgery
In the first 2 years addressing utilisation and capacity issues and reversing financial deficits identified which will create the capacity for developing a specialty specific surgical portfolio to support the delivery of the private care strategy, the non-surgical portfolio, including research, presented through the financial assessment, market assessment and national trends
2.3) Quality of Service and patient experience
The Royal Marsden continues to provide an excellent service to its patients and their families by ensuring that cancer services are designed around their holistic needs. The Trust is continually assessing the quality of its service using all the nationally mandated cancer audits, the ISO 9001 framework for quality of its chemotherapy and radiotherapy services and the national patient excellence award (Craig M).
To monitor patient’s satisfaction with the service and their overall patient experience the Trust uses the following methodologies to gain real time information about the patient experience: Picker hand held frequent feedback service; the meridien survey in the community, and the national inpatient and outpatient picker surveys. In addition the RM patients have placed the Trust in the top 10% of Trusts since the inception of the Friends and Family Test.
3) Risk
3.1) NHS Contracts
It is now very unlikely that NHS Contracts will have been agreed with NHS England and CCGs in time for the activity, income, CQUIN or QIPP values to be properly validated in the operational plan. In the short term the plan contains the following assumptions:
For NHSE and CCGs
. That a cost and volume based contract will continue to apply; with all activity being paid at the national tariff rate. This is consistent with the long standing arrangements in place and is considered low risk.
. CQUIN will be agreed at the full value; consistent with previous and considered lower risk.
. QIPP of 6% (approximately £6m) will not be successfully levied against the contract; other than for schemes mutually agreed as deliverable – this assumption is also consistent with previous experience but is considered higher risk. There is likely to be a (recoverable) cash deduction against contract sums in the first quarter pending contract signature.
For Sutton and Merton Community Services
The existing contract expires on 31st March 2014 and does not automatically roll-over to a new contract. Local commissioners have been engaged in this process and have offered to extend the contract for a further year; with some investment proposed in new services.
The Trust accepts that this one-year extension is the most that can be offered under European procurement rules pending full tender; however the Trust has made it clear that it will not accept any new financial risk over this timescale and additionally will require a new ‘block’ contract value to reflect activity changes over the first three years. Some new investment will also be required in IT upgrades.
4) Monitor
Monitor has divided its annual plan review into two distinct phases:
Phase 1 – operational plans for 2014 – 16 with supporting financial projections. Monitor will assess two year supporting financial projections and will seek to understand the degree to which Foundation Trusts have started planning for, and have already begun implementing, transformational initiatives.
In doing so Monitor will work with NHSE and the NHS TDA to reconcile key commissioner and provider planning assumptions and to highlight and local health economies where there are major planning ‘divergences’.
Phase 2 – Strategic Plan for submission on 30th June 2014. Monitor will focus on the robustness of FT strategies to deliver high quality care on a sustainable basis. They will focus on the degree to which each FT has developed realistic transformational schemes and aligned its plans with those of other actors within the local health economy.
4.1) Operating Plan declarations
Foundation Trust Boards will be required to make the following declarations for the Operational Plan:
The Operational Plan is intended to reflect the Trust’s business plan over the next two years. Information included should accurately reflect the strategic and operational plans agreed by the Trust Board.
In signing below, the Trust is confirming that:
. The Operational Plan is an accurate reflection of the current shared vision of the Trust Board having had regard to the views of the Council of Governors and is underpinned by the strategic plan;
. The Operational Plan has been subject to at least the same level of Trust Board scrutiny as any of the Trust’s other internal business and strategy plans;
. The Operational Plan is consistent with the Trust’s internal operational plans and provides a comprehensive overview of all key factors relevant to the delivery of these plans; and
. All plans discussed and any numbers quoted in the Operational Plan directly relate to the Trust’s financial template submission.
5) Conclusion
The Council is asked to approve the operational plan and declarations (in section 4 below and in appendix 1); and to note the contract risk in the current position.
APPENDIX 1 - Corporate Governance Statement
The Board is satisfied that The Royal Marsden NHS Foundation Trust applies those principles, systems and standards of good corporate governance which reasonably would be regarded as appropriate for a supplier of health care services to the NHS.
The Board has regard to such guidance on good corporate governance as may be issued by Monitor from time to time.
The Board is satisfied that The Royal Marsden NHS Foundation Trust implements:
(a) effective Board and Committee structures;
(b) clear responsibilities for its Board, for Committees reporting to the Board and for staff reporting to the Board and those Committees; and
(c) clear reporting lines and accountabilities throughout its organisation.
The Board is satisfied that The Royal Marsden NHS Foundation Trust effectively implements systems and/or processes:
(a) to ensure compliance with the Licence holder’s duty to operate efficiently, economically and effectively;
(b) for timely and effective scrutiny and oversight by the Board of the Licence holder’s operations;
(c) to ensure compliance with health care standards binding on the Licence holder including but not restricted to standards specified by the Secretary of State, the Care Quality Commission, the NHS Commissioning Board and statutory regulators of health care professions;
(d) for effective financial decision-making, management and control (including but not restricted to appropriate systems and/or processes to ensure the Licence holder’s ability to continue as a going concern;
(e) to obtain and disseminate accurate, comprehensive, timely and up to date information for Board and Committee decision-making;
(f) to identify and manage (including but not restricted to manage through forward plans) material risks to compliance with the Conditions of its Licence;
(g) to generate and monitor delivery of business plans (including any changes to such plans) and to receive internal and where appropriate external assurance on such plans and their delivery; and
(h) to ensure compliance with all applicable legal requirements.
The Board is satisfied:
(a) that there is sufficient capability at Board level to provide effective organisational leadership on the quality of care provided;
(b) that the Board’s planning and decision-making processes take timely and appropriate account of quality of care considerations;
(c) the collection of accurate, comprehensive, timely and up to date information on quality of care;
(d) that the Board receives and takes into account accurate, comprehensive, timely and up to date information on quality of care;
(e) that The Royal Marsden NHS Foundation Trust including its Board actively engages on quality of care with patients, staff and other relevant stakeholders and takes into account as appropriate views and information from these sources; and
(f) that there is clear accountability for quality of care throughout The Royal Marsden NHS Foundation Trust including but not restricted to systems and/or processes for escalating and resolving quality issues including escalating them to the Board where appropriate.
The Board of The Royal Marsden NHS Foundation Trust effectively implements systems to ensure that is has in place personnel on the Board, reporting to the Board and within the rest of the Licence holder’s organisation who are sufficient in number and appropriately qualified to ensure compliance with the Conditions of this Licence.
OPERATIONAL PLAN 2014 - 16
1) Executive Summary
The operational plan is presented here using parameters agreed by Board (with advice from Governors) and designed to deliver long term financial and clinical sustainability with a low- risk profile.
There are four key drivers of the operational plan; financial, clinical (including Research) and workforce sustainability alongside quality of services and patient experience.
1.1) Financial sustainability
The Board has previously functioned on its requirement to remain financially sustainable over a longer period of at least 10 years. This is set out in more detail in the Strategic Plan 2014 – 19 and requires annual operating revenue surplus (at current prices) of at least £20m to deliver its 10 year capital replacement programme and maintain sufficient cash headroom to meet its working capital needs (assumed to be at least £10m at current turnover). In this scenario new investment is funded either through loan or similar facilities based on revenue positive business cases; or where appropriate through charitable grants (for non-core NHS activities).
1.1.1) Revenue
The proposed revenue plan is as follows:
2013/14 2013/14 2014/15 2015/16 Plan Outturn** Plan Plan £000s £000s £000s £000s
183,824 NHS Income 189,600 187,800 185,500 24,565 Research and Development 25,300 17,900 17,300 67,404 Private Patients 69,000 82,400 94,200 42,466 Other Income 49,100 52,300 52,300
318,259 Total Income 333,000 340,400 349,300
297,657 Operating Expenditure 316,800 323,900 336,700 Cost efficiency * (4,400) 0 (6,200) 4,609 Dividend / Interest 4,600 4,900 5,200
15,993 Development Reserve 16,000 11,600 13,600
‘*’ Improvement to Q3 forecast out-turn represents surplus required during Q4; for 2015 – 16 this represents further cost reduction required. ‘**’ Forecast at Q3
In the short term, and taking into account the risks outlined below, this 2-year operational plan provides sufficient cash and capital to meet the minimum requirements for sustaining operational performance and service quality; but does not provide the financial headroom required to commit to longer term investments such as new IT solutions and major building and site upgrades.
The Royal Marsden NHS Foundation Trust Page 1
OPERATIONAL PLAN 2014 - 16
1.1.2) Capital
The following capital expenditure is affordable within the revenue surplus; further details are contained in section 2.7:
2013/14 2013/14 2014/15 2015/16 Plan Capital Programme Outturn Plan Plan £000s £000s £000s £000s
10,200 Internal Finance 7,200 10,000 9,400 14,000 Equipment Loan 5,600 15,000 10,000 6,000 Charity Donations 3,100 3,000 0 30,200 Total Capital Expenditure 15,900 28,000 19,400 0 Loan Interest and Repayments 0 1,400 2,700 30,200 15,900 29,400 22,100
Financed By: 14,000 Loan Finance 6,500 14,100 10,000 6,000 Charity Donations 3,100 3,000 0 16,000 Surplus 16,000 11,600 13,600 36,000 Total Financing 25,600 28,700 23,600
This shows £19.4m funds available (contingent on delivering the revenue surplus) and a likely loan requirement of £40m over 4-years; starting in 2015 – 16.
1.1.3) Cash
The cash plan set out in the table below; along with a committed working capital facility with Lloyds Bank will ensure a low risk profile is maintained over the period:
2013/14 2014/15 2015/16 Cash Flow Outturn Plan Plan £000s £000s £000s
EBITDA 20,100 19,500 18,900 Movement in working capital (10,000) 0 0 Cash from operations 10,100 19,500 18,900 Capital expenditure (15,900) (28,000) (19,400) Loan Finance (net) 6,500 12,700 7,300 PDC Dividend Paid (4,400) (4,700) (4,800) Movement in Cash (3,700) (500) 2,000 Closing Cash 10,600 10,100 12,100
Continuity of Service Risk Rating COSSR
Capital Servicing 4 4 4 Liquidity 3 3 3 Overall 4 4 4
The Royal Marsden NHS Foundation Trust Page 2
OPERATIONAL PLAN 2014 - 16
1.1.4) Margin for transformation and development
This 2-year operational plan for financial sustainability is built on delivering improved margins through the following key objectives:
i. Service transformation and integration
The Trusts strategy covers a number of transformational initiatives being developed by and between providers. These are summarised in the next sections below and set out in more detail in the 5-year Strategic Plan.
ii. Fair prices for NHS activity
The Royal Marsden has been independently assessed in the highest quartile (best) of NHS providers for the costs of delivering specialist services. But its services to NHS commissioners are paid under tariff at 80% of the cost of providing these services; resulting in a loss of £27m per annum (roughly 20%). Positive margins from providing private care have been used to subsidise this shortfall; but this is no longer appropriate or sustainable other than in the very short term
The Trust will be submitting its case for Local Tariff Modification to Monitor in March; using the process already described and approved. Improvement is expected in services associated with cancer, outpatient services, paediatrics and Critical Care during the next two years but it is too soon to assess the likely impact during this period in advance of testing our case with Monitor. iii. Improved productivity and expenditure cuts
The Trust is continuing to pursue a Cost Improvement Programme (CIP) based on procurement, outsourcing (such as for drug supply) and scale economies; however the scope for delivering benefits to commissioners (through tariff deflator and QIPP cuts) and to the bottom line through this route is becoming more difficult. Maximum 5% is deliverable over the two years through this route.
iv. Increase in NHS activity and income
Nationally a combination of a growing and ageing population with improved prospect of survival is resulting in increases in both cancer incidence and prevalence. The British Journal of Cancer cites a prevailing trend of +3% growth in cancer prevalence per annum. This data is further supported by the Trust’s own referral and activity data which bears out the fact that hospital cancer populations have increased continuously over recent years. Furthermore treatment options for patients have also increased. All of this leads us to safely predict increases in the coming year across most treatment modalities, but most likely in outpatients attendances, chemotherapy, and imaging.
The Royal Marsden NHS Foundation Trust Page 3
OPERATIONAL PLAN 2014 - 16 v. Increase in private activity
The Trust plans to increase its private income to at least £100m (from £70m) as quickly as possible. The key factor that drives an increase in PP income is increasing inpatient capacity. The Trust has identified additional PP inpatient capacity for 2014 - 15 and 2015 - 16; however, the £100m target is likely to require the Trust to identify capacity outside the existing hospital sites. The opportunities for this level of expansion will be explored in 2014 - 15.
Going forward surpluses made on this activity should be used to support developments in quality of cancer care, facilities and technology; and not to subsidise NHS tariff.
1.2) Clinical sustainability
This 2-year operational plan for clinical sustainability is built on delivering improvements across key initiatives:
1.2.1) Service Portfolios
Services are managed by tumour type and differentiated according to whether they are provided to NHS patients, private patients or for research; creating portfolios of activity. The service line objective is to achieve a positive contribution across the portfolio. This task is supported by service line reporting and patient level costing systems in order to understand the impact of cancer tariffs and clinical decision making on the underlying service sustainability.
Alongside this there are links to national service specifications will ensure that services continue to comply with the criteria laid down by Clinical Reference Groups (CRGs) on behalf of commissioners. A number of Trust experts are represented on these national bodies.
1.2.2) Access policy
Since the national tariff for cancer funds (on average) only 80% of the costs of all cancer care, and since the Trust as a specialist provider cannot subsidise these losses with surpluses from other NHS services, the Trust has advised its Commissioners that it may seek commissioner support for taking some services outside the NHS contract and tariff regime.
Revision to the access policy will involve realigning capacity and hospital resource allocation to achieve a more clinically sustainable level of service provision. The main areas of focus will be prioritising referrals based on agreed catchment areas for each tumour group, a clinical need which cannot be met at another centre or an opportunity to enter into a clinical trial that is only offered at the Royal Marsden. In addition triage of non-elective admissions to ensure priority is given to those patients requiring the specific and specialist services of the Royal Marsden
The Royal Marsden NHS Foundation Trust Page 4
OPERATIONAL PLAN 2014 - 16
1.2.3) Surgery
Surgery accounts for c. £32.5m of Trust income and makes a net loss of £8.2m. Given current tariff pressures this position will worsen if not addressed through transformation in the surgical portfolio. In addition The Trust is facing significant capacity constraints which impact on the ability to deliver other approved strategies (e.g. Private patients and Research and Development)
In the first 2 years addressing utilisation and capacity issues and reversing financial deficits identified which will create the capacity for;
i. Developing a specialty specific surgical portfolio to support the delivery of the private care strategy, the non-surgical portfolio, including research, presented through the financial assessment, market assessment and national trends
ii. Delivery of elements of the surgical portfolio through robust partnership to protect the business against regulatory threat, strengthen surgical research links, address capacity concerns and support strategic growth,
iii. Management of the surgical workforce to ensure a safe, sustainable and affordable portfolio, to support the delivery of the private care and NHS service strategy, including the development of academic surgery.
iv. Investment in estate to expand the Chelsea footprint will enable delivery of private surgical activity and more efficient day surgery.
1.2.4) The London Cancer Alliance
The Royal Marsden was a core founder, and is host of the London Cancer Alliance (LCA). The LCA is the Integrated Cancer System (ICS) for West and South London and provides a quality and accreditation system across 16 provider Trusts; and works collaboratively with two Academic Health Science Networks, primary care and the voluntary sector. The LCA is led by two Clinical Directors one of which is the RM Chief Nurse. The LCA works across patient pathways to improve quality, to reduce unwanted variation, and to improve outcomes and the patient’s experience of care. The LCA now has 2, 500 clinicians actively engaged driving clinical standards and innovation so that all Londoners can experience world class cancer care.
Since its inception the LCA has worked with all providers to ensure across South and West London that it has robust data to monitor for improvement. Across all tumour pathways and all treatment modalities, including survivorship and palliative care, the LCA is publishing exemplar pathways to ensure that patient journeys are seamless. For each tumour type clinicians are writing evidence based guidelines to ensure that wherever in London the person is treated they are receiving the best cancer care.
The Royal Marsden NHS Foundation Trust Page 5
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1.2.5) The Royal Marsden School
The Royal Marsden School offers comprehensive cancer and palliative care courses tailored to meet the needs of healthcare professionals from organisations across the UK (and worldwide) and is the UK's only dedicated provider of cancer education. The School provides academic programmes at both Degree and Masters level. In addition, the School offers a wide range of stand-alone modules at Degree and Masters level. A large number of individually planned projects and unaccredited study days are provided to a diverse stakeholder group to meet patient and service requirements in cancer and palliative care.
School activity has progressively increased with numbers of places rising from 373 in the academic year 2003/2004; to 1229 in the academic year 2012/2013. With the School now in its twelfth year and going from strength to strength, future developments will focus on increasing the multi-professional portfolio and providing a flexible cancer education pathway. The School is also working closely with local organisations and education commissioners in developing a range of activities that respond to the rapidly changing demands of clinical service delivery.
The overall aim of The School is to provide excellence in education that is both relevant to practice and enhances the lives of patients and their loved ones living with and after cancer. Through a sound strategy that promotes a dynamic and changing curriculum and that is increasingly accessible to cancer practitioners both in the UK and overseas, the School can justifiably be recognised as a leading provider of education in cancer and its associated long-term conditions.
In 2013/14 The RM School has diversified to embrace the “Out of Hospital” agenda and include the first course for Nurses new to the Community. This has been well evaluated by the first students and will be the first in a new portfolio of programmes for nurses and bands 1-4 in acute and in the out of hospital setting.
1.2.6) Community Services Integration
The community services division have been working with partners across both health and social care to transform services so that they are fit for purpose in supporting the out of hospital strategy and the Better Care Fund. Services will ensure that care is patient centred, meets their needs in a holistic way, and is available 7 days a week. Services will focus on supporting long term conditions and end of life care, and will provide intensive home support to those that need it; to prevent unnecessary admission to hospital and also to support timely discharge. Care teams in the community will realign themselves so that they relate more closely to primary care; enabling closer working and the ability to identify those most at risk and in need of services. These care teams will work in a more integrated way with social care; providing care that can wrap around the patient.
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1.3) Quality of services and patient experience
The Royal Marsden continues to provide an excellent service to its patients and their families by ensuring that cancer services are designed around their holistic needs. The Trust is continually assessing the quality of its service using all the nationally mandated cancer audits, the ISO 9001 framework for quality of its chemotherapy and radiotherapy services and the national patient excellence award (Craig M). To monitor patient’s satisfaction with the service and their overall patient experience the Trust uses the following methodologies to gain real time information about the patient experience: Picker hand held frequent feedback service; the meridien survey in the community, and the national inpatient and outpatient picker surveys. In addition the RM patients have placed the Trust in the top 10% of Trusts since the inception of the Friends and Family Test.
There is robust evidence that a necessary precursor for a positive patient experience is staff engagement and a good staff experience (Mabel et al 2012). The national staff survey illustrates that RM staff feel engaged, are proud of their Trust and would recommend it to friends and family.
Healthcare is a staff dependent industry with the major costs to the Trust being staff time. It is therefore essential that the Trust has effective, robust timely recruitment and people management policies. The following areas are those where quality of care and costs can be impacted and therefore the Trust is placing a major focus in these areas:
. Significant reduction in agency staffing – nursing, medical and all corporate areas. Some temporary staff use is inevitable where there are sudden gaps in service provision however it is key to the quality of the service that this is the exception. When agency staff are used to fill gaps in frontline services patients comment on lack of continuity and a reduction in the quality of their care.
. In February 2013 The Trust achieved NHSLA level 3 and with it the reduction in its insurance premium. The Trust Finance Director and Chief Nurse met with the NHSLA CEO and discussed the need to ensure that the Trust’s insurance premium in the future appropriately reflects the low risk as compared to other multi-specialty Trusts. In February 2014 the Trust received its latest NHSLA assessment and scored green across all risk areas.
1.4) Clinical Research
The Royal Marsden clinical research strategy will prioritise the research that has been identified as having the most benefit to patients, and ensures that they benefit from the latest advances in cancer treatment. Research ultimately improves treatment options, and there is evidence to show that patients do better in hospitals that conduct research, even if they are not part of a study themselves. There are several elements within the research strategy:
1.4.1) Clinical Research Network (CRN)
The Royal Marsden is leading the South London CRN and is spearheading the rise of clinical research in the NHS, according to a league table from the National Institute
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for Health Research (NIHR) Clinical Research Network. The Royal Marsden increased its studies from 159 in 2011/12 to 187 in 2012/13, and it is the top trust in England in the acute specialist trust category for the number of studies it conducted last year.
1.4.2) Biomedical Research Centre for Cancer
The Royal Marsden, together with its academic partner, The Institute of Cancer Research (ICR), is designated as the UK’s only Specialist Biomedical Research Centre for Cancer. The specific remit of the BRC is to facilitate rapid and effective translation of scientific findings regarding the genetic and molecular basis of cancer into improved therapeutic strategies that are ultimately tested in large-scale national trials. The award of BRC status is made by the National Institute for Health Research (NIHR) and is done on a five year basis. We have to bid for this funding every five years – the next renewal is due in 2016 (for commencement, if approved, on 1st April 2017).
1.4.3) Investment in Clinical research
i. West Wing Unit
The Royal Marsden’s new £2.6 million West Wing clinical research facility at Sutton opened to its first patients in March this year. The facility is a dedicated space for patients participating in clinical trials. The unit will increase the opportunities for translating early-phase studies conducted in the Drug Development Unit into late-phase research.
ii. Centre for Molecular Pathology (CMP)
The NIHR/BRC CMP is a shared building between the Royal Marsden and the opened in 2012 and is now fully functional with both a service and discovery function.
iii. RM Clinical Trials Unit
The Royal Marsden Clinical Trials Unit was formed in early 2014 as a specialist unit with a specific remit to design, conduct, analyse and publish clinical trials and other well-designed studies. Based in Sutton, it will operate cross-site, acting as a co-ordination hub for all Biomedical Research Centre funded activity. The CTU team will work with clinicians and researchers to conduct the highest quality clinical research.
1.4.4) Commercial Research Income
The Royal Marsden has a strong track record of delivering commercial studies with long standing relationships with pharma and technology; in 2012-13 commercial income was £10.8m and in 2013-14 is forecast to be £7.3m. The investment in research capability described above will ensure the Royal Marsden continues to grow income form commercial research.
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1.5) Workforce
The Royal Marsden’s workforce is the Trust’s most valuable asset and is essential to support us in continuing to achieve our vision of providing excellent care delivered by expert and caring staff and enable our achievements in cancer research, treatment and education. The Trust attracts and retains a high concentration of clinical academics in conjunction with our academic partner the Institute of Cancer Research; as a result Royal Marsden / ICR are the fourth most cited cancer institutions internationally
The Royal Marsden is committed to developing and sharing knowledge of cancer both for existing staff and in the wider NHS and beyond. For example, the Royal Marsden School offers comprehensive cancer and palliative care courses tailored to meet the needs of healthcare professionals from organisations across the UK as well as internationally. The Trust is the UK's only dedicated provider of cancer education. In the last academic year it offered 756 module places, 193 study days, 280 other types of activity. This unique facility, with lecturers who are also regularly engaged in clinical practice, enables us to develop our workforce to rapidly respond to changing requirements through high quality education bespoke programmes.
The Royal Marsden’s medical education is highly rated by our trainees and in Speciality School visits. In a joint initiative with The Royal Brompton NHS Foundation Trust, we have developed a state-of-the-art Education and Clinical Skills and Simulation Centre dedicated to deliver a range of high fidelity full immersion, clinical situational awareness and clinical skills based teaching activities for the benefit of staff in both Trusts and geographically in the wider NHS, particularly on medical education programmes.
Levels of staff engagement are consistently rated highly through the annual NHS staff survey. The support given by Royal Marsden line managers is rated particularly well and there is a clear commitment of staff to deliver high quality and safe care to patients.
In delivering the operational plan over the next two years, there is a need to maintain and build on these strengths and ensure the Royal Marsden is in a position to respond to the levels of transformational change that are needed and the focus is on the following key initiatives:
1.5.1) Strengthening clinical leadership
The Royal Marsden is further strengthening clinical leadership at all levels in the organisation to support service line management and ensure that clinical intelligence informs business decisions. This will be enabled by creating Clinical Business Units to ensure that this is achieved within the Divisions and multi-professional leadership development will maintain a focus on delivering a high performance culture that delivers results through engendering staff accountability and engagement and developing service improvement skills and those to support transformational change.
1.5.2) Pay and Remuneration
There are a number of key initiatives around pay and remuneration over the next two years which will support a high performance culture; the national changes in terms
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and conditions will be implemented and a review of consultant and junior doctor contracts to reward and incentivise good performance will be conducted. There is a commitment to reduce temporary staff spend (both bank and agency);bank pay rates will be reviewed so these are aligned to market conditions, can be flexed according to supply and demand and support the Trust’s financial strategy.
1.5.3) Recruitment and retention
Recruitment and retention of high quality staff underpins excellence and will directly support the Trust’s business strategy; the ‘employee brand’ will be promoted to continue to attract the highest quality staff. Hard to recruit areas will be targeted through a range of initiatives including developing new attraction strategies, recruitment pipelines and talent pools, assessment centres and international recruitment, where appropriate. Local solutions will be developed to respond to areas of high turnover.
1.5.4) Maximising potential through productivity and efficiency
There are a number of components of the operational plan for the next two years to support staff in working to their optimum and delivering on the quality and efficiency agenda. High quality workforce information and systems are critical to monitoring progress and focusing effort related to improving workforce productivity and efficiency. Workforce expenditure controls will be developed to appropriately control costs and drive efficiencies whilst maintaining quality. A particular focus will be the further reductions in temporary staff spend.
The aim is to ensure staff are working as efficiently and effectively as possible and performance is positively managed, reducing overall unit costs through workforce productivity and staff performance management improvements to optimise quality patient care and minimise the requirement for more formal action. Structures and ways of working will be reviewed to ensure that appropriate skill mix and working processes are in place and that staff are working at an appropriate level.
Internal communication strategies and mechanisms to support and engage with staff will be developed; in particular this will include implementing further ways to involve staff in the development of strategies and planning, for example, continuing with open meetings with senior staff.
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2) Operational Plan
2.1) The short term challenge
The short term financial challenge is demonstrated, in headline terms, by the waterfall diagram below.
£18,000 Surplus for Development 2014/15 £16,000 £2,200 £14,000 £4,400
£12,000 £5,700 £10,000 £5,800 £8,000
£6,000 £11,600 £4,300 £11,600
£4,000 £5,300 £2,000 £3,300
£0 Efficiency (R&D) 14/15 Programme Cost Inflation Cost Tariff Deflator Tariff PP Growth Net PP Project Diamond Proposed Surplus Proposed Other Cost Changes Cost Other Surplus at Q3 13/14 Surplus required Q4 required Surplus
A combination of the tariff deflator, cost pressures within Divisions, inflation and loss of Project Diamond funding was factored into the efficiency assumptions agreed by the Board. Improvements for private care and efficiency are sufficient to meet the surplus required to fund the minimum cash and capital programme requirements set out elsewhere in this plan; with possible improvement to come from on-going negotiations over Project Diamond funding and over local tariff modification.
Key short term challenges have been identified as follows:
2.1.1) Commissioner Engagement
Meaningful engagement with NHSE has, to date, been very limited and it has not been possible to secure contract heads of terms at the time of writing; in particular for discussing service and financial strategies as part of the NHSE, Monitor and TDA joint initiative in strategic planning for the next two and the following three years.
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Contract for Cancer Services
The Trust does not have any contract or contract heads in place with NHSE and the Trusts request for escalation in line with the national timetable has not been agreed by NHSE. In addition NHSE has not, so far, been prepared to discuss the Trusts 6- month notice letter (see Appendix 1). This letter contains important plans for activity management and tariff modification, among other things, which may potentially delay their implementation.
Contract for community services
The Trust does not have any contract or contract heads in place with CCGs, London Boroughs and NHSE. The Trust has already provided commissioners’ with legal advice to the effect that the existing contract cannot be rolled over past 31st March.
The Trust has notified commissioners that it is not prepared to take any financial risk on this one-year only contract and that, potentially, a new arrangement will be required from 1st April. The operational plan has been prepared on this basis for 2014 - 15.
2.1.2) Fair pricing
Local tariff modification and 2015 tariff
The Trust has been working with commissioners for some years to address problems with cancer tariff, paediatric top-ups and specialist service provision. A very thorough case for modification to the tariff will be presented to Monitor; covering the entire period 2014 – 16. This is not yet included in the income assumptions for either year.
In addition the Trust has been informed that Project Diamond funding will not be provided from NHS Research and Development resources in future. PD Trusts have been directed to NHSE (as part of contract negotiations) and Monitor (as part of local price modifications) to recover these funds. Continuation of this funding for at least a further year until tariffs can be addressed remains possible.
Cancer tariff working group
This group is led by the Royal Marsden NHSFT and University College London Hospital NHSFT; with support from Ernst and Young. These two Foundation Trusts have extensive knowledge of cancer care and have highly developed patient level costing and benchmarking systems. They are actively involved in leading roles within the two London Integrated Cancer Systems, three London AHSNs and in Project Diamond and the Shelford Group (UCLH only).
EY has led the recent work, among other things, with Project Diamond Trusts and has evaluated comparative cost and PBR data. The Christie Hospital and Guys and St. Thomas’ NHS Foundation Trusts have also lent their support to this work. Appendix 2 provides a more detailed summary of this work.
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2.1.3) Cash Management
NHS commissioners have been particularly poor payers in 2013 – 14; with more than £10m outstanding for long periods. Significant cash pressures are expected in at least Q1 of 2014 and a fully committed working capital facility is in place.
2.2) Quality Plans
The quality framework uses key national and international metrics to assess and monitor patient safety, the effectiveness of patient care and patient and staff experience these include the following (although this should not be regarded as an exclusive list):
2.2.1) Patient Safety
i. The prevention and control of Health Care Associated Infections (HCAI). People with cancer are vulnerable to infection because they are immuno – compromised, receive complex multi-modality treatment and inpatient care and require multiple courses of anti-microbials. The Trust therefore takes concerted positive action to prevent and control infection utilising the best international evidence to guide its infection prevention and control programme.
ii. The use of the WHO Surgical Safety Checklist to ensure the safety of patients and staff in theatre. The use of the checklist is prospectively audited to ensure compliance and that any lessons learnt are shared.
iii. The use of the Patient Safety First initiatives for high risk drugs, patient vital signs monitoring and leadership for safety.
iv. Procurement and maintenance of medical equipment throughout the Trust that is coordinated and maintained centrally and through medical device passports in each clinical area.
v. ISO 9001 for chemotherapy and radiotherapy attained again in 2013/14.
vi. JACIE accreditation for the quality and safety of Blood and Marrow transplant attained again in 2013/14.
vii. The use of the National Modified Early Warning Score (MEWS) and Situation Background Assessment Recommendation (SBAR) throughout all clinical areas to ensure that any clinical deterioration is monitored and acted upon rapidly. viii. Modern and well maintained resuscitation equipment in all areas of the Trust including non-ward areas.
ix. A comprehensive and well-designed mandatory training programme for all clinical staff on patient safety. The Royal Marsden leads an excellent simulation programme for multi-professional teams in the acute or emergency scenario in patient care. This facilitates clinical staff to be experienced at working together in a time critical emergency setting.
x. The Executive Medications group that is multi-professional and works to continuously improve medicines safety at all points of care.
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xi. Falls monitoring and audits to constantly improve the environment and care of people who are at risk of falls.
2.2.2) Effectiveness of care
In cancer care the key issues that are essential are:
i. Early and effective access to definitive treatment: The Royal Marsden has strategies in place to ensure that all referrals are managed effectively through the system in a timely and effective way. One of the most difficult issues for a tertiary cancer centre is when referrals arrive late from another Trust this is being proactively addressed at CEO level locally and centrally. The Trust is a core member of The London Cancer Alliance and is working with all other providers in West and South London to improve clinical pathways and best practice patient navigation at provider Trusts that feed into the RM.
ii. The right treatment given by the right person in the right place: The Royal Marsden meets all the essential Peer Review components of the core members of the MDT. The cancer patient experience survey (CPES) also revealed that patients thought there were the right number and skill mix of nurses on duty. The 2013 CQC unannounced inspection also assessed staffing levels and skill mix and found no concerns. iii. Reducing length of stay whilst ensuring that there are no avoidable readmissions: The RM has been actively working on reducing length of stay and has an active Enhanced Recovery Programme (ERP) and 23 hour Breast surgery programme. There is however more work to do around a small group of patients who have a prolonged length of stay. Various initiatives are currently being designed and will be instituted and evaluated this year. These initiatives include reducing non elective admissions by ensuring Consultant evaluation prior to admission, developing the out of hospital transitions into the community, ensuring that all inpatients are evaluated daily and have active care plans.
iv. Therapeutic cancer care that is evidence based and continuously evaluated: The Royal Marsden is a research rich organisation and at ay one time is leading over 500 clinical trials. This means that the patient has access to key cancer therapeutics. The Royal Marsden also has an excellent Health Services Research structure which ensures that all clinical professionals are enabled to be involved in research that examines systems and care as well as therapeutics.
v. Cancer Education and Training: The Royal Marsden has the only dedicated training School for Cancer Nursing and Allied Health professionals and provides most of the postgraduate cancer training for nurses in England. In 2013 / 14 fior the third consecutive year the School was awarded the highest quality indicator in London by the NHS Health Education England.
vi. Clinical Audit: The RM completes all mandatory national cancer audits and then has a comprehensive programme of clinical audit responsive to patient and strategic requirements.
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OPERATIONAL PLAN 2014 - 16 vii. Access Policy: ensuring that those patients that require care at the Royal Marsden are able to access services when needed through matching demand to available capacity. Initiatives to reduce demand include reviewing each service to define the referral catchment area. Patient referrals should then only be accepted from the defined catchment area for each condition or where there is a clinical or research need to attend the Royal Marsden rather than the patient’s local Trust. It is also essential that capacity is used as effectively as possible by only admitting non-elective patients who require specialist cancer care at the Royal Marsden and reducing length of stay.
2.2.3) Patient Experience
The patient experience is monitored through using Picker hand held devices in all clinical areas and outpatients to gain the individual patient experience, with these results fed directly back to Ward Sisters, Matrons and up through the Executive Directors to the Board. From 1st May 2013 all inpatient wards (except children’s) also had the Friends and Family Test applied. The majority of comments have been extremely positive but where there have been suggestions for improvement these have been systematically fed back to clinical areas for action. Since the inception of the FFT the RM has constantly been in the top 10% of high performing Trusts.
All the national patient surveys are also conducted and where there is anything other than an excellent score an action plan with key deliverables is agreed. One of the important deliverables going forward is to ensure that the patient / and or their family are not overburdened with questionnaires. The Royal Marsden is a research rich environment which means that many of our patients are on clinical trials and therefore undertake associated quality of life questionnaire or patient diaries. It is essential therefore to monitor the volume of questionnaires that patients are subjected to and this will be closely monitored with the Patient Experience group in 2014 onwards.
All Matrons, through to Directors read complaints and praise letters and themes for learning and improvement from these are fed into improvement plans across the Trust. At the Board Quality Assurance and Risk (QAR) committee the Chairman and Non-Executive Directors all see complaints and discuss the response and any remedial actions with the Executive Directors. Following the Francis report and its recommendations the Trust has made some improvements to its complaints policy and practice. More complainant meetings are being provided at an early stage with positive feedback. The PALS team has also been conducting weekly ward rounds to ensure that inpatients have a route to raise concerns easily that can be actioned immediately.
Members of the senior Medical, nursing and AHP teams are leading or members of the new national Clinical Reference Groups, The Trust is also represented on the London Children’s Strategic Clinical Network, The London Cancer Strategic Clinical Network and the London SCN Oversight group. Professional clinical leads continue to lead other cancer tumour specific national and international advisory boards for cancer or their profession and this knowledge is also therefore available to the Trust.
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2.2.4) Quality priorities and targets for 2014-16
The following priorities and targets are updated for 2014 – 15.
Safe Care
i. Reduction in Healthcare Associated Infections (MRSA bacteraemia and Clostridium Difficile infections). Applies to Acute beds @ RM and patients of Sutton and Merton Community Services (SMCS) Less than 1 MRSA bacteraemia
a. Less than 16 C Difficile infections (target for 14/15) b. (Report in Quality Account the number of C. Difficile infections per 100,000 bed days)
ii. Rate of patient safety incidents and percentage resulting in severe harm or death
a. (In 2012-13 the number of deaths from serious incidents per 100 admissions was 0; the number of severe harms from incidents per 100 admissions was 0.012) Acute beds and SMCS b. Reduction in the rate of patient safety incidents per 100 admissions and the proportion that have resulted in severe harm or death
iii. Percentage of admitted patients risk assessed for Venous Thrombo-embolism. Maintain above 95% the number of patients who have a completed VTE risk assessment
Effective Care
iv. Reduction in community acquired grade 3 and 4 pressure ulcers: SMCS Reduce the incidence of severe community acquired pressure ulcers (Grade 3 & 4)
v. Increase the number of patients that die in their preferred place of death (The National Primary Care Snapshot Audit in End of Life Care (2009) found that the number of patients achieving their preferred place of death is 42 %.). Acute and SMCS achieve more than 42% of patients dying in their preferred place of death.
vi. Increase the numbers of patients who have an Holistic Needs Assessment. Increase in the number of designated patients will be offered a Holistic Needs Assessment by the end of 2013-14
vii. Emergency re-admissions to hospital within 28 days of discharge. Reduction in the number of avoidable re-admissions to hospital within 28 days of discharge viii. The RM acute service is on track to achieve 100% of its CQUIN payments in 2013/14 and the SMCS division is currently achieving
Patient Experience
ix. Reduction in chemotherapy waiting times and improvement in patient experience related to waiting times. Reduction in chemotherapy waiting times at Sutton and Chelsea and improvement in the patient experience related to waiting times.
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x. Ensure that we are responding to in-patients’ personal needs improvement in responses to 5 questions (in the CQC national survey described above) as monitored through the Inpatient Frequent Feedback Surveys
xi. Percentage of staff who would recommend The Royal Marsden to friends or family needing care.
a. Patient Experience survey introduced into SMCS in December 2013. To achieve a baseline measurement and if possible benchmark with other community services.
xii. Improve communication, particularly when patients arrive for first appointments. Increase or maintain the high percentage of positive comments in dedicated patient feedback. xiii. Reduce the length of time a patient waits for medicines or equipment at the point of discharge. Increase or maintain the high percentage of positive comments in dedicated patient feedback.
Children’s services
xiv. The uptake of immunisation working in partnership with primary care. Increase the percentage of children receiving pre-school immunisations in partnership with GPs.
2.3) Activity Plan
The following table shows the current projected activity volumes for 2013 - 14, with the anticipated values for 2014 - 17. These predictions are based on prevailing activity trends and include both NHS and Private Patient activity.
NHS & PP Activity 2013/14 2014/15 2015/16 2015/16 Projected Outturn
Inpatient admissions 10,124 10,209 10,296 10,383 BMTs 211 214 218 222 Day case admissions 11,942 12,025 12,108 12,192 Chemotherapy Attends 46,739 50,135 53,779 57,688 Consultant Outpatients 164,287 170,23 176,996 183,714 Ward Attends 24,448 25,671 26,954 28,302 Radiotherapy Attends 74,402 75,414 76,440 77,480
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2.4) Operational requirements and capacity
Despite the pressure on NHS commissioner budgets there is no evidence of any reduction in demand for specialist cancer services and new referrals continue to increase. The table below shows the 1 year and 3 year growth in referrals between 2010/11 and 2013/14.
New Referrals %age Growth over 2010/11 2011/12 2012/13 2013/14* 1 year 3 years
NHS Patients 15,574 16,000 16,426 18,087 10.1% 16.1% Private Patients 2,940 3,047 3,018 3,458 14.6% 17.6% All Patients 18,514 19,047 19,444 21,545 10.8% 16.4%
*forecast from 11 months data
There are no plans to cut the total number beds, theatres and other patient care facilities (in broad terms) in the next two years; however the operational plan has identified a number of services where no funding is provided by any commissioner; or where funding is significantly less than the 80% average seen across the NHS portfolio. Since it is unlikely that new tariffs will be agreed by commissioners these services will be reviewed against clinical and patient safety criteria for early decision; or alternative, non-NHS funding.
2.5) Productivity, efficiency and CIPs
The financial planning process is now nearly complete and Divisional budgets have been scrutinised by the Trusts Medical Director and Chief Nurse to assess any potential impact of these plans on the quality and experience of care provided by the Trust. This work has been carried out under a number of key themes:
. Firstly by ensuring that the Trust delivers the financial surplus in 2013 – 14 (£16m); an improvement of £4.4m in Q4 based around reducing agency premium costs and improving private income.
. Reducing new cost pressures (cost not being incurred today) in the first cut plan by at least 50%.
. Implementing the new access policy; coupled with key aspects of the surgery strategy.
. Assessing all unfunded services to NHS patients.
. Reviewing all charges received from, and charges to, 3rd parties.
. Increasing private patient activity.
In addition the management team is considering the implications for deferring all capital schemes not funded by loan or charity for 6 months in order to preserve cash.
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2.6) Financial Assumptions
2.6.1) Financial planning assumptions
The Board agreed a set of high level planning assumptions for 2013 / 14 and the subsequent two financial years when it approved the Annual Plan in May. These have been updated for changes to the tariff deflator (£0.5m) and for the new pension arrangements (£1m) in the table below:
Year ended 31st March 2015 2016 2017 All figs in £'000's
Efficiency required (2014 plan) 16,200 14,000 14,000 Additional efficiency for:
Increase in tariff deflator 500
Pension arrangements 1,000
Revised target for 2015 17,700 14,000 14,000
This table shows that a programme of efficiency savings of between £14 - 18m per year is required to deliver a sustainable surplus available for development of between £18 – 20m; the level at which financial sustainability can be demonstrated. Annual improvements to liquidity (£18m over 10 years) will also be delivered.
2.6.2) Efficiency Requirement
The efficiency requirement comprises the following:
Year ended 31st March 2015 2016 2017 All figs in £'000's
Efficiency requirement External factors (incl. tariff cut) 5,700 5,000 5,000 Cost inflation 5,000 5,000 5,000 Increase surplus 1,000 1,000 1,000 Other (incl. possible loss of Project Diamond) 6,000 3,000 3,000
Total Efficiency Required 17,700 14,000 14,000
The efficiency requirement represents a required improvement equivalent to approximately 5% of the current cost base and is in line with estimates elsewhere across the NHS.
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2.7) Capital Programme
The first two years of capital programme has been revised to fit within a reduced surplus for development and ensures that existing schemes in progress (most notably for the PACS replacement in IT) can be completed. As in previous years a small allocation for essential minor works and backlog maintenance is allocated to the Director of Projects and Chief Operating Officer; with the remaining funds set aside for the schemes that will be required to deliver the capacity upgrades required for private care.
The equipment replacement loan will fund the remaining short term requirements for essential medical equipment.
2013/14 2013/14 2014/15 2015/16 2016/17 Plan Capital Programme Outturn Plan Plan Plan £000s £000s £000s £000s £000s Internally Financed Medical Equipment & 500 Infrastructure 400 500 0 0 6,000 IT Schemes 3,500 5,000 5,000 5,000 3,000 Backlog & Minor Works 2,100 1,600 2,000 2,000 Private Patients Chelsea & Sutton 200 2,400 0 0 700 Other 1,000 500 2,400 1,300 10,200 Total 7,200 10,000 9,400 8,300
Loan Financed 14,000 Equipment Loan (Current) 5,600 15,000 0 0 Equipment Loan (Proposed) 0 0 10,000 10,000 14,000 Total 5,600 15,000 10,000 10,000
Donated Assets 2,500 West Wing 2,500 0 0 0 0 Gamma Camera (from legacy) 0 600 0 0 3,500 Other 600 300 0 0 0 Robot 0 2,100 0 0 6,000 Total 3,100 3,000 0 0
30,200 Total Capital Programme 15,900 28,000 19,400 18,300
Requirements for major investment in the following schemes will be addressed as part of business cases still to come to Board and will be addressed in more detail as part of the 5- year Strategic Plan.
. New build in Sutton; including land purchase and upgrade of accommodation.
. Replacement of the Trusts Electronic Patient record and associated IT schemes.
. Purchase of the Fulham Wing of the Royal Brompton Hospital
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Appendix 1 – Trusts six-month notice letter to NHSE
30 September 2013
Dear Commissioner
The Royal Marsden NHS Foundation Trust (“the Trust”) 2014/15 6 Months’ Notice Letter
This letter sets out the following:
1 the conclusion of the Trust’s 2013/14 activity and the starting point for contractual negotiations and activity planning for 2014/15;
2 current work and future developments being carried out by the Trust as part of the Trust’s active drive to achieve transformation of the delivery of cancer services;
3 details of potential changes occurring at individual service level within the Trust (as listed in the Appendix to this letter), and constitutes formal six month notice to Commissioners of the Trust’s proposed service changes, as required under the NHS contract.
1) Contract Variations and 2014/15 Contract Negotiations:
Contract variation to out-turn
The Trust expects that forecast out-turn performance will form the basis of contract negotiations for 2014 / 15. The NHS contract requires us to agree and document all agreed changes (both to the 2013/14 and 2014/15 contracts) for in-year performance by way of formal signed contract variations.
2014 / 15 Contract timetable
Commissioners have recently clarified the position on contract negotiations that run beyond 31st March. In addition they have confirmed the requirement for 6 months’ notice of any changes by the contracting parties.
Therefore, the Trust proposes that the Trust and Commissioners aim to conclude contract negotiations by 14 February 2014 – in the (hopefully unlikely) event that the parties have been unable to reach final agreement by this date this will allow sufficient time (in accordance with the current contractual dispute resolution procedure) for any escalation required and still achieve signature by 1 April 2014.
The Trust accepts the 6-months requirement and will expect to function on requests from commissioners received before 1st October 2013; provided these are clearly submitted in this form.
Outstanding items for 2013 / 14 contract
The following items are outstanding from the 2013 / 14 contract:
. SBRT/IMRT implementation and funding – the Trust has experienced difficulties this year in obtaining funding approval for SBRT. The Trust welcomes Commissioners current engagement on this issue and would like to continue
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OPERATIONAL PLAN 2014 - 16
discussions on ways to improve patient access to these treatments (as set out in further detail in the Appendix).
. Paediatric top-up – the Trust provides specialist paediatric cancer services from its Sutton site and believes that Commissioners should exercise their discretion in awarding the Trust the specialist paediatric top-up (as has been awarded to other NHS Trusts).
. Critical Care review and pricing - the Trust currently provides critical care services at a 30% discount to its actual costs. The Trust can no longer afford to provide these services at such a discount and will therefore require an increase in the local price for critical care under the 2014/15 contract. The Trust welcomes the clinically led research programme into cancer critical care that the Trust and Commissioners have agreed to carry out this year.
2) Improvements in cancer care and value
The Trust would like to discuss with Commissioners the opportunities for working together more closely going forward. The Trust strongly believes that a collaborative relationship between the Trust and Commissioners will assist innovative commissioning and improve delivery mechanisms, with the ultimate aim of achieving strategic transformation in the delivery of cancer services.
Fair national tariff for cancer
As a provider of specialised cancer services, the Trust is continuously working to identify ways to improve efficiency and effectiveness while sustaining, and improving, the excellent standard of care provided to our patients.
The Trust has been independently assessed as the most efficient provider of specialist services in the UK. However, as Commissioners are aware, the Trust loses £20 to £25 million per year on the provision of NHS cancer services, a loss which is currently subsidised by the Trust’s non-NHS private activity. Without action to improve the tariff for cancer, this loss will increase by £5 million year on year; a position which is unsustainable.
Monitor expects to publish its forward guidance on tariff setting on 3rd October 2013 and it is therefore not possible to fully anticipate how cancer tariffs can be addressed in advance of publication. This 6-months’ notice letter therefore sets out the Trusts request to work with specialist and CCG commissioners, and Monitor, in agreeing new and fairer tariffs for cancer care; in line with the published guidance. In addition local price modifications based on a cancer diagnosis for all national tariffs, for use in the 2014 / 15 contracts may also be required.
New hospital development in Sutton
In the past 4 years the Trust has invested £170m in capital development for advancement of cancer care and translational research. Over the next 10 years the Trust has prepared plans to invest a further £280m. In line with these plans the Trust is preparing an outline business case for a new hospital development on its site in Sutton. This will be shared at an early stage with Commissioners in the next few weeks.
This £80m capital development will be funded from the Trusts own capital replacement funds, long term borrowing and charitable sources. The Trust would like to discuss and agree with its Commissioners potential options for acquiring land and buildings on the Sutton Hospital site as part of the capital build programme.
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The Trust expects to fund the revenue costs of the new capital development and services provided in it mostly from its current NHS revenue streams and from new commercial and research activity. However early analysis indicates that local commissioner support for approximately £21m over the first 7 years would be required. Discussion on this investment could be aligned with the work on delivering fairer cancer tariffs already noted.
Molecular Diagnostics
Expanded use of molecular diagnostics provides a significant opportunity to improve treatment and outcomes for cancer patients whilst reducing wastage and improving value for taxpayers. The Trust already carries out a significant volume of mainstream tests for which it is unable to recover costs, since there is no tariff in place for such tests. Current funding from pharmaceutical companies is finite and the Trust therefore requests Commissioners support in order to continue to provide these critical services to patients.
Service design and reconfiguration
The Trust fully recognises the finite amount of resources available and the pressures faced by Commissioners in funding a nationally increasing level of activity across the NHS. In light of this, the Trust believes that innovative ways of working are required and would like to discuss these with Commissioners.
Specifically:
. The London Cancer Alliance - following the creation of the London Cancer Alliance in 2012, RMH has played a key role in developing clinically led pathway redesign groups. This will impact across the entire patient pathway.
. Coordinate My Care (“CMC”) - CMC is a clinical service developed by the Trust to encourage patient choice, preserving dignity and autonomy at the end of life and provides a care service that enables health professionals from primary, secondary and community care to put the patient at the centre of health care delivery. Where patients have a CMC record, 79% of them die in their preferred place of death and over 80% of deaths occur outside of the acute setting. The Trust’s CMC team is currently working with each CCG across London to implement QIPP plans, which rollup to a potential £46m saving across London if 50% of End of Life Care patients have a CMC record across London.
. Surgical Strategy review – the Trust is currently undertaking a full scale review of its surgical portfolio to identify and implement short and long term changes to improve efficiency and quality of care, including the consideration of a new model of care moving patients away from CCU where it is right and appropriate to do so.
. Sutton and Merton Community Services – the Trust has provided community services in Sutton and Merton since April 2011 (as commissioned by Sutton and Merton CCGs, the London Boroughs of Sutton and Merton and NHS England) under a block contract arrangement. The Trust will be notifying Commissioners of its intentions relating to these services under a separate notice letter.
. Outsourcing of Pharmacy services - the Trust has carried out extensive research and project planning into the potential outsourcing of pharmacy services (and the benefits of such in terms of patient experience and efficiencies for Commissioners) and would now welcome Commissioner involvement in the development of a joint homecare strategy for cancer patients.
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. Improvements in diagnostic imaging – the dramatic improvements in imaging available have led to an increase in diagnostic activity within the Trust (and therefore an associated increase in cost). However, the increased use of diagnostic imaging and its ability to assist with early cancer diagnosis, define disease extent, provide a roadmap for therapy planning and guide intervention enables much more efficient treatment overall.
Decommissioning
The Trust is fully aware that NHS funding is increasing only very slowly in real terms and that commissioners are required to operate with finite funding allocations. The Trusts extensive engagement in service redesign and transformation is evidence of our commitment to supporting commissioners in this task.
The Trust has also been developing its service line reporting and patient level costing systems in order to understand the impact of cancer tariffs and clinical decision making on its underlying service and financial sustainability. A clearer picture is emerging for where risk is greatest; but it is not yet clear how much progress can be made in reforming the cancer tariff for 2014 / 15.
Since the national tariff for cancer funds (on average) only 80% of the costs of all cancer care, and since the Trust as a specialist provider cannot subsidise these losses with surpluses from other NHS services, this letter provides notice that the Trust may seek commissioner support for taking some services outside the NHS contract and tariff regime [For the purposes of the 6-months’ notice letter only this applies to all NHS Services provided at the Trust]. This might also involve realigning capacity and hospital resource allocation to achieve a more sustainable outcome.
Please be assured that patients, their care, and their experience of care continue to be our highest priority.
The Appendix to this letter sets out potential changes occurring at individual service levels within the Trust which will be supported by detailed activity and financial data where required.
We look forward to working with Commissioners going forward. Please do not hesitate to contact me if you require any additional information or clarification.
Yours sincerely
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Appendix 2 – fair tariffs for Cancer activity
Problem definition
The working group has been developing a number of tariff themes:
i. Tariff currency - National average tariffs (using HRGs) are largely based upon procedures undertaken rather than on the diagnosis of the patient - cancer is, of course, a diagnosis, not a procedure. This often means that procedures will cost considerably more to deliver when the patient has cancer. This problem is fundamental because many services (particularly surgery) provided to cancer patients as part of PBR can also be provided to patients without a cancer diagnosis. In the past this has resulted in top-up arrangements being implemented; such as for children’s services; but there is no such top-up currently in place for cancer.
ii. Tariff coverage - Most patients with cancer are receiving treatment and care for long periods; but this care is not always associated with procedures. Tariff does not adequately cover inpatient spells associated with only limited, or even no, procedures.
iii. Care complexity – cancer services provision is likely to be more complex with multiple co-morbidities a factor in treatment planning and delivery. Cancer is not necessarily the most complex or expensive activity; but given its prevalence and the diversity of provision the impact of poor tariffs is much greater.
iv. Outpatient follow-up tariffs – tariffs applied to outpatient follow up appointments are discounted, compared to their underlying reference cost, in part to incentivise providers to discharge patients more quickly. This mechanism is often inappropriate for cancer care where services are provided using protocols requiring longer follow up care pathways and where costs of follow up during active treatment are at least as much as the first appointment. This problem could potentially be solved quite quickly within PBR tariff rules.
v. Impact of private patient income netted off from NHS tariff – we recognise and welcome the change in approach to collection of private patient costs as part of the 2013 / 13 reference costs return. This will help Monitor to understand the gross cost of providing NHS cancer care. Given that this issue has been identified and acknowledged, it is important that its impact is adjusted quicker than the 3-year delay between reference costs collection and tariff implementation.
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Next steps
These issues are sometimes complex and often poorly understood. The working group will shortly be publishing a range of audience relevant briefings in advance of an engagement event for key stakeholders. This is being planned, in association with UCL Partners, to develop a consensus for the changes required.
In addition to an open invitation to join the engagement event, the working group has invited Monitor and DH to share the more detailed findings of the work we have undertaken to date and to discuss how we might work together going forwards to improve the national tariff for patients and the health economy.
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COUNCIL OF GOVERNORS PAPER SUMMARY SHEET
Date of Meeting: Agenda item
14th May 2014 Item 7.2
Title of Document: To be presented by
Financial Report 2013/14 Alan Goldsman, Director of Finance Executive Summary
This report provides a brief summary of the Trust’s unaudited financial results for the 12 months ended 31st March 2014.
Author: Contact Number or Date: E-mail: Alan Goldsman, Director of Finance 8th May 2014 2151 PA
THE ROYAL MARSDEN NHS FOUNDATION TRUST
FINANCE REPORT – 12 MONTHS ENDED 31st March 2014
1) Introduction
This report provides a brief summary of the Trust’s unaudited financial results for the 12 months ended 31st March 2014.
2) Summary
The Trust is in the final stages of preparing its accounts for audit and expects to be reporting a surplus for development of £11.1m for the year ended 31st March 2014 (plan £16m). The Trust has maintained a Continuity of Services Risk Rating of 4 (out of 4) in line with plan. Surplus for Development £18 £16 £14 £12 £10 £8 £6 £11.7 £11.2 £11.1 £10.6 £9.3
£4 £8.8 £8.1 £7.3
£2 £5.9 £4.4 £1
£0 £0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Actual Plan
The Trusts financial performance in 2013 / 14 been achieved by delivering increased activity and income (above plan and above previous years volumes); but with costs for this activity and for key areas of financial pressure (in particular for temporary staffing) creating an underlying financial risk. Planned reductions in temporary staffing costs and increasing private care over the final quarter have had limited success and surplus performance has been flat since December.
The Trusts capital programme has been either delayed or reprioritised within this reduced financial surplus so that (despite earlier concerns) the Trusts cash position has been improved at year end. Note that this reprofiling / prioritisation is reflected in the Operational Plan for 2014- 16 recently approved by the Board.
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3) Cash The chart below shows the cash balance at the end of March (£20m) using the scale on the left hand axis and the liquidity days for the Trust, using the scale on the right. The balances over the last 12 months are shown for reference:
Cash and Liquidity
£25.0 35
30 £20.0 25
£15.0 20 £m
15 Days £10.0
10 £5.0 5
£0.0 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Cash £15. £12. £10. £10. £9.0 £11. £9.5 £10. £6.6 £7.5 £18. £20. Liquidity 18 19 21 24 25 27 27 30 29 29 27 28
The Trusts liquidity since the start of the year has improved steadily in line with the improving surplus; with some flattening off over the last quarter. The key concern has been late payment by NHS commissioners; with a very dramatic improvement in the last few weeks of the year when (we believe) the Commissioner allocations have become clearer. There is limited confidence that this pattern will not be repeated in 2014 / 15 and the Trust is taking all reasonable steps to avoid using its working capital facility; in particular by preserving cash over the first and potentially second quarters by deferring expenditure where it is safe and sensible to do so. 4) Capital
The table below shows capital expenditure against the re-forecast plan, covering both NHS and Charity funded schemes.
Capital Performance (figures in £000)
YTD Revised YTD Plan YTD Variance Annual Plan Actual NHS Internally Financed 7,008 7,008 5,778 1,230 Loan Financed 11,655 11,655 4,354 7,301 Donated 3,165 3,165 2,307 858 Total 21,828 21,828 12,439 9,389
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Where possible schemes financed from internal resources (mostly for IT £1.5m) have been deferred or re-prioritised. For the loan finance schemes there are two major items of equipment purchased in April 2014 rather than March 2014 that explain the variance.
5) Revenue
The summary financial position is reported in the Appendix; showing £11.1m surplus available as a ‘development reserve’ for the capital programme. The capital expenditure item above shows £5.8m expenditure from internally generated resources, with the balance explaining in part the improvement in cash reported earlier.
5.1) Income
Operating income is £16m more than planned; a small increase in the over-performance trend over the last quarter compared to the first three-quarters. This is mostly explained by the Cancer Drugs Fund and on other drugs lines where costs are invoiced outside of the PBR Tariff arrangements without any contribution to Trust overheads or surplus. Although this does not represent a financial risk to the Trust in the short term there is evidence that NHS England has significantly under estimated the funding consequences of decisions made to include these drugs on the approved schedule. This has been estimated elsewhere at over £80m excess cost nationally and may be one reason why NHS England has not yet confirmed contract values for 2014 / 15 (see contract item elsewhere on this agenda). Private patient activity has significantly increased; in particular with the ward at Chelsea available for a full year. Results show an additional £8m income (14%) to £67.8m in the full year. Set against this the planned improvement in data capture for billing (£2m) has not delivered the margin envisaged in the plan (as part of the efficiency programme). This explains, in part, why the Trusts overall revenue surplus has not met its target level. 5.2 Expenditure
Operating expenditure is £20.4m adverse to plan at year end; a significant component of which is explained by the costs of drugs noted above and at no short term risk to the surplus margin. Other than this the key variances are as follows; . Expenditure on staff employed through agencies has increased by £2m (25%) to £10.2m. Elsewhere staffing costs has increased by a further £6.8m (5%) to £150.8m. Since there was no general pay uplift for staff during the year this is explained by salary increments (under national pay arrangements) for those staff not yet at top of scale, and use of the Trusts own staff ‘bank’ where volumes have also increased significantly.
The most acute areas for staffing cost have been in nursing, medical, pharmacy, histopathology and clerical grades.
. Clinical Services Division (£3.6m adverse) – of this variance approximately one-third is explained by pay costs already noted above. The balance is broadly explained by activity
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growth; some of which is associated with NHS activity that is not adequately compensated under the NHS payments system and some with unplanned / unfunded changes where the controls in place have not been sufficient to prevent this.
The Trust has broadly been successful in meeting its efficiency target; with the exception of the PP data collection and billing already noted, and for procurement, where approximately £600k out of a targeted £1m price reduction was delivered. There is however a more than compensating (procurement driven) improvement of approximately £2m on capital schemes.
6) Conclusion
The Trust has maintained a low risk financial rating over all of 2013 / 14 but at some cost to delivering its medium term capital programme; where schemes have been deferred or reprioritised within the reduced surplus available. The cash position has been strengthened over the year; although this has only been realised very late in the year and the position has fallen below our internal management target at times. Managing cash will remain a particular focus during at least the first 6-months of 2014 / 15 where expenditure will be deferred if it is safe and sensible to do so. The are no new consequences for the Operational Plan 2014 – 16 resulting from these full year results however improvements in use of staffing agencies and controls in clinical support services will be prioritised within the two-year efficiency programme set out in the Operational Plan.
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Annual Year to Date Budget Budget Actual Variance £'000 £'000 £'000 £'000
Operating Income 148,941 NHS Clinical Income 148,941 157,606 8,665 34,882 NHS Community Services 34,882 34,751 (132) 67,404 Private Patient Income 67,404 68,109 705 24,565 Research and Development 24,565 25,232 668 42,467 Other Operational Income 42,467 48,579 6,112 ______318,259 Total Operating Income 318,259 334,277 16,018
Operating Expenditure 78,704 Cancer Services 78,704 80,651 (1,947) 76,464 Clinical Services 76,464 80,087 (3,623) 31,873 Community Services 31,873 32,510 (637) 19,867 Private Patients 19,867 22,483 (2,616) 43,915 Other Divisions 43,915 44,190 (275) 46,835 Other Operating Expenditure 46,835 58,106 (11,271) ______297,658 Total Operating Expenditure 297,658 318,026 (20,368)
______20,601 EBITDA 20,601 16,251 (4,350) ______
4,609 Dividend Payable / Interest 4,609 5,163 (554)
______15,992 Development Reserve 15,992 11,089 (4,904) ______
6,236 Depreciation / Donated Capital Income 6,236 9,429 (3,193)
______9,757 Retained (Surplus)/Deficit 9,757 1,660 (8,097) ______
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COUNCIL OF GOVERNORS PAPER SUMMARY SHEET
Date of Meeting: Agenda item
14th May 2014 Item 8.1
Title of Document: To be presented by
Key Performance Indicators Q4 Nicky Browne, Director of Performance and Strategy Implementation
Executive Summary
This paper is to provide the Council with an update on the Trust’s performance for quarter 4 2013/14.
Author: Contact Number or Date: E-mail: Nicky Browne, Director of Performance 8th May 2014 and Strategy Implementation 8024 PA
THE ROYAL MARSDEN NHS FOUNDATION TRUST
COUNCIL OF GOVERNORS
KEY PERFORMANCE INDICATORS
QUARTER 4 2013/14
1. PURPOSE
This paper is intended to provide the Council of Governors with an update on the Trust’s performance for quarter 4 2013/14.
The report includes the balanced scorecard for the Trust and a commentary on the red-rated indicators in the quarter 4 report and actions underway to improve performance.
Please note that the quarter 3 data item for Hospital Standardised Mortality Ratio is not included in the scorecard. Dr Foster has updated the baseline period, meaning HSMR figures against this new baseline cannot be compared to previous figures.
The Scorecard, including its KPIs and definitions and thresholds will be reviewed during quarter 1 and 2 2014/15 to ensure the indicators remain relevant and up to date.
2. PERFORMANCE FOR QUARTER 4
Attachment 1 shows the balanced scorecard report for quarter 4 for 2013/14.
As agreed a commentary is only provided for indicators where performance is ‘red’ rated.
(NB ▲ shows improvement from the previous quarter, ►◄ shows no change and ▼ shows deterioration).
3. Quality Account Indicators
The quality account indicator is rated red in quarter 4 due to the total number of cases of C diff for 13/14. The total number of cases was 19 against the Trust’s annual DoH trajectory of 11 and the Monitor de minimus target of 12 cases. New guidance was issued by the DoH in February 2014 which clarified what should be reported in terms of C diff cases. Importantly this guidance acknowledged that there would always be groups of patients with C diff colonisation and identified the need to move away from year-on-year reduction targets to reducing numbers of avoidable C diff.
There was also 1 case of MRSA for the year to date against a national standard of zero tolerance. This was the first case of MRSA at The Royal Marsden since October 2011 and a full root cause analysis has been carried out. Please note that this does not impact on the Monitor Governance Risk Rating score as Monitor has a de minimus of 6 for MRSA cases.
Please note that the 1 serious incident reported in quarter 3 was deescalated.
4.0 Cancer Waiting times targets
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At the time of submission to CoG (30 April 2014) the Cancer Waiting Times data is not yet available and therefore the draft quarter 4 position has been included in the dashboard.
The Trust met all cancer waiting times targets, including the 62 day GP urgent referral standard (following reallocations in line with the London Cancer Alliance reallocation policy).
4.1 Zero tolerance on 52 week waiters – 2 breaches
The Trust had two 52 week breaches (incomplete 18 week pathways) reported in quarter 4. This was attributable to one patient within the Sarcoma tumour group, who was waiting more than 52 weeks in January and February. The patient was on a benign pathway and was delayed due to patient fitness as an assessment needed to be carried out at The Royal Brompton. There was then a further delay due to patient choice as the patient wanted to wait for treatment. The patient was treated at the beginning of March.
The full milestone report for the patient was analysed and presented to the Trust’s Clinical Quality Review Group (chaired by NHS England), which agreed the Trust should not be fined as the circumstances were out of the Trust’s control.
Forecast: The Trust does not currently have any 52 week waiters.
4.2 Asset utilisation
4.2.1 Theatre utilisation Sutton – Q4 performance 52% , target 80%
The underlying utilisation figures reflect the long-standing function of the theatres at Sutton, namely a mixed case-load including line placement, dermatology, bronchoscopy, paediatrics and breast surgery.
These issues and actions have been discussed in previous reports submitted to the Board and Council of Governors and it is important to note that the theatres are staffed in line with activity.
4.2.2 Number of inpatients discharged whose LOS >15 days – Q4 performance 273, target <200
The Trust actively manages all long-stay patients in the hospital ensuring that tests and treatment are carried out in a timely manner so patients are not kept in hospital any longer than they need to be. In addition there is a financial and patient satisfaction imperative in keeping patients’ lengths of stay to a minimum. All patients with a length of stay of greater than 10 days are reviewed and reported to the Trust Senior Management Team, including clinical leads, enabling a review of all treatment and care planning for long stay patients.
There are a number of work streams focused on reducing length of stay overseen by a Project Board which are detailed below. This Project Board is now being restructured to also look more proactively at patient journeys across the wider health economy to ensure, where appropriate, the repatriation of patients to hospitals and healthcare providers closer to their home.
• A daily tracking and alert system for all patients extending their estimated length of stay. This system requests the reasons for extending stay, the discharge plan and
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consultant and senior team engagement in any problems with discharge or appropriate repatriation
• Tracking and performance managing extended length of stay with the introduction of a formal MDT review of all patients staying over 21 days by the consultant lead of the patient and the Divisional Medical Director for Clinical Services
• Piloting a bedside information system to ensure patients are aware of their discharge date and what is being arranged to support their discharge.
• Efficient discharge & TTO process (take home drugs) with the development of a protocol for nurse-led discharge
• ‘Enhanced Recovery Programme’ for certain cohorts of patients undergoing surgery (now extended to Urology, GI and other surgical specialties)
• Shifting the standard model of care from the inpatient setting to ambulatory care particularly in the haemato-oncology practice
• Increasing admission on the day of surgery
• 23 hr breast surgery for patients undergoing breast surgery without reconstruction as an mandated plan unless appropriate clinical needs outlined
• The Trust is now set to refresh its benchmark of length of stay performance against national peers by procedure type to ensure performance levels are at least as good as the higher percentile providers.
• Surgical strategy includes initiatives to improve length of stay, including cohorting short stay surgical patients to drive improvements in length of stay
4.3 Actual recruitment vs. target recruitment (commercial interventional clinical trials) – Q4 performance 58.5%, target >85%
The Trust’s performance for quarter 4 2013/14 is 58.5%.
Actions to improve performance have been reported to the CoG previously:
• Performance Coordinator attends Senior Trial Coordinator meetings to provide updates on the Trust’s performance. This allows research teams to see the impact of their continued work and provides a ‘Q & A’ forum to answer queries and consolidate the importance of the benchmarks.
4.4 Workforce The overall mandatory training compliance rate for quarter 4 2013/14 is the highest ever reported at 80%. This improvement has been achieved following significant and sustained efforts to support managers and staff in completing their mandatory training including the implementation of the WIRED mandatory training reporting system; providing increased and different options for training including e-learning; and confirming responsibilities and processes for compliance monitoring. A continued focus on mandatory training monitoring and completion is needed to ensure these rates are sustained and increased to meet the compliance target.
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4.4.1 Appraisal and PDP rates (including doctors) – Q4 performance 74%, target 85%
The appraisal and PDP rate in quarter 4 has reduced to 74% from 81% in the previous quarter, following a significant increase over the last year. A review of the data to be recorded has identified a small backlog but this does not account for the scale of the decrease. Managers are being asked to continue to focus on this as a priority area and to monitor compliance rate to drive the rate up.
ATTACHMENT 1 - Balanced Scorecard Report for Quarter 4 2013/14
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BALANCED SCORECARD end Q4
1. To achieve the highest possible quality standards for our patients, exceeding their expectations, in terms of outcome, safety and experience
Patient Safety, Quality & Experience Trend Q4 Actual from Q3 Q3 Actual Monitor governance risk rating TBC n/a
Quality Account indicators ►◄
Serious incidents (excl pressure sores) 0 ▲ 1
Mortality Hospital Standardised Mortality Ratio (1 qtr in arrears) - Q3 data blank as new method of measurement 88.8% 30 day mortality post surgery 0.9% ▼ 0.5% 30 day mortality post chemotherapy 0.3% ▲ 0.4% 100 day HSCT mortality in previous 6 months (Deaths related to SCT) 4.2% ▼ 3.9% 100 day HSCT mortality in previous 6 months (All deaths) 5.8% ▲ 7.7%
Cancer staging Staging data completeness sent to Thames Cancer Registry (1 qtr in arrears) 74% ►◄ 74%
Patient satisfaction Inpatient 87.0% ▼ 88.6% Outpatient 84.3% ▼ 85.0% Day Unit 89.9% ▲ 89.7% Waiting times for day chemotherapy (over 3 hrs) 12% ►◄ 12% % of formal complaints reopened (indicator under review) Mixed sex accommodation breaches 0 ►◄ 0 PP access to single rooms - Chelsea % 99.6% ▼ 99.8% PP access to single rooms - Sutton % 99.2% ▼ 99.5%
Cancer waiting times targets 2 wk wait from referral to date first seen: all cancers 97.0% ▼ 97.8% symptomatic breast patients 94.3% ▼ 95.8% 31 day wait from diagnosis to first treatment 99.2% ▲ 99.1% 31 day wait for subsequent treatment: surgery 97.9% ▲ 97.0% drug treatment 99.5% ▼ 100.0% radiotherapy 99.5% ▼ 99.7% 62 day wait for first treatment: GP referral to treatment (reallocated) 86.7% ▼ 89.7% screening service referral (reallocated) 91.5% ▲ 87.5%
Referral to treatment waiting times Maximum time of 18 wks from referral to treatment - admitted 96.0% ▲ 94.9% Maximum time of 18 wks from referral to treatment - nonadmitted 98.5% ▼ 99.0% Maximum time of 18 wks from referral to treatment - still waiting 97.9% ▲ 97.7% No of patients waiting > 52 wks(Sum of monthly snapshot totals) 2 ►◄ 2
2. To improve the productivity and efficiency of the Trust in a financially sustainable manner, within an effective governance framework
Trend Finance & Efficiency Q4 Actual from Q3 Q3 Actual Monitor Continuity of Services Risk Rating 4 ►◄ 4 Capital Servicing Capacity (times) 4.0 ▼ 5.1 EBITDA Margin (%) 4.9% ▼ 6.1% Achievement of planned year to date operating surplus (%) 79% ▼ 101% NHS activity Income Variance (£000) 2,972 ▲ 2,441 PP activity Income Variance (£000) 601 ▼ 767 Liquidity (days) 27.5 ▲ 26.0 Achievement of Efficiency Programme (%) 89% ▼ 90% CQUINS % achievement (acute) TBC 100%
Asset utilisation Bed occupancy - Chelsea 85% ►◄ 85% Bed occupancy - Sutton 84% ▲ 80% Theatre utilisation - Chelsea 88% ▲ 82% Theatre utilisation - Sutton 52% ►◄ 52% Utilisation of diagnostic radiology 28500 ▲ 27495
Delivering or exceeding Target Improvement ▲ Underachieving Target No change ►◄ Failing Target Deterioration ▼ 3. To deliver the Trust's clinical and research strategy; redefining our market position to better meet the needs of patients and commissioners, and increasing market penetration
Trend Clinical and Research Strategy Q4 Actual from Q3 Q3 Actual New referrals Total new referrals 5660 ▲ 5279 Total GP referrals 2592 ▲ 2272 GP referrals - urgent suspected cancers for diagnosis 1547 ▲ 1385 Referrals from Surrey 1030 ▲ 966
RMH market share annually measured 2011/12 ►◄ 2011/12 RMH market share - England (planned cancer admissions) 2.30% ►◄ 2.30% RMH market share - London (planned cancer admissions) 14.10% ►◄ 14.10%
Personalised care - building molecular diagnostics Internal referrals 813 ▲ 770 External referrals 806 ▲ 780 CRUK Stratified Medicine Programme (awaiting phase 2) 94 216
Private care PP inpatient beddays and regular day attenders - Chelsea 4103 ▼ 4187 PP inpatient beddays and regular day attenders - Sutton 1688 ►◄ 1668
Efficient clinical models No of inpatients discharged whose LOS > 15 days 273 ▼ 258
Research 70 day target (for externally sponsored trials only) % studies recruiting 1st patient within 70 days 73% ▲ 71% Accrual to target % actual accrual vs target accrual 59% ▲ 57%
4. To recruit, retain and develop a high performing workforce to deliver high quality care and the wider strategy of the Trust
Workforce Trend Q4 Actual from Q3 Q3 Actual Human Capital - workforce establishment Bank & agency as % of total FTE 13.0% ▼ 12.7% Agency as % of total pay bill 5.9% ▼ 5.3%
Workforce productivity Vacancy rate 8.0% ►◄ 8.0% Staff turnover rate 11.8% ▼ 11.1% Sickness rate (thresholds to be set) 3.2% ▼ 2.8% Consultants job plans 94% ▲ 92% Junior doctor rota compliance 100% ►◄ 100%
Quality & development Consultant appraisal (number with current appraisal) 84% ▲ 83% Appraisal & PDP rate 74% ▼ 81% Statutory and Mandatory Staff Training 80% ▲ 77%
Employee experience annually measured Staff survey indicators (annual) 3.95 ►◄ 3.95 Staff job satisfaction (annual) 3.71 ►◄ 3.71 Staff who would recommend RMH as place to work 73.4% ►◄ 73.4%
Delivering or exceeding Target Improvement ▲ Underachieving Target No change ►◄ Failing Target Deterioration ▼
COUNCIL OF GOVERNORS PAPER SUMMARY SHEET
Date of Meeting: Agenda item
14th May 2014 Item 8.2
Title of Document: To be presented by
Quality Accounts for March 2014 Shelley Dolan, Chief Nurse
Executive Summary
The monthly Quality Account reports the current Trust performance against the targets for 2013/14 described in the Annual Quality Account (2012/13) under the following three nationally agreed categories:
• Safe care • Effective care • Patient experience
Recommendations
The Council is invited to note the performance of the Trust against the agreed national and local quality targets for March 2014, and the actions being taken.
Author: Contact Number or Date: E-mail: Shelley Dolan, Chief Nurse 8th May 2014 2121 PA
The Royal Marsden NHS Foundation Trust Quality Account for March 2014 Dr. Shelley Dolan, Chief Nurse
1.0. Introduction
The monthly Quality Account reports the current Trust performance against the targets for 2013/14 described in the Annual Quality Account (2012/13) under the following three nationally agreed categories:
• Safe care • Effective care • Patient experience
2.0. Safe Care
2.1. Reduction in Healthcare Associated Infections (MRSA bactereamia and C Difficile infections)
Target: <11 C Difficile infections and <1 MRSA bactereamia
Performance: Table 2.1 shows that the Trust had three attributable C Difficile (CDI) cases in March 2014. As shown in the table below the target this year for the Trust is 11 cases of CDI and therefore the Trust has now breached its target. The Chief Nurse has previously updated Monitor, NHS England (London region) and the Board on the challenge of achieving this target each year as the target number decreases. Cancer patients are particularly susceptible to CDI for the following reasons:
• Damage caused to the gut lining by radiotherapy and or chemotherapy • The requirement for multiple antimicrobials due to the immunosupression caused by the cancer and its treatment. • Long periods of hospitalisation and acute care.
From April 2014 there is new guidance from NHS England which mandates that all CDI positive patients are reported. However in recognition of the concern across England with this particular target and monetary penalties imposed on Trusts where the CDI has been unavoidable, there is a new system whereby each CDI will be discussed with the relevant commissioners who will then decide whether it was avoidable or unavoidable and therefore whether a penalty should be levied. The CDI target for The RM for 2014/15 is 16 cases. It should be noted that all of the cases in 2013/14 would appear from the analysis to be unavoidable.
There have been no cases of Methicillin Resistant Staphylococcus Aureus (MRSA) for January
Table 2.1
No. Organism RMH Attribut RMH attributable able to Annual March2014 RMH Trajectory 1 YTD 1. MRSA 0 0 *0 bactereamia
2. C.Difficile 3 19 11
3. CPO 0 8 n/a Carbapenama se-producing organisms
*MRSA has a target of zero but Monitor has a de minimus of six cases.
2.2. Rate of patient safety incidents and percentage resulting in severe harm or death
To include: • Reduction of severe/moderate risk medication errors • Reduction of harm from falls
Target: Reduction in the rate of patient safety incidents per 100 admissions and the proportion that have resulted in severe harm or death
Performance:
2.2. (1) Reduction in Falls
Target: < 0.7 moderate risk (resulting in harm) falls per 1000 bed days Year to date – April to March 2014 the Trust has met the target.
2 Patient Fall Incidents
Analysis of data between years reviewed at Falls Steering Group, conclusions may differ from data below 45
40
35 33 32 31 31 30 30 29 29 29 29 29 29 29
27 26 25 25 25 24 23 23 22 22 22 22 22 21 21 21 20 20 20 20 20 19 Number ofNumber Incidents 18 18 17 17 16 16 16 16 15 15
12 12 11 11 10 10 9 8 8 7 6 5 5 5 5 3 3 3 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2010 04 2010 05 2010 06 2010 07 2010 08 2010 09 2010 10 2010 11 2010 12 2010 01 2011 02 2011 03 2011 04 2011 05 2011 06 2011 07 2011 08 2011 09 2011 10 2011 11 2011 12 2011 01 2012 02 2012 03 2012 04 2012 05 2012 06 2012 07 2012 08 2012 09 2012 10 2012 11 2012 12 2012 01 2013 02 2013 03 2013 04 2013 05 2013 06 2013 07 2013 08 2013 09 2013 10 2013 11 2013 12 2013 01 2014 02 2014 03 2014 Near Miss All Other Patient Fall Incidents
3 Severity: Harm as a % of all Patient Fall Incidents
Analysis of data between years reviewed at Falls Steering Group, conclusions may differ from data below 80%
70%
60%
50%
40% % of Patient Fall Incidents Fall Patient of % 30%
20%
10%
0% 2010 04 2010 05 2010 06 2010 07 2010 08 2010 09 2010 10 2010 11 2010 12 2011 01 2011 02 2011 03 2011 04 2011 05 2011 06 2011 07 2011 08 2011 09 2011 10 2011 11 2011 12 2012 01 2012 02 2012 03 2012 04 2012 05 2012 06 2012 07 2012 08 2012 09 2012 10 2012 11 2012 12 2013 01 2013 02 2013 03 2013 04 2013 05 2013 06 2013 07 2013 08 2013 09 2013 10 2013 11 2013 12 2014 01 2014 02 2014 03
% Harm
4 Severity of Patient Fall incidents:
Severity - Current Period 2013 2013 2013 2013 2013 2013 2013 2013 2013 2014 2014 2014 Tota 04 05 06 07 08 09 10 11 12 01 02 03 l None / Insignificant 16 11 18 12 20 16 22 16 15 13 19 10 663 Low / Minor (Minimal harm) 6 9 11 4 5 9 5 6 7 8 3 9 397 Moderate (Short term harm) 0 0 2 0 0 2 1 1 1 0 0 1 31 Severe / Major (Permanent or long term harm) 0 0 0 0 0 0 0 0 0 0 0 0 1 Death / Catastrophic (Caused by the incident) 0 0 0 0 0 0 0 0 0 0 0 0 0 Totals: 22 20 31 16 25 27 28 23 23 21 22 20 1092 % Harm 27% 45% 42% 25% 20% 41% 21% 30% 35% 38% 14% 50% 39%
2.2. (2) Reduction in medication errors
Target: To increase the reporting of near misses and decrease the incidents that cause actual harm (low<2 per 1000 bed days and moderate <0.17 per 1000 bed days).
N.B. To place medication errors in perspective, annually 0.05% of all medicines administered result in a medication error. For March 2014 this is 0.03%
5
Medication Incidents
Analysis of data between years reviewed at Executive Medications Safety Group, conclusions may differ from data below 120
106 100
91
85 80 76 77 74 74 73 71 68 65 64 65 63 63 62 60 60 57 56 55 54 55 55 54 51 52 52 51 50 50 49 49
Number of Incidents 48 48 46 45 44 45 40 41 35 33 33 31 29 28 26 26 25
20 19 18 17 17 14 14 15 12 12 12 13 10 10 10 11 10 10 10 11 11 10 10 11 11 11 9 9 8 8 8 9 8 6 7 6 7 6 6 7 7 6 6 6 4 2 3 2 2 0 2010 04 2010 05 2010 06 2010 07 2010 08 2010 09 2010 10 2010 11 2010 12 2011 01 2011 02 2011 03 2011 04 2011 05 2011 06 2011 07 2011 08 2011 09 2011 10 2011 11 2011 12 2012 01 2012 02 2012 03 2012 04 2012 05 2012 06 2012 07 2012 08 2012 09 2012 10 2012 11 2012 12 2013 01 2013 02 2013 03 2013 04 2013 05 2013 06 2013 07 2013 08 2013 09 2013 10 2013 11 2013 12 2014 01 2014 02 2014 03
Near Miss All Other Medication Incidents
6
Severity: Harm as a % of all Medications Incidents
Analysis of data between years reviewed at Executive Medications Safety Group, conclusions may differ from data below 80%
70%
60%
50%
40% % of Medication Incidents Medication of % 30%
20%
10%
0% 2010 04 2010 05 2010 06 2010 07 2010 08 2010 09 2010 10 2010 11 2010 12 2011 01 2011 02 2011 03 2011 04 2011 05 2011 06 2011 07 2011 08 2011 09 2011 10 2011 11 2011 12 2012 01 2012 02 2012 03 2012 04 2012 05 2012 06 2012 07 2012 08 2012 09 2012 10 2012 11 2012 12 2013 01 2013 02 2013 03 2013 04 2013 05 2013 06 2013 07 2013 08 2013 09 2013 10 2013 11 2013 12 2014 01 2014 02 2014 03
% Harm
7
Severity of medication incidents:
Severity - Current Period
2013 2013 2013 2013 2013 2013 2013 2013 2013 2014 2014 2014 Tota 04 05 06 07 08 09 10 11 12 01 02 03 l None / Insignificant 55 61 66 97 63 56 86 54 44 49 53 44 2240 Low / Minor (Minimal harm) 27 18 20 22 20 19 16 16 12 13 19 12 747 Moderate (Short term harm) 2 0 0 2 2 4 0 3 2 3 1 1 70 Severe / Major (Permanent or long term harm) 0 0 0 0 0 0 0 0 0 0 0 0 4 Death / Catastrophic (Caused by the incident) 0 0 0 0 0 0 0 0 0 0 0 0 0 Totals: 84 79 86 121 85 79 102 73 58 65 73 57 3061 %Harm Medication Incidents 35% 23% 23% 20% 26% 29% 16% 26% 24% 25% 27% 23% 27%
Medication errors notes and actions:
• Omitted drugs and missed visits have reduced in the community since September and further again since December when the last community locality started using the T card system • A review of the ‘time and day of the week of medication incidents’ is currently being undertaken. • Further work has been completed to improve the Controlled Drug section of the Medication chart to aid safe prescribing.
2.3. Percentage of admitted patients risk assessed for Venous Thrombo-embolism (VTE)
Target: 95% have completed VTE risk assessments
8 Performance: The Trust consistently achieves >90% compliance with risk assessment (CQUIN target is 90%). All patients with confirmed VTE as reported by radiology undergo a Root Cause Analysis (RCAs). 98% of patients are achieving appropriate prophylaxis therefore we have reached our CQUIN target of 98%. The VTE steering board monitor all confirmed VTE and scrutinise the RCAs.
9
Percentage of admissions assessed for VTE ((number assessed + low risk admissions)/all admissions)
100.0%
90.0%
80.0% 70.0%
60.0%
50.0%
40.0%
30.0% 20.0%
10.0%
0.0% Jul-13 Jul-12 Jul-11 Apr-13 Apr-12 Apr-11 Oct-13 Oct-12 Oct-11 Jun-13 Jan-14 Jun-12 Jan-13 Mar-13 Jun-11 Jan-12 Mar-12 Jan-11 Mar-11 May-13 Feb-14 May-12 Feb-13 May-11 Feb-12 Feb-11 Aug-13 Nov-13 Aug-12 Nov-12 Aug-11 Nov-11 Sep-13 Dec-13 Sep-12 Dec-12 Sep-11 Dec-11 Dec-10 Mar-14 (draft)
3.0. Effective Care
3.1 Incidence of Trust acquired pressure ulcers
3.2.1 The number and severity of hospital acquired pressure ulcers are used internationally as a proxy for the effectiveness of care provision. Many people with cancer and or co-morbidity are more vulnerable to tissue damage for the following reasons; multiple hospital admissions, frailty, multiple drugs including high dose steroids (decreases skin elasticity), immobility, malnutrition or susceptibility to infection.
3.2.2 Data for this report was taken on 1st April (acute) and 3rd April (community services) 2014 from DATIX. Data may have been updated since then.
3.2.3 Total number of Trust acquired pressure ulcers for the month of March: 57 [acute=30, community services=27]
3.2.4 For serious incident reporting to Steis [Strategic Executive Information System] as Acute/Community Services acquired at category 3 and 4 for the month of March: 6 [acute=0, community services=6]
10 3.2.5 Number of Trust acquired category 3 and 4 pressure ulcers
Trust acquired category 3and 4 pressure ulcers, monthly totals April 2012- March 2014
14
12
10
8 acute 6 community services
4
2
0
Apr Apr Jul May June July Aug Sep Oct Nov Dec Jan Feb Mar May Jun Aug Sep Oct Nov Dec Jan Feb Mar
3.2.6 Number of Trust acquired pressure ulcers, all grades
Trust acquired pressure ulcers, all categories April 2012-March 2014
60
50
40
acute 30 smcs
20
10
0
June Aug Oct Dec Feb June Aug Oct Dec Feb Apr '12 April '13
11 3.2.7 Number of Trust acquired pressure ulcers per 1000 bed days (Royal Marsden hospital inpatients only)
The following table shows how many inpatients have acquired pressure ulcers per 1000 bed days. This does not include community services. The Trust 2013/14 target is <4 per 1000 bed days.
Trust acquired pressure ulcers (all categories) per 1000 bed days (hospital inpatients only) April 2012 - March 2014
6 5 4 3 2 1 0
2012 052012 062012 072012 082012 092012 102012 112012 122013 012013 022013 032013 042013 052013 062013 072013 082013 092013 102013 112013 122014 012014 022014 03
Description of European Pressure Ulcer Advisory Panel (EPUAP) pressure ulcer classification system.
EPUAP Description of Stage 1 Non blanching redness of intact skin 2 Partial thickness skin loss or blister 3 Full thickness skin loss (fat visible) 4 Full thickness tissue loss (muscle/bone visible)
Prevention of community acquired pressure ulcers actions
• Tissue viability nurses to clarify the category of pressure ulcers within 24 hours of reporting on datix and take the lead for the investigation of all categories 3 and 4 pressure ulcers in the community. • Ensure that at each pressure ulcer panel there is clinical representation from the patients’ localities to aid discussion and learning. • Every month to use the first of the fortnightly pressure ulcer incident panels to review the ongoing category 3 and 4 pressure ulcers’ action plan and update. • Identify the person who will feedback recommendations from each panel to the local clinical team, as well as sharing cross cutting issues with the wider staff audience. • Community nurse managers to be emailed weekly a collated list of category 1 and 2 pressure ulcers, to ensure that documented assessment and plans of care are in place and access to appropriate pressure relieving equipment, e.g. mattresses, offloading boots and cushions.
12 3.3. Emergency re-admissions to hospital within 28 days of discharge
Target: Reduction in the number of avoidable re-admissions to hospital within 28 days of discharge
Some emergency re-admissions following discharge from hospital are an unavoidable consequence of the original treatment, however some can be potentially avoided through ensuring the delivery of optimal treatment according to each patient’s needs, careful planning and support for self care. By 2012/13 Trusts will be expected to include in their Quality Account the percentage of patients of all ages and genders who were re-admitted within 28 days of being discharged; and the national average for the above percentage (NHS Operating Framework 2012/13). It is important to note that some readmissions will inevitably include patients who are admitted with side effects of treatment therefore it may be difficult to explain any differences between RMH with other acute Trusts.
Performance: Within 28 days of original admission there were the following emergency admissions:
Reported % of Emergency Readmissions
0.70%
0.60%
0.50%
0.40%
0.30%
0.20% % of eligible admissions resulting in an eligible re-admission eligible resulting in an admissions of % eligible
0.10%
0.00% Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13Month Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14
4.0 Patient Experience
4.1 Reduction in chemotherapy waiting times and improvement in patient experience related to waiting times
Target: Reduction in chemotherapy waiting times at Sutton/Chelsea and improvement in the patient experience related to waiting times
Performance: Data in the following graphs are for all chemotherapy attendances, for NHS and Private Patients.
13 Table 1: Chelsea chemotherapy waiting times
Table 2: Sutton chemotherapy waiting times
14
Table 3: Kingston chemotherapy waiting times
Scheduled Care for NHS Medical Day Units (MDU) – Chelsea and Kingston
Scheduled care has been in place in on the NHS MDU in Chelsea since December 2011 and NHS MDU in Sutton since March 2013. All patients attending the MDU are scheduled both for the outpatient and treatment parts of their attendance. Both MDUs aim to see patients within 30 minutes of their scheduled appointment time and within 1 hour of their scheduled treatment time.
Minimum waiting times
Sutton has approximately 44% more day unit activity (across all areas of research, private patients and NHS). In the table below there are differences at each site due to demand placed on the services
Minimum times for the various appointments are highlighted in the table below:
Type of Drug not Drug Drug Treatment manufactured manufactured manufactured on the same day on the same day on the same day not clinical trial and clinical trial
Minimum time between appointments 120 minutes 180 minutes 240 minutes
(Sutton)
Minimum time 90 minutes 180 minutes between
15 appointments
(Chelsea)
Long waiters
It is standard practice that all patients are treated on the 2-stop pathway, including patients on clinical trials where the protocol allows. As part of trial setup all sponsors are being challenged if they insist on patients being treated on the same day and routinely now only for clinical safety reasons and for drugs with short expiries would the 1-stop process apply. There is concern that there are still a small proportion of patients who wait in excess of five hours particularly at the Chelsea site. The Nurse Consultant for IV therapy has been asked to focus on this and attempt to reduce this wait. The Audit and Finance committee has also requested that the Internal Auditors explore this area in 2014. Further action will therefore be reported back to the Board and QAR over the next few months.
4.2 Ensure that we are responding to inpatient’s personal needs
The Friends and Family Test
The NHS “Friends and Family Test” was announced by the Prime Minister on 25 May 2012. All Trusts are expected to be “live” by the 1st April 2013. Nationally all patients will be asked a simple question to identify if they would recommend a particular A&E department or ward to their friends and family. The results of the test will be used to improve the experience of patients by providing timely feedback alongside other sources of patient feedback. It will highlight priority areas for action.
The Royal Marsden elected to be an early implementer site and therefore started collecting the data in February 2013. Outside all wards across the Trust is a Poster and Collection Box. All adult patients who have been an inpatient for more then one night are asked to complete the Friends and Family Test form and then to put it straight into the collecting box. Once a week the forms are collected and an external company collates and presents the data.
The national mandated question asked is:
“How likely are you to recommend our ward to friends and family if they need similar care or treatment?”
The patients then select their answer from the following Likert Scale:
Extremely likely; Likely; Neither likely nor Unlikely; Unlikely; Extremely unlikely; Don’t know.
The Royal Marsden has then chosen to add a second question:
What was good about your care and what could be improved?
Patients answer this question with free text comments.
16 March (508) responses
Following a lower response rate in February (119 responses) the methodology for collecting the cards that patients complete and place in the boxes was changed. Since then 508 forms have been collected in March and reported against.
Alongside positive comments 48 ( 9.4%) patients made suggestions for improvement. These were around food (improving the flavour of food, food served cold when should be hot, increasing variety of inpatient for a long time, breakfast served at 0900/0930 and then lunch at 12/1230), temperature of rooms (some found them too hot, some too cold), noise from other patients and visitors (TVs loud, left on for long periods), delays (waiting for drugs on discharge, waiting for treatment so start, getting to room on admission), occasionally mixed messages from staff (e.g. how long to wear stockings for), lack of communication about relatives after operation, privacy and dignity (one comment of an extra curtain needed around a bed space, one comment around doctors needing to observe privacy and lastly several comments about wi-fi running very slowly.
National FFT results reporting:
Inpatient data was collected for 170 Acute NHS trusts and independent sector providers.
Nationally, for February the overall average inpatient score for NHS trusts and independent sector was 73 with specialist hospitals scoring higher than general acute trusts.
In February, The Royal Marsden was in the top twenty percent of trusts nationally with a score of 87. The table below shows the results for the Trust over each quarter to date. At the time of reporting (8th April) national figures were available up to February 2014 only.
The Royal Marsden Q1 Q2 Q3 Q4 (to Feb) Overall FFT score 95 94 92 90 Response number 585 635 450 318
17
4.3 Frequent Feedback Survey Results
Frequent feedback survey results 2013-14
Each of the following charts show the results of the 2013-14 frequent feedback survey for either the last 12 months or as long as the survey has been running. The charts show the number of responses each month and what the score was against the target. The target is a stretch target imposed by the Trust and agreed by the Patient Experience group chaired by the Chief Nurse and composed of Governors and Staff.
1 Inpatients
15 - Have you found someone on the hospital staff to talk to about your worries and fears?
- - - Target Percent Positive
18 16 - Are you given enough privacy when discussing your condition or treatment
- - - Target Percent Positive
19
2. Medical day Unit- daycase
17 - Do you feel that the different people treating and caring for you (e.g. GP, hospital doctor, clinical nurse specialist, community nurses) are working closely together to provide you with the best possible care?
- - - Target Percent Positive
20
18 - Overall, do you feel you were treated with respect and dignity today?
- - - Target Percent Positive
21
31 - Were you given any notes or a record of your consultation to take away with you, explaining your treatment options and other information in more detail?
- - - Target Percent Positive
22 3. Outpatients
12 - If you had any worries or concerns about your condition or treatment, did you feel able to discuss them with the staff in charge of your care?
- - - Target Percent Positive
23
20 - Were you given enough privacy during your Consultation?
- - - Target Percent Positive
24
23 - Were you allocated a 'key worker', or someone to contact if you are concerned about your care/ treatment before your next appointment?
- - - Target Percent Positive
5.0. Board members are invited to note the performance of the Trust against the agreed national and local quality targets for March 2014, and the actions being taken. 25
26
COUNCIL OF GOVERNORS PAPER SUMMARY SHEET
Date of Meeting: Agenda item
14th May 2014 Item 8.3
Title of Document: To be presented by
Annual Quality Accounts for 2013 / 14 Shelley Dolan, Chief Nurse
Background
For the last four years the Trust has been required to produce an Annual Quality Account following the specific guidance issued by the Department of Health and Monitor.
Executive Summary
The enclosed paper is the draft Annual Quality Accounts to be discussed at the Council of Governors.
Author: Contact Number or Date: E-mail: Shelley Dolan, Chief Nurse 8th May 2014 2121 PA
Quality Account 2013/14
Contents
Part 1 What is a Quality Account? Statement on Quality from the Chief Executive
Part 2 Performance against priorities for Quality improvement 2013-14 Statements of assurance from the Board Priorities for the coming year for the Hospital
Priority 1- Reduction in Healthcare Associated Infections (MRSA bacteraemia and Clostridium difficile infections) Priority 2- Reduction in the rate of incidents resulting in severe harm or death Acute and SMCS Priority 3- Percentage of admitted patients risk assessed for Venous thromboembolism Priority 4- Reduction in community acquired pressure ulcers Reduction in community acquired grade 3 and 4 pressure ulcers: Applies to SMCS Priority 5- Increase in the number of patients who die in their preferred place – acute and community Priority 6- Increase in the number of patients who are offered a Holistic Needs Assessment Increase the numbers of patients who have an Holistic Needs Assessment Priority 7- Avoidance of emergency re-admissions to hospital within 28 days of discharge Priority 8- Reduction in chemotherapy waiting times and improvement in patient experience related to waiting times Priority 9- Responding to inpatient’s personal needs Priority 10- Staff recommending The Royal Marsden to friends and family. Patient Experience survey for SMCS Priority 11- Improve communication, particularly when patients arrive for first appointments Priority 12- Reduce the length of time a patient waits for medicines or equipment at the point of discharge Priority 13- The uptake of immunisation working in partnership with primary care
Part 3 Outline of Quality Improvements in 2013-2014 The quality priorities for 2014-2015 The quality objectives and priorities of the Trust for the last three years In summary for 2014-15 Statements of assurance from the Board
Part 4 Review of quality performance previous years performance Appendices Appendix 1: Quality Indicators where national data is available from the Health and Social Care Information Centre (data not available yet) Appendix 2: Statements from key stakeholders Appendix 3: Statement of Director’s responsibilities in respect of the Quality Account Appendix 4: Independent Auditor’s Assurance Report
1
What is a Quality Account?
All NHS hospitals or trusts have to publish their annual financial accounts. Since 2009 as part of the movement across the NHS to be open and transparent about the quality of services provided to the public, all NHS hospitals must publish a Quality Account. The public and patients can also view quality across NHS organisations by viewing the Quality Accounts on the NHS Choices website: www.nhs.uk
The dual functions of a Quality Account are to:
1. Summarise performance and improvements against the quality priorities and objectives we set ourselves for 2013/14. 2. Outline the quality priorities and objectives we set ourselves going forward for 2014/15.
Review of 13/14 Set out priorities Quality Information Quality Improvement 14/15
Look Back Look Forward
To begin with, we have detailed how we performed in 2013/14 against the priorities and objectives we set ourselves under the following categories: • Safe care • Effective care • Patient experience
Where we have not met the priorities and objectives that we set ourselves, we have explained why, and outlined the plans we have put in place to ensure improvements are made in the future.
Secondly, we have outlined our quality priorities and objectives for 2014/15 under the same categories. We have detailed how we decided upon the priorities and objectives we have set ourselves, and how we will achieve and measure our performance. The regulated Statements of Assurance are also included in this part of the report.
The Quality Account is an important document for the Board, which is accountable for the quality of the service provided by the trust and can be used in the scrutiny and leadership of the trust. Frontline staff are encouraged to use the Quality Account to compare or benchmark their practice with other trusts or, if comparable information does not exist to help improve their service.
For patients, carers and the public the Quality Account should be a document that is easy to read and understand, and highlights key areas of safety and effective care delivered in a caring and compassionate way. It should also show how a trust is concentrating on any improvements that can be made to care or experience; it is also hoped that it may also help patients with choice.
It is important to remember that some parts of the Quality Account are compulsory. They are about important areas –and generally they are presented as numbers in a table at the end of this Quality Account. If there are any areas of the Quality Account that are difficult to read or understand or you would like any help with the content, please contact us via our Patient Advice and Liaison Service (PALS) on 0800 783 7176 or online at www.royalmarsden.nhs.uk
2
The Quality Account is divided into four sections:
1. A statement on quality from the Chief Executive (CE) 2. Performance against priorities for quality improvement 2013/14 and statements of assurance 3. Outline of quality priorities 2014/15 and an explanation of who the trust has involved in determining the priorities including statements from key stakeholders such as Healthwatch (replaced Local Involvement Networks from April 2013), Health and Wellbeing Boards and the Commissioners of Services. It is important to note that with the new architecture of the NHS, The Royal Marsden NHS Foundation Trust will work more closely in 2014/15 with the two Clinical Commissioning Groups in Sutton and Merton to ensure that the Quality Account also reflects their needs. 4. Review of quality performance
3
Part one
Introduction to the Royal Marsden NHS Foundation Trust and a statement on quality by the Chief Executive
The quality of patient and family care and experience is central to all that we do at The Royal Marsden. The Royal Marsden NHS Foundation Trust is the largest comprehensive cancer centre in Europe and together with its academic partner the Institute of Cancer Research (ICR) is responsible for the largest research programme in cancer in the UK.
This year has been another outstanding year for the Trust as we have continued to achieve high ratings from our two major regulators, Monitor and the Care Quality Commission (CQC). Our ongoing commitment to meet the challenges of continuing to deliver quality care and experience within a cost-effective framework underpins our corporate objectives for 2013/2014:
1. Improve patient safety and clinical effectiveness 2. Improve patient experience 3. Deliver excellence in teaching and research 4. Ensure financial and environmental sustainability
Our commitment to quality improvement is evidenced by the following achievements in April 2013 - March 2014:
Customer Service Excellence Standard
The Royal Marsden is proud to have been the first hospital in 2008 to be awarded the Customer Service Excellence Standard (CSE) as a mark of public services that are ‘efficient, effective, excellent, equitable and empowering – with the citizen always and everywhere at the heart of public services provision’ (CSE 2008). We are assessed regularly and on 18 December 2013 the Trust was found again to be compliant and retained the award for the sixth year.
The Information Standard
The Information Standard is an independent certification for organisations producing evidence-based health and care information for the public. Any organisation achieving the Information Standard has undergone a rigorous assessment to check that the information they produce is clear, accurate, balanced, evidence-based and up-to-date. The Trust was first certified four years ago and was also invited to assist in piloting the updated standards. In November 2013 the Trust achieved the standard against the pilot standards which have now been finalised. Providing patients with clear and accurate information is an important part of the patient’s journey and the Trust is pleased to have maintained this quality standard.
Our staff leading quality
All of our staff place quality at the centre of care on a daily basis and this was also recognised externally in 2013/14. The Trust’s Head and Neck Unit took the award at the Quality in Care Excellence in Oncology Awards for ‘Improving the quality of life and experience of care for people living with cancer’. At the same awards our radiotherapy staff were commended for their work on the Heartspare trial, which aims to reduce the risk of heart disease from breast radiotherapy in the ‘Cancer team of the year’ category. Separately our Chief Nurse was awarded a Lifetime Achievement Award by the European Oncology Nursing Society which honours individuals who, during their working lifetime, act as inspirational leaders; and our Nurse Consultant for Palliative Care was awarded a Macmillan Clinical Excellence and Fellowship awards.
4
Capturing our Patient Experience in the Community
Our successful integration with Sutton and Merton Community Services continues and we have implemented a new customer feedback system for our patients who are cared for by our community staff. This new system allows us ‘real-time’ access to the results and enables us to give our services and teams feedback and quality improvement suggestions immediately after our patients have passed them on to us.
Further Embedding Our Values
For several years the Royal Marsden has promoted a set of 16 distinct values that help us ensure that our patients receive the best possible treatment and care. Following the publication of the Francis Report our staff have become even more committed to making these values more visible. Staff in the Critical Care Unit have identified four core values that they believe are the most important to them and what they aspire to be and redefined what they mean to them. This process is being cascaded throughout the Trust.
The Royal Marsden School
The School continues as a key part of the organisation in its delivery of high quality education in cancer care, leadership, ongoing professional development and training. For the third consecutive year it was awarded 100% in the Quality and Contract Performance Management Assessment confirming its position as the best performing provider in London of Continuing Personal and Professional Development (CPPD).
International Patients Development
In 2013/14 there has been investment in developing the service provided to international patients. In particular two dedicated International Patient management positions were established: International Patients Advocacy Manager and International Relations Manager to manage the internal and external service affairs respectively.
This is the fifth year that we have published a Quality Account and we are grateful for the feedback we received on last year’s Quality Account from patients, carers, the public through Healthwatch, the Health and Wellbeing Boards and our commissioners and governors.
Last year saw the publication of many high profile national reports such as the Berwick Review into patient safety and the government’s response to the Francis Report with key messages for everyone working in the health and care system. We welcome mandates or actions that will improve any aspects of patient care, outcomes or experience and look forward to being involved in this work as it progresses in 2014.
We are also very proud of the excellent hard work that the staff of the Royal Marsden undertake on a daily basis and their everyday commitment to safety and quality. We have aimed to demonstrate this within this Quality Account and enable our staff to personally articulate the importance of this in their roles via personal quotes throughout the document.
I would like to thank all patients, carers, staff, Healthwatch, HWB, governors and commissioners who have contributed to this Quality Account for 2013/14.
I can confirm on behalf of the Board of The Royal Marsden NHS Foundation Trust that to the best of my knowledge, the information presented in this Quality Account is accurate and fairly represents the range of services we provide.
Cally Palmer CBE Chief Executive XXX 2014
5
Part two Performance against priorities for quality improvement 2013/14 and statements for assurance
Introduction
The table below summarises the specific quality priorities and targets we set ourselves for Safe care, Effective care and Patient experience for 2013/14 in the trust. The priorities marked with * were mandatory quality indicators in 2013-14 and are expected to remain mandatory for 2014/15. There were three new (^) quality priorities for 2013/14.
Table 1: Quality priorities and targets for 2013-14 Priority Category Priority Measure/Target for number 2013/14 1 Safe care *Reduction in Healthcare Less than one MRSA Associated Infections (MRSA bacteraemia bacteraemia and Clostridium Less than 11 C Difficile difficile infections) Applies infections to Acute beds at The Royal (report in Quality Account the Marsden and patients of number of C. difficile Sutton and Merton infections per 100,000 bed Community Services (SMCS) days) 2 Safe care *Rate of patient safety Reduction in the rate of incidents and percentage patient safety incidents per resulting in severe harm or 100 admissions and the death proportion that have resulted (in 2012/13 the number of in severe harm or death deaths from serious incidents per 100 admissions was 0; the number of severe harms from incidents per 100 admissions was 0.012) Applies to acute beds and SMCS
3 Safe care *Percentage of admitted Maintain above 95% the patients risk assessed for number of patients who have Venous thromboembolism a completed VTE risk assessment 4 Effective care Reduction in community Reduce the incidence of acquired category 3 and 4 severe community acquired pressure ulcers: Applies to pressure ulcers (Category 3 SMCS and 4) 5 Effective care Increase the number of Achieve more than 42% of patients that die in their patients dying in their preferred place of death (The preferred place of death. National Primary Care Snapshot Audit in End of Life Care (2009) found that the number of patients achieving their preferred place of death is 42 %.) Applies to acute and SMCS 6 Effective care Increase the numbers of Increase the proportion of patients who have been designated patients who will offered an Holistic Needs be offered a Holistic Needs Assessment Assessment by the end of 2013/14
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7 Effective care *Avoidance of emergency re- Reduction in the number of admissions to hospital avoidable re-admissions to within 28 days of discharge. hospital within 28 days of discharge 8 Patient Reduction in chemotherapy Reduction in chemotherapy experience waiting times and waiting times at Sutton and improvement in patient Chelsea and improvement in experience related to waiting the patient experience related times to waiting times 9 Patient *Ensure that we are Improvement in responses to experience responding to in-patients’ five questions (in the CQC personal needs national survey described above) as monitored through the Inpatient Frequent Feedback Surveys 10 Patient *Percentage of staff who To maintain or increase the experience would recommend The Royal staff survey result to this Marsden to friends or family specific question in the needing care survey.
Introduce a Patient To achieve a baseline Experience survey for SMCS measurement and if possible benchmark with other community services. 11 Patient ^Improve communication, Increase or maintain the high experience particularly when patients percentage of positive arrive for first appointments comments in dedicated patient feedback. 12 Patient ^Reduce the length of time a Increase or maintain the high experience patient waits for medicines percentage of positive or equipment at the point of comments in dedicated discharge patient feedback. 13 Childrens The uptake of immunisation Increase the percentage of services working in partnership with children receiving pre-school primary care immunisations in partnership with GPs.
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Priority 1: Reduce the incidence of Healthcare Associated Infections (HCAIs) Reduction in Healthcare Associated Infections (MRSA bacteraemia and Clostridium difficile infections) Applies to Acute beds at The Royal Marsden and patients of Sutton and Merton Community Services (updated Q4)
Target: To reduce the number of Clostridium difficile Infections (CDI) to 11 in 2013/14 or less and maintain a very low incidence of Meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia.
Quote: “The Infection Prevention team work closely with clinical teams to ensure potentially infectious side rooms are decontaminated using Hydrogen Peroxide Vapour to reduce the risk of HCAI in our vulnerable patient group.”
Sarah Whitney Clinical Nurse Specialist Infection Prevention and Control
Patients with cancer are more vulnerable to infection and if an infection is sustained, they are more likely to develop serious complications from it. We therefore see reducing the incidence of HCAIs as an essential safety and quality priority. This priority was selected in 2009/10 and remained an important priority in 2013/14. The Infection Prevention Team undertakes and oversees extensive audit programmes focussing on environmental hygiene and standardisation of cleaning and decontamination processes. Appropriate antimicrobial prescribing is crucial in ensuring the reduction of Clostridium difficile alongside prompt and effective treatment and care for any patients suffering with diarrhoea especially amongst the immune suppressed who are particularly at risk of this type of infection. A robust process of screening and treating all patients for MRSA is implemented and audited to ensure the risk of bacteraemia is reduced as much as possible.
How did we perform in 2013/14?
The Trust continues to implement the Hydrogen Peroxide decontamination programme across Sutton and Chelsea to minimise the transmission of HCAI.
The Trust maintained excellent hygiene standards by way of regular peer review audits on each clinical area and importantly ensured the correct cleaning products and standards were upheld to reduce the risk of Clostridium difficile infection. On a daily basis the infection prevention team prioritised the use of isolation rooms to ensure the risk of cross infection is reduced.
The trust total number of attributable Clostridium difficile cases for the year was 19 against a target of 11 and MRSA bacteraemia is 1 meaning we have breached on both these reportable organisms.
Table 1: Number of attributable MRSA bacteraemia cases
Infection Number Number Number Number Royal attributa attributa attributa attributa Marsden ble ble ble ble annual 2010/11 2011/12 2012-13 2013/14 level 2013/14 MRSA 2 1 0 1 ≤1 bacteraemia Clostridium 34 18 15 19 11 difficile
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Graph 1 Number of attributable Clostridium difficile (CDI).
C.difficile cases ( Attributable)
20
15
10
5
0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Trust trajectory limit (max 11) 0.8 1.6 2.4 3.2 4 4.8 5.6 6.4 7.2 8 8.8 11 Trust cumulative total from 1.4.13 1 2 2 4 4 5 7 9 10 11 16 19 Sutton cumulative total from 1.4.13 1 2 2 3 3 4 5 6 7 8 11 13 Chlesea cumulative total from 1.4.13 0 0 0 1 1 1 2 3 3 3 5 6 Trust month total 1 1 0 2 0 1 2 2 1 1 5 3
What actions are we planning to improve our performance?
Key plans to improve HCAI rates include a focus on antimicrobial prescribing audits and the prescribing of proton pump inhibitors to reduce Clostridium difficile infection. MRSA treatment takes time and work is underway to ensure the time between prescribing MRSA treatment and significant events such as surgery or high dose chemotherapy is sufficient to reduce the risk of a blood stream infection even further
How will improvements be measured and monitored?
Improvements will be monitored by the monthly Infection Prevention and Control Team meeting. This is a multidisciplinary meeting chaired by the Chief Nurse, who is the Director of Infection Prevention and Control for the Trust. Bacteraemia caused by both meticillin- resistant and meticillin-sensitive Staphylococcus aureus (MRSA and MSSA), vancomycin- resistant enterococci (VRE) and Escherichia coli will be reported externally to the new Public Health England, as will all confirmed Clostridium difficile infections. Numbers of selected infections will be monitored internally to the Board in the Trust Board Scorecard and published in the quarterly Integrated Governance Reports. Reduction in HCAIs remains a priority for 2014/15 to prevent further harm to patients.
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Priority 2: To reduce the rate of patient safety incidents that have resulted in severe harm or death (Applies to acute beds and SMCS (Q4 updated)
Target: Reduction in the rate of patient safety incidents per 100 admissions and the proportion that have resulted in severe harm or death In 2012/13 the number of deaths from serious incidents per 100 admissions was 0; the number of severe harms from incidents per 100 admissions was 0.010.
How did we perform in 2013/14?
Patient safety incidents resulting in severe harm or death
This year is the second time that this indicator has been required to be included within the Quality Account alongside comparative data provided, where possible, from the Health and Social Care Information Centre. The National Reporting and Learning Service (NRLS) was established in 2003. The system enables patient safety incident reports to be submitted to a national database on a voluntary basis designed to promote learning. It is mandatory for NHS trusts in England to report all serious patient safety incidents to the Care Quality Commission as part of the Care Quality Commission registration process.
The trust reports all patient safety incidents reported on Datix to the NRLS. Prior to NRLS producing their six monthly reports, the trust re-submits all patient safety incidents which captures changes made as a result of investigations. The NRLS does not update its previously reported figures so these changes may not be reported by the NRLS and the data held by the trust may not be the same as that reported by the NRLS.
The tables below separate out the information for firstly the acute hospital sites of Chelsea and Sutton and secondly for Community Services. Previously this data has been presented as a combined table. The data shows that the trust has made an improvement and reduced the rate of reported incidents that caused severe harm or death from 0.010 in 2012-13 to 0.008 in 2013-14.
Table 1: Chelsea and Sutton patient safety incidents 2013- 2012-13 Q1 Q2 Q3 Q4 Measure 14 Inpatient and daycase admissions 61366 15291 16098 16106 16611 64106 and Regular Day Attendees Rate of reported patient safety incidents (Severe harm or Death), 0.010 0.013 0.006 0.000 0.012 0.008 per 100 admissions
Number of patient safety 6 2 1 0 2 5 incidents (Severe harm or Death)
Total patient safety incidents 2137 586 635 568 563 2352 Patient safety incidents (Severe harm or Death) as % of all patient 0.28% 0.34% 0.16% 0.00% 0.36% 0.21% safety incidents
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Table 2: Community Services patient safety incidents 2013- Q1 Q2 Q3 Q4 Measure 2012-13 14 Number of contacts (total number of face to face and non face 136,53 133,39 137,12 134,33 1,073,5 532,119 appointments attended and 5 4 5 3 06 ‘outcomed’) Rate of reported patient safety incidents (Severe harm or Death), 0% 0% 0% 0% 0% 0% per number of contacts
Number of patient safety 0 0 0 0 0 0 incidents (Severe harm or Death)
Total patient safety incidents 869 220 269 213 281 983 Patient safety incidents (Severe harm or Death) as % of all patient 0% 0% 0% 0% 0% 0% safety incidents
Benchmarking with national data. The National Reporting and Learning Service report that for the period April-September 2013 the proportion of incidents resulting in severe harm or death remains less than 1% of all incidents reported. For the period April 2013 to March 2014, The Royal Marsden is well below this rate at 0.21% for the hospitals during 2013-14 and 0% for Community Services as displayed in the tables above.
What did we do in 2013/14? • We strengthened the use of the World Health Organisation (WHO) Surgical Safety Checklist to promote the safety of patients in the pre, peri and post operative period. • We invested in new digital assisted defibrillators throughout the trust to be used in the event of cardiac arrest. • We strengthened the use of the national venous thromboembolism prevention and treatment algorithims across the trust. • We continued to work on preventing medication errors and falls.
What actions are we planning to improve our performance? • To increase the use of the Team Simulation for Emergency situations to other clinical teams. • Introduce the use of the new National Early Warning System which will be audited throughout 2014/15. • Investigate the use of VitalPac systems to ensure clinical teams intervene early when patients deteriorate.
How will improvements be measured and monitored? • Through the specialist Morbidity and Mortality meetings • Clinical Audit • National mandatory audits
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Priority 3: Reduction in venous thromboembolism (VTE) events/clot formation Percentage of admitted patients risk assessed for Venous Thromboembolism (updated Q4)
Target: Maintain above 95% the number of all appropriate patients who will have venous thromboembolism (VTE) assessment within 24 hours of admission and receive the appropriate dose of prophylaxis.
VTE is a collective term for deep venous thrombosis and pulmonary embolism. A deep vein thrombosis is a blood clot that forms in a deep vein (usually in the leg) and sometimes a clot breaks off and travels to the arteries of the lung where it will cause a pulmonary embolism. VTE can be avoided by giving preventative treatment (prophylaxis) to patients at risk. Patients with cancer are at greater risk of developing VTE; therefore this continues to be a safety priority for us.
How did we perform in 2013/14?
We have achieved the NHS Commissioning for Quality and Innovation (CQUIN) target of 95% compliance for ensuring all of our patients are appropriately assessed for risk of VTE in 2013- 14. We have continued to monitor our compliance with appropriate prophylaxis prescription as part of a Key Performance Indicator (KPI). Furthermore we have also achieved this at more than the 95% level of appropriate prophylaxis being prescribed to prevent VTE.
VTE 2012/13 2012/13 2012/13 2012/13 2013/14 2013/14 2013/14 2013/14 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Quarter 96% 97% 97% 96% 98% 97% 95% 97% target Prophylaxis 96% 96% 96% 96% 98% 97% 100% 98% prescribed
What did we do in 2013/14?
The multidisciplinary VTE Steering Board is now well established and VTE risk assessment for all appropriate patients is embedded clinical practice in the hospital. All elective inpatients are sent information leaflets in advance of their admission to inform them of what they can do to help prevent clot formation. Furthermore, posters and patient information leaflets are available in the clinical areas or from Patient Advice and Liaison Service (PALS).
More specifically the steering group has directed the following actions:
• Ensured that every confirmed diagnosis of a hospital acquired VTE undergoes a root cause analysis (RCA) to determine the underlying cause of the VTE and if any other preventative action could be taken. The consultant in charge is asked to fill in a specific VTE RCA of the patient. Compliance with this is now measured as part of our CQUIN programme. • Performance managed the compliance with risk assessment; detailed performance reports are sent out to appropriate staff daily. Appropriate prophylaxis prescriptions are monitored monthly. • The VTE Risk Assessment may be completed using either the patient’s drug chart, this also contains information on appropriate prescribing for the junior doctors, or risk assessment may be completed within the electronic clinical documentation system as part of the clerking process. • The day units are developing a specific patient information leaflet which advises patients to consider buying stockings if they notice a reduction in energy levels and reduced mobility when at home. • Updating of the VTE Patient Information booklet in line with NICE guidance published in June 2012. • An audit of patient’s receipt of written and verbal information around VTE on their
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admission (audit underway at time in May).
What actions are we planning to improve our performance in 2014/15?
• Daily score cards will be sent to VTE leads to check on progress • Monthly compliance checking VTE reassessment within 24 hours • All hospital acquired thrombosis will be reviewed by consultants who will check for recurring themes • Monthly VTE Steering Group meetings have been scheduled • VTE discussion and presentation at each Junior Doctors Induction • Ongoing audit of patient information and support received in the Outpatient departments • Developing specific patient information for patients in day care. • Ensuring there is minimal delay when patients present with a potential clot, review time from attendance to appropriate radiological intervention quarterly. • Plan to audit whether patients are provided with both written and verbal VTE patient information (plan to start following approval in February 2014).
How will improvement be measured and monitored?
VTE incidents and performance with assessment and prevention procedures will be monitored by the VTE Steering Board. Performance will also be monitored at the Key Performance /CQUIN Steering Board and through the monthly Board scorecard. The trust has achieved its targets; however this will continue to be included as a priority for 2014/15 as this remains an important indicator of improvement in protecting patients from avoidable harm. In 2014/15 the actions described above will be ongoing and embedded into practice. This will be demonstrated by ongoing monitoring and audit of compliance.
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Priority 4: Reduction of pressure ulcers data (part updated Q4)
Target: To reduce the incidence of severe community acquired category 3 and 4 avoidable pressure ulcers.
Quote: “The Community Nursing Teams have developed their knowledge and skills extensively both in the management and prevention of pressure ulcers within the community environment, which is often diverse and challenging. This knowledge has caused a change in the culture of pressure ulcer treatment within the Community Nursing Teams and has improved the quality of care provided to patients.”
Jane Hopping Clinical Nurse Specialist for Quality and Safety Sutton and Merton Community Services
How did we perform in 2013/14?
This remains a challenging but important priority for community services and we have continued to focus upon the prevention and management of pressure ulcers for the benefit of patients. A review of the entire caseload of patients was undertaken in January 2014, to provide assurance of the accuracy of reporting the incidence of category 1, 2, 3 and 4 pressure ulcers. By identifying the category 1 and 2 pressure ulcers in a timely manner and ensuring that all appropriate patient assessments, treatments and provision of pressure relieving equipment is in place, it is anticipated that the development of avoidable category 3 and 4 pressure ulcers will be diminished.
The table below shows the number of community acquired category 3 and 4 pressure ulcers. The number of category 3 pressure ulcers increased in February 2014, which can be attributed to improved reporting of all pressure ulcers as incidents. We have maintained less than 0.25 of the total number of community nursing accepted referrals acquiring category 3 or 4 pressure ulcers whilst under the care of community services for the last two years.
Number of community acquired pressure ulcers
2012/13 2013/14
Category 3 39 50
Category 4 7 5
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The chart below outlines the number of pressure ulcers (category 3-4) that were acquired within the community setting during the period April 2011 to March 2014.
Community acquired category 3 and 4 pressure ulcers April 2013- March 2014
60 50
40 category 3 month total 30 category 4 month total yearly cumulative total 20 10 0 Oct Jan July Nov Mar Aug Feb May Sep Dec June Apr'13
What actions are we planning to improve our performance?
A large programme of work continues by community services to address pressure ulcer prevention and management strategies, which is led by a group of key stakeholders. All Category 3 and 4 incidents are investigated and presented at monthly panels to identify root causes and to learn from incidents to improve care for patients. The findings from panels are presented to the trust’s Integrated Governance and Risk Management Committee and shared with commissioners. From these panels the following pieces of work will also continue as follows:
• Reviewing the category 1 and 2 pressure ulcers and ensuring that all appropriate care is in place for these patients. • Shared learning for teams by encouraging representative attendance from each locality at panels and sharing all action plans with community nursing teams. • Training programmes for internal staff are now mandatory on pressure ulcer prevention and management, including the importance of documenting patients’ assessments, care plans and the availability of pressure relieving equipment for patients. • Training and education for local authority staff (formal carers) is available. • Work on joint care planning with local authority staff that provide care to patients known to the community nursing teams. • Provision of the expert resource of a Tissue Viability Nurse in each of the 4 current community nursing localities. • The Pressure Ulcer Prevention and Management policy will be reviewed and updated to reflect any changes in documentation and processes.
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Priority 5: To increase the number of patients that die in their preferred place of death. Applies to acute and community services (updated Q4)
Target: To achieve more than 42% of patients dying in their preferred place of death.
To increase the numbers of patients dying in their preferred place of death where previously indicated and recorded on Coordinate my Care (CMC) to over 42% as reported in The National Primary Care Snapshot Audit in End of Life Care (2009). Coordinate My Care is a communication clinical service that aims to coordinate end of life care for patients who often receive care from multiple providers, allowing patients to have choice and improved quality of end of life care. Coordinate my Care is hosted by The Royal Marsden NHS Foundation Trust.
How did we do in 2013-2014?
Of the 13 patients who died that were registered with Coordinate my Care, eight achieved their preferred place of death, a further one person died at home, one person died in a nursing home (which was their usual residence) and for the remaining three people no actual place of death was recorded.
What actions are we planning to improve our performance? • Education • Palliative care in-house study days to include advance care planning • Nursing education on identifying progression of the dying phase • Close working between palliative care and oncology teams • Education and training for nursing homes in Sutton and Merton to help facilitate optimal end of life care and care planning • Involvement of Hospital2Home team when patients are being officially discharged from hospital with no further follow up appointments scheduled • Use of the weekly Palliative Care multidisciplinary team meeting to ensure that preferred place of care and death is being addressed for patients known to the Palliative Care Team • Support and active engagement with Coordinate my Care following its roll out across London with associated education programme to: • Highlight the importance of addressing preferences with patients for end of life care • Improve documentation between different healthcare providers to ensure smooth transfer of accurate, up to date information on end of life care preferences
How will improvement be measured and monitored?
• Weekly review of outcomes for preferred place of care and death for patients referred to the Hospital2Home service • Weekly reporting on ‘preferred place of death’ from the Coordinate my Care team. This information is then disseminated to lead clinician and lead end of life commissioner within each Clinical Commissioning Group. • Monthly/quarterly reporting on interventions in nursing homes of Sutton and Merton to commissioners • Some errors/additions have been found when using Electronic Patient Record to validate Coordinate My Care.
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Priority 6: To increase the number of patients who are offered an Holistic Needs Assessment (updated Q4)
Target: Increase the proportion of designated patients who will be offered a Holistic Needs Assessment by the end of 2013/14
The National Cancer Survivorship Initiative (NCSI) has delivered a programme of work designed to improve patient outcomes and their experience of healthcare.
A key intervention identified as being the most important building block for achieving good outcomes in 2014 is the Recovery Package: a combination of assessment and care planning, treatment summary and cancer care review, and patient education and support events (Health and Wellbeing clinics).
A holistic needs assessment (HNA) is a process of gathering information from the patient and /or carer in order to inform discussion and develop a deeper understanding of what the person living with and beyond cancer knows, understands and needs.
If the patient chooses to identify any concerns or needs then a care plan is completed which takes into account any holistic needs that have been raised by the patient. In quarters 3 and 4, 34 new patients chose to identify needs and a further five identified holistic needs at the end of their treatment.
Holistic Needs Assessment is not a one-off exercise, but is the basis of assessment and care planning from diagnosis onwards.
How did we perform in 2013/14?
An audit of activity from October to December 2013 showed that 649 of 817 (79%) new patients that were seen by Clinical Nurse Specialists were offered a Holistic Needs Assessment. This shows an improvement from the previous year when from April 2012 to March 2013, 1035 out of 3231 (32%) new diagnosed patients seen by Clinical Nurse Specialists were offered a Holistic Needs Assessment.
What did we do in 2013/14?
The trust is in the process of rolling out HNA and Care Planning across all tumour types at two designated points in the patient pathway in line with the agreed London Cancer Alliance metrics of 25% achievement in Quarter 1 & Quarter 2 increasing to 50% achievement for Quarter 3 & Quarter 4. This target has been achieved. The metric states that each person will be “offered” an HNA and those accepting will have a care plan developed. Thirty-nine patients chose to have a care plan developed.
• Firstly within 31 days of diagnosis or transfer of care to The Royal Marsden • Secondly at a point 6 weeks from completion of primary treatment (to note this varies for each tumour type)
In addition to this The Royal Marsden was chosen as a prototype site for the Macmillan electronic holistic needs assessment project, to test the electronic holistic needs assessment and provide feedback to shape further development.
Currently eHNA is underway for breast and gynaecology patients at the start and end of treatment. Uniquely, at The Royal Marsden Macmillan Patient Support Worker’s lead the assessment with CNS support for care planning and reviewing.
Data collection started in Quarter 1 & Quarter 2 and during Quarter 3 & Quarter 4 a spreadsheet has been designed to enable monthly collection of data by each Clinical Nurse Specialist (Key Worker). This is then submitted to the Divisional Clinical Nurse Director (DCND) and will be monitored, collated and submitted by the DCND and the Nurse
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Consultant Living With & Beyond Cancer (LW&BC) quarterly to the London Cancer Alliance and the trust Quality Account.
Practical support is also being offered to all those undertaking Holistic Needs Assessment from a variety of sources and individual teams and Clinical Nurse Specialists are undertaking service evaluations to demonstrate the strengths and weaknesses of their own areas and develop action plans.
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Priority 7: Avoidance of emergency readmissions to hospital within 28 days of discharge (updated Q4)
Target: To achieve a reduction in the number of avoidable re-admissions to hospital within 28 days of discharge.
How did we perform in 2013/14? The chart below shows the percentage of patients that were readmitted within 28 days from April 2012 to March 2014. Readmissions have remained below 1% of all admissions since April 2012. Some emergency re-admissions following discharge from hospital are an unavoidable consequence of the original treatment, however some can be potentially avoided through ensuring the delivery of optimal treatment according to each patient’s needs, careful planning and support for self care. Since 2012/13 Trusts are expected to include in their Quality Account the percentage of patients of all ages and genders who were re-admitted within 28 days of being discharged; and the national average for the above percentage (NHS Operating Framework 2012/13). It is important to note that some readmissions will inevitably include patients who are admitted with side effects of treatment therefore it may be difficult to explain any differences between The Royal Marsden with other acute Trusts.
Reported % of Emergency Readmissions
0.70%
0.60%
0.50%
0.40%
0.30%
0.20% % of eligible admissions resulting in an eligible re-admission eligible an in resulting admissions eligible % of
0.10%
0.00% Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- 12 12 12 12 12 12 12 12 12 13 13 13Month13 13 13 13 13 13 13 13 13 14 14 14
The table below shows the number of patients that were readmitted within 28 days from April 2013 to March 2014.
Month Number of patients readmitted within 28 days April 2013 6 May 4 June 7 July 10 August 7 September 7 October 8 November 12 December 12 January 10 February 3 March 0
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What did we do in 2012/13?
Together with the South West London Acute Commissioning Unit we undertook an external audit of all readmissions over a 12 month period. The results were presented at the Clinical Quality Review Group (CQRG)
What actions are we planning to improve our performance? • Continuous review and evaluation of clinical care especially using the Enhanced Recovery Programme (ERP) • Monthly prospective audit to monitor rates.
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Priority 8: Reduction in chemotherapy waiting times and improvement in patient experience related to waiting times (updated Q4)
Target: To reduce chemotherapy waiting times at Sutton and Chelsea and improve the patient experience related to waiting times.
How did we perform in 2013/14? The management of chemotherapy waiting times is a particular challenge for the organisation because of the complexity of checking it is safe to proceed to chemotherapy. Chemotherapy needs to be prepared in an aseptic unit (where staff are gowned and gloved to prepare chemotherapy). Furthermore several checking procedures have to be undertaken. In addition, the data below also includes patients who are on clinical trials. Some chemotherapy research studies need up to four hours preparation time once go-ahead for treatment has been confirmed.
Patients are asked to give their feedback in real time. As they leave the outpatients department volunteers ask patients to give their responses on hand held devices to a variety of questions about their appointment.
As displayed in the figure below, there has been a gradual improvement in the number of patients seen either on time or early whilst there has been a significant decrease in patients waiting between 30 minutes to one hour. This improvement was delivered via the following interventions:
• Introduction of a new appointment system at Chelsea site to improve treatment appointments and reduce waiting times • Planned introduction of scheduling system at Sutton from April 2013. • Improvements in pre-prescribing of chemotherapy to give pharmacy time to prepare chemotherapy in advance of the visit • Production of a new patient information leaflet to inform patients about the process of chemotherapy production • Improved communication between the staff and patients to keep them informed about their wait • Announcements are made every 30 minutes in the outpatients department if clinics are running behind • Individual staff have been tasked to inform individuals in the medical day unit of reason why they have to wait
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Figure 1: How long after the stated appointment time did the appointment start?
How long after the stated appointment time, did the appointment start?
100%
90% Don't know/ Can't remember 80% I waited more than 1 hour 70% 60% I waited between 31 and 60 minutes 50% I waited between 16 and 30 40% minutes 30% I waited up to 15 minutes
20% I was seen on time, or early 10% 0% Yr5 Q1 Yr5 Q2 Yr5 Q3 Yr5 Q4
What actions are we planning to improve our performance? The Trust is working hard at reducing the chemotherapy waiting times and improving the patient experience through the following:
• New information leaflets explaining the visit for treatment • Waiting time information for display on the Medical Day Unit has been implemented • Staff will continue speaking with individual patients when delays to appointments occur • Improved alignment of the medical staff daily schedule with the configuration of MDU appointment times.
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Priority 9: Ensure that we are responding to inpatients’ personal needs (Q4 update)
Target: To improve in the responses to five questions related to “Improving responsiveness to personal needs of patients”. These five questions are taken from the national inpatient survey which is reported by the Care Quality Commission.
Delivery of personalised medicine is one of the trust’s strategic priorities. It is therefore important that we understand the patient experience when they attend out-patient departments, day units and inpatient areas. In May 2009 we started using frequent feedback hand-held devices in our day units and outpatient areas and the matrons are responsible for developing action plans in response to recurrent concerns. In 2012 these started being used in the inpatient areas.
How did we perform in 2013/14?
Inpatient Survey 2013 CQUIN data
The NHS Commissioning for Quality and Innovation (CQUIN) groups together five questions from the annual national inpatient survey that indicate how trusts perform in “Improving responsiveness to personal needs of patients". The following five questions are below and the first table shows the most recent results and the second table shows the scores over the previous three years.
Q32 Were you involved as much as you wanted to be in decisions about your care and treatment? Q34 Did you find someone on the hospital staff to talk to about your worries and fears? Q36 Were you given enough privacy when discussing your condition or treatment? Q56 Did a member of staff tell you about medication side effects to watch for when you went home? Q62 Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital?
The external organisation was commissioned by 76 trusts to undertake the Inpatient Survey 2013. The results in the following table are taken from that data and show that the trust exceeded the average results from the other trusts.
Table 1: 2013 results 2013 Q32 Q34 Q36 Q56 Q62 The Royal Marsden 73.8 61.1 82.1 63.2 92.4
All trusts 54.8 38.4 72.7 40 69.8
The Patient Experience CQUIN results as calculated against all trusts participating in the National Inpatient Survey for The Royal Marsden from previous years are as follows. Note these were not calculated by CQC for the 2013 survey.
Table 2: CQUIN results 2010-2012 Year Q32 Q34 Q36 Q56 Q62 Overall CQUIN score 2012 86.8 76 92.2 73 93 84.2 2011 83.4 75.7 91.6 70.4 92.8 82.8 2010 82.3 74.6 90 68.4 94.5 82
Friends and Family test
The NHS “Friends and Family Test” was announced by the Prime Minister on 25 May 2012. All Trusts were expected to be “live” by the 1st April 2013. Nationally all patients are asked a
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simple question to identify if they would recommend a particular A&E department or ward to their friends and family. The results of the test will be used to improve the experience of patients by providing timely feedback alongside other sources of patient feedback. It will highlight priority areas for action.
The Royal Marsden elected to be an early implementer site and therefore started collecting the data in February 2013. Outside all wards across the Trust there is a Poster and Collection Box. All adult patients who have been an inpatient for more then one night are asked to complete the Friends and Family Test form and then to put it straight into the collecting box. Once a week the forms are collected and an external company collates and presents the data.
The national mandated question asked is:
“How likely are you to recommend our ward to friends and family if they need similar care or treatment?”
The patients then select their answer from the following scale:
Extremely likely; Likely; Neither likely nor Unlikely; Unlikely; Extremely unlikely; Don’t know.
The Royal Marsden has then chosen to add a second question:
What was good about your care and what could be improved?
Patients answer this question with free text comments. Comments are reviewed by the matrons and ward staff and where appropriate actions are taken.
The table below shows the Trust’s results for NHS and private care patients. 2013-14 Apr May Jun July Aug Sep Oct Nov Dec Jan Feb Mar
Trust score (out of 100) 95 95 95 94 95 93 90 90 88 90 87 92
Average score
(NHS and private care) (out of 5) 4.9 4.9 4.9 4.9 4.9 4.9 4.9 4.9 4.9 4.9 4.86 4.92
Number of responses 189 142 254 170 222 243 149 256 191 290 119 508
^ following a low response rate in February 2014 ward staff were asked to ensure the cards were handed out and the methodology for collecting cards was changed.
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The table below shows the number of patients that were discharged each quarter and how many responded. The trust achieved the target set for the response rate each quarter. 2013/14 Quarter Q1 Q2 Q3 Q4 Discharges 2191 2471 2234 1681 Responses 585 635 596 711 Response Rate 27% 26% 27% 42% Target 25% 25% 25% 25%
National FFT results reporting
NHS England display the information that has been collected each month for 170 Acute NHS trusts and independent sector providers for inpatients. http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends- and-family-test-data/
Nationally, for March the overall average inpatient score for NHS trusts and independent sector was 73 with specialist hospitals scoring higher than general acute trusts.
In March, The Royal Marsden was in the top ten of trusts nationally with a score of 94. The table below shows the results for the Trust over each quarter to date.
The Royal Marsden Q1 Q2 Q3 Q4 Overall FFT score 95 94 92 91 Response number 585 635 450 711
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Priority 10: Monitoring of the percentage of staff who would recommend The Royal Marsden to friends and family (updated Q4)
Target: To maintain or increase the staff survey result to this specific question in the annual national staff survey.
The national staff survey is conducted annually. In 2012/13, 87% (421/485) of staff agreed with the statement: If a friend or relative needed treatment, I would be happy with the standard of care provided by this trust which is used as an indicator of this priority.
What did we do in 2013/14?
We continued to discuss patient services with staff and work with them to identify and implement ways in which services could be improved. We shared outcomes of patient surveys and our monitoring reports with staff. The results of these tests are used to plan improvements and shared with staff both in the local ward areas and more widely across the trust including in open meetings held by the Chief Executive.
How did we perform in 2013/14?
In the 2013/14 staff survey 87% (1450/1670) of staff agreed with the following statement: If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation. This maintains the high rate of last year’s result.
In 2013/14 all staff (rather than a sample) had the opportunity to give feedback through the staff survey. Therefore there are much higher numbers of respondents than previous years. The same rates of agreement have been achieved.
Table1: Numbers of staff responding to question in national staff survey Agreed or strongly Neither agree nor Disagreed or strongly agreed disagree disagreed 2013 1450 (87%) 179 (11%) 41 (2%) 2012 421 (87%) 51 (10%) 13 (3%) 2011 408 (84%) 55 (11%) 19 (4%)
What actions are we planning to improve our performance?
• Continue to encourage staff feedback on how our patient services could be improved • Regular promotion of quality monitoring reports and other information on our performance, including the patient ‘friends and family’ test responses to staff • Conduct quarterly staff ‘friends and family’ tests
How will improvement be measured and monitored?
• Conduct quarterly staff ‘friends and family’ tests from Q1 2014/15 onwards
To be updated Priority Target
Introduce a Patient Experience survey for To achieve a baseline measurement and if SMCS possible benchmark with other community services.
What did we do in 2013/14? How did we perform in 2013/14? What actions are we planning to improve our performance? How will improvement be measured and monitored?
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Priority 11: ^Improve communication, particularly when patients arrive for first appointments. (Q4 updated)
Target: Increase or maintain the high percentage of positive comments in dedicated patient feedback.
Within our outpatient departments we strive to communicate well to our patients ensuring that they have a good experience particularly when attending for their first appointment. We are continually seeking feedback on our communication and for several years have asked patients to give feedback in real time of their outpatient experience including questions around communication. As they leave the department, volunteers ask patients a variety of questions about their appointment using a hand held device. The Matrons and Sisters are responsible for developing action plans in response to recurrent concerns. The results of these surveys are also shared with patients and staff at a local and Trust level.
What did we do in 2013/14? - Purchased additional information display screens to inform patients of waiting times in clinics - Commenced reception staff putting out regular tannoy announcements to update patients on all clinics running > 30 minutes late - Devised and implemented Outpatients (OPD) leaflet informing patients of what to expect during their OPD visit and contact details for further info - Implementation of staff board – informing patients of name of Doctors and nurses (with photographs) in clinics for that day - Patient information board regularly updated informing patients of recent patient feedback results and actions we have taken to date - Administrative co-ordinator role introduced into high volume clinics to assist with co-ordination and smooth running of clinic and to ensure reception staff informed of clinic times enabling them to update patients via tannoy / display screens - Improved signage across the trust including way finder assisting patients finding there way to OPD (particularly on first visit) - Designed new posters ‘What is your key worker’ informing patients around the role of the ‘Key worker’ and amendments made to Clinical Nurse Specialist (CNS) contact cards to clearly state that they are their ‘key worker’ - Revision and update of information on the Trust’s outpatient internet website page. - Refurbishment of clinic rooms and purchasing of new chairs for waiting areas
How did we perform in 2013/14? (Combined average results for across site: Sutton and Chelsea)
Q2 Did you understand the purpose of your visit and what to expect?
Quarter 2013/2014 Q1 Q2 Q3 Q4 Yes, completely 91% 91% 95% 96% Yes, to some extent 8% 7% 4% 3% No 1% 1% 1% 1% Don’t Know 0% 1% 0% 0%
Q3 When you arrived at the Outpatients department were you greeted politely at reception and made to feel welcome?
Quarter 2013/2014 Q1 Q2 Q3 Q4 Yes 98% 99% 99% 99% No 2% 1% 1% 1% Don’t Know / Can’t remember 0% 0% 0% 0%
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Q7 Were you kept informed about your waiting times?
Quarter 2013/2014 Q1 Q2 Q3 Q4 Yes 58% 63% 55% 50% No, but I would have been liked to have been kept informed 21% 18% 25% 33% No, but I didn’t mind 21% 18% 19% 15% Don’t Know / Can’t remember 0% 1% 1% 2%
Q10 Did the member of staff explain the results of the tests in a way that you could understand?
Quarter 2013/2014 Q1 Q2 Q3 Q4 Yes, completely 85% 80% 80% 91% Yes, to some extent 10% 10% 10% 6% No 3% 7% 10% 2% Don’t Know 2% 3% 0% 1%
Q11 Did the member of staff listen to what you had to say?
Quarter 2013/2014 Q1 Q2 Q3 Q4 Yes, definitely 93% 92% 94% 93% Yes, to some extent 4% 6% 5% 6% No 0% 0% 0% 1% Don’t Know 3% 2% 1% 0%
Q12 If you had any worries / concerns about your condition or treatment, did you feel able to discuss them with the staffing charge of your area?
Quarter 2013/2014 Q1 Q2 Q3 Q4 Yes, completely 88% 88% 92% 90% Yes, to some extent 8% 9% 7% 8% No 1% 1% 1% 2% Don’t Know 3% 2% 0% 0%
Q14 If you were given any new meds, or meds were changed did the staff explain the reason for change in a way you could understand?
Quarter 2013/2014 Q1 Q2 Q3 Q4 Yes, completely 79% 75% 70% 85% Yes, to some extent 8% 7% 5% 8% No 10% 12% 25% 7% Don’t Know 3% 6% 0% 0%
Q15 Were you given any written or printed information about your condition or treatment?
Quarter 2013/2014 Q1 Q2 Q3 Q4 Yes 87% 94% 95% 98% No, but I would have liked it 11 4% 4% 2% Don’t Know / Can’t remember 2% 2% 1% 0%
Q21 Were you allocated a ‘key worker’, or someone to contact if you are concerned about your care / treatment before your next appointment?
Quarter 2013/2014 Q1 Q2 Q3 Q4 Yes 62% 76% 76% 78% No 34% 21% 22% 21% Don’t Know 4% 3% 2% 1%
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What actions are we planning to improve our performance in 2014 / 2015? - Continue with Patient Experience Working Group taking actions and new initiatives forward to improve the patient experience / communication - Increase the number of display screens in OPD to include Trust and department initiatives - Regular review of Picker patient feedback data – questions have been reviewed to better reflect the areas we need feedback on and the picker action plan to be reviewed quarterly and fed back to the Integrated Governance and Risk Management committee - Ensuring patients requiring blood tests pre first appointment are informed of this and have their clinic appointment scheduled accordingly - Reduce the number of same day scans to prevent waiting times and enhancing patient experience and smooth running of clinic - Introduce a robust system to monitor doctors’ leave in order to pro-actively manage clinic numbers and reduce waiting times - Introduce nurse-led telephone clinics for follow up patient to reduce the number of face-to face appointments and prevent patients from attending the hospital unnecessarily - Introduce nurse-led chemo toxicity assessment clinics to reduce the waiting times for patients attending a chemotherapy clinic - Implementation of a patient reminder system using text messages to remind patients of their appointments and enable them to cancel or change their appointment more easily - Demand and capacity analysis to be undertaken by the clinical units - Close liaison with the London Cancer Alliance to review the most appropriate pathways for patients - Review of all patient information leaflets
How will improvement be measured and monitored? - Monthly Picker data analysis and action planning - Implementation of ‘Friends and Family’ in outpatient areas - Regular review of waiting times - OPD and Rapid Diagnostic Assessment Centre Steering Group regular review - OPD patient experience monthly meeting regular review
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Priority 12: ^Reduce the length of time a patient waits for medicines or equipment at the point of discharge. (update Q4)
Target. Increase or maintain the high percentage of positive comments in dedicated patient feedback.
Medication
What did we do in Q1 2013/14? An audit of discharge medication prescribing time and turnaround time showed that a considerable number of discharge prescriptions arrived either after 5pm the evening before or on the morning of discharge.
A multidisciplinary team reviewed the discharge medication prescribing process, roles and responsibilities to inform re-design of the pathway and process. The importance of prescribing discharge medication well in advance of discharge and as soon as the medication requirements are known was highlighted to prescribers.
There had been a number of incidents associated with delays in discharge because of a lack of a particular syringe driver (which administer subcutaneous medication continuously). Previously these syringe drivers had been distributed to the wards and were managed locally, a large number of drivers went missing and were not returned (this equipment would often go home with the patient). Clinical Engineering, in response to these incidents developed a new system where they hold the reserve syringe drivers and each syringe driver is provided on a named patient basis. This has meant we have a reliable central stock because each syringe driver is logged out, its ongoing requirement in and out of hospital is subsequently checked by the team and less are lost.
How did we perform in Q2 and Q3 2013/14? Some improvement in performance of planned discharge and medication availability at discharge, particularly on those wards with a dedicated Medicines Management Technician. A number of discharge prescriptions were still written immediately before discharge. There have been no incidents associated with delays in discharge associated with lack of the subcutaneous syringe driver.
What actions are we planning to improve our performance? We are in the final stages of awarding a contract for a partner to provide different medication supply options. The multidisciplinary team will then review re-design of the pathway and process and will make proposals for pathway redesign in Q4. We will continue to monitor the accessibility of the syringe driver. A monthly report is sent to the Clinical engineering lead which is then actioned.
How will improvement be measured and monitored? • Audit of discharge prescription prescribing time and availability at discharge. • Number of discharges delayed by medication supply. • Audit of syringe driver availability completed quarterly.
Discharge
What did we do in 2013/14? In 2013/14 we piloted a patient bedside tool to ensure patients were informed of their discharge plans including if they required medicines for discharge and when they were on the ward. The tool is called “ticket home” and in the first two months there has been an improvement in the number of patients who have had medicines at the time they were due to be discharged. However, this initiative has proven challenging in the non-elective patient group. Attention will be focussed on elective surgical patients. We have also piloted a member of the discharge team reviewing all patients who are being discharged in the next 24/48hrs to ensure medical review and to take out medications (TTOs)
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have been prepared in advance of the discharge date.
What actions are we planning to improve our performance? Roll out the ticket home project involving elective surgical patients in the first instance. Continue to have a daily monitoring role for the discharge team
How will improvement be measured and monitored? Both the Ticket Home and Discharge Review project will continue and will be monitored and reported to the Non-Elective Working Group and the Chief Operating Officer Operational meetings.
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Priority 13: The uptake of immunisation working in partnership with primary care (Q4 update)
Target: Increase the percentage of children receiving pre-school immunisations in partnership with GPs.
What did we do in 2013/14?
As providers of the CHIS (Child Health Information System), we have responsibility for the management of the database containing information about immunisations given to children aged 0-19. As the immunisation schedule evolves, the Child Health Information System is responding in its ability to report on new immunisations given. Rotavirus, childhood ‘flu vaccine and meningitis B may all be added for reporting in the coming year, 2014/15.
As such, the Child Health Information System team has been communicating monthly with every GP practice, informing them of the children on their lists who are missing or due a pre- school immunisation and which immunisation it is. The advent of a new electronic reporting system commissioned for GP practices and run by an external company has effectively reduced this communication, as the latter system extracts all the required data. However, management of these data is still required (i.e. identifying those children missing immunisations, in order to maintain the most accurate data); therefore, the Child Health Information System team continues to send monthly reports to practices where children’s immunisations are missing.
In order to ensure the greatest accuracy of immunisation data, significant effort has been made by the Child Health Information System team to ensure that the caseloads are maintained accurately. This involves discharging children no longer registered with practices, thereby ensuring percentages reported to COVER (Cover of Vaccination Evaluated Rapidly) are the best reflection of the immunisation coverage achieved.
The Service Manager for Children’s Information and Public Health continues to attend a joint borough immunisation meeting, at which there is representation from Public Health England, Clinical Commissioning Group immunisation leads and borough public health departments. The Royal Marsden attends as the provider and the group works to find partnership solutions to increase promotion and uptake of immunisations in local populations.
The Service Manager has commenced meeting regularly with the Clinical Commissioning Group lead for immunisations and has agreed to send information to both Clinical Commissioning Group leads re any practice that is not engaging with our failsafe processes (missing immunisations, registration and deregistration of patients) in order that they can be followed up.
How did we perform in 2013/14?
GP engagement continues and monthly contacts are made with every practice in relation to children’s GP registrations and deregistrations. We now regularly receive electronic reports about registrations and deregistrations into the Healthy Child Programme administration team from 41 practices; this is an increase from 27 last month. Practices which have not yet become involved are in discussion with the project lead. There remain 10 practices outstanding – 5 in Merton and 5 in Sutton – that have not yet commenced electronic notification of registrations and deregistrations. Meetings are now booked with practices to endeavour to move this forward.
‘Missing immunisations’ reports continue to be sent out monthly to all general practices in Sutton and Merton. The GPs make three attempts to contact the children who have missed a vaccination and, if these attempts fail, they can send a list to the health visitor to follow up.
The graph below shows the levels of immunisation achieved by local practices over the last two financial years, using practices’ own data as collected and processed by the Child Health
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Information System. Note that data for the final quarter of 2013/14 are due to be submitted to NHS England and to Public Health England only at the end of May 2014, so figures were not available for presentation at the time of this report’s publication. Each cohort below shows the date that the child reached at the time of the immunisation.
2013/14 data shown up to Q3 only; Q4 data are not available until end of May 2014
What actions are we planning to improve our performance?
We are continuing to work with each practice and to monitor data flows and returns. These have shown significant improvement throughout the year.
Health-visitor update sessions were delivered to all health-visiting teams across the trust and discussions held re the importance of emphasising and reminding clients of the immunisation programme and its timeline.
How will improvement be measured and monitored?
Monthly reports are sent to the Clinical Quality Review Group (attended by commissioners and providers), demonstrating the actions and improvement in each general practice’s pre- school immunisation rates; and the immunisation COVER data is sent quarterly to NHS England and to Public Health England.
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Part 3: Outline of Quality Improvements in 2013-2014
Monitor issued ‘Detailed requirements for quality reports 2013/14’ in February 2014. From 2011/12, all acute trusts are required to have limited assurance work performed on their Quality Accounts and Monitor issued ‘2013/14 Detailed guidance for external assurance on quality reports’ in February 2014 to assist trusts. The trust chose to include the proposed core set of quality indicators for requirements for 2013/14. Some of the indicators are not very relevant to us e.g. ambulance response times, therefore these have been excluded.
However, we also felt it was important to consult with our members and governors to incorporate their views about “quality” into the Quality Account.
The process for agreeing the priorities for quality improvement were as follows:
October 2013 - Key milestones and timetable outlined at the Patient Experience and Quality Account group were agreed. Members of the Patient experience feedback group were: Governors, Healthwatch, Sutton Health and Wellbeing Board, Patients and Carers, Matrons from the hospital and community services.
November 2013 - Review of first draft of the annual Quality Account 2013/14 priorities and progress - Member’s event to discuss progress with developing and selection of quality priorities
January 2014 -Review of progress - Review second draft of annual Quality Account 2013/14 - Agreed on process for selecting quality priorities
February 2014 - Engagement - Final draft of annual Quality Account 2013/14 - Senior Nurse and Therapies committee invited to review priorities - Council of Governor’s meeting assisted in the selection of priorities - Patient Experience and Quality Account group select quality improvement priorities - Chief Nurse to discuss and agree measurable targets alongside relevant trust staff - Engagement and refinement- penultimate draft to Council of Governors, Healthwatch, Commissioners, Specialist commissioners, Health and Wellbeing Board, Patient and Carer Advisory Group; to comment and provide a statement about the annual Quality Account - Draft to external stakeholders for comments and statements. - Draft to trust staff for comments.
March 2014 - Engagement - Patient Experience and Quality Account group finalise quality improvement priorities and targets for 2014-2015 - Council of Governors meeting to review draft and give comments - Chief Nurse informs Board of progress to date and obtain approval of quality improvement priorities and targets for 2014-2015
April and May 2014 - Engagement and refinement - Progress against 2013/14 targets to be added to final draft of annual Quality Account - Copy to Marketing and Communications Department - To external auditors for review - Final copy to designer via marketing and communications team
May and June 2014 - Submission and publication - Reviewed at the trust’s Audit committee - Trust’s Annual Report submitted to Monitor by 30 May 2014 - Trust to publish annual Quality Account on NHS Choices website and trust website and submit copy to Department of Health by 30 June 2014
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The quality priorities for 2014/15
The proposed quality priorities and targets for 2014-2015 are displayed in the table below. The priorities marked with * were mandatory quality indicators in 2013-14 and remain mandatory for 2014/15. New priorities are marked with ^
Table 1: Quality priorities and targets for 2014/15 Category Quality Priority Target Safe care 1 *Reduction in Healthcare Less than one MRSA bacteraemia Associated Infections (MRSA Less than 16 C. Difficile infections bacteraemia and Clostridium (report the number of C. difficile difficile infections) Applies to infections per 100,000 bed days) Acute beds at The Royal Marsden and patients of Sutton and Merton Community Services (SMCS) Safe care 2 *Rate of patient safety Reduction in the rate of reported incidents and percentage patient safety incidents per 100 resulting in severe harm or admissions that have caused severe death harm or death to below 0.01. (in 2013/14 the rate of severe harm or death from incidents per 100 admissions was 0.008 for acute and 0 for community) Applies to acute beds and Community Services
Safe care 3 *Percentage of admitted Maintain above 95% the number of patients risk assessed for patients who have a completed VTE Venous thromboembolism risk assessment Effective 4 *Avoidance of emergency re- Reduction in the number of care admissions to hospital within avoidable re-admissions to hospital 28 days of discharge. within 28 days of discharge to below 0.3%. Effective 5 Reduction in community ^ Reduce the number of acquired care acquired category 3 and 4 Category 3 and 4 pressure ulcers pressure ulcers: Applies to whilst under the care of community Community Services services to less than 0.2%. ^90% of category 3 and 4 pressure ulcers both inherited and acquired whilst under the care of community services have improved to category 1, 2 or healed between the start and the end of the quarter. Effective 6 Increase the numbers of To increase the proportion of care patients who have an designated patients who will be Holistic Needs Assessment offered a Holistic Needs Assessment to 80% by the end of 2014/15.
Patient 7 *Ensure that we are Remain in the top 20% of trusts for experience responding to in-patients’ the Friends and Family question for personal needs. hospital inpatients.
Introduce Friends and To increase by 10% from the Family Test question for baseline measurement and community services clients benchmark with other community services.
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Patient 8 *Percentage of staff who To maintain or improve the experience would recommend The Royal response to this specific question in Marsden to friends or family the survey to more than 87%. needing care. Patient 9 Reduction in chemotherapy To improve the chemotherapy experience waiting times and waiting times at Sutton and Chelsea improvement in patient so that no more than 10% of experience related to waiting patients wait more than one hour. times Patient 10 Improve communication, To improve or maintain the high experience particularly when patients percentage of positive comments in arrive for first appointments dedicated patient feedback above 90% on arrival at clinic appointments. Patient 11 Reduce the length of time a Reduce the number of patients by experience patient waits for medicines 10% who wait for more than two at the point of discharge hours. Children’s 12 ^To improve the health Support parents in primary schools services screening for children, by offering ‘ Parental drop- ins’ with promoting a follow up health the school nurse to assist parents in screening appointment in dealing with their child’s health to year? with the school nurse, achieve health screening in 80% of following receipt of the all schools who request this parent and school health support. questionnaires.
The table below summarises the quality objectives and priorities of the trust for the last five years. Community services are detailed from 2011-12 onwards.
2009/10 2010/11 2011/12 2012/13 2013/14 SAFETY *=mandatory Incidence of Reduction of Reduction of *Reduction in *Reduction in healthcare healthcare healthcare Healthcare Healthcare associated associated associated Associated Associated infections infections infections Infections Infections
Reduction in Reduction in Reduction in *Rate of patient *Rate of patient medication medication medication safety incidents safety incidents errors incidents incidents and percentage and percentage resulting in resulting in severe harm or severe harm or death death
Incidence of falls Reduction in Reduction in ------falls falls. (hospital services) A 15% increase in number of falls screens compared to 2010-11 (SMCS) Assessment, Reduction in *Percentage of *Percentage of monitoring and venous admitted admitted treatment of thromboembolis patients risk patients risk venous m (blood clots) assessed for assessed for thromboembolis venous Venous m thromboembolis thromboembolis m m Compliance with Compliance with
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national health national health visiting targets: visiting targets: ------new birth visits new birth visits (SMCS) (SMCS) Safeguarding children priorities------compliance with national guidance and training (SMCS) Mortality rate, Reduction in the Reduction in the Reduction in the ------hospital hospital hospital hospital standardised standardised standardised standardised mortality ratio mortality ratio mortality ratio mortality ratio (HSMR) (HSMR) (HSMR) (HSMR) EFFECTIVE CARE *= mandatory Incidence of Reduction in the Reduction in the Reduction in Reduction in hospital acquired incidence of incidence of community community pressure ulcers hospital acquired hospital acquired acquired grade 3 acquired grade 3 pressure ulcers pressure ulcers and 4 pressure and 4 pressure (hospital ulcers ulcers: Applies services) to SMCS Reduction in pressure ulcers especially grades 3 and 4 (SMCS) Achieve more Increase the than 42% of number of patients dying in patients that die ------their preferred in their preferred place of death place of death Effective length Reduced length Reduced length of stay of stay of stay ------Increase the Increase the numbers of numbers of patients who patients who ------have been have an Holistic offered an Needs Holistic Needs Assessment Assessment *Reducing the *Avoidance of number of emergency re- emergency re- admissions to ------admissions to hospital within hospital within 28 days of 28 days of discharge. discharge. PATIENT EXPERIENCE *=mandatory Patients in pain To be in top 20% To be in top 20% *Improve or *Ensure that we of trusts for key of trusts for key maintain a high are responding areas on the areas of national score in relation to in-patients’ national inpatient survey to responding to personal needs inpatient survey inpatients’ personal needs in the national survey Patients treated To be in top 20% To be in top 20% ^Improve
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with dignity and of trusts for key of trusts for key communication, respect areas on the areas of national particularly national outpatient survey ------when patients outpatient survey arrive for first appointments Patients given Roll out of the Roll out of the enough real time patient real time patient ------information on feedback feedback discharge throughout the throughout the trust trust New initiatives to Reduction in Reduction in improve the chemotherapy chemotherapy patient waiting times waiting times experience in and and 2011/12. 1) To improvement in improvement in reduce patient patient chemotherapy experience experience waiting times, 2) related to waiting related to waiting To improve the times times patient experience of hospital transport, 3) To improve communication at every part of the patient journey *Percentage of *Percentage of staff who would staff who would recommend The recommend The ------Royal Marsden Royal Marsden to friends or to friends or family needing family needing care care* Introduce a Patient Experience survey for SMC ^Reduce the ------length of time a patient waits for medicines or equipment at the point of discharge The uptake of ------immunisation working in partnership with primary care
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Statements of assurance from the Board
Review of services During 2013/14 The Royal Marsden NHS Foundation Trust provided and/or sub-contracted comprehensive cancer services and community services.
The Royal Marsden NHS Foundation Trust has reviewed all the data available to them on the quality of care in 100% of these relevant health services.
The income generated by the relevant health services reviewed in 2013/14 represents 100% of the total income generated from the provision of relevant health services by The Royal Marsden NHS Foundation Trust for 2013/14.
The data reviewed in part three of this Quality Account covers the three dimensions of quality: patient safety, clinical effectiveness and patient experience. In all areas the data has been available to review the service.
Participation in clinical audits (updated Q4 2013/14)
At The Royal Marsden we undertake many clinical audits for quality improvement. We participate in all the national cancer audits which are applicable to the organisation. This allows us to benchmark against other hospitals in England and sometimes across the world. We also have a comprehensive programme of local clinical audits which clinical staff including consultants, junior doctors, nurses and allied health professionals conduct regularly to improve local areas of care. During 2013/14 22 national clinical audits and two national confidential enquiries covered relevant health services that The Royal Marsden provides.
National clinical audit and confidential enquiries (updated Q4)
National confidential enquiries are “inspections” that are carried out nationally to investigate areas of care where there may have been problems or where the patients may be particularly vulnerable. All hospitals are asked to take part in them so that all care across England can be monitored. During 2013/14 The Royal Marsden registered and/or participated in 22 of the national clinical audits and all national confidential enquiries in which it was eligible to participate in (Table 1). Many of the national audits undertaken by other hospitals cannot be undertaken at The Royal Marsden because we only have patients with cancer. The national clinical audits and national confidential enquiries that The Royal Marsden participated in, and for which data collection was completed for the period 2013/14, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry (Table 1 and 3).
Table 1: National clinical audits The Royal Marsden participated in 2013/14 No National Clinical Audits Participated Cases submitted (%)
1 National Oesophago-Gastric cancer Yes 100% of cases diagnosed at the audit (OG) Audit trust
2 National Bowel Cancer Audit Yes 100% of cases diagnosed at the (NBOCAP) trust
3 National Lung Cancer Audit Yes Note: Tertiary Trust. (LUCADA) Standards do not apply as most
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No National Clinical Audits Participated Cases submitted (%)
patients are not “first seen” at tertiary Trusts. Treatment data submitted
4 National Head and Neck Cancer Yes 100% of cases diagnosed at the (DAHNO) trust
5 National Emergency Laparotomy Yes Organisational audit Audit (NELA) completed. Data collection started in January 2014
6 National Prostate Cancer Yes Participated in Organisational survey
7 Sentinel Stroke National Audit Yes 100% Programme (SSNAP)
Other National Audits
8 Intensive Care National Audit & Yes 100% Research Centre (ICNARC) Case Mix Programme (CMP)
9 The Association of Breast Surgery Yes 100% (ABS) & NHS Breast Screening Programme
10 Breast Cancer Clinical Yes 100% Outcome Measures (BCCOM) Project
11 National Health Service Cancer Yes 100% Screening Programme (NHSCSP) Audit of Invasive Cervical Cancer
12 Royal College of Radiologists (RCR) Yes 100% National Audit of Current Patterns of Practice and Opinions on Prostate Brachytherapy in the UK 2013
13 RCR survey of anal cancer Yes Participated in survey chemoradiotherapy 2013
14 RCR Audit Leads Survey 2013 Yes Participated in survey
15 RCR NSCLC (Non-Small Cell Lung Yes 100% Cancer) Radical Radiotherapy audit
16 The British Association of Urological Yes 100% Surgeons (BAUS) Nephrectomy audit 2013
17 BAUS Total Cystectomy audit Yes 100%
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No National Clinical Audits Participated Cases submitted (%)
18 BAUS Radical Prostatectomy audit Yes 100%
19 BAUS Retroperitoneal Lymph Node Yes 100% Dissection (RPLND)
20 Pilot of a new national process for Yes Pilot local study review by NHS Pharmacy (National Institute for Health Research (NIHR))
21 National Comparative Audit of Blood Yes Organisational survey Transfusion Programme: Red Cell Survey
22 National Comparative Audit of Blood Yes Organisational survey Transfusion Programme: Online National Patient Blood Management Survey
The reports of 14 national clinical audits were reviewed by The Royal Marsden in 2013/14. The Royal Marsden will take the following actions to improve the quality of healthcare provided, where appropriate.
Table 2: National clinical audits published reports and actions taken in 2013/14 No National Clinical Audit reports Description of actions published in 2012/13
1 National Oesophago-Gastric Cancer Audit Report reviewed Report 2013
2 National Bowel cancer Audit Report 2013 Report reviewed
3 National Head & Neck Cancer Audit 2012 Report disseminated
4 NHSCSP Audit of invasive cervical cancer Report disseminated National report 2011
5 RCR National Re-audit of Radiotherapy Report reviewed in the Treatment of Malignant Spinal Cord Compression 2012
6 RCR Caseload and Outcome after Report disseminated Brachytherapy 2013
7 RCR UK Survey of Any Qualified Provider Report disseminated of Ultrasound Services 2012
8 RCR National Audit of Appropriate Report disseminated Imaging 2012/13
9 RCR National Audit of NPSA and Report disseminated RCR Safety Checklist for Radiological
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No National Clinical Audit reports Description of actions published in 2012/13
Interventions 2012/13
10 BAUS Analyses of Nephrectomy dataset, Report disseminated June 2013
11 BAUS Analyses of Prostatectomy Dataset, Report disseminated June 2013
12 BAUS Analyses of Cystectomy Dataset, Report disseminated June 2013
13 Sentinel Stroke National Audit Report disseminated Programme (SSNAP): Second pilot report
14 National Audit of Intermediate Care Await confirmation Report 2013
Table 3: National confidential enquiries The Royal Marsden eligible to participate in 2013/14 National Confidential Enquiry into Participated % cases Patient Outcome and Death (NCEPOD) submitted studies
1 Tracheostomy care Yes 100%
2 Subarachnoid Haemorrhage Yes 100%
3 Gastrointestinal Haemorrhage Yes Ongoing
4 Lower Limb Amputation study No Not applicable
5. Sepsis Yes Ongoing
The report of two national confidential enquiries report was reviewed by The Royal Marsden in 2013/14. The Royal Marsden intends to take the following actions to continue to improve the quality of healthcare provided.
Table 4: National Confidential Enquiries reports published in 2013/14 and actions No National Confidential Enquiry into Patient Description of actions (local) Outcome and Death (NCEPOD) studies
1 Alcohol Related Liver Disease: Measuring Not applicable. the Units? (2013)
2 Subarachnoid Haemorrhage: Managing the To be presented to surgical audit group Flow (2013) meeting.
The reports of 73 local clinical audits and local action plans to improve the quality and outcomes of patient care were reviewed by The Royal Marsden in 2013/14. The following actions are examples of some of the actions taken. Should you require more information about
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the local audits please contact the Quality Assurance department on 02078082702 or email [email protected] .
Title of local audit Action points from local audit
Benefit and patients acceptability of Presentation of results at surgical audit group meeting a supervised preoperative fitness to raise awareness. training programme Meeting with physiotherapy team to review evaluation and referral process. Patient survey planned to explore acceptability and logistic problems planned. Abstract submitted. Anti-emetic use in Paediatric Review and update of anti-emetic guidelines. inpatients Peer review – Skin cancer patients To review GP and key worker fax-back process. To re- 2012/13 audit within a year. Local management of B3 lesions Re-evaluate the management of indeterminate (B3/B4) with atypia/B4 lesions found on vacuum assisted breast biopsy lesions in relation to new vacuum assisted breast biopsy clinical guidelines in six months' time. Meeting nutritional needs – audit of New protected mealtime posters printed. food service Food and nutrition policy reviewed.
Yoga patient experience survey Yoga sessions commenced at Chelsea site. Patient survey planned. Audit of Cisplatin side effects for Pharmacy proforma to be amended to record whether head and neck patients patient has been asked about tinnitus. Neutropenic sepsis pathway audit Continue audit in current format on monthly basis to monitor the Trust’s performance. Change methodology after publication of recommendations from the London Cancer Alliance. User survey for complaints handling Ensure questions that are asked are answered directly. Ensure responses are easier to understand. Specify the intended actions with timescales in the responses. Annual audit of exclusions in the To write to the GP Lead of a particular practice Sutton and Merton Diabetic Eye highlighting the high number of patients opting out. Screening Programme (community To review all temporary exclusions identified to ensure services) exclusion managed in accordance with local policy. To amend DESP administration policy To investigate with software supplier the occurrences of patients being recorded as deceased but still appearing in the programme size and exclusion categories To hold an exclusions workshop for all administration staff to provide refresher training on DESP exclusions policy and acceptable evidence required Re-audit in 1 year. Sutton and Merton DESP Slit Lamp Training and maintaining skills as a slit lamp examiner. Audit (community services) Re-audit planned.
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Developing a Self referral service to Improving the communication of this new service to Children’s physiotherapy for older service users, improving on the content and format in children with cerebral palsy the leaflet. (community services) Implement the service from September 2013 onwards Audit efficacy of service in the next 1-2 years
Consultant Treatment Outcomes has been published on the NHS Choices and The Royal Marsden website. The Royal Marsden will take the following actions to improve the quality of healthcare provided, where appropriate.
Consultant Treatment Outcomes reports and actions taken in 2013/14 No Consultant Treatment Outcomes Linked to NHS Description of actions Choices from The Royal Marsden website
1 Urological surgery: nephrectomies Yes Report reviewed
2 Colorectal surgery Yes Report reviewed
3 Upper gastrointestinal surgery Yes Report reviewed
4 Head and neck cancer surgery Yes Report reviewed
Participation in clinical research (updated Q4)
The Royal Marsden and The Institute of Cancer Research form the largest centre for cancer research in Europe. This is important because it means that our patients and our staff are always aware of the latest research in treatments, medicines and therapies that make such a major difference to outcomes and the experience of care. If you would like to find out more about our research work please go to our website www.royalmarsden.nhs.uk
The number of patients receiving relevant health services provided or subcontracted by The Royal Marsden from April 2013 to March 2014 that were recruited during that period to participate in research approved by a research ethics committee was 5272 patients into 303 different trials.
Revalidation of doctors (updated Q4)
The trust has made 55 positive recommendations in support of revalidation since April 2013. Established processes are in place to manage doctor’s appraisal and revalidation, and these are supported by clear governance arrangements. Revalidation is reported and discussed at all levels including the trust Board. The trust reports externally on revalidation on a quarterly basis and in September 2013, received a “green” RAG rating from the NHS revalidation support team with regards to its systems to support.
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Use of the CQUIN payment framework (Q4 updated pre 30th April)
Commissioning for Quality and Innovation (CQUIN) payments are a mechanism for commissioners to reward quality by linking a proportion of the trust’s income (2.4% - 2.5% in 2013/14) to the achievement of quality improvement goals. In 2012/13 cancer specialist services received 100% of its CQUIN goals. This equated to approximately £3 million of income. Sutton and Merton Community Services (SMCS) achieved 86.7% of its CQUIN goals in 2012/13, which equated to approximately £712,500 of income. In 2012/13 The Royal Marsden achieved 100% of its CQUIN target which is £3 million In 2011/12 The Royal Marsden achieved 93% of its CQUIN target which is £1.7 million. In 2012/13 Sutton and Merton Community Services achieved 86.7% of its CQUIN target which is £712,500. In 2011/12 Sutton and Merton Community Services achieved 90% of its CQUIN target which is £418,000. Goals for 2013/4 were agreed in the following subject areas for cancer specialist services and for community services. . Cancer specialist services: − Friends and Family Test − NHS Safety Thermometer – increasing the percentage of harm free care − Dementia - identification of patients with dementia and other causes of cognitive impairment alongside their other medical conditions, to prompt appropriate referral and follow-up after they leave hospital and to ensure that hospitals deliver high quality care to people with dementia and support their carers − Venous thromboembolism - risk assessment and root cause analysis − End of life care - improving care for patients approaching the end-of-life in hospitals − Chemotherapy waiting times and patient experience − Modernising outpatients – including patient information, improving waiting times, reducing non-attendances, improving the use of Choose and book and reducing the proportion of inappropriate face-to-face contacts − Agreed treatment plans within 24 hours of admission − London Cancer Programmes best practice commissioning pathways − Completion and submission of specialised dashboards − Completion and submission of bone marrow transplant dashboard identifying unrelated donors. . Sutton and Merton Community Services: − NHS Safety Thermometer – improving pressure ulcer recording and management − Prevention of admission – including improving quality in nursing and residential homes by offering a training package to help management of key conditions − Reducing emergency department attendances in those aged under 18 by helping families to manage minor ailments. − Diabetic Eye Screening Programme
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Cancer specialist services CQUIN goals – Quarters One, Two and Three 2013/14
Commissioners have confirmed that the acute Trust has met 100% of its CQUIN goals in Q1,2 and 3. The quarter 4 2013/14 report is due to be submitted to commissioners by 30th April 2014.
Sutton and Merton Community Services CQUIN goals – Quarters One, Two and Three 2013/14
Based on reports submitted to commissioners, community services had achieved 60% to quarter 3. However this does not include deferment of assessmnet of the pressure ulcer CQUIN until quarter 4 (worth 20%) of total CQUIN. The quarter 4 2013/14 report is due to be submitted to commissioners by 30th April 2014.
What others say about the provider
Statements from the Care Quality Commission (CQC) (updated Q4)
The Royal Marsden NHS Foundation Trust is required to register with the Care Quality Commission and its current registration status is “registered with no conditions”.
The Care Quality Commission has not taken enforcement action against The Royal Marsden NHS Foundation Trust during 2013/14.
To assist the CQC during 2013/14 the Royal Marsden NHS Foundation Trust, community services division has participated in the special review of children transferring to adult care. The Royal Marsden has not participated in any investigations by the CQC during the reporting period, 2013/14.
Data quality
Good quality information is very important in underpinning the effective delivery of the best patient care.
The Royal Marsden NHS Foundation Trust submitted records during 2013/14 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 99.9% for admitted patient care, 99.9% for outpatient care, and none for accident and emergency care (specialist cancer trust and community services without an accident and emergency department). See table 1 below.
The percentage of records that included the patient’s valid General Medical Practice Code was 99.8% for admitted patient care, 99.8% for outpatient care and none for accident and emergency.
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Table 1 Data quality - England and Wales (Updated 2013/14)
% completeness
NHS number GP practice
2011/12 2012/13 2013/14 2011/12 2012/13 2013/14
Inpatient & Day 98.6 99.9 99.9 99.0 99.7 99.8 cases
Outpatients 98.8 99.8 99.9 99.1 99.7 99.8
Although data quality at The Royal Marsden is very good the trust strives for continual improvement. The Royal Marsden NHS Foundation Trust implements the following actions to improve data quality: 1. A dedicated data quality team are responsible for running routine validation checks and reports to identify errors and inconsistencies in data entry. 2. In 2013 trust wide monthly communications started promoting the importance of accurate information and data collection centrally for all trust staff. 3. Trust wide audits of data quality involving key information points are conducted annually.
Information Governance Toolkit attainment levels (Q4 updated)
The Royal Marsden Information Governance Toolkit Assessment overall score for 2013/14 was 88%, submitted on 31st March 2014 and was graded satisfactory. This maintains the score of 88% from 2012/13. The Information Governance Toolkit is available on the Health and Social Care information Centre (HSCIC) website https://nww.igt.hscic.gov.uk/
Payment by Results Clinical coding error rate (Q3 updated)
The Royal Marsden was not subject to the Payment by Results clinical coding audit during 2013/14 by the Audit Commission. However a full coding audit was carried out by a qualified coding auditor to standard coding methodology and the error rates reported for diagnoses and treatment coding are in Table 2 below. 200 episodes were reviewed within the sample. These results should not be extrapolated further than the actual sample audited.
Table 2 Clinical coding
Coding Errors 2009/10 2010/11* 2011/12 2012/13 2013/14**
Primary Diagnosis Errors 5.0% 2.5% 3.5% 8.0% 6.0%
Primary Procedure Code Errors 35.7% 2.1% 12.4% 4.7% 5.11%
Secondary Diagnosis Errors 7.2% 1.9% 2.9% 5.1% 2.55%
Secondary Procedure Code Errors 12.8% 8.4% 26.4% 8.8% 4.19%
* The trust was not eligible for an Audit Commission Clinical Coding Audit in 2010-11; these figures are therefore based on an audit commissioned by The Royal Marsden in November 2010.
**These figures are taken from the Information Governance Clinical Coding Audit in December 2013, which used the latest version of the NHS Health and Social Care Information Centre audit methodology.
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Part four
Review of quality performance (previous year’s performance) National targets (updated Q3) due 9th May
Cancer waiting times National 2013/14 2013/14 2013/14 2013/14 2013/14 targets Target performanc performan performance performance performance 2013/14 e Q1 ce Q2 Q3 Q4
All urgent GP 93% 97.1% 94.9% 97.8% referrals seen within 14 days
All referrals for 93% 94.0% 90.5% 95.8% breast symptoms seen within 14 days
Treatment within 31 96% 100% 98.6% 99.1% days of decision to treat for first treatment
Subsequent surgical 94% 98.2% 97.2% 97% treatment started within 31 days of decision to treat
Subsequent drug 98% 100% 99.6% 100% treatment started within 31 days of decision to treat
Subsequent 94% 99.1% 99.5% 99.7% radiotherapy treatment started within 31 days of decision to treat
Treatment started 85% 85.0% 85.3% 89.7% within 62 days of urgent GP referrals *
Treatment started 90% 93.2% 93.2% 87.5% within 62 days of recall date for urgent screening centre referrals * Figures include agreed reallocations between trusts
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NHS 18 week targets (updated Q4)
Target/ Priority Nationa 2011/12 2012/13 2013/14 2013/14 2013/14 2013/14 Nationa l Target % % % % % % l target 2013/14 achieve achieve achieved achieved achieved achieved 2014/15 d d Q1 Q2 Q3 Q4
Patients requiring 90% 94.8 96.0 95.4 96.1 94.9 96.0 90% admission who waited <18 weeks from referral to treatment (not national targets since 2010)
Patients not 95% 98.8 98.6 99.0 99.1 99.0 98.5 95% requiring admission who waited <18 weeks from referral to treatment (not national targets since 2010)
Access targets (updated Q3) due 9th May
Target/ Priority National 2011/12 2012/13 2013/14 2013/14 2013/14 2013/14 National Target % % % achieved % achieved % achieved % achieved Target 2013/14 achieved achieved Q1 Q2 Q3 Q4 2014/15
Operations Less 0.3% 0.5% 0.5% 0.8% 0.5% Less cancelled by the than 5% than 5% Trust at the last minute
Last minute 0.0% 0% 0.0% 0.0% 0.0% 0% 0% cancelled operations not subsequently performed within one month
The Royal Marsden NHS Foundation Trust met all key performance waiting times and access targets in 2012/13 and 2013/14 with the exception of the breast symptomatic target during Q2.
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Appendix 1: Quality Indicators where national data is available from the Health and Social Care Information Centre (updated Q4)
Since 2012/13 NHS Foundation trusts have been required to report performance against a core set of indicators using data made available to the trust by the Health and Social Care Information Centre (HSCIC).
The Trust considers this data is as described as taken from the Health and Social Care Information Centre.
The Trust has taken actions to improve the percentage and so the quality of its services (see priorities for each indicator in Part 2 for further information).
Not all of the core indicators are relevant to The Royal Marsden NHS Foundation Trust for example those relating to the ambulance response times. The tables below show those core indicators which are relevant and how the trust compares against other trusts and shows the highest and lowest national scores.
Core Indicators
Trust quality priority 1 Core indicator 24) The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information centre with regard to the rate per 100,000 bed days of cases of C. difficile infection reported within the trust amongst patients.
National highest National lowest Average The Royal (all acute and (all acute and NHS Period Marsden specialist trusts) specialist trusts) trusts April 2012 to March 2013 25.2 30.8 0* 17.3 April 2011 to March 2012 31.4 58.2 0* 22.2
* The Trust is advised by HSCIC that the zero recorded here may be due to missing data from other trusts reported to the centre.
Trust quality priority 2 Core indicator 25) The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre Incidents reported within the trust during the reporting period and the number and percentage of such patient safety incidents that resulted in severe harm or death.
Patient Safety Incidents: Rate National National highest lowest Average (all Acute (all Acute Acute The Royal Specialist Specialist Specialist Period Marsden Trusts) Trusts) trusts October 2012 to March 2013 13.3 31.0 3.8 9.1 April 2012 to September 2012 11.3 24.6 3.1 7.8
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Patient Safety Incident: Number National National highest (all lowest (all Average Acute Acute Acute The Royal Specialist Specialist Specialist Period Marsden Trusts) Trusts) trusts October 2012 to March 2013 1541 1675 174 808 April 2012 to September 2012 1305 1720 99 758
Patient Safety Incidents resulting in severe harm or death: Rate National National highest lowest Average (all Acute (all Acute Acute The Royal Specialist Specialist Specialist Period Marsden Trusts) Trusts) Trusts October 2012 to March 2013 0 0.11 0* 0.03 April 2012 to September 2012 0.03 0.12 0* 0.03
Patient Safety Incidents resulting in severe harm or death: Number National National highest (all lowest (all Average Acute Acute Acute The Royal Specialist Specialist Specialist Period Marsden Trusts) Trusts) Trusts October 2012 to March 2013 0 21 0* 3 April 2012 to September 2012 3 26 0* 4 * The Trust is advised by HSCIC that the zero recorded here may be due to missing data from other trusts reported to the centre.
Trust quality priority 3 Core indicator 23) The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of patients who were admitted to hospital and who were risk assessed for venous thromboembolism during the reporting period.
National National highest (all lowest (all acute and acute and The Royal specialist specialist Average Period Marsden trusts) trusts) acute trusts October 2013 to December 2013 95.49% 100.00% 77.70% 95.77% June 2013 to September 2013 97.25% 100.00% 81.70% 95.69%
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Trust quality priority 7 Core indicator 19) The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of patients aged – i) 0-14; and ii) 15 or over, readmitted to a hospital which forms part of the Trust within 28 days of being discharged from a hospital which forms part of the Trust during the reporting period ().
Patients aged 16+
The National National Royal highest (all lowest (all Average specialist England Period Marsden trusts) trusts) trusts national 2011/12 data standardised to persons 2007/08 9.47 14.09 0* 9.73 11.45 2010/11 data standardised to persons 2007/08 7.61 17.10 0* 9.61 11.43
* The Trust is advised by HSCIC that the zero recorded here may be due to missing data from other trusts reported to the centre.
Trust quality priority 9 Core indicator 20) The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regards to the trust’s responsiveness to the personal needs of its patients during the reporting period.
Average weighted score (out of 100)
National The Royal highest National lowest Average NHS Period Marsden (all trusts) (all trusts) Provider April 2012 to March 2013 84.2 84.4 57.4 68.1 April 2011 to March 2012 82.8 85.0 56.5 67.4
Trust quality priority 10 Core indicator 21) The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of staff employed by, or under contract to, the trust during the reporting period who would recommend the trust as a provider of care to their family or friends.
National highest National lowest The Royal (all specialist (all specialist Average Period Marsden trusts) Trusts) (acute trusts) 2013 87 94 40 67.4 2012 87 94 62 65
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Appendix 2: Statements from key stakeholders
Royal Marsden Quality Account 2013/14
Chair’s statement :-
As Chair of Sutton Council’s Scrutiny Committee I am pleased to provide some brief remarks on the Royal Marsden’s Quality Account for 2013/14. The Account provides a useful overview of the work of the Trust and we appreciate the increasing presence regarding the work of the Sutton & Merton Community Services arm. Sutton’s Scrutiny Committee looks forward to working more closely with colleagues at the Royal Marsden over the coming year to better understand the Priorities and issues covered in the Quality Account and share performance information on a more regular basis. . We also look forward to building on the success of the recent joint public meeting held with the Trust and our fellow scrutiny committee colleagues from Kensington and Chelsea.
9th April 2014 Councillor Mary Burstow
Merton CCG Governing Body member and Chair, SMCS Clinical Quality Review Group Statement in response to the Royal Marsden Hospital Quality account, in relation to Sutton and Merton Community Services 7th April 2014
Merton CCG ‘hosts’ the contract for Sutton and Merton Community Services (SMCS) with other commissioners, including Sutton CCG and Public Health teams within Sutton and Merton Local Authorities. Their views have been sought in providing this feedback. We understand that NHS England, who also commission some community services (for example health visiting, immunisations) will respond separately. The commissioners welcome the contribution of RMH Executive colleagues at the monthly Clinical Quality Review meetings. We see the obvious commitment from RMH Trust management to strengthen the leadership of community services and thereby to make a difference for our patients in the community. We would also like to thank all the staff in SMCS for their dedication and commitment to patients in Sutton and Merton. We note that several of the priority areas in this quality account (for the past year and future years) reflect community issues, and we share the ambition to improve care in these areas, including for example, reduction in community acquired pressure ulcers, the patient experience survey for SMCS, end of life care, immunisations and the staff survey. We note the improvements already made and welcome the openness and transparency with which these have been presented.
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We look forward to working with the Trust over the next year on continued improvement in these areas.
Jenny Kay Director of Quality Merton Clinical Commissioning Group
Dr Caroline Chill Governing Body member and Clinical Lead for community services, Merton Clinical Commissioning Group. Chair, SMCS Clinical Quality Review Group
The Royal Marsden NHS Foundation Trust 2013-2014 Annual Quality Account Although the Quality Account is an important document for the Trust’s Board it also sets out for the hospital’s several constituencies a public assessment of its performance within the framework of the regulatory environment and, importantly, its priorities and objectives for quality improvement during the 2014/2015 reporting year. Putting patients first is the dominant recurring theme throughout the Quality Account. The Trust has, of course, responded to the Frances Report, but this response is only but one aspect of the rigor applied by all members of the Marsden community to ensure that the Hospital leads in all aspects of cancer care. Responding to inpatient needs, further reduction in chemotherapy waiting times and shortening the waiting time for medicines will favourably impact the patient experience and these are but a few examples of what are described in the Quality Account with, of course, detailed action plans. We also need to be mindful of the challenges that exist in community services. The steps the Trust are seeking to implement to prevent and manage pressure ulcers demonstrates but one aspect of the focus the Hospital is lending to improving care for patients in the Sutton and Merton community. The Patient Carer Advisory Group acknowledges the dedication and loyalty of all Royal Marsden staff. We are very grateful for all they do as they care for patients and their families. We commend this Quality Account. Yours sincerely
Charles McGregor Chairman – the Patient Carer Advisory Group 28th April 2014
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Statement from the Council of Governors on the Quality Account 2013/14
The Council of Governors routinely reviews Quality Accounts information and has discussed priority quality issues at each of the Council of Governors meetings.
A sub group of the Council of Governors, the Patient Experience and Quality Account Group, has also reviewed feedback from patients, including from the frequent feedback surveys, and has influenced the questions used in these surveys, to reflect patients’ interests.
Governors agreed the process for developing and selecting priorities for quality improvement and they have met with patient, carer and public members at two Members’ Events, in November and February 2013 where the focus centred on themes from the Quality Account. These events allowed Governors and members to discuss the current priorities and to feedback their views on future areas relating to patient safety, clinical effectiveness and patient experience.
Dr Carol Joseph, Public Governor for Kensington and Chelsea served as the representative at the Patient Experience and Quality Account Group, which was set up to assist and monitor the development of the Quality Account throughout the year.
The Royal Marsden strives to improve the presentation of data each year to make the Quality Account, now in its fourth year of publication, more succinct, interesting, and readable by the general public as well as by healthcare professionals. This year Governors have seen a considerable improvement in the layout of the information, making it easier to read and digest.
Based on their involvement and the feedback they have received from members and other patients and carers, Governors endorse the key priorities for improvement as set out in the Quality Account.
Carol Joseph Public Governor for Kensington 23rd April 2014
Statement from Healthwatch Sutton
Despite its [of necessity] length, the RMH Quality Account is an easily navigable and intuitive document, and is exceptionally well-presented.
Having been part of the RMH Patient Experience Group for some while now, it is evident what you 'preach', you also 'practice'.
On behalf of all the patients and carers that Healthwatch Sutton represent, we are very pleased to be working with you, and very proud of you and all that you do.
Regards
David Williams Vice Chair Healthwatch Sutton
26th March 2014
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Healthwatch Central West London response to the Royal Marsden NHS Foundation Trust Quality Account 2013-2014
Healthwatch CWL appreciates our working relationship with the Royal Marsden NHS Foundation Trust. We acknowledge the good work of the Trust in ensuring improving quality of services for patients and in engaging a wide range of service users and the public for this purpose. We commend overall improvements from last year in various quality areas; the Trust’s actions to drive improvements including purchasing additional screens to inform patients on waiting times in clinics, and defibrillators in the Radiography suite to improve patient experience and safety. We are very pleased to note the strong performance of the trust in the recent CQC Hospital Intelligent Monitoring inspections (March 2014)1. However, we would like to comment specifically on the following areas:
Priority 5: Increase number of patients that die in their preferred place of death We welcome the various initiatives the trust has implemented to improve this outcome. We would also like to know what the trust will put in place to ensure that the views of family and carers are also considered, particularly through end of life and after the death of a patient.
Priority 6: Increase number of patients who are offered a Holistic Needs Assessment (HNA) We commend improvement in number of new patients offered a HNA (67%). However, we note only 2.5% of new patients have completed care plans. What will be done to both drive up the proportion of people receiving care plans and improve completed HNA rates?
Priority 7: Avoidance of emergency readmissions to hospital within 28 days of discharge We acknowledge overall improvements in number of readmissions and plans to continually monitor rates. We however would like the Royal Marsden to state what actions it is taking to prevent readmissions, how the reasons for readmissions will be monitored, and what actions the trust intends to take in order to address underlying causes.
Priority 9: Ensure that we are responding to inpatients’ personal needs
1 http://www.cqc.org.uk/sites/default/files/media/reports/RPY_102v2_WV.pdf
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Please state what actions the trust will take to meet the target of improved responsiveness to the needs of patients, as there are no actions stated in the draft Quality Account.
Coding Errors On page 39, clinical coding error rates were 6% for primary diagnosis error and 5% for primary procedure code error. These figures are worrying particularly if they are due to mitigating events or have resulted in a never event. The trust should state where there are mitigating factors, impact and learning outcomes from these errors. We understand the trust intends to put a narrative with this section to address this point.
Accessibility As mentioned in our statement last year, we would like the trust to state how they plan to improve the profile and accessibility of quality accounts, particularly amongst people with low and no literacy rates. Again, we understand the trust is aware of the need to include a glossary in the final version of the quality account.
We presume the trust will extend this learning to all patient information leaflets as mentioned in priorities 3, 8 and 11.
Defibrillators in the Radiography Suite We very much welcome the purchase of a large number of defibrillators for the Radiography Suite.
Care Quality Commissions Patient Experience Survey We take note of national surveys carried out by the Care Quality Commission (CQC) of inpatient and outpatient experiences at the Royal Marsden NHS Foundation Trust. As dignity is a key priority for Healthwatch CWL, we would welcome further detail on how the trust has improved and/or plans to improve on:
Inpatients (report from April 2013)2:
• Noise on the wards • Getting help from staff on the wards • Single sex accommodation • Collecting patients' views (about quality of care they received during their stay in hospital) • Discharge planning including information post discharge and communicating with other providers on the patient pathway.
We are pleased to note the Macmillan Fellowship award for a staff members work on establishing the Hospital2Home service and would welcome further detail3.
2 http://www.cqc.org.uk/survey/inpatient/RPY
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Outpatients4 • Waiting times • Cleanliness of facilities.
National Cancer Patient Experience Programme We also note results from the National Cancer Patient Experience Programme, National Survey 2012/135 and scope for the Trust to improve in: • Communications with patients on their treatment and tests • Contact with Clinical Nurse Specialists • Information on Support Groups • Patients feel they treated as a set of cancer symptoms
In summary, we compliment the trust on their efforts to continually provide quality care to all patients. We would like to continue our good relationship with the Royal Marsden NHS Foundation Trust and work together to improve dignity on the wards and person centred care in outpatients.
Contact
Ms Swabrina Njoku Borough Manager (Kensington &Chelsea) Ph: 0208 964 1490 Email: [email protected]
7th April 2014
3 http://www.nursingtimes.net/nursing-practice/clinical-zones/cancer/macmillan-cancer-support- honours-macmillan-professionals-at-excellence-awards-2013/5065273.article 4 http://www.cqc.org.uk/survey/outpatient/RPY 5 National Cancer Patient Experience Survey 2012/13 http://www.quality- health.co.uk/resources/surveys/national-cancer-experience-survey/2013-national-cancer-patient- experience-survey-reports/2013-london-strategic-health-authority/47-the-royal-marsden-nhs- foundation-trust/file
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Appendix 3 Statement of director’s responsibilities for the quality report
The directors are required under the Health Act 2009 and the National Health Service Quality Accounts Regulations to prepare quality accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that foundation trust boards should put in place to support the data quality for the preparation of the quality report.
In preparing this quality report, directors have taken steps to satisfy themselves that the content of the quality report meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2013/14.
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 2013 to June 2014 • Papers relating to quality reported to the Board over the period April 2013 to June 2014 • Feedback from the commissioners dated 07/04/14 • Feedback from the Governors through the Council of Governors throughout the year dated 23/04/14 • Feedback from local Healthwatch organisations dated 26/03/14 and 07/04/14 • The trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Regulations 2009, dated 22/04/14 • The 2013 national in-patient survey results , dated 16/01/14 • The 2013 national staff survey, dated 04/02/14 • The Head of Internal Audit’s annual opinion over the Trust’s control environment dated xx/xx/14 • CQC quality and risk profiles dated April 2013 to March 2014
- The Quality Report presents a balanced picture of The Royal Marsden NHS Foundations 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) as well as the standards to support data quality for the preparation of the quality report.
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
Mr R. Ian Molson Chairman XXX May 2014
Cally Palmer CBE Chief Executive Officer XXX May 2014
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Appendix 4: Independent Assurance Report (To follow)
Independent Auditor’s Report to the Council of Governors of The Royal Marsden NHS Foundation Trust on the Quality Report
We have been engaged by the Council of Governors of The Royal Marsden NHS Foundation Trust to perform an independent assurance engagement in respect of The Royal Marsden NHS Foundation Trust’s Quality Report for the year ended 31 March 2014 (the “Quality Report”) and certain performance indicators contained therein.
Deloitte LLP Chartered Accountants St Albans
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COUNCIL OF GOVERNORS PAPER SUMMARY SHEET
Date of Meeting: Agenda item
14th May 2014 Item 8.4
Title of Document: To be presented by
Update on Outpatient Waiting Times Liz Bishop, Chief Operating Officer Background
It was noted by the Council of Governors on 5 March 2014 that there may be an issue with the management of clinics, and more specifically the time that patients have to wait to see a doctor and patient experience.
Executive Summary
The RM has an Out-patient Working Group, which is systematically addressing the issues relating to the management of waiting times, and is responsible for implementing other quality initiatives to improve patient flows and patient experience through the outpatient departments throughout the hospital. The summary of actions to date, and work planned for future improvement, are summarised in this paper. Our data indicates that the waiting time position for patients in the main out-patient departments has shown a small improvement over the course of 2013/14, despite an increase in activity of 6.6% compared to 2012/13. Action has been taken by the Outpatient Working Group to improve both the communication with patients and the flow of clinics to avoid delays. However, it is recognised that further improvement is required and work has begun with each tumour Clinical Unit to address some of the outstanding issues. Alongside the short term plans we are currently working on developing a comprehensive modernisation plan to enable Outpatient Teams to deliver an enhanced more patient focussed service.
Conclusion
The Council of Governors are invited to discuss the challenges relating to managing out- patients and the actions to date and advise on any future information they would like to receive.
Author: Contact Number or E-mail: Date:
Bernadette Cronin, Deputy 0207 808 2212 29th April 2014 Director, Clinical Services [email protected]
Update on Outpatient Waiting Times
1.0 Introduction and Background
This paper summarises the clinic waiting time position for 2013/14, and describes factors contributing to excessive waiting times, the actions taken to date to improve this and ongoing plans to maintain this improvement.
Outpatient clinics in Sutton and Chelsea take place in the following departments: • Main Outpatient Departments • Rapid Diagnostic Assessment Centres (RDAC) • Haematology (Sutton) • Paediatrics (Sutton) • Medical Day Unit (Chelsea).
Some cases, they are uni-disciplinary focussing specifically on surgical, radiotherapy, medical oncology, research and chemotherapy patients whilst, in other cases, it is more appropriate for joint clinics where oncologists and surgeons see patients in the same clinic. Where necessary, the multi-disciplinary team extends to include diagnosticians and therapists (e.g. Dietitians and Speech and Language Therapists) so that we can ensure that our patients get the best access to care within the outpatient environment.
In order to make the best use of our skilled staff and meet the needs of patients, the configuration of each clinic varies slightly depending on the specialty. Where possible, and appropriate, patients can be cohorted into clinics designed to see, for example, only new patients, only follow up patients or only research patients but, in the majority of cases, clinic templates are set up to allow a mix of new, follow up and research patients within one clinic. It should be noted that, from a commissioning perspective, any appointment that is not the patient’s first appointment at RM is classified as a “follow up” and this, therefore, includes a mix of patients who are currently on treatment as well as those who are on post treatment follow up. There is always a need to be flexible because the length of time a patient may require for consultation can vary considerable, for example, if they have relapsed.
There are a total of 375 different NHS clinics across both sites as well as clinics held at Kingston Hosptial The majority of these clinics (298) are held in the main Out Patient Departments therefore these clinics have been the initial focus of the management teams.
2.0 Waiting time position 2013/14
Below is a summary of waiting times for 2013/14 showing the percentage of patients waiting for less than 30 minutes, 30-60 minutes and over 60 minutes.
Site Q1 30 30- Over Q2 30 30- Over Q3 30 30-60 Over Q4 30 30-60 Over mins 60 60 mins 60 60 mins mins 60 mins mins 60 or less mins mins or less mins mins or less mins or less mins
Chelsea % 80.2 14.9 4.9 % 83.4 12.0 4.6 % 82.5 12.8 4.7 % 80.3 15.0 4.7
Sutton % 74.8 16.5 8.7 % 77.1 15.9 7.1 % 77.9 15.9 6.3 % 76 16.6 7.4
Both sites have seen a small improvement in the percentage of patients seen within 30 minutes of their appointment time and a reduction in the percentage of patients waiting over 60 minutes; improvement is slow and difficult to maintain. These small percentage improvements have been achieved against a backdrop
1 of an increase, from the previous financial year, in NHS outpatient activity of 6.6% (approximately 10,000 appointments) and, therefore, in real terms represent a more significant improvement. The position in Q4 deteriorated slightly, in part due to a year high peak in activity during this time (see below).
Total Trust NHS Outpatient attendances activity 2013-14 compared to 2012-13
16,000
14,000
12,000
10,000 NHS Outpatient attendances activity 2012/13 8,000 NHS Outpatient attendances activity 2013/14 6,000 Attendances 4,000
2,000
0 1 2 3 4 5 6 7 8 9 10 11 12 Months
Patient survey data (Picker) for both sites in March 2014 indicates that 59% reported that they had been kept informed about their waiting times. As a result of this, it was agreed at the April 2014 Patient Experience Group meeting, that efforts would be made to update patients about delays every 15 minutes rather than every 30 minutes which is the practice currently in place.
3.0 Factors that contribute to long waiting times in Outpatients
There are a number of challenges facing the Outpatient department which contribute to delays in clinic resulting in a poor patient experience. Appendix 1 shows the detail of the issues and the actions taken to date. The issues largely relate to the following:
• Increase in a activity • Issues relating to staff resource • Space constraints • IT limitations • Staff and patient expectation • Complexity of workload • Communication
4.0 Plans for the future
It is recognised more improvement is required and the following next steps are proposed: • To develop and implement plans for improved communication regarding actual number of doctors planned for each clinic. • Develop speciality specifics solutions e.g. introduction of telephone clinics, nurse led clinics, discharge patient protocols. • Develop monthly information reports to allow managers to tackle the most problematic clinics. • Continued review of the number of follow up appointments per patient, with a view to aligning RM practice with the revised Pathway Group Clinical Guidelines due to be published through the London Cancer Alliance.
2 • Expansion of the Administration Co-ordinator role to provide enhanced support to all clinics that require it. • An Outpatient modernisation plan will be prepared. This plan will include:
Reduction in waiting time for clinics: Further extension of Outpatient opening hours to cover 8:00am - 8:00pm, including access to all the necessary support services (e.g. pharmacy, blood room, histopathology). Self check in and automated waiting time monitoring and communication systems to free up administrative time to directly support clinics. Zoned clinic and linked waiting areas for patients. Improved utilisation of existing space to increase clinic room availability. Introduction of Electronic Document Management system to ensure all records are available electronically in the department, including radiology and test bookings. Increase in nurse led clinics to improve patient flow. Improved experience and communication for waiting patients: Health and wellbeing facilities for patients e.g. relaxation room and therapies. Extending communication screens to ensure they can be contemporaneously updated with key information regarding, including waiting times on a clinic by clinic basis. Wireless connectivity available for patient access to entertainment systems.
5.0 Conclusion
Our data indicates that the waiting time position for patients has shown a small improvement over the course of 2013/14, despite an increase in activity of 6.6% compared to 2012/13. Action has been taken by the Outpatient Team to improve both the communication with patients and the flow of clinics to avoid delays. However, it is recognised that further improvement is required and work has begun with each Clinical Unit to address some of the issues that still provide challenge. Alongside the short term plans we are currently working on developing a comprehensive modernisation plan to enable Outpatient Teams to deliver an enhanced more patient focussed service.
3 Appendix 1 Challenges Impact on department and patients Action Plan Timescale and actions
Increasing demand. • More patients being seen in existing • Patients are asked to arrive in advance for Completed • In 2013/14, compared with the clinics leads to busy, over-running blood tests and the reception desk is now previous year, there was an average clinics and consequent delay for open earlier to accommodate these arrivals. increase of over 800 appointments per patients. Over-running morning clinics • A review of the number of true follow up (i.e. Completed month. impact on afternoon clinic start times. off treatment) outpatient attendances per
• Referrals to Outpatients increased by • Research trial protocols often require patient for each Clinical Unit has been 11.7% between 2012/13 and 2013/14. additional tests/checks which take performed to assess whether patients are more time and therefore may cause attending RMH unnecessarily. This review • The increasing number of research clinics to run late. initially identified 6 out of 14 Clinical Units trials means that research patients are were slightly over-performing against the often seen within the main Outpatient agreed standards, however a more thorough clinics. investigation was conducted for two of these units which demonstrated that, in the majority of cases, these additional visits resulted from a change in the patient’s clinical condition and therefore did not constitute a true off treatment follow up.
• Clinic templates have been updated to better Completed match the flow of patients and ensure that time slots and the number of appointments per clinic more accurately reflect the clinic experience. September 2014 • The weekly Trial Set up Meeting and West Wing Unit will help to plan and create capacity for research clinics. Staff resources • Outpatients has minimal influence in • There is now greater compliance in leave October 2014 • Variation and unpredictability of managing this crucial resource. booking arrangements for Consultants and medical cover for clinics, due to • In the absence of full information the next steps are to plan the junior doctor overrunning multi disciplinary team workforce leave to ensure medical cover for regarding the actual number and skill meetings, unexpected absence and mix of medical staff who will be present clinics. reliance on research doctors/junior in clinic, appropriate adjustment is • Review of MDT scheduling to assess whether medical staff whose attendance at challenging and can result in clinics these can be better planned to avoid clashes October 2014 clinic is inconsistent. being overbooked for the available with Outpatient clinics. manpower. 4
Space constraints • Clinics increasingly share clinic hub • There is now a clear clinic feasibility process Completed • The increased demand generates rooms and clinic rooms which impacts in place to ensure all aspects of clinic set up, frequent requests for new clinics to be on the availability of consultation i.e. space, nursing and administrative set up, with a net increase of 15 rooms. As a result, there are occasions resource requirements, templates, predicted additional clinics set up during when a doctor is available to see a activity and opportunities for growth and 2013/14. This has been achieved patient but they have to wait for a room potential impact on other clinics, have been within the existing staffing structure to become available for the addressed prior to new clinics being and space constraints through more consultation. established. This ensures optimal use of
creative use of both of these resources. current resource. • A number of nurse led and telephone clinics Completed have also been set up via this group. • Additional estate or refurbishment options December 2014 are currently being explored. Information Technology • The limitations of the current IT • Piloting of dedicated IT resource to Pilot completed – limitations system mean, for example, that there is troubleshoot and fix problems as they business case • The Outpatient booking system is the no option to easily change clinic happen has shown tangible benefit and required to continue oldest part of the RMH electronic templates week by week or to copy helped to prevent bottlenecks. service. patient system. It is inflexible to the clinics to another day (if extra clinics needs of a modern Outpatient need to be run) or view doctors’ • We have piloted an appointment reminder Pilot completed – Department. availability. service in selected clinics which has shown a business case • The majority of Outpatient clinics are • Unavailability of PCs and/or printers reduction in DNAs from 13% to 5% and required to continue note-less (99% Chelsea/65% Sutton) causes a direct delay in clinic. If PCs positive satisfaction survey feedback from service. and therefore rely on access to patient and printers break down during the patients. A case is being put together to clinic this causes a delay whilst they are records on the Electronic Patient extend this service to all main Outpatient Record. Current processes require fixed and restricts the flow of and RDAC clinics. appointments. Highest priority printing and scanning of patient consent forms. items agreed in 12 • Prioritised list of OPD requirements, which month plan. Other
vary in complexity, submitted to IT. requirements need to be aligned with overarching plan for enterprise-wide IT solution.
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Idealistic expectations • This very short turnaround time is • Introduction of Administration Co-ordinators Completed for pilot into selected clinics has improved preparation • There is often a very tight turnaround sometimes not achievable, resulting clinics - business for clinic, e.g. chasing up test results prior to time between patients having tests in a delay whilst the clinical team case being developed clinic, and has helped to manage the flow of (imaging, pathology, laboratory etc.) wait for or chase the results. to support expansion doctors and patients during clinic. This was into all required and the results being available for the • Occasionally patients do not want to piloted during 2013/14 and, along with positive clinics. outpatient attendance. wait and prefer to return for another feedback from consultants about how these • There is an expectation that many appointment which contributes clinics now run, has demonstrated some patients will attend for a complex scan further to the activity pressure. significant benefits: and the results will be available on the Urology clinic where the waits of over same day for the clinic appointment. 60 minutes have reduced from 8% to 1%. Melanoma clinic where waits of over 60 minutes have reduced from 7% to 4%. Sarcoma/Melanoma clinic where waits of under 30 minutes have increased
from 42% to 44% and over 60 minutes reduced from 22% to 6%.
• Review of the Imaging pathway forms a key theme for the Imaging Strategy. This will December 2014 enable us to better model workflows, ensure that we understand the variation in capacity needed across the working week and map our resource to this. Complexity of workload • Some discussions with patients • Work with the Service Managers and Clinical October 2014 • Although each clinic template is necessarily take much longer and Leads to better understand the skill mix within tailored to match the expected flow of patients may present in clinic with each clinic and allocate patients appropriately. a clinic in terms of numbers of patients clinically urgent issues that have to be • Make use of clinic co-ordinator resource to help and the ‘type’ of appointment (e.g. dealt with there and then. This can deal with unexpected delays and manage other new, follow-up) there is an inherent have a significant impact on patients patients so that the impact on them is minimal. unpredictability in the nature of each due to be seen within the same clinic appointment which is difficult to who may, as a result, be delayed. anticipate.
6 Effective Communication • Busy staff sometimes struggle to keep • Work has been done to improve patient Completed but communication in the Outpatient department, • Patients are more tolerant of everyone informed. under constant including information about the Nursing Team, delays if they are kept well review • Lack of information increases stress updates on waiting times for clinic, a revised informed and understand the on patients. Outpatient patient leaflet and updated website reasons for these. information.
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COUNCIL OF GOVERNORS PAPER SUMMARY SHEET
Date of Meeting: Agenda item
14th May 2014 Item 9
Title of Document: To be presented by
Equality Strategy Samantha Greenhouse, Assistant Director of Organisational Development
Background The Equality, Diversity and Inclusion (EDI) Steering Group, which includes a representative from the Council of Governors, has leadership responsibility for developing and delivering equality, diversity and inclusion priorities that are aligned with the Trust aims and business strategy. The Group also monitors that the Trust meets its legal requirement as a public organisation to have due regard to the need to eliminate discrimination, advance equality of opportunity and foster good relations. The paper presents the Equality Strategy and reports on progress towards the Equality Objectives. Executive Summary The Equality Strategy for 2014 – 2016 is to enhance our capacity to plan for and respond to diverse and changing patient and service needs through the application of equality, diversity and inclusion principles, policies and practices. The strategy includes four equality priorities, which aim to support the delivery of the Trust’s aims by ensuring we have appropriate and high level equalities information upon which to make robust decisions; by maintaining our reputation as a “good practice” employer so that we can select staff from the widest talent pool possible and by developing our workforce to be capable of providing the right high quality and effective services to a diverse group of patients. Progress has been made against the Trust’s two Equality Objectives for 2012 – 2016 and priority areas action for 2014-15 agreed. Conclusion The Trust is satisfied that it is fulfilling its statutory duties in relation to the Equality Act 2010. Author: Contact Number or Date: E-mail: Lisa Neden – Equality and Diversity 8th May 2014 Specialist Lead and Samantha 020 7808 2142 Greenhouse, Assistant Director of Organisational Development
The Royal Marsden NHS Foundation Trust
Report from the Equality, Diversity and Inclusion Steering Group to the Council of Governors – April 2014
1. Introduction
The purpose of this report is to present the Trust’s Equality Strategy and progress towards the Equality Objectives to the Council of Governors.
2. Background
In Promoting Equality and Human Rights in the NHS, a guide for Non- executive Directors it was stated that “The NHS should be a service for everyone, with equity of access and equity of treatment at its core. Provision of health care should be personal, and individuals should receive adequate information about their health needs and the choices available to them. Despite these values, sustained excellence in many parts of the NHS and significant achievements since the mid 1990s, health inequalities persist that lead to significantly higher rates of illness and death among certain groups in society.”
The Public Sector Equality Duties became law in 2011, requiring public organisations to have due regard to the need to eliminate discrimination, advance equality of opportunity and foster good relations. As part of these, the Trust is required to set one or more equality objectives and publish equality information annually.
The Trust’s published equality information is updated annually and includes an equality profile of our workforce and patients, our staff survey findings by demographic group and a summary of the Equality Impact Assessment (EIA) findings. EIAs are conducted for all policies, services and organisational change to identify any potential for inequality and to highlight actions needed to address any issues. The Equality, Diversity and Inclusion Steering Group approve the information for publishing on our website and agree actions arising from the findings.
3. Equality Governance and Risk
An Equality, Diversity and Inclusion (EDI) Steering Group was established in 2013 to take the place of the Equality and Diversity Committee and Operational Group. A representative from the Council of Governors sits on the group. The new group has leadership responsibility for developing and delivering equality, diversity and inclusion priorities that are aligned with the Trust aims and business strategy. The group met three times in 2013 to approve the equality objectives and monitor progress against the equality, diversity and inclusion agenda.
The group aims to monitor and mitigate against the main potential risks of legal non-compliance and reputational risk both as a service provider and employer if the Trust is not seen as a provider which personalises their services to meet the wide variety of patient needs.
1 4. Equality Strategy
The Trust Equality Strategy and delivery plan have been developed by the EDI Steering Group to support the priorities of The Royal Marsden and deliver the equality objectives.
Our Equality Strategy for 2014 – 2016 is:
To enhance our capacity to plan for and respond to diverse and changing patient and service needs through the application of equality, diversity and inclusion principles, policies and practices.
Delivering this strategy requires focus on four specific equality priorities, with action plans developed for each. These priorities are outlined in Appendix 1 with detailed action plans developed locally.
Our equality priorities aim to support the delivery of the Trust’s aims and priorities by ensuring we have appropriate and high level equalities information upon which to make robust decisions; by maintaining our reputation as a “good practice” employer so that we can select staff from the widest talent pool possible and by developing our workforce to be capable of providing the right high quality and effective services to a diverse group of patients.
The action plans will be monitored by the EDI Steering Group.
5. Equality Objectives
In 2012 two Equality Objectives were agreed by the Management Executive and the then Equality and Diversity Committee after discussion with patients, carers, members, governors, directors, managers and staff and a number of internal and external forums and organisations.
These are:
1. Between April 2012 and March 2016 to demonstrate an improvement in staff experiences of working for the Trust (particularly disabled and Black and Minority Ethnic (BME) staff reporting worse experiences in the staff survey) through improving staff knowledge and skills in how to identify and respond to the individual needs of others 2. To demonstrate an improvement in patient experiences of accessing and receiving care and services that take into account individual needs and preferences over the period April 2012 to March 2016
The patient focused objective was chosen to reflect one of our key business objectives, ensuring that we provide quality personalised patient care and experiences for our patients that effectively meet their individual needs. Following a review of older patient information including findings from patient surveys, the EDI Steering Group has agreed a focus on the older patient
2 experience for 2014/15, to support Priority 1 of the Equality Strategy and the second Equality Objective.
The measures for the Equality Objectives are included within the targeted deliverables of the Equality Strategy delivery plan in Appendix 1.
Key progress over the last year includes:
A substantial increase in the number of staff who have undertaken equality and diversity training since April 2012, from 41% to 78% in December 2013. Further development of the services and support available to patients with learning disabilities both in the hospital and in the community including an easy read guide to making a complaint. Holistic Needs Assessments (HNA) are being conducted electronically in Breast and Gynaecology Clinical Units as part of a pilot, supported by Macmillan, to bring HNA tools to patients via electronic tablets. A policy around the purpose and usage of HNAs is in development. An increased proportion of staff with declared sexual orientation, 38% in 2011 compared with 63% in 2013. In the 2013 Stonewall Workplace Equality Index we improved 100 places to come 186 out of 369 organisations. In 2013 we established a Network for lesbian, gay and bisexual (LGB) staff, agreeing terms of reference and consulting on employment policies and future focus. A significant increase in the number of equality impact assessments conducted for policies, 89 in 2013 compared with 19 in 2012. Regular promotion of staff wellbeing services including the Workplace Adviser service, Staff Support Facilitators and Occupational Health. Commissioning a training programme, Candid Conversations to ensure managers are able to effectively and fairly handle difficult conversations with their staff around performance management, grievances etc.
6. Conclusion The Trust is satisfied that it is fulfilling its statutory duties in relation to the Equality Act 2010.
3 Appendix 1 Delivering the Equality Strategy:
Our Equality Strategy is to enhance our capacity to plan for and respond to diverse and changing patient and service needs through the application of equality, diversity and inclusion principles, policies and practices
Equality priority Why? Targetted deliverables
1. To improve the To ensure that we are able to meet the diverse Year on year improvement in inpatient and outpatient survey findings patient experience by needs of both hospital and community between 2012 and 2016 for questions related to care and treatment reducing inequalities patients including privacy and dignity, information and communication* and developing greater understanding of To be the “chosen provider” Increase in number of Holistic Needs Assessments offered and individual patient conducted* needs To make the most of each patient encounter All new or returning cancer hospital patients who meet the recognised To support the most vulnerable people in our definition of learning disability are offered a Buddy and hospital passport, society to access our services either via admission or registration*
New methods for seeking Community Services patient feedback rolled out including piloting Friends and Family test. To develop a network of charity and voluntary organisations with which we can discuss specific equality, diversity and inclusion issues, in order to increase the opportunities for talking with people about our priorities and the impact these may have on people from different groups and backgrounds
Report to EDI Steering Group outlining length of stay and other data for our older patients in the hospital and community, conclusions and recommendations
2. To support the To ensure that our staff are diversity aware, Annual increase in the percentage of staff who have undertaken training in development and sensitive and thoughtful to the individual equality and diversity to achieve and maintain 90%* embedding of our needs of patients and of each other
4 Equality priority Why? Targetted deliverables equality and diversity Improvement in staff survey findings for training in equality and diversity values through the To build high performing teams where for all staff between 2012 and 2016* employee journey difference is respected and conflicts are (recruitment, learning resolved swiftly and informally Improvement in staff survey findings for BME and disabled staff for and development, questions related to violence, bullying and harassment and equal appraisals, employee To support the development of the Trust opportunities for career progression and promotion between 2012 and relations) brand 2016*
Clear processes for identifying and implementing reasonable adjustments for staff and applicants with disabilities. 3. To support the To identify if there are any groups of people Equality impact assessments (EIAs) to be conducted for any major development of new who could be excluded through our plans reconfiguration of services to ensure business development and clinical and business organisational change decisions are informed by appropriate information. models including To identify other business development Specifically EIAs to be conducted for: partnership and opportunities, By considering those protected collaboration, by equality groups involved we may identify 1. the development of Private Care in the Trust identifying and others who are not addressing any equality risks or To provide quantitative and qualitative 2. collaborative working in Pharmacy and Pathology opportunities information for business development and organisational change 3. collaborative working with the ICR
To support the provision of the most appropriate and cost effective services for 4. the development and implementation of the surgical strategy and patients imaging strategy
5. the development and implementation of the research strategy. To ensure any proposed joint appointments are conducted in a manner consistent with our equality policy
5 Equality priority Why? Targetted deliverables
6. Community Services support to the CCGs to deliver the out of hospital care strategy
7. all organisational change where staff may be at risk of redundancy or redeployment 4. To comply with To minimise costly legal or internal employee current equalities relations cases Increased number of staff with declared sexual orientation to improve legislation including equality monitoring between 2012 and 2016* Public Sector Equality To maintain reputation as “a good practice” Duty employer within the NHS
There are national equality policy reviews Proportions of patients who are using our services are broadly consistent including the Public Sector Equality Duty and with local and national population data, where data is gathered* equality legislative requirements are unlikely to diminish under the current government. * These relate to measures agreed for our Equality Objectives 2012 – 2016 by the Management Executive and Equality and Diversity Committee
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COUNCIL OF GOVERNORS PAPER SUMMARY SHEET
Date of Meeting: Agenda item
14th May 2014 Item 10.1
Title of Document: To be presented by
Audit and Finance Committee: Annual Report for 2013 / Ian Farmer, Chair of Audit and 14 Finance Committee
Executive Summary
This report reviews the work of the Audit and Finance Committee undertaken in the period 1 April 2013 to 31 March 2014 and sets out how the Committee has met its terms of reference and priorities.
Conclusion
The Council is asked to note the annual report for Audit and Finance Committee 2013/14.
Author: Contact Number or Date: E-mail: Ian Farmer, Chair of Audit and Finance 8th May 2014 Committee
Audit & Finance Committee Annual Report April 2013-March 2014
1. INTRODUCTION
The purpose of the report is to review the work of the Audit & Finance Committee (AFC) undertaken in the period 1st April 2013-31st March 2014 and to set out how the Committee has met its terms of reference and priorities.
2. COMMITTEE MEMBERSHIP
Reverend Dame Sarah Mullally stepped down from the Committee at the beginning of the year and Dame Nancy Hallett was appointed to replace her. Gregory Andrews finished his term as Committee Chairman on 31st March and Ian Farmer was appointed with effect from 1st April 2014.
In attendance were the Director of Finance and Chief Nurse, along with representatives of Internal Audit (KPMG), External Audit (Deloitte LLP) and the Local Counter Fraud Specialist (Tiaa, formerly known as Parkhill).
Meetings were organised and supported by the Director of Finance’s team.
4. MEETINGS
Four meetings were held over the year on 17th April 2013, 28th May 2013, 18th September 2013 and 29th January 2014. Currently there are four meetings planned during 2014/15 on 9th April, 28th May, 17th September 2014 and 28th January 2015.
5. ASSURANCE
The Audit and Finance Committee (AFC) shares responsibility with the Quality Assurance and Risk Committee (QAR) in providing assurance to the Board that the Foundation Trust is properly governed and that risks are appropriately identified and managed across the full range of the Trust’s activities.
The AFC is responsible for all matters relating to financial risk. Both Committees work collaboratively to ensure that all aspects of risk are covered and that the Board receives comprehensive assurances on the Trust’s activities.
Co-ordination with Quality, Assurance and Risk Committee
The Chair of AFC and QAR have discussed priorities for the respective Committees and the use of internal audit resources to provide assurance in key risk areas. In addition, forward Agendas and Minutes are regularly provided to each Committee and key items from QAR are reported at each AFC meeting.
Terms of Reference
The AFC Terms of Reference was updated and presented at the 18th September 2013 meeting for the Committee’s annual review. 6. INTERNAL CONTROL AND RISK MANAGEMENT
The Committee covered the following areas during the year:
Efficiency Programme (standing item)
The AFC undertook in depth reviews of several work streams:
• Portfolio analysis, service line reporting and use of benchmarking • Contracting Arrangements 2013/14 • Centralised Procurement • Impact of Pensions Auto Enrolment
Financial Performance (standing item)
The AFC reviewed the Trust’s financial performance vs. plan at each meeting, discussed trends and variances and reviewed key financial assumptions. The work on portfolio analysis and its use across the Trust was reviewed at several meetings during the year.
Losses, Compensation and Waivers (Standing item)
The AFC considered and noted details of waivers in the procurement process at each meeting and received an annual report on minor losses and write-offs.
Standing Financial Instructions
A review of proposed revisions to the Trust’s Standing Financial Instructions was presented at the 18th September 2013 meeting. Changes included the Trust’s Governance arrangements as a result of the new Health and Social Care Act 2012.
INTERNAL AUDIT
The Internal Audit Plan, covering the period 1st April 2013 to 31st March 2014 was discussed and agreed. The plan, which had been developed by the Head of Internal Audit in discussion with the Chairman of the AFC, the Director of Finance and Chief Nurse, reflected the Board Assurance Framework and a number of priority areas identified by both AFC and QAR.
Summary of Internal Audits Completed 2013/14
The following internal audit reports received during the year related to the 2012/13 audit plan:-
Planned Audit Review Received by Assurance Completed Committee Status
Portfolio Analysis Jan 2013 Apr 2013 Adequate
2
The following internal audit reports received during the year related to the 2013/14 audit plan:
Planned Audit Review Received by Assurance Completed Committee Status
Serious Incidents Sep 2013 Sep 2013 Adequate
Health and Safety Arrangements Sep 2013 Jan 2014 Adequate
Revalidation process & compliance Dec 2013 Jan 2014 Adequate
Review of arrangements for compliance Dec 2013 Apr 2014 Adequate with NHS Provider Licence
Risk Management & Board Assurance Framework Feb 2014 Apr 2014 Adequate
Financial systems and reporting Jan 2014 Apr 2014 Adequate
Community Services: Governance Mar 2014 Due May Adequate Arrangements and benefits realisation 2014 (draft)
Community Services: benefits realisation Mar 2014 Due May Adequate 2014 (draft)
IT Strategy Mar 2014 Due May Adequate 2014 (draft)
Board governance/Board succession Mar 2014 Apr 2014 Adequate planning
Implementation of Internal Audit Recommendations
The Committee review at each meeting the progress made on implementation of recommendations. A number of additional processes were agreed during the year to ensure accountability for recommendations and their timely clearance.
Technical Updates
KPMG LLP presents a Technical update covering developments relevant to Trust sector at each meeting which the Committee finds extremely useful.
The Committee held a closed session (Non-Executives only) with KPMG in April 2013.
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8. COUNTER FRAUD
Counter Fraud Strategy 2013/14
The AFC reviewed and approved the Counter Fraud Strategy developed by the Trust’s Local Counter Fraud Specialists at the 17th April 2013 meeting. The AFC noted that adopting a clear strategy enforced the Trust’s absolute commitment to countering fraud.
A new Counter Fraud Policy and Procedure was reviewed and approved by the Committee at the 18th September 2013 meeting.
Investigations
The AFC reviewed the results and progress of a number of fraud investigations conducted during the year.
9. EXTERNAL AUDIT
The Annual Audit Plan was presented by the Trust’s External Auditors, Deloitte LLP and approved at the 18th September 2013 meeting.
Representatives from Deloitte were present at each meeting and the AFC considered written and verbal reports on the progress of their audit and issues which had arisen.
The Committee held a closed session (Non-Executives only) with Deloitte in May 2013.
10. FINANCIAL REPORTING AND FINANCIAL REVIEW
Financial performance and key financial assumptions
The Committee reviews the financial performance of the Trust and tests key financial assumptions at each meeting.
Financial Statements to 31st March 2013
The AFC reviewed the draft Financial Statements of the Trust for the 2012/13 financial year at the 28 May 2013 meeting, and these were recommended for approval by the Chief Executive on behalf of the Board. The Director of Finance presented the draft. There was a discussion on a number of areas including:
• Asset valuation processes and impairment charges • Bad debt provisions • PCT Property Transfers • Presentation of the results on the Trust and clarification on the way accounting impairment adjustments were explained • Charity Consolidation – the RMCC does not fall under the definition of a subsidiary necessary for consolidation • Quality Accounts and local quality indicator
At this meeting, the AFC also received a report from the Trust’s External Auditors and had the opportunity to discuss the results of the audit and the Letter of Representation to Deloitte LLP to be signed on behalf of the Board.
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The AFC received the report of the Head of Internal Audit, who was able to give a substantial assurance opinion for 2012/13 based on the work he had undertaken.
11. FUTURE PLANS
The AFC has identified the following priorities for its work in 2014/15:
• Efficiency Programme • Funding of Capital Programme • Intellectual Property • Funding for Sutton Rebuild • Research and Development Funding • Sutton & Merton Community Services • Private Care Strategy • Benchmarking
In conjunction with QAR, the AFC will also review:
• Quality Accounts • Risk Management Arrangements and Board Assurance Framework • Liability Insurance
Ian Farmer Chair, Audit and Finance Committee 11 April 2014
5
COUNCIL OF GOVERNORS PAPER SUMMARY SHEET
Date of Meeting: Agenda item
14th May 2014 Item 10.2
Title of Document: To be presented by
Audit and Finance Committee: Highlight Report from Ian Farmer, Chair of Audit and meeting held on 9th April 2014 Finance Committee
Executive Summary
The Chairman of the Audit and Finance Committee will provide the Council of Governors an update on the meeting held on 9 April 2014.
Conclusion
For information.
Author: Contact Number or Date: E-mail: Ian Farmer, Chair of Audit and Finance 8th May 2014 Committee
Audit & Finance Committee Highlight Report to Board
AFC Meeting date: Wednesday 9th April 2014, 09.30 a.m.- 11.30 a.m.
Key issues/papers/ Key decisions and Key points for presentations actions agreed Board to note received and discussed
1. Private discussion with Control environment advisors described as “upper quartile”. No issues of concern. Room however, for efficiency improvements
2. External audit – year end No significant findings to audit in progress date
3. Potential judgement area External audit – anticipated around revenue key judgement areas recognition re CCG and NHS England boundary due to lack of clarity.
4. External audit – Sector Compliance to updated Changes required to audit Developments reporting requirements in hand committee report
Executive investigating Residual risk not thought to employed vs self-employed be material status and potential tax risk PAS/EPR challenges considered “large, complicated and risky”
C Diff targets likely to be missed. Potential fines and regulatory risk
5. Internal Audit – Progress Licence compliance KPMG reported that report accountability to be “substantial assurance can be supplemented by audit trail of given that there is a generally signed accountability sound system of internal control and key financial &
Organogram of divisional management processes. responsibilities to be tabled for These are designed to meet discussion at next AFC meeting the trusts objectives and controls are generally being applied consistently".
Nominations Committee Board & Sub-committee self- governance compliance to be evaluation process to be confirmed or explained undertaken on a more regular and formal basis 6. Internal audit – Follow up Four assignments completed of outstanding during period. recommendations Recommendations not yet implemented reduced from 22 to 9
7. Internal audit – Plan for Due process having been 2014/15 followed, proposed plan for 2014/15 was discussed and accepted
8. Counter Fraud TIAA were requested to include No new matters of refresher training for all staff significance were raised levels over time
9. Finance report Cost overruns due to agency and contract staffing
Cash generation adverse to plan resulting in capex deferrals – strategic consequences? 10. Service provider – Counter Current contract terminates Board to note action endorsed Fraud (TIAA) June 2014. TIAA not considered by AFC to be adding value. Management to fold CF into Internal Audit assignment
11. Service provider – Internal Management recommended that Board to note endorsement Audit (KPMG) KPMG internal audit contract be by AFC extended by 2 years in partnership with C&W and RBH. Renewal warranted to provide continuity and secure favourable financial terms
12. Service provider – External Deloitte having provided this The board to be requested to Audit (Deloitte) service for many years, consider a paper on this management were asked to matter in due course prepare a paper for consideration by the board outlining the merits, process and governance implications associated with putting the External Audit out to tender
COUNCIL OF GOVERNORS PAPER SUMMARY SHEET
Date of Meeting: Agenda item
14th May 2014 Item 10.3
Title of Document: To be presented by
Audit and Finance Committee: Tendering of the external Ian Farmer, Chair of Audit and auditor Finance Committee
Background The appointment of the Trust’s external auditor is reserved for the Council of Governors.
Executive Summary This paper summarises a proposed tendering and seeks both agreement and support from governor representatives to participate in the evaluation process, the Trust Board and Audit and Finance Committee recommend retender of these services.
Conclusion That external audit services be tendered and recommendation brought for decision by Governors at their September 2014 meeting. Governors who are interested in participating in the evaluation and selection process should please inform the Head of Corporate Governance and explain reasons why.
Author: Contact Number or Date: E-mail: Ian Farmer, Chair of Audit and Finance 8th May 2014 Committee Alan Goldsman, Director of Finance
APPOINTMENT OF THE TRUST’S EXTERNAL AUDITOR
1. Introduction
The appointment of the Trust’s external auditor is reserved for the Council of Governors. The NHS Foundation Trust Code of Governance issued by Monitor states that NHS Foundation Trusts should appoint an external auditor for a period of time which allows the auditor to develop a strong understanding of the finances, operations and forward plans of the organisation. The current best practice is for a three to five year period of appointment. Deloittes LLP have completed three years of a three year contract which has the option to extend for a further two years. Their total term of appointment to date is at least 17 years and in view of this extended period of office, good governance would require that their re-engagement be carefully considered. This paper summarises a proposed tendering and seeks both agreement and support from governor representatives to participate in the evaluation process, the Trust Board and Audit and Finance Committee recommend retender of these services. The European Union has voted to approve a Regulation and Directive to reform the audit market which is subject to final ratification by the Council of Ministers, and is likely to come into force during 2014. This will require the mandatory rotation of auditors after 10 years or a maximum of twenty years where a tender has taken place. Our understanding is that envisaged transitional rules would allow us to extend Deloittes appointment post tender to 2020, if that were to be considered desirable. The Regulation also includes a list of services that external auditors are prohibited from providing including services linked to tax compliance and advice, investment and financing structures.
2. Procurement Regulations
European Law requires that all contracts in excess of £111,762 are subject to tender to ensure fairness and transparency. Over the contract term the contract will exceed this value. The Trust is proposing to utilise a Framework Agreement. This provides public sector organisations with a cost effective procurement route which has already been subject to a tender exercise in line with European Law. Organisations are required to invite all suppliers listed on that Framework to submit proposals, and the suppliers have already been subject to checks on their financial standing, insurance cover and ability to deliver the services etc.
3. Specification of Services
A specification of services will be prepared based on the Audit Code for NHS Foundation Trusts issued by Monitor in March 2011. This requires that the External Auditors provided an audit of the financial accounts, value for money review and audit of the quality accounts. The technical criteria will include their standing in the healthcare sector to cover financial and non financial audit work, ensuring they have appropriate resources and quality control processes in place, ensuring they will be able to meet the terms of the Audit Code for NHS Foundation Trusts, their ability to manage the various relationships and value added services in addition to the core audit activity. The length of the proposed contract is for a 3 year term with the option to extend for a further 2 years. A 5 year arrangement commencing in April 2015 would take us through to 2020. 4. Evaluation of Tenders
A prequalification questionnaire (PQQ) will be sent to establish that firms meet the key criteria to provide the external audit services. An Invitation to Tender (ITT) will be sent to those providers who meet PQQ criteria. The ITT will include the basis on which tenders will be evaluated. The evaluation will be based on a combination of Technical and Price criteria. Technical evaluation will consist of: - Review and scoring of written responses - Scoring of Supplier Presentations It is proposed that written tender documents are scored and evaluated against the criteria set out in the specification by: Janice Stephens – Associate Director of Finance (Chair) Charlotte Monniot - Head of Financial Accounting Helen Mills – Head of Quality Assurance Governor Representative At presentations the suppliers will be requested to cover a number of specific questions based on the specification. The proposed evaluation panel will be: Ian Farmer (Chair) – Non Executive Director and Audit and Finance Committee Chair Non Executive Director and Audit and Finance Committee Member (TBC) Governor Representative x 2 Shelley Dolan – Chief Nurse Janice Stephens – Associate Director of Finance
5. Proposed Timetable
The proposed appointment will be effective from April 2015 (for the 2015/16 financial year); Deloittes LLP will provide audit services for 2014/15 financial and quality accounts. Evaluation will take place during July and August in order that a decision can be ratified by the Council of Governors at their September 2014 meeting. Governors who are interested in participating in the evaluation and selection process should please inform the Head of Corporate Governance and explain reasons why.
6. Recommendation
That external audit services be tendered and recommendation brought for decision by Governors at their September 2014 meeting. Governors are asked to advise on their required participation in the evaluation and selection process.