Annual Report and Accounts 2010/11
Royal Bolton Hospital NHS Foundation Trust Annual Report and Accounts 2010/11
Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) of the National Health Service Act 2006
Contents
1 Foreword 7
2 Directors’ Report 12
3 Remuneration report 18
4 Disclosures for NHS Foundation Trust Code of Governance 21
5 Quality Report 32
6 Staff Survey 69
7 Regulatory ratings 70
8 Other Public Interest Disclosures 73
9 Statement of accounting officer’s responsibilities 78
10 Statement on internal control 79
11 Independent auditor’s report 90
12 Annual Accounts 2010/11 95
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Royal Bolton Hospital NHS Foundation Trust Annual Report and Accounts 2010/11 1 Foreword
1.1 Chairman’s Welcome It has been a successful year in many ways. We have continued to improve on our mortality rates. We are financially stable and have been planning for the integration with our community provider arm in the next financial year. This year each of our specialties has undertaken a thorough review led by our clinicians. This continues our commitment to have a clinically led service, supported by able and experienced managers. The year has seen changes to our Trust Board. David Fillingham left the Trust in June 2010 and Lesley Doherty, previously Director of Nursing and Performance, was appointed as Chief Executive in October. Andrew Cogan was appointed as Director of Operations in January 2011 and Dee Sissons was appointed as Director of Patient Safety Experience and Chief Nurse in March 2011 to start in May 2011. Carol Davies and Ebrahim Adia joined us as new Non‐Executive Directors. The Board of Directors has a rich experience of hospital and community services. I have been very impressed by our staff’s team work, vision and commitment. I know that this will continue under our renewed Board of Directors and as we move forward to becoming an integrated care organisation
Cliff Morris 31st May 2011 Chairman Royal Bolton Hospital NHS foundation Trust
Lesley Doherty, Chief Executive and Cliff Morris Chairman
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Royal Bolton Hospital NHS Foundation Trust Annual Report and Accounts 2010/11 Page 1 Foreword
1.2 Chief Executive’s Welcome
This has been a year of many changes and challenges. A new Government and new requirements under a new Secretary of State for Health. Here in Bolton we had the departure of David Fillingham, CEO, to take up a Chief Executive post leading in quality across the North West. It was subsequently a great privilege for me to be appointed as CEO in October, having been a Director in the Trust since 2003. This achieves a long held ambition of mine to lead an organisation such as Bolton, supporting staff to provide quality health services. We have also been planning for organisational change as we look forward to becoming a new integrated care organisation providing community services as well as the inpatient and outpatient services we currently provide. I have been meeting with staff from both the hospital and the community and with partners and local stakeholders, such as the local area forums, PCT and Links, to ensure that our joint aim for excellence for patients becomes a reality. There have been highs and lows. The Ombudsman Report on Care of Elderly published in February, and in particular a patient experience from Bolton in 2005, were reminders that each of our patients deserves not only a high standard of care, but also that this is delivered with respect. We are a different organisation now than we were at that time. Our work on the Exemplar Programme and our quality improvement process, Bolton Improving Care System (BICS), have made genuine rapid improvement in patient care, safety and experience. 2010/11 has seen the fruition of that work and has led to significant improvements as this annual report describes. It is of great importance that we ensure that our staff are trained, skilled and supported. It is a key value of the Trust that we respect our staff whatever their role and invest in them as individuals as we know, without doubt, that this not only improves job satisfaction but also has a direct impact on the quality and standard of care given. Our staff survey demonstrates we are getting things right by involving staff in change and decisions and how best to provide care. By being a good employer we are already directly impacting on good patient care. We still need to improve, however. Patients needing urgent care and particularly those who access our A&E services are not always seen in a timely manner. We are working across Bolton with GPs and community teams to improve the services we jointly provide for patients requiring urgent access to care. The NHS, as with many public sector organisations, faces challenges in the future. We know, however, that we have the right approach, the right team and the right strategy to face the future with optimism and tenacity as a successful integrated care organisation. Our annual report provides the information to support that.
Lesley Doherty Chief Executive 31st May 2011
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Royal Bolton Hospital NHS Foundation Trust Annual Report and Accounts 2010/11 Page 1 Foreword
1.3 Trust Profile Royal Bolton Hospital NHS Foundation Trust is a busy acute Trust providing hospital services from its site at the Royal Bolton Hospital in South West Bolton, close to the boundaries of Salford and Wigan. Due to its location, the hospital has a non‐elective catchment population of 310,000, compared with a resident Bolton population of 262,000. In fact it is the busiest hospital for emergencies in Greater Manchester, receiving around 28% more ambulance arrivals than any other hospital. In 2010/11, the Royal Bolton Hospital: • had 108,485 attendances to Accident and Emergency • had 42,982 non elective admissions (including obstetrics) • delivered 4,730 babies • had 622 inpatient beds, 32 day case beds and 15 endoscopy beds
Making it Better 2011/12 will see the culmination of the Making it Better project to transform the Royal Bolton into a specialist centre for maternity, paediatric and neonatal care. A £20 million investment has seen an expansion of both facilities and staffing to cater for women and babies from Bury and Salford as well as Bolton. The facilities include a specialist new neonatal unit – one of three tertiary centres in Greater Manchester providing care to the sickest and smallest babies.
Better Care Together Subject to formal approval, the majority of clinical and provider services currently provided by Bolton Primary Care Trust (NHS Bolton), will transfer to the management of the Trust, resulting in a new‐style organisation providing integrated healthcare in both the hospital and community setting. The value of services to be transferred is £71m and involves around 1,560 members of staff. The Trust has engaged widely in developing its vision and high level strategy for the integrated organisation. In summary:
Our Vision: By 2016 we will match the best integrated care organisations internationally for the quality and efficiency of our services.
Our Aims: We will strive for excellence – putting the people we care for at the centre of how we plan and deliver our services. We have three fundamental aims: • best care for better health (for our patients and our community) • responsible use of resources (for the taxpayer) • staff, patients and the public – valued, respected and proud.
Our core purpose: • a major provider of urgent/unplanned care to Bolton and beyond • a specialist provider of women’s and children’s services in hospital and community • a local provider of community‐based services aimed at preventing ill health and harm • a provider of a defined range of planned elective and diagnostic services across patient pathways
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Royal Bolton Hospital NHS Foundation Trust Annual Report and Accounts 2010/11 Page 1 Foreword
1.4 A year of good news Once again the Royal Bolton Hospital has celebrated a year of improvements, developments and recognition. Here are some of the highlights.
April Our catering manager, Margaret Meadows, was named as 'Healthcare Caterer of the Year' in the annual Cost Sector Catering Awards, one of the most respected awards schemes in the industry. She was nominated for the award for her excellent leadership and providing quality services at the best value for money.
May The first completed facilities opened under the Making it Better programme to transform services for women, children and babies opened. The new extension to the delivery suite in the Princess Anne Maternity Unit took seven months to complete and includes seven new delivery rooms and the latest high tech facilities for mothers in labour. In May our staff and patients were honoured by the arrival of royalty when Her Royal Highness, Princess Alexandra, visited the eye unit of the hospital to look around and present certificates to members of staff. The Princess was given a behind the scenes tour of our renowned eye unit and heard about our pioneering work to treat people with age‐related macular degeneration, she then met with staff who had successfully completed our Exemplar programme to improve standards on wards.
In June we were awarded £123k through the region‐wide Advancing Quality programme in recognition of the way we treat patients who have had a heart attack, been admitted with pneumonia or had a hip or knee operation. Royal Bolton Hospital was in the top five hospitals for meeting the standards on pneumonia and the top ten for heart attack and hip or knee. Only the top fifty per cent of hospitals receive financial rewards.
In July the Mayor and Mayoress of Bolton, Councillors John and Lynda Byrne, visited during National Transplant Week to sign the Organ Donation Register and meet our award winning bereavement and donor team. The team provides support and advice to bereaved families on a number of important issues including organ donation. In Bolton there are around 91,000 people on the register, and 87 people waiting for transplants. One donor can save or transform up to nine lives and many more can be helped through the donation of tissue. In July Our Director of Workforce and Organisational Development, Nicky Ingham was awarded Healthcare People Management Association HR Director of the Year following nomination by Chair of Staff Side. In July building work began on a brand new children’s unit at the Royal Bolton Hospital. When complete, the new purpose‐built unit will replace the current children’s wards G5 and B1, transforming a currently vacant wing of the hospital into a state of the art facility for paediatric care. The new unit will have 42 beds, including extra single rooms with en suite facilities. It will have additional high dependency care for very poorly children, 11 observation and assessment beds for children who need close monitoring, a play area, and a lounge for young people.
In September, we held a listening event where members of the public came along to share their views on hospital services and how they can be improved. Patient feedback is vital for us to know whether we are getting things right or not, and this event gave us some great insight in an informal and friendly setting.
In October, Lesley Doherty was appointed as our new Chief Executive, replacing David Fillingham who left the Trust earlier in the year. An experienced nurse and midwife as well as a senior manager, Lesley has been in the NHS for 33 years. She was previously Director of Nursing and Performance and has been at the Royal Bolton since 2003. ‐ 10 ‐
Royal Bolton Hospital NHS Foundation Trust Annual Report and Accounts 2010/11 Page 1 Foreword
She brings a wealth of experience to the role, including previous experience of running a hospital. Trust Chairman Cliff Morris said: "Lesley has a proven track record of achieving great results. Despite her senior managerial experience, she remains a nurse at heart. She is always enthusiastic, determined and tackles any challenge head on, whilst always putting the needs of patients first." In October, the first phase of our new specialist 17 cot neonatal unit and our new Antenatal Day Unit opened,
In November Chief Executive Lesley Doherty signed up to the One Bolton pledge on behalf of the Royal Bolton Hospital. The pledge, which was launched earlier in 2010, promotes equality, celebrating communities and encouraging harmony.
In December it was an early 'Whites' Christmas for poorly youngsters, when stars from Bolton Wanderers visited them in hospital. Players spent time on wards to spread some festive cheer, met children and gave out gifts, as well as signing autographs and posing for photographs.
In January we won a national award for the quality of food we give our patients. Royal Bolton triumphed in the Hospital Catering Award category given to hospitals who have improved the standard of food and its nutritional value. Initiatives that have seen the catering, dietetics and health promotion teams work together, include reducing salt and sugar levels, providing information on healthy eating and replacing unhealthy options with alternatives, for example, low fat crisps. In January we were also named as the winner in the national Patient Safety Awards 2011 in the category Patient Safety in Surgery. Work has included the introduction of a theatre checklist, reducing cancellations and reducing the time spent finding equipment and stock. It has led to improvements for patients and staff.
In February A TV company in South Korea was so impressed with the hospital's success in increasing tissue donation that a team travelled more than 5,000 miles to find out more. A film crew visited the hospital to record footage of the award winning team talking about their work. The crew also spoke to an accident and emergency consultant, a relative of a donor and a recipient.
In March we launched our healthy eating campaign programme, removing the majority of high fat, sugar and salt items from vending machines and shops. The Trust used the Food Standards Agency traffic light system to assess the food and drink on sale at the hospital ‐ full fat crisps have been replaced with low fat varieties, sugary drinks with diet options, ensuring the hospital leads my example in encouraging people to make healthier choices.
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Royal Bolton Hospital NHS Foundation Trust Annual Report and Accounts 2010/11 Page 2 Directors’ Report
2.1 Business Review – 2010/11
Introduction
The review which follows considers the financial performance of the Trust for 2010/11. The Accounts included within this report have been prepared under a Direction issued by Monitor.
Financial Performance in 2010/11
£m Revenue 201.1 Operating Expenses 189.7 EBITDA 11.4 Depreciation, PDC Interest and Other 9.3 Surplus/(Deficit) before impairments* 2.0
*The impairments had a total value of £9.1m giving the reported deficit of £7.2m
Main Sources of Income
Royal Bolton Hospital Foundation Trust, in common with all NHS Hospital Trusts receives by far the majority of its income from providing patient care services. These are paid for by Primary Care Trusts who receive an allocation of funds directly from the Department of Health. Table 1 below provides an analysis of income in 2010/11 and compares this to 2009/10 financial year:
Table 1 2010/11 2010/11 2009/10 2009/10 £m % £m % Patient services income * 177.5 88.3 169.9 88.1 Other income 23.6 11.7 22.9 11.9 Total 201.1 100.0 192.8 100.0
* Monitor requires trusts to ensure that the proportion of private patient income as a percentage of total patient services income does not exceed a Trust‐specific agreed percentage. In RBH FT’s case, the maximum percentage is 0.11% and in 2010/11 private patient income was £0.1m or 0.08% of total patient income.
Income derived from NHS Bolton, the Trust’s main commissioner, was £135.2m, being 76% of the total patient services income figure. As the lead commissioner, NHS Bolton works closely with RBH FT to control finances and ensure that all national and local standards and targets are met.
Revenue and Activity
Table 2 below shows the inpatient activity outturn figures for the Trust: Table 2 Plan Actual Difference Diff (%) Elective activity ‐ Anaesthetics and Surgery 20,421 20,308 ‐113 ‐0.6 ‐ Medicine and Emergency Care 6,401 6,106 ‐295 ‐4.6 ‐ Women’s/ Children’s Health 2,182 1,925 ‐257 ‐11.8 Subtotal elective 29,004 28,339 ‐665 ‐2.3 Non elective activity ‐ Anaesthetics and Surgery 6,591 6,975 384 5.8 ‐ Medicine and Emergency care 15,451 16,922 1,471 9.5 ‐ 12 ‐
Royal Bolton Hospital NHS Foundation Trust Annual Report and Accounts 2010/11 Page 2 Directors’ Report
‐ Women’s/Children’s Health 19,653 19,364 ‐289 ‐1.5 Sub total non elective 41,695 43,261 1,566 3.8
Grand total 70,699 71,600 901 1.3
Table 3 below shows the position on outpatients, A&E and diagnostic imaging services:
Table 3 Plan Actual Difference Diff (%) New outpatient attendances 81,494 84,426 2,932 3.6 Follow up attendances 149,826 147,019 ‐2,807 ‐1.9 Outpatient procedures 18,489 33,657 15,168 82.0 Total outpatients 249,809 265,102 15,293 6.1
A&E attendances 110,420 108,462 ‐1,958 ‐1.8
Table 4 is a comparison of the percentage differences between actual activity outturn and plans for 2010/11 (actual/plan), actual activity outturn in 2010/11 compared to actual outturn in 2009/10 (actual/actual) and income received in 2010/11 compared to planned income (income/plan).
Table 4 Actual/plan Actual/actual Income/plan % % % Elective activity ‐2.3 ‐0.8 ‐4.8 Non elective activity 3.8 1.6 3.8 Outpatients and procedures 6.1 5.5 6.9 A&E ‐1.8 0.2 ‐2.3
Table 2 shows that elective activity was significantly below plan across all divisions. Table 4 shows that casemix complexity for elective activity was lower than planned i.e. where the income variance is greater than the activity variance. This is mainly apparent in orthopaedics where although activity is 7.4% below plan income is 13.5% below plan. It is important to note that the plan for orthopaedics included the activity transferred from Manchester Surgical Centre with assumed income at average specialty cost.
Table 2 also shows that the plan for non‐elective activity was exceeded by 3.8%. Table 4 shows that non‐elective activity was 1.6% higher than 2009/10. This variance was the result of significantly higher than planned activity levels from NHS Bolton, Ashton, Leigh and Wigan (ALW), and Salford.
In planning for 2010/11 NHS Bolton made the assumption that non elective activity would reduce by 2.2%, this did not occur and remains a significant risks for the Trust going forward (see below).
NHS ALW significantly over‐performed against contract for non‐elective activity in 2009/10. There was however no incentive for ALW to increase the contract value for 2010/11 in line with the outturn, as the national rules on non‐elective admissions which set the baseline at 2008/9 outturn levels proved too favourable to that PCT. By the end of the year, therefore the PCT was in the position where it significantly benefited from the zero tariffs for activity above the higher threshold.
The over‐performance against the income plan for Salford PCT was mainly as a result of an increase in the number of excess bed days required by Salford patients.
Table 5 below summarises the position on non‐elective income.
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Royal Bolton Hospital NHS Foundation Trust Annual Report and Accounts 2010/11 Page 2 Directors’ Report
Commissioner Gross over‐ Not Subject to 30% Tariff 0% Tariff Net over‐ performance threshold (i.e. performance against plan 2008/9 outturn) £m £m £m £m £m Bolton 2.6 2.6 0.0 0.0 2.6 ALW 0.9 0.3 0.2 0.3 0.4 Salford 0.5 0.3 0.1 0.1 0.3 Other 0.2 0.2 0.0 0.0 0.2 Total 4.2 3.4 0.3 0.4 3.5
The 2011/12 Operating Framework has again pegged the baseline for non‐elective activity to 2008/9 financial year, which means that there remain significant risks for the Trust if this type of activity continues to rise. However, steps will be taken in 2011/12 to mitigate the risk, which can be summarised as follows:
• First, for PCTs outside of Bolton, the contract option for the payment for non‐electives has been changed so that rather than having a lower threshold (where the tariff is reduced by 70%) and a higher threshold (where no tariff is paid at all) when activity rises above the 2008/9 activity level, there will now be no higher threshold. The down side is that under the previous option RBH was paid 30% for all activity under the lower threshold, but in fact this only applied to Bolton activity in 2010/11 as although the PCT’s activity was above plan it was also below the lower threshold (i.e. 08/09 outturn). • The integration of hospital and community services in Bolton and the agreement of a block contract for non‐electives mean that the success of the Trust in lowering non‐elective activity will be rewarded in that the Trust will keep the income to invest in improved community services, to enable more patients to be treated outside of hospital. • The block contract also assists the Trust in mitigating the potential impact of non‐elective readmissions after a non‐elective episode within 30 days, as the PCT has agreed that any fines will be reinvested in the Trust to enable the necessary improvements to be made to reduce such occurrences. For elective readmissions, the national policy of non‐payment applies.
Within the Trust’s overall income of £201.1m in 2010/11 was a sum of £0.6m for transitional support relating to the Making it Better (MiB) programme. Further support amounting to £0.9m is planned for 2011/12. Confirmation has been received from commissioners that they will mitigate the losses arising from any late transfer of services.
Operating Expenses
Overall, the Trust performed well with regard to its pay and non‐pay budgets. Only one of the divisions overspent against budget (Anaesthetics and Surgery) and this was more than offset by the under‐ spending in all the other divisions and corporate services. The main reason for the overspending budgets was the inability to secure permanent appointments to a number of clinical posts thereby incurring substantial locum costs during the year. The plans for 2011/12 have been made to recruit to these posts (some appointments had already been made by April 2011) and non‐recurring financial support has been approved by the Board in recognition of the fact that in some areas permanent consultants will not take up their posts until later in the financial year.
It is pleasing to report that since 2008/9 the number of waiting list initiatives undertaken has reduced by 41%. It remains the Trust’s intention to continue the drive to provide patient care from budgeted capacity.
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Royal Bolton Hospital NHS Foundation Trust Annual Report and Accounts 2010/11 Page 2 Directors’ Report
During 2010/11 the Trust chose to invest in two main areas requiring non‐recurring funds. Firstly, the Trust paid just over £1.0m for new beds. Out of a total bed stock of circa 800 beds/trolleys, 540 beds and 45 trolleys were replaced with the newest models available. This will go a substantial way to improve the hospital experience for patients and also for nurses and other staff. Additionally, the Trust has made provision for a number of mutually agreed resignations, amounting to just over £0.4m. These resignations will give the Trust more flexibility going into 2011/12 when seeking to redeploy those who may be affected by the significant savings programme for 2011/12.
Savings
For 2010/11 the Trust had a savings target of £7.2m, which was 3.7% of the opening budget for the year. It is satisfying to be able to report that £7.2m of recurring savings were made during the year and so the 2011/12 financial year started without the legacy of outstanding savings from the previous year. Nevertheless, the hospital savings target for 2011/12 is £9.6m or 5% of turnover. This is a large increase in the level of savings required and there is no doubt that from 2011/12 onwards 5% savings each year is going to be a major problem for hospital and community services to resolve.
Cash Flow and Statement of Position
With regard to capital, the outturn was a marginal underspend of £0.1k against the plan. Throughout the year the Making it Better (MiB) scheme had been behind schedule, mainly due to equipment purchases being delayed, but by the end of March 2011 the position had been rectified and the outturn was in line with projections.
The impact of accruing for the MiB capital spending at the yearend meant that capital creditors increased significantly by the year end. As the MiB loan is however drawn down a month in arrears this had no impact for the Trust overall cash balance. Therefore, the fact that cash was £1.3m higher than planned at the year‐end was as a result of the higher than planned surplus achieved by the Trust.
Financial Risks and Risk Ratings
Taking into account the Trust’s financial performance, financial efficiency and liquidity, a financial risk rating (FRR) of 3.45 was achieved by 31st March 2011 (on a scale of 1 to 5 where 1 is considered high risk and 5 is considered low risk) as follows:
Financial Criteria Weight M12 M12 Weighted % Score Risk Average Rating 1. % of Plan 10 108.02% 5 0.50 2. EBITDA Margin 25 5.62% 3 0.75 3. Return on Assets 20 4.57% 3 0.60 4. Iand Surplus 20 1.01% 3 0.60 5. Liquidity* 25 25.49 4 1.00 Total 100 3.45
* Includes the working capital facility of £13.5m and cash of £7.6m.
Summary of 2010/11 Performance
Overall, the Trust achieved a surplus of £2.0m in 2010/11, made its recurring savings target, had a cash balance of £7.6m and achieved an FRR OF 3.45. This ensured the Trust finished the year in a healthy financial position. ‐ 15 ‐
Royal Bolton Hospital NHS Foundation Trust Annual Report and Accounts 2010/11 Page 2 Directors’ Report
Looking Forward
The new financial year, 2011/12, will be tougher financially than 2010/11. The main reasons are that the savings target for hospital services at £9.6m or 5% of turnover is higher than in 2010/11; penalties for readmission to hospital take effect; a £0.9m integration premium has to be delivered for commissioners; and there has been a tightening up overall of a range of quality criteria that must be met by the Trust.
But it is not all bad news: during 2010/11 the Trust undertook a substantial programme of specialty reviews which sought to improve clinical engagement within the Trust on quality, sustainability and affordability metrics and the benefits of this should assist in developing a robust and clinically owned strategy for the Trust from 2011/12 onwards. Similarly, the impending integration of hospital and community services in Bolton will provide ample opportunities for rationalising patient pathways and identifying further savings opportunities. And as mentioned in previous reports, the Making it Better strategy comes to fruition during 2011/12, bringing with it growth in patient numbers and extra income – which is a better context from which to seek the substantial savings that are required.
The savings plans that have been identified for 2011/12 are similar to those in previous years, i.e. a combination of small initiatives. A more strategic approach is planned for 2012/13 onwards, building on a number of organisation wide developments e.g. e‐rostering, digital dictation, estate rationalisation, the outcome of the specialty reviews and integration.
By September 2011 the Trust will have utilised £22m of its prudential borrowing limit (PBL) of £45.2m. Once the community services are integrated the PBL should increase, enabling the Trust to develop more schemes via borrowing, if it is financially sound to do so.
Conclusion
Financially 2010/11 was a successful year for the Trust. The £7.2m savings programme was delivered recurrently and the surplus was higher than planned. The Trust was able to replace most of its bed stock during the year and the capital programme was delivered in full in line with its plans. By the start of 2011/12 the full programme of savings plans had been identified and a contingency plan developed for the downside scenario. The Trust can look forward with confidence to 2012/13.
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2.2 Statement as to disclosure to auditors Each of the Directors at the date of approval of this report confirms that: So far as the Director is aware, there is no relevant audit information of which the NHS Foundation Trust’s auditor is unaware; and The Directors has taken all the steps that they ought to have taken as a Director in order to make themselves aware of any relevant audit information and to establish that the NHS Foundation Trust’s auditor is aware of that information
2.3 Additional disclosures Pensions Disclosure The accounting policies for pensions and other retirement benefits are set out in note 1.3 to the accounts and details of senior employees’ remuneration can be found in the remuneration report on page 19.
Statement of accounts preparation The accounts have been prepared under direction issues by Monitor, the independent regulator for Foundation Trusts, as required by paragraphs 24 and 25 of Schedule 7 to the National Health Service Act and in accordance with the NHS Foundation Trust Annual Reporting Manual 2010/11.
Statement on register of interests The Trust Secretary maintains a register of other significant interests held by Directors and Governors which may conflict with their responsibilities. Access to the register can be obtained by submitting a written request to the Trust Secretary
2.4 Going concern After making appropriate enquiries, the Directors have a reasonable expectation that the NHS Foundation Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts.
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Royal Bolton Hospital NHS Foundation Trust Annual Report and Accounts 2010/11 Page 3 Remuneration Report
3.1 Remuneration Report The remuneration report has been prepared in compliance with the relevant elements of sections 420 to 422 of the Companies Act 2006, Regulation 11 and Schedule 8 of the Large and Medium‐sized Companies and Groups (Accounts and Reports) Regulations 2001 and elements of the NHS Foundation Trust Code of Governance.
3.2 Nomination and Remuneration committee The remuneration and conditions of service of the Chief Executive and Executive Directors are determined by a Nomination and Remuneration Committee, comprising membership as below. Chair – Cliff Morris, Chairman Margaret Blenkinsop, Senior Independent Director Arthur Rawlinson, Non‐Executive Director Roger McMullan, Non‐Executive Director Yaseer Ahmed, Non‐Executive Director Alan Rothwell, Non‐Executive Director (1st April 2010 – 30th June 2010) Carol Davies, Non Executive Director (1st September 2010 onwards) Ebrahim Adia, Non Executive Director (1st December 2010 onwards The Nomination and Remuneration Committee met three times during the reporting period to consider the appointment of a new Chief Executive, the performance of the Executive Directors and the remuneration of the Executive Directors. The Chief Executive and Director of Workforce and Organisational Development attended meetings other than when matters being discussed would have meant a conflict of interest. Minutes of meetings were recorded by the Trust Secretary. In October 2010, the Nomination and Remuneration Committee appointed a new Chief Executive. Applicants for the post were invited to participate in an assessment centre and successful participants were then interviewed by a panel. The panel made their recommendation to the Nomination and Remuneration Committee and the appointment was approved by the Council of Governors. In considering the Executive Directors’ remuneration, the Committee take into account the national inflationary uplifts recommended for other NHS staff, any variation in or change to the responsibility of Executive Directors and relevant benchmarking with other NHS and public sector posts. The performance of Executive Directors and the Chief Executive is discussed at the Remuneration Committee. Executive Directors are subject to annual appraisal by the Chief Executive who is herself appraised by the Chairman. The contracts of employment of all Executive Directors, including the Chief Executive, are permanent and are subject to six months notice of termination. No performance‐related pay scheme (e.g. pay progression or bonuses) is currently in operation within the Trust and there are no special provisions regarding early termination of employment. All other senior managers are subject to Agenda for Change pay rates, terms and conditions of service, which are determined nationally. There are two exceptions to this in that there are two managers who chose to remain on local terms and conditions when Agenda for Change was introduced. These individuals do not receive any inflationary pay uplift. There is also a Governors’ Nomination and Remuneration Committee. This Committee has met on four occasions during the reporting period and successfully appointed two new Non‐Executive Directors.
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Name and Title 2010/11 2009/10 Salary Other Taxable Salary (Bands Other Taxable (Bands of Remuneration Benefit of of £5,000) Remuneration Benefit of £5,000) (Bands of Lease Car (Bands of Lease Car £5,000) £5,000) £000 £000 £ £000 £000 £ Executive Directors D Fillingham (until 31st May 2011) 25 ‐ 30‐ ‐ ‐ 155‐160 ‐ ‐ Chief Executive L Doherty Acting Chief Executive (from 1st 125‐130 ‐ ‐ 100‐105 ‐ ‐ May) B Andrew 95‐100 ‐ ‐ 95‐100 ‐ ‐ Director of Corporate Services G Raphael (From 21/10/09) 110‐115 ‐ ‐ 45‐50 ‐ ‐ Director of Finance A Schenk 85‐90 ‐ ‐ 85‐90 ‐ ‐ Director of Service Development J Bene 50 ‐ 55 125‐130 ‐ 45‐50 120‐125 ‐ Medical Director N Ingham Director of Workforce and 85‐90 ‐ ‐ 85‐90 ‐ ‐ Organisational Development A Cogan (from 3rd May 2010) 85‐90 ‐ ‐ ‐ ‐ ‐ Director of Operations M Sinfield (from 1st May 2010) 55‐60 ‐ ‐ ‐ ‐ ‐ Acting Director of Nursing Non Executive Directors C Morris Chairman 40‐45 ‐ ‐ 30‐35 ‐ ‐
M Blenkinsop 10‐15 ‐ ‐ 10‐15 ‐ ‐
Y Ahmed 10‐15 ‐ ‐ 10‐15 ‐ ‐
A Rawlinson 10‐15 ‐ ‐ 10‐15 ‐ ‐
A Rothwell (until 27th July 2010) 0‐5 ‐ ‐ 10‐15 ‐ ‐
R McMullan 10‐15 ‐ ‐ 10‐15 ‐ ‐
C Davies (from 1st September 8‐10 ‐ ‐ ‐ ‐ ‐ 2010)
E Adia (from 30th November 0‐5 ‐ ‐ ‐ ‐ ‐ 2010) ‐ 19 ‐
Royal Bolton Hospital NHS Foundation Trust Annual Report and Accounts 2010/11 Page 3 Remuneration Report
Name and Title Real Real Total Lump sum at Cash Cash Real increase in increase in accrued age 60 Equivalent Equivalent increase in pension at pension pension at related to Transfer Transfer Cash age 60 lump sum at age 60 at 31 accrued Value at 31 Value at 31 Equivalent (Bands of age 60 March 2011 pension at March 2011 March 2010 Transfer £2,500) (Bands of (Bands of 31 March Value £2,500) £5,000) 2011 (Bands of £5,000) £000 £000 £000 £000 £000 £000 £000
D Fillingham 5‐7.5 10‐12.5 37‐37.5 110‐112.5 654 852 (3) Chief Executive
L Doherty 10‐12.5 30‐32.5 47.5‐50 110‐112.5 869 742 76 Acting Chief Executive
B Andrew Director of Corporate 0‐2.5 0‐2.5 40‐42.5 120‐122.5 746 802 (54) Services
G Raphael 0‐2.5 5‐7.5 40‐42.5 112.5‐115 712 741 (33) Director of Finance
A Schenk Director of Service 0‐2.5 0‐2.5 47.5‐50 110‐112.5 665 698 (36) Development
J Bene 0‐2.5 5‐7.5 30‐32.5 87.5‐90 463 493 (29) Medical Director
N Ingham Director of Workforce 0‐2.5 0‐2.5 12.5‐15 40‐42.5 169 190 (17) and Organisational Development A Cogan (from 3rd May 2010) 0‐2.5 5‐7.5 22.5‐25 70‐72.5 346 357 (14) Director of Operations M Sinfield (from 1st May 2010) 2.5‐5 10‐12.5 17.5‐20 55‐57.5 330 296 19 Acting Director of Nursing
Pension arrangements for the Chief Executive and all Executive Directors are in accordance with the NHS Pension Scheme. The accounting policies for pensions and other relevant benefits are set out in Note 1.8 to the accounts.
31st May 2011
Lesley Doherty Chief Executive ‐ 20 ‐
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4.1 Statement of Compliance with the Code The Trust Secretary reviews our compliance with the NHS Foundation Trust Code of Governance and prepares a report for the Audit Committee. The Audit Committee considered this report at its meeting on February 8th 2011 and agreed that Royal Bolton Hospital NHS Foundation Trust complies with the main and supporting principles of the Code of Governance. The Code is implemented through key governance documents, policies and procedures of the Trust, including but not limited to: The Constitution Standing Orders Standing Financial Instructions Scheme of Delegation Code of Conduct (for Directors, for Governors and for Senior managers) Staff Handbook Standards for Behaviour and Attitude at Work.
4.2 The Council of Governors As set out in the constitution, the Council of Governors consists of 24 public elected Governors, six staff Governors and eleven appointed partner Governors (this was increased from 10 in February 2010 following an amendment to the constitution to include a representative of Bolton LINk). The Council of Governors meet in public four times a year. The statutory duties of the Governors are to: Set the terms and conditions of Non‐Executive Directors Approve the appointment of future Chief Executives Appoint or remove the Trust’s external auditor Consider the annual accounts, annual report and auditor’s report Be consulted by the Board of Directors on the forward plans for the Trust The Board of Directors and the Council of Governors enjoy a strong and developing working relationship. Mr Cliff Morris chairs both and acts as a link between the two. Each is kept advised of the other’s progress through a number of systems, including informal updates via the Chairman, ad hoc briefings, exchange of meeting minutes and attendance of the Board of Directors at the Council of Governors and by individual Directors at Council of Governors sub‐committees.
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Elected Governors ‐ Public Constituency End of period Attendance (4 Committee/Sub Name Area Date Elected Involved in other groups of office held) Group Membership
Christina Aspden Rest of England Oct 08 Sept 10 2/4 A Divisional quality Mohammed Ayub Great Lever Oct 10 Sept 13 2/2
Ann Bain Breightmet Oct10 Sept 13 2/2 PEAT inspection
Denise Baldwin Rest of England Oct 09 Sept 12 4/4 P 100 voices
Derek Burrows Kearsley Oct 08 Sept 10 4/4 P
Kate Cowpe Rest of England Oct 08 Sept 12 4/4 M Making it Better
Hanif Darvesh Crompton Oct 10 Sept 13 1/2
Mike Doyle Astley Bridge Oct 08 Sept 10 2/2 A,N,M,P
Dave Eaton Rest of England Oct 08 Jan 11 0/2 P Heaton and Ken Hahlo Lostock Oct 09 Sept 12 4/4 M,P Mortality
John Hartshorne Rumworth Oct 08 Sept 10 2/2 P Little Lever and Eric Hyde Darcy Lever Oct 08 Sept 11 4/4 P,M Divisional quality
Ellen Knowles Harper Green Oct 09 Sept 10 1/2 P,M Westhoughton Pauline Lee and Chew Moor Oct 09 Sept 12 4/4 P 100 voices
Paul McCarthy Farnworth Oct 09 Sept 12 3/4 M,P, H Westhoughton Helen McSorley South Oct 09 Sept 12 2/4 P Geoffrey Minshull Bromley Cross Oct 08 Sept 11 3/4 A Ronald Parkinson Rumworth Oct 10 Sept 13 2/2 H
Mike Phillips Rest of England Dec 10 Sept 13 1/1 H Pt exp., workforce, Jack Ramsay Bradshaw Oct 08 Sept 11 4/4 M,P,N Clin Gov.
Barbara Ronson Horwich NE Oct 08 Sept 12 4/4 P green issues Horwich and Isabel Seddon Blackrod Oct 08 Sept 10 4/4 P 100 voices Tonge with the Jim Sherrington Haulgh Oct 08 Sept 10 4/4 P,N, H Patient experience
Lynne Siddall Astley Bridge Oct 10 Sept 13 1/2
John Taylor Smithills Oct 08 Sept 11 4/4 M,P, H
Linda Toy Great Lever Jan 09 Sept 10 0/2
Victor Williams Halliwell Oct 10 Sept 13 2/2
Barbara Winder Hulton Oct 08 Sept 11 4/4 M,P Key: A: Audit. N: Nomination and remuneration. M: Membership and member communications. P: Patient, staff and visitor experience, H – More than a Hospital ‐ 22 ‐
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Elected Governors – Staff Constituency End of Period of Attendance (4 Committee and Sub Name Area Date Elected Office held) Group Membership Nurses and Carol Bernstein Midwives Oct 09 Sept 12 3/4 P
Jean Cummings All other staff Oct 08 Sept 11 4/4 P
Dipak Fatania All other staff Oct 08 Sept 10 2/2 M
David Hamer AHP and scientists Oct 08 Sept 13 4/4 N Doctors and Simon Kelly Dentists Oct 08 Sept 11 2/4 P Nurses and Janet Roberts Midwives Dec 10 Sept 13 1/1 P Nurses and Maria Sinfield Midwives Oct 09 May 10 2/2 P
Chris Tinsley All other staff Oct 10 Sept 13 2/2 P, H
Appointed Governors Name Representing Date Appointed Attendance (4 Committee and Sub held) Group Membership
Tim Evans NHS Bolton Oct 08 1 Oct 08 – Dec 10 Dr. Riad Falouji Bolton Local Medical Committee 0 Dec 10 Jack Firth Bolton LINk 1/1 Bolton Council For Voluntary Oct 08 P Geoffrey Hargreaves Services 4 Jan 10 P, M Dr. Liaqat Natha Bolton Local Medical Committee 1/1 Dec 09 Robert Nettleton Bolton University 3/4 Oct 08 – Dec 10 Dr. George Ogden Bolton Local Medical Committee 3 Bolton Connexions (Youth July 09 M Farhan Patel Governor) 1/2 Feb 10 – Dec 10 P Mike Phillips Bolton LINk 2/2 Jan 10 Dr. Aarya Prabhakaran Bolton Local Medical Committee 1/1 Bolton Council For Voluntary Oct 08 P Thaira Qureshi Services 3/4 Bolton Metropolitan Borough April 10 ‐ Linda Thomas Council 4/4 Bolton Metropolitan Borough Oct 08 N John Walsh Council 4/4 Oct 08 P Jill Wild Salford University 4/4
Key: A: Audit. N: Nomination and remuneration. M: Membership and member communications. P: Patient, staff and visitor experience, H – More than a Hospital ‐ 23 ‐
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4.3 Elections to the Council of Governors Elections to the Council of Governors were held according to the constitution in August and December 2010. Results were as reported below.
Seat Turnout Governor elected Astley Bridge 43% Lynne Siddall Breightmet 38% Ann Bain Crompton uncontested Hanif Darvesh Great Lever uncontested Mohamed Ayub Halliwell uncontested Victor Williams Horwich and Blackrod uncontested Isabel Seddon Kearsley uncontested Derek Burrows Rumworth uncontested Ronald Parkinson Rest of England 24.7% Mike Phillips Tonge with the Haulgh uncontested Jim Sherrington Allied Health Professionals uncontested David Hamer All other staff 28% Chris Tinsley Nurses and Midwives 21% Janet Roberts
4.4 Directors’ and Governors’ Register of Interests A register is kept of Directors’ and Governors’ interests. Access to the register can be gained either by contacting the Trust Secretary or from the Trust website.
4.5 Developing understanding The Board of Directors has taken steps to ensure that Members of the Board, and in particular the Non‐ Executive Directors, develop an understanding of the views of Governors and members about their NHS Foundation Trust. Mr Cliff Morris chairs both the Board of Directors and the Council of Governors and with the assistance of the Trust Secretary is the link between the two bodies. The full Council of Governors meets a minimum of four times a year and these meetings are attended by representatives of the Executive Directors, the Senior Independent Director and representatives of the Non‐Executive Directors. The Governors’ meetings provide the opportunity for the Governors to express their views and raise any issues so that the Executive Directors can respond. Minutes of the meeting are shared with the Board of Directors so they can pick up and respond to any issues raised. The Governors have two formal sub‐committees dealing with Auditor appointment, and nomination and remuneration. These are attended by the Chair of Audit and Director of Finance (auditor appointment) and by the Senior Independent Director (nomination and remuneration) The Governors also have three sub‐groups, each chaired by a Governor nominated by the group, the chairs of the sub‐groups will meet with the Chairman on a regular basis, these groups are also attended by the Trust Secretary. The Director of Corporate Services, Head of Communications, Deputy Director of ‐ 24 ‐
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Nursing and Head of Governance and Patient Experience also attend appropriate sub group meetings as required. The Trust recognises the importance of being accessible to members. Council of Governors meetings are held in public and publicised on the Trust website, member newsletters and notices around the hospital. The Governors representing the electoral wards of Bolton attend the local area forums run by Bolton Council to meet individual members and members of the public and hear their views.
4.6 Board of Directors The Board of Directors comprises the Chairman, Chief Executive, Senior Independent Director, five independent Non‐Executive Directors, five voting Executive Directors and three non‐voting Corporate Directors. (The composition of the Board has changed over the period of the report with the addition of an additional independent Non‐Executive Director in December 2010 appointed to provide expertise on community services and an additional Corporate Director appointed in January 2011.) The Board meets in private on the last Tuesday of each month and a summary of the minutes is published on the public website. The Directors have collective responsibility for setting strategic direction and providing leadership and governance. The Scheme of Delegation which is included in the Trust’s standing orders, sets out the decisions which are the responsibility of the Board of Directors and those which have been delegated to a sub‐ committee of the Board. The Trust has an Executive Board which consists of the Executive Directors and other senior post holders. The Executive Board meets monthly and is chaired by the Chief Executive. Its remit is to consider the operational management of the day to day business of the Trust.
4.7 Balance, Completeness and Appropriateness There is a clear separation of the roles of the Chairman and the Chief Executive, which has been set out in writing and agreed by the Board. The Chairman has responsibility for the running the Board, setting the agenda for the Trust and for ensuring that all Directors are fully informed of matters relevant to their roles. The Chief Executive has responsibility for implementing the strategies agreed by the Board and for managing the day to day business of the Trust. All of the Non‐Executive Directors are considered to be independent in accordance with the NHS Foundation Trust Code of Governance. Whilst on appointment the Chairman has to meet the Code’s ‘test of independence’, it does not apply to this role thereafter. The Board considers that the Non‐Executive Directors bring a wide range of business, commercial and financial knowledge required for the successful direction of the Trust. The Executive Directors are experienced and were collectively responsible for drafting the various strategies which formed the Trust’s application for Foundation Trust status. These strategies were agreed by the whole Board and now form the basis of the relationship with the Regulator. All Directors are equally accountable for the proper management of the Trust’s affairs. All Directors are subject to an annual review of their performance and contribution to the management and leadership of the Trust. During the Foundation Trust application process, the Board used external facilitators to work with the Directors on Board development. At the present time the Board is satisfied as to its balance, completeness and appropriateness, but will keep these matters under review. ‐ 25 ‐
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4.8 Our Directors Cliff Morris Chairman (Appointed November 2008 for four years) A former Bolton Mayor, Cliff is Leader of the ruling Labour Group on Bolton Council and the Chair of Social Services. Cliff was appointed Chairman in 2003.
Lesley Doherty Chief Executive (October 2010 to present day) Acting Chief Executive (June 2010 – October 2010) Director of Nursing (to June 2010), Lesley joined the NHS in 1976 a qualified nurse and midwife with varied clinical and operational experience across health care provision, including regional and national roles. She joined Bolton in 2003 as Director of Nursing, moving to include the day to day management of the Trust in 2005. In October 2010 she was appointed Chief Executive.
David Fillingham Chief Executive (to June 2010) David was appointed Chief Executive in 2004; he was formerly Director of the NHS Modernisation with extensive senior experience in the health service. David left the Trust in June 2010 to take up a new role with Advancing Quality.
Gary Raphael Director of Finance Gary is a qualified Chartered Institute of Public Finance and Accountancy (CIPFA) accountant and has held a number of senior finance posts in both London and the North West. Gary joined the Trust in 2009.
Jackie Bene Medical Director Jackie’s primary responsibilities are safety and quality improvement and ensuring the good medical practice of all doctors working in the Trust. Jackie was appointed Medical Director in 2008 having been a consultant in Elderly Medicine at the Trust since 1998.
Beverley Andrew Director of Corporate Services As Director of Corporate Services Beverley is responsible for corporate governance including risk management, patient experience and quality, estates strategy, communications and emergency planning. Beverley started her career in Bolton in 1978.
Maria Sinfield Acting Director of Nursing (June 2010 – Maria joined the Trust in 2007. She was previously deputy head of nursing and head of clinical practice. Amongst her responsibilities she leads on infection control for the Trust.
Ann Schenk Director of Service Development As Director of Service Development, Ann is responsible for strategic and business planning, service improvement through the development of the Bolton Improving Care System (BICS) and Information Technology. She has worked in a variety of NHS planning and business management posts since 1979.
Nicky Ingham – Director of Workforce and Organisational Development Nicky is responsible for the Workforce and Organisational Development requirements of the Trust, including staff health and wellbeing, staff engagement, skills development, provision of HR advice and employee services. Nicky joined the Trust in 2005.
Andrew Cogan Director of Operations (Jan 2011 to present day) Acting Director of Operations June 2010 – Jan 2011) Andrew is responsible for the day to day running of the Trust’s operational services. Andrew has worked for a number of acute hospitals in Greater Manchester and Merseyside since 1989 and joined the Trust in 2005 initially as Divisional Manager for Diagnostics and Therapies and then as Divisional Manager for Surgery. Andrew commenced in his current role in January 2011.
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Non Executive Directors Margaret Blenkinsop: (Deputy Chair/Senior Independent Director) appointed April 2009 for four years Margaret career was spent in education, retiring as a Director of Bolton’s Children's Services in 2006. She serves the Board as Deputy‐Chair and is the Non‐Executive Director lead for Safeguarding. Margaret is also Chair of Bolton’s Octagon Theatre, she joined the Trust in 2005.
Yaseer Ahmed: appointed November 2008 for four years Yaseer became a Non‐Executive Director in 2003. He is Managing Director of Pearl Commercial Investments and a Manager of Bolton Council of Mosques
Arthur Rawlinson: appointed April 2009 for four years Arthur's background is in Information Technology, retiring as UK General Manager for Data Centres within Fujitsu Services in 2002. He is a member of the Audit, Finance, IT and Clinical Governance Committees and Chair of the Hospital's Charitable Trust Fund. Arthur joined the Trust in 2005.
Roger McMullan: appointed April 2008 for four years Roger, as well as having been Director and Company Secretary at Warburtons Ltd. set up Bolton Business Ventures in the 1980s, one of the first enterprise agencies in the UK.
Alan Rothwell: (Chair of Audit Committee) (till June 2010) Alan is a chartered accountant with recent and relevant financial experience including main board Directorship at North West based Ultraframe PLC and Greenalls PLC and interim finance director of the Argos Retail Group.
Carol Davies (Chair of Audit Committee) appointed September 1st 2010 for three years Carol is currently Director of Finance and Resources at Mount St Joseph Business and Enterprise College. She has also held senior finance positions in a number of other organisations, including Bolton Council and Trafford Health Authority. She is a qualified accountant with the Chartered Institute of Management Accountants.
Ebrahim Adia (Appointed November 30th 2010 for three years) Dr Ebrahim Adia is a senior lecturer in Education at the University of Central Lancashire (UCLan) and is a former joint Vice‐Chair of NHS Bolton. He is a member of the Trust’s Audit Committee. He joined the Trust in 2010.
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Attendance at meetings
Board of Audit Council of Remuneration Directors Committee Governors Committee (11 meetings) (6 meetings) (4 meetings) (3 meetings) Cliff Morris 11 n/a 3 3 David 3/3 n/a 1/1 n/a Fillingham Lesley Doherty 10 n/a 3 n/a
Gary Raphael 11 5/6 4 n/a
Jackie Bene 11 n/a 3 n/a Beverley 11 5/6 4 n/a Andrew Maria Sinfield 7/10 n/a 1/3 n/a
Andrew Cogan 8/10 n/a 4 n/a
Ann Schenk 11 n/a 2 n/a
Nicky Ingham 8 n/a 2 n/a Margaret 10 5/6 3 3 Blenkinsop Yaseer Ahmed 8 4/6 2 2 Roger 8 5/6 3 3 McMullan Arthur 11 5/6 4 3 Rawlinson Alan Rothwell 3/3 2/2 1/1 1/1
Carol Davies 7/7 4/4 2/2 1/1
Ebrahim Adia 4/4 1/2 0/1 1/1
n/a = not applicable ‐ attendance not required at this committee ‐ 28 ‐
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4.9 Audit Committee At its meeting on January 12th 2009 the Council of Governors approved the appointment of the Audit Commission as its external auditors for a further two years until March 31st 2011. The Audit Committee met on six occasions during the period April 1st 2010 and March 31st 2009 and at its February meeting conducted a self assessment of the effectiveness of the committee. The purpose of the Audit Committee is to provide the independent assurance to the Board that there are effective systems of governance, risk management and internal control for all matters relating to corporate and financial governance and risk management. Key activities during the period April 1st 2010 and March 31st 2011 were: • Reviewing the Board Assurance Framework and Risk Register • Reviewing financial statements including the restatement of accounts under IFRS • Receiving reports from the internal and external auditor • Receiving internal reports On occasion the Trust may decide to request additional services from the Audit Commission. The Council of Governors delegated specific authority for commissioning additional services to the Trust’s Audit Committee subject to an overall policy cap on directly attributable fees which should not exceed 50% in aggregate of the approved annual statutory audit fee in any twelve month period. This would be on the understanding that the Audit Committee takes responsibility for agreeing any specific areas of additional work to be undertaken and, in doing so, considers whether the external auditor or any other organisation is best placed to provide the service i.e. based on relevant experience, expertise in that particular area and value for money.
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4.10 Membership Every member of the public over the age of 16 can become an FT member of the Royal Bolton Hospital and give their views on how they think we should develop our services. Through our members, we can really get to know what the public wants and, more importantly, act on that as our services evolve.
Membership strategy We are committed to building a membership that is representative of and reflects the local communities we serve in terms of disability, age, gender, socio‐economics, sexuality, ethnic background and faith.
Public members Membership of the Trust is open to anyone who resides in England although we would expect the majority of our members to reside in Bolton and the surrounding areas of Salford, Wigan, Bury and South Lancashire. There is a lower age limit of 16 but no upper age limit. There are no limits on the number of people who can register as members. Public members are placed in constituencies based on where they live. There are 20 constituencies representing the electoral wards of Bolton and one to represent the rest of England.
Staff members We have elected to adopt an opt out arrangement in respect of staff membership. Under this arrangement, staff will automatically be registered as a member of the Trust unless they have completed the opt out form which was circulated with payslips prior to authorisation as a Foundation Trust. New members of eligible staff are provided with information and a form at induction. Staff membership is open to everyone who is employed by the Trust full or part time on a contract with no fixed term or those staff on fixed term contracts of 12 months or more. Membership is also available to those bank staff who have an agreement to work for the Trust and have done for 12 months or more. Staff working for the Trust’s contractor for portering and domestic services are also eligible for staff membership if they meet the above criteria. Staff membership ceases at the point that the member leaves the service of the Trust, but individuals can then choose to become a public member.
Benefits of membership Although there are no financial benefits to FT membership, there are also no costs. There is, however, much satisfaction in being in a position which can help local people and local services. There are no benefits to members in terms of access to services. During 10/11 we held four Medicine for Members events. These informal and informative talks were well attended and well received. There will be a continuing programme of these events which will be publicised through the members’ newsletter and the Trust website. We will use our members as a valuable resource calling on those who have expressed a willingness to participate in surveys and focus groups to gain a snapshot view of the user’s perspective.
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Membership recruitment We aim to continue recruiting new members and are using a variety of methods to ensure we reach as many people as possible. People wishing to join can do so by registering online at www.royalboltonhospital.nhs.uk or by calling 0870 703 6352. Alternatively application forms are available throughout the hospital.
Contact procedures for members that wish to communicate with Governors and/or Directors Members who wish to communicate with Governors may do so by email to [email protected] or by post c/o the Trust Secretary. To communicate with Directors contact [email protected] Membership Statistics
Public Constituency Last Year Next year (estimated) At year start (1 April 2010) 4239 4589 New members 385 Members leaving 145 At year end (31 March 2011) 4589 5000 Staff Constituency Last Year Next year (estimated) At year start (1 April 2010) 3647 3640 At year end (31 March 2010) 3640 5700
Analysis of current public membership
Public Constituency Number of members Eligible membership Age 0 ‐ 16 41 3646 17 ‐ 22 331 15597 22+ 4107 241844 Ethnicity White 3593 232343 Mixed 41 2602 Asian or Asian British 662 23619 Black or Black British 91 1654 Other 202 869 Socio‐economic groupings ABC1 2327 94931 C2 1114 31850 D 597 41712 E 551 33489 Gender
Male 2140 126943 Female 2449 133764
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Introduction
Continually improving the standard of our care is a fundamental aim of the hospital. In developing our Quality Account we took into account the views of staff, patients, partners and stakeholders. We set ourselves high goals. In this, our third quality account, you will see that we have made good progress, particularly in making a real difference in improving our mortality rates where the Trust has made significant progress from its position just a few years ago, but also against the other priorities we agreed last year with our stakeholders.
Patient safety and experience underpin all that we do. This has been strengthened by our Exemplar Programme, which was introduced in 2007 and involves our wards and departments undertaking a structured process to ensure that not only the basics of care but also the improvement of care are part of our daily work. It provides good assurance that our care is of a high standard and We demonstrate our public accountability by displaying the information throughout the hospital. Our Quality Account is agreed not only with our staff, but also with our patients and stakeholders as we look to address what is important to everyone.
We are currently working on plans to integrate acute and community services to form a new integrated care organisation which will bring further improvements to the quality of care we provide. We have worked closely with our stakeholders particularly our Governors to consider the priorities for our new integrated organisation in 2011/12. The Non‐Executive Directors and the Governors worked together to agree which priorities should be included in this report and after much deliberation agreed the priorities for 2011/12 are:
• To continue to focus on improving mortality.
• To continue our programme of work to reduce the number of people who do not attend their outpatient appointments
• To continue focusing on clinical correspondence.
• To continue our programme to improve appraisals and development for our staff.
• To improve patient safety through the Safety Express programme
This Quality Account describes in detail why our priorities are important to us, how we will measure our performance and what we are going to do. The Board of Directors are committed to this and will closely monitor progress and support this at every level.
We will continue to use the Bolton Improving Care System (BICS) as the method of seeing our processes through the users’ eyes and engaging staff in solving problems which cause frustration to staff and patients. This report also includes an update on the great results we have had this year for infection control and our work to reduce waiting time in our Accident and Emergency Department. We recognise that patients in our A&E department have not always been seen in a timely manner and are working to address this.
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Statement of directors’ responsibilities in respect of the quality accounts
The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that foundation trust boards should put in place to support the data quality for the preparation of the quality report.
In preparing the quality report, directors are required to take steps to satisfy themselves that: • the content of the quality report meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2010‐11; • 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 2010 to June 2011 − Papers relating to Quality reported to the Board over the period April 2010 to June 2011 − Feedback from the commissioners dated 22/06/2010 − Feedback from governors dated 27/01/2011 and 03/02/2011 − The trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated May 2011; − The 2010 national patient survey (published April 2011) − The 2010 national staff survey (published March 2011) − The Head of Internal Audit’s annual opinion over the trust’s control environment dated 14/04/2011 − Monthly CQC quality and risk profiles.
• the Quality Report presents a balanced picture of the NHS foundation trust’s performance over the period covered; • the performance information reported in the Quality Report is reliable and accurate; • there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Report, and these controls are subject to review to confirm that they are working effectively in practice; • the data underpinning the measures of performance reported in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review; and the Quality Report has been prepared in accordance with Monitor’s annual reporting guidance (which incorporates the Quality Accounts regulations) (published at www.monitornhsft.gov.uk/annualreportingmanual) as well as the standards to support data quality for the preparation of the Quality Report (available at www.monitornhsft.gov.uk/annualreportingmanual).
The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Report.
By order of the Board 31st May 2011
Chairman Chief Executive ‐ 33 ‐
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Overseeing Quality
The Trust has made arrangements for promoting, overseeing and monitoring the quality of care which we deliver. It is a central part of our broadest planning and performance review cycle, through ensuring quality is a key responsibility of every member of staff, and is reflected in their personal objectives, personal development and appraisal. Indeed the Trust made staff appraisal one of our key experience priorities in 2010/11 in view of the clear evidence which demonstrates that regular appraisal has a direct and positive impact on both organisational performance and patient care. Although good progress has been made on staff appraisals it was agreed that this should continue to be a key priority for the new integrated care organisation.
At a corporate level, the Executive Board and Board of Directors receive routine reporting on indicators of quality. Our suite of reports ‘Best Possible Care’ and ‘Improving Health’, provide regular updates on key patient safety and experience measures, and provide one of the ways in which the Trust routinely monitors performance on the elements in the quality report.
From April 2010 new arrangements streamlined reporting arrangements from the ward to the Board. A new Risk and Assurance Committee was established to gain assurance from divisions and directorates through a series of Trust‐wide committees which highlighted significant and high level risks to this new committee.
Divisional performance is formally reviewed by the Executive Directors through a series of performance review meetings.
Externally, the Trust is also accountable through contracts with the Primary Care Trust (NHS Bolton). A local quality framework is in place, with key performance targets which are regularly monitored by commissioners and which may be subject to penalties for under‐performance. In addition, the CQUIN (Contracting for Quality, Improvement and Innovation) set of indicators provides an opportunity for the Trust to attract payment for achievement of ‘stretch’ quality targets.
The Care Quality Commission (CQC) produces an ongoing quality and risk profile for each Trust which determines the level of inspection undertaken. The Trust is currently registered without conditions by the CQC.
The independent FT regulator Monitor also holds the Trust to account and monitors performance by way of the annual plan and quarterly compliance declarations as part of the Compliance Framework. As an FT, our governors also act as a check and balance to the Board of Directors and receive regular feedback on the Trust’s performance over a range of indicators. The governors’ Patient, Staff and Visitor Subcommittee takes a particular interest in patient safety and experience, and has been actively involved in agreeing priorities for inclusion in this report
Finally, the Trust uses internal and external auditors to assist the Board in understanding strengths and weaknesses of specific systems, providing a level of external assurance which underpins a good understanding of how the Trust is performing.
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What is BICS?
Improving what we do – The Bolton Improving Care System (BICS)
The Bolton Improving Care System (BICS) is both the Trust’s strategy and its system for improvement. It embraces practical day to day methods of problem solving; redesigning services to deliver better care; involving patients in improving what we do; and involving all staff in the continuous pursuit of best possible care. It is at the heart of our plans for driving safety, quality and productivity.
The problem solving approaches in BICS use “lean” methods, borrowed initially from the manufacturing industry, but adapted and applied to healthcare. Although, at first glance, it may seem that healthcare has little in common with manufacturing, our own experience and the experience of many other organisations has demonstrated that a focus on improving processes, removing waste and improving quality is very relevant to tackling the biggest challenges faced by this hospital and by healthcare in general.
We have a vision that the Trust will be an organisation where the whole workforce is involved every day in making our processes better. The starting point of this approach is seeing “waste” and removing it from the way we work. Waste is the kind of thing staff and patients see all too often in our everyday work – wasted effort because things are in the wrong place; wasted supplies; wasted time duplicating work or doing unnecessary tasks or just waiting for things to be done; wasted effort, sometimes having to put things right that weren’t right first time; wasted talent of people who are over‐burdened or distracted from what they really come to work to do – deliver good care.
We fundamentally believe that removing waste reduces defects, improves quality of care, improves the experience of patients and staff and reduces costs.
After four years of using lean methods, the Trust has seen some marked benefits (in clinical outcomes, workforce engagement, efficiency and patient experience) but we recognise that we are still early on our journey of transformational change.
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Royal Bolton Hospital NHS Foundation Trust Annual Report and Accounts 2010/11 Page 5 Quality Report – Priorities for improvement in 2011/12
PRIORITY ONE: Reducing the Trust’s mortality rate
Why this is important to us
The Trust’s Hospital Standardised Mortality Rate (HSMR) has been high for a number of years, although concentrated work on improving patient pathways with high mortality rates has achieved significant reductions and especially so in the last year.
The HSMR is a risk‐weighted measure which is calculated by assessing the number of actual deaths in comparison to the number of “expected” deaths. Whether death is “expected” is based on clinical coding, which describes the severity of a patient’s illness, and their contributory medical problems, when they are admitted to hospital. The HSMR is a comparative measure. A rate of 100 would reflect a risk‐weighted mortality rate at the national average level, for the mix of patients received by the hospital.
The HSMR is currently calculated using a methodology developed by an organisation called Dr Foster Intelligence. In April 2010 the Trust’s HSMR was 116 but all the improvement work over the last year has seen the HSMR drop to 92.8 as of February 2011, which is a 20% reduction. The Trust is one of the fastest improving hospitals in the North West and is consistently improving faster than the England average. There is however, still work to do in order for the Trust to achieve its goal of being in the top 50% of hospitals in England in the next year.
There are other ways of calculating the hospital mortality rate and the Trust will be working over the next year with an organisation called CHKS who produce a measure called the RAMI (Risk Adjusted Mortality Indicator).
Furthermore, the Department of Health have been developing a new metric, the SHMI (Standardised Hospital Mortality Indicator) to be used universally across England by all providers. It is expected that this will become the national metric sometime later this year.
How we propose to measure our performance
We will track our improvement by measuring:
i) The Dr Foster risk‐weighted HSMR and the CHKS measure RAMI (Risk Adjusted Mortality Indicator). ii) Changes in the hospital’s crude (unadjusted) death rate for specific conditions, and across the Trust as a whole.
Where do we start from?
The Trust has seen a steady decline in its HSMR over the last three years, falling to 116 (on the rebased measure) at the end of the 2009/10 year. The present position, as of February 2011 is 92.8 but in actual fact 102 when rebased compared to the England average.
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Over the last four years we have also experienced a consistent reduction in the unadjusted mortality rate (actual deaths), which fell by 6.6% in the last year.
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What are we aiming for in the year ahead?
We aim to achieve:
− An HSMR for the twelve months April 2011 to March 2012 of less than 85. − At least a 10 % reduction in unadjusted mortality, compared to 2010.
What we will do
The Trust has a five point mortality plan, which is overseen by the Mortality Reduction Group, chaired by the Medical Director and representatives from clinical services from across the Trust. The progress of the project is reported monthly to the Board of Directors together with the most up‐to‐date trends in mortality.
The five work streams are:
1. The reduction of deaths associated with respiratory disease, especially pneumonia
2. The prevention of avoidable death of deteriorating patients, through monitoring and prompt intervention
3. The provision of better pathways of care for patients at the end of life, so that such patients do not spend their final days in hospital if this can be avoided
4. The use of “care bundles” to embed best practice in the treatment of key clinical conditions.
5. Improvement in the accuracy of clinical coding through closer involvement of the doctors concerned in a patient’s care
The Trust is also collaborating with hospitals across the North West in an initiative to review and improve hospital death rates, supported by the Strategic Health Authority and external sources of expertise on clinical best practice and the use of clinical data.
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PRIORITY TWO: Reducing the number of people who do not attend their outpatient appointments
Why it is important
When a patient does not attend (DNA) a booked appointment it wastes valuable capacity, incurs unnecessary cost and in effect, prevents another patient having access to an earlier appointment. Waiting times have reduced significantly over recent years and many more patients are now involved in choosing the date and time of their appointments. This was a priority of the Trust last year, and DNAs were reduced thanks to a number of initiatives such as telephone reminders. The progress however was not as significant as we hoped, so in consultation with our Council of Governors we have agreed that this should be a priority for the forthcoming year.
Where we start from
DNA Rate 2008/09 2009/2010 2010/2011 New patients 9.0% 8.8% 9.5% Follow‐up 11.0% 11.3% 10.9% Outpatients
What we are aiming for in the year ahead
We aim to reduce the DNA rate to no more than 6% for new patients and 8% for follow‐up patients.
How we will achieve this Several initiatives have been implemented with the aim of reducing the DNA rates for both first and follow‐up appointments. Whilst progress has been made, the Trust is yet to see the level of reduction that it was looking for. A call reminder service has been piloted across Gynaecology, ENT and Gastroenterology. During the initial phase of the pilot (October through December 2010) DNA rates have fallen by 0.6% for new patients and 2.3% for follow‐up patients. An additional bonus of this work has been to enable patients to rebook their appointments if necessary, thereby avoiding a potential DNA. The pilot has been extended to cover Paediatrics and it is planned to extend this pilot to other specialties, with a view to implementing it on a permanent basis if similar decreases are achieved. Work is also ongoing in conjunction with PCT colleagues to increase the number of fully booked new appointments through the Choose and Book service. This provides patients with greater choice of appointment. New appointments booked through the Choose and Book service have increased from 38% to 55% during this time, with RBH being one of the highest foundation trust users of the Choose and Book service across the North West Region. The number of directly bookable services has increased from 45 to 75 during this year. For those appointments booked via Choose and Book we believe there is a reduced DNA rate as the appointment is agreed with the patient at the time.
In January 2011, as part of our BICS improvement work the booking team held an event around slot utilisation. At 60 days a 45% reduction in wasted new patient slots for surgical clinics in general ‐ 39 ‐
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outpatients had been realised with an approximate financial gain of £66,000 to the Trust. This event has had a positive impact on DNA rates as a result of the telephone access team confirming appointments.
By March 2011 Vascular Clinic DNA rates have fallen from 8% to 5% and General Surgery from 9% to 6% overall. Expansion of this work is planned for 2011/12 which should have a further positive impact on reducing the Trust’s DNA rates.
We recognise that one of the contributory factors to patients not attending appointments is when we make changes to existing appointments; there is also a programme of work to reduce this which we recognise as a source of frustration for our patients.
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PRIORITY THREE: Improving clinical correspondence
Why this is important to us
Successive annual NHS Inpatient Surveys have highlighted the importance to our patients of good discharge planning and clear communication. This is an area on which the Trust’s performance in the patient survey has been relatively poor. We also know from the patient diaries and interviews, carried out as part of our “patient experience‐based design” work, that shortcomings in discharge arrangements can cause clinical, practical and emotional problems for patients.
The Trust has been working hard over the last year to improve our performance in notifying GPs of their patient’s discharge from both inpatient care and from outpatient appointments. This notification process is important because GPs need to know what has happened in hospital so they can continue to care for patients in the longer term.
Our work so far
In 2009 the Trust introduced better and faster systems for transferring discharge information to GPs electronically when a patient leaves the hospital. Although some further improvements to this system are planned, we believe this has improved the continuity of care that patients receive, helping us to work better with patients’ GPs to manage their care when they go home.
In 2009/10 significant improvements were made in the daily review and discharge planning for patients who have been admitted as emergencies (particularly patients with medical conditions) through a system called “patient gateways”. This has resulted in reducing unnecessarily extended stays in hospital, and focusing better on the preparations for patients to go home.
Objectives
By the end of March 2012 we aim to send at least 95% of inpatient discharges to GPs within 24 hours and 99% within two days.
We are also aiming to send 99% of all outpatient discharge letters within five days
Where we start from?
Audit is currently in hand to accurately assess the proportion of patients’ discharge summaries sent to GPs within 24 hours. This will enable us to calculate a reliable starting point.
How we will achieve this
With respect to inpatient discharges, a new electronic system has been developed in conjunction with hospital staff and GPs using Ascribe, a specialist Bolton based Healthcare IT company. This new system will enable medical and other staff at the hospital to create a single discharge summary which contains all the relevant information, including medication changes, to facilitate safe and effective transfer of
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The discharge summary will be produced prior to the patient leaving the hospital. The document can then be transferred electronically to GPs within 24 hours of the patients discharge and patients will also receive a paper copy of this notification to take with them at discharge. Digital dictation has also been introduced to reduce delays between dictation and transcription of correspondence following an outpatient attendance. This has been done with a view to ensuring that GPs receive a letter within 5 days of the patient’s attendance. To support this project a total of 297 clinicians and 154 secretaries have been trained to date. The project has also required over 260 SpeechMikes, 130 Digital Portable Memos and 150 Transcription kits to be programmed and distributed to departments. The next stage of the project is to move forward with the implementation of the system at eight of the services based in the community. Using BICS tools medical, nursing, pharmacy, IT and secretarial staff have been involved in developing the project plan and also in designing the process to enable new ways of working to ensure the successful implementation of both Digital Dictation and Ascribe discharge summaries.
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PRIORITY FOUR: Improving the appraisal and development of staff
Why it is important
Appraisal has a direct impact upon quality of patient care, including vital elements such as mortality. Appraisal has direct links to staff engagement, motivation and performance. In the last 12 months, there has been much focus on the number of appraisals undertaken, however the annual staff survey shows us there is also a requirement to improve the quality of appraisal.
How we propose to measure our performance
There is a trust target of a minimum of 80% appraisals completed. This was achieved in 2010/11 and will continue to be measured against in 2011/12.
Recent Staff Survey results show that 39% staff had a well structured appraisal in last 12 months this puts the Trust in the highest 20% of acute trusts. However we want to seek improvements to this by working on an internal audit of the appraisal policy and process undertaken in 2010 using further audits to focus on appraisal quality and process.
Where we start from
Staff Survey results – the 2010 results for RBH show a significant improvement of 15% from the 2009 survey. This puts the Trust in the highest 20% of all acute Trusts for having a well‐structured appraisal in the last 12 months. 80% of staff who responded to the survey had been appraised with a personal development plan (PDP) in the last 12 months. It has been recognised that following integration with the provider arm of the PCT work will need to be done to bring appraisals for this group of staff in line with existing RBH staff.
The Best Employers Group identified that sustainment of appraisal performance whilst raising quality is an area to focus upon for 2011/12.
What we are aiming for in the year ahead
Continued Improvement in the number of appraisals undertaken alongside improvements in the quality of the appraisals undertaken. Work will also continue on aligning the impact of appraisal on other key workforce performance indicators such as overall staff satisfaction, attendance, productivity and the reputation of the Trust as a place to work and be cared for as a patient.
What we will do
• reinforce the value of quality appraisal and its relationship with an improved staff and patient experience (cultural) • Support the development of materials to promote a quality appraisal – e.g. local DVD • Continue Organisational Development and Learning targeted interventions to areas requiring support • Ensure a link to the Exemplar programme to support clinical areas
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PRIORITY FIVE: Safety Express
The Safety Express programme is a national improvement programme that aims to reduce harm from pressure ulcers, falls, catheter acquired urinary tract infections (CAUTI) and venous thromboembolism (VTE) ‐ the collective name for deep vein thrombosis (DVT) and pulmonary embolism (PE)
These four areas were selected because:
• They are avoidable
• They impact negatively on patient experience and outcome
• They rely on the whole system getting it right
• They are applicable to all care settings
The programme involves staff who are at the forefront of care both in the hospital and in the community. It sets ambitious improvement goals to increase the proportion of patients who complete their journey of care without experiencing any one of the four areas of harm.
What is harm?
Harm is defined in many ways but a widely accepted definition is that harm is “unintended injury resulting from, or contributed to, by clinical care that requires additional monitoring, treatment or extended stay in hospital.” Simply, this is a something the patient experiences either because of something we should have done but didn’t, or something we didn’t do but should have.
Why the programme is important to us
We want to see a significant reduction in all four harms to ensure that 95% of our patients do not suffer any of the 4 harms. The focus for the programme is on rapid acceleration and spread, therefore using BICS methodology, front line teams (direct care givers) are pivotal in designing and testing changes aimed at reducing harm so we can realise the benefits across the health economy.
The benefits of working in collaboration with other organizations will help us share and learn together and to move together at a pace and scale which is previously unprecedented.
How we propose to measure our performance
We will track progress through measuring each of the harms across the integrated organisation. We will also be measuring the number of patients who have none of the four harms. The purpose of such close measurement is for teams to understand that harm is not one person’s ‘fault’ but to see harm as the responsibility of the system and amenable to changes in the systems and processes across organisations and between health professionals.
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Where we start from
Falls and Found on Floor (All Wards)
120 108 105 102 95 100 82 92 84 89 73 80
60
40 number of patients 20
0 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10
Number of Pressure Ulcers Grade 3 & 4 (all Wards)
22 20 20 18 16 14 12 11 12 10 10 8 number of patients 6 4 4 3 3 2 0 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10
No of Patients with catheter associated urinary tract infection 80 65 64 65 64
60
40 number of patients 20
0 Sep-10 Oct-10 Nov-10 Dec-10
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No of Patients coded with a DVT/PE on discharge 24 24 22 22 18 19 19 20 16 18 13 14 16 14 10 12 10 8 number of patients 6 4 2 0 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10
What we are aiming for:
Reduce Category III and IV pressure ulcers by 75% in hospital
Reduce Category III and IV pressure ulcers by 25% in community
Reduce Catheter acquired urinary tract infection by 50%
Reduce serious injury from falls by 50%
Reduce VTE by 50%
What we will do
Four working groups have been established who will during 2011/12 focus improvements in each of these areas to achieve rapid improvement across the health economy. This will include involvement of frontline teams to engage patients and their families in the quest for safe care. The groups are supported by a steering group. Representatives of our Council of Governors sit on each of the groups and on the main steering group.
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Review of services During 20010/11 the Royal Bolton Hospital NHS Foundation Trust provided and/or sub‐contracted seven regulated activities (as defined by the CQC) across 38 specialities (as per schedule two of the Terms of Authorisation) The Royal Bolton Hospital NHS Foundation Trust has reviewed all the data available to them on the quality of care in these NHS services.
Participation in clinical audits
During April 2010‐March 2011, 39 national clinical audits and 4 national confidential enquiries covered NHS services that Royal Bolton Hospital NHS Foundation Trust provides.
During that period Royal Bolton Hospital NHS Foundation Trust participated in 72% of the national clinical audits and 100% of the national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Royal Bolton Hospital NHS Foundation Trust participated in, and for which data collection was completed during April 2010‐March 2011, 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. Where the organisation did not participate a justification is given.
Audit Participation % cases submitted Peri and neonatal Perinatal mortality Y 21 stillbirths, 14 neonatal, 0 maternal (CEMACH)
Neonatal intensive and Y 100% special care (NNAP) Children Paediatric Pneumonia N Major organisational changes to Childrens Services and staffing delayed participation. The hospital will participate in 2011‐12 Paediatric Asthma N Major organisational changes to Childrens Services and staffing delayed participation. The hospital will participate in 2011‐12 College of Emergency Y 100% Medicine (CEM): Paediatric Fever RCPH National Paediatric Y 88% Diabetes Audit
Acute Care British thoracic Society N A local audit was completed against BTS standards within a (BTS): Emergency Use of programme of improvements to the Respiratory Service to Oxygen redesign how the Respiratory Nurse team worked. The team won a Process Excellence Award: Europe for Best Process Improvement Project in Service and Transaction. They also presented a poster at the International Forum on Quality and Safety in Healthcare. ‐ 47 ‐
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Audit Participation % cases submitted BTS: Adult Community N The hospital participates in the North West Advancing Acquired Pneumonia Audit Quality Programme which involves measuring performance of all cases every month against a care bundle. Improvement work and audit on a care bundle also took place within Mortality Reduction workstreams.
BTS: Non Invasive N There are plans to participate in the next round. Ventilation (NIV) Audit Improvement work within Mortality Reduction workstreams reviewed current practices and an action plan was implemented. So far this involved training staff in the use of NIV. BTS: Pleural Procedures N The Trust did not participate in this audit but did audit services last year and presented the findings at the European Respiratory Society meeting in Barcelona in September 2010 National Cardiac Arrest N The hospital did not participate but improvement work in Audit Mortality Reduction workstreams includes in depth analysis of arrest calls using Root Cause Analysis and sharing learning through the North West Collaborative. The organisation will participate in 11‐12.
National Confidential Y 100% Enquiry into Patient Outcome and Death (NCEPOD)Cardiac Arrest Study CEM: Vital Signs in Majors Y 100%
Adult Critical Care‐ICNARC Y 100% Case mix program Potential Donor Audit (NHS Y All ICU deaths audited, currently do not audit A&E deaths Blood and Transplant) for this audit
Long term conditions
National Adult Diabetes N The community provider provides care for both inpatients Audit and outpatients and participated. Royal Bolton Hospital submitted data to the National Diabetes Inpatient Audit (76 inpatients) Heavy Menstrual Bleed Y ongoing Audit ‐ 48 ‐
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Audit Participation % cases submitted Chronic Pain (National Pain Y Stage 1: Organisational audit complete (1) Audit)
National IBD Audit Y ongoing
BTS/ European: COPD Audit N The hospital participated in the 2009 audit and will participate in next round. A programme of improvements to the Respiratory Service to redesign how the Respiratory Nurse team worked took place over the year. The team won a Process Excellence Award: Europe for Best Process Improvement Project in Service and Transaction. They also presented a poster at the International Forum on Quality and Safety in Healthcare.
BTS: Adult Asthma Y 187%
BTS: Bronchiectasis N The hospital did not participate as the audit was released when changes to services were in progress in the form of dedicated clinics. There are plans to participate in the next round of the audit. Elective procedures National Confidential Y 83% Enquiry into Patient Outcome and Death (NCEPOD) Perioperative Care Study National Joint Registry Y 100% National PROMS Y 50% programme National Confidential Y 100% Enquiry into Patient Outcome and Death (NCEPOD) Surgery in Children Cardiovascular disease Peripheral Vascular Surgery Y 100% (VSGBI Vascular Surgery Database)
Carotid Intervention Audit Y 100% Cardiovascular Disease Familial Y 100% Hypercholesterolemia Audit MINAP : Myocardial Y 100% Ischemia National Audit Project National Heart Failure Audit N Heart Failure is audited through the North West Advancing Quality programme and is reported monthly through the ‐ 49 ‐
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Audit Participation % cases submitted Clinical Safety and Quality Improvement Committee. Acute Stroke (SINAP) Y 80%
National Sentinel Stroke Y 95% Audit Renal Disease Renal Colic (College of Y 100% Emergency Medicine) Cancer National Lung Cancer Audit Y 111% National Bowel Cancer Audit Y 154 tumours Programme Head and Neck Cancer Audit Y 43 patients (DAHNO) Trauma National Hip Fracture Y 100% Database TARN: Trauma Audit and Y 47% Research Network
National Falls and Bone Y 100% Health Audit O Neg Blood Use (National Y No limit defined (31 cases) Comparative Audit of Blood transfusions) Platelet Use (National Y No limit defined (9 cases) Comparative Audit of Blood Transfusion)
Reviewing reports of national clinical audits and confidential enquiries
Of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) reports published during the year, two were relevant to the organisation.
A Mixed Bag: Parenteral Nutrition The Nutritional Steering Group reviewed services in the light of the report. A nutritional nurse was appointed and specialist nutritional rounds were introduced. As a result there is closer monitoring of the use of parenteral nutrition.
An Age Old Problem: Elderly Patients Undergoing Surgery A review of the report took place and a progress report is scheduled for May 2011.
The reports of ten national clinical audits were reviewed by the provider in April 2010‐March 2011 and Royal Bolton Hospital NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided.
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Breast Reconstruction The report was reviewed by the lead consultant and a detailed local audit compared results to the national report. The hospital performs well in comparison to peers, offering higher than national and regional rates of reconstruction and lower than the national average complication rates at mastectomy and flap donor sites. Reports were taken to both the Breast Services Governance meeting and a general surgeons’ meeting. Further plans are in progress and these will be reported at the Clinical Safety and Quality Improvement Committee in 2011.
National Continence Care The report was reviewed by the Lead Nurse for Older People. A gap analysis was conducted and will go to Clinical Safety and Quality Improvement Committee in 2011. Other improvements and monitoring will be linked to major Trust work streams during 2011‐12.
Dementia A gap analysis was undertaken and the need to improve awareness and education amongst clinical staff was noted. A research study in collaboration with Manchester University is now in progress, with the intention of improving staff knowledge and improving patient experience.
Perinatal Mortality (CEMACH) The report was presented in a departmental multidisciplinary meeting and for 2011 the planned actions include reviewing and updating decreased foetal movement guidelines and to evaluate access of the outreach midwife service by vulnerable areas/groups.
National Paediatric Diabetes Audit Clinicians reviewed the way information from annual reviews was fed back to patients. A new system of Dietetic support was also introduced to the clinic.
Adult Critical Care‐ICNARC Case Mix Programme The reports are reviewed at several forums including the Adult Critical Care Strategic Group, Clinical Safety and Quality Improvement Committee and Critical Care Governance. The 2010 data informed a strategic review of critical care and improvement work on critical care bedflow.
BTS Adult Asthma Audit The report was reviewed by the lead consultant. Some deficiencies were identified in the following up of asthmatic patients and further action is planned for 2011.
Myocardial Ischaemia National Audit Project (MINAP) Reports are reviewed within the specialty every quarter to assess compliance with national guidelines. Feedback is also provided to the ambulance service and will continue following the introduction for patient transferred for primary angioplasty
National Hip Fracture Database The 2010 report was reviewed at divisional and board level. Within the divisions monthly and weekly reports continue to be circulated to improve practice.
Trauma Audit and Research Network (TARN) Reports are reviewed within the divisions by senior clinicians and at the Trust Clinical Safety and Quality Improvement Committee. Improvements have been made to senior medical rotas to ensure greater coverage in Accident and Emergency Department and at weekend. Improvement work has led to the introduction of a new process to confirm competencies for chest drain insertion in A&E. Efforts to improve completeness of data this year means the survival outcome analysis for the Trust benchmarked well against national results. ‐ 51 ‐
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Reviewing reports of local clinical audits
The reports of ten local clinical audits were reviewed by the provider in April 2010‐March 2011 and Royal Bolton Hospital NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided:
Audit Actions to Improve Quality of Care Management of Cholestesis in • Patient information leaflet. pregnancy • Improve documentation in notes Use of antiemetics with • Change of sticker to include regular antiemetic postoperative Patient • Training sessions for surgical ward staff Controlled Anaesthesia (PCA) • Re‐audit after six months to include all areas where PCAs may prescription be prescribed Observation of Women with • Further training and involvement of midwives in epidural Epidural Analgesia during analgesia. Labour Audit • Encourage culture of regular monitoring of sensory levels • Ethyl chloride spray to be kept at bedside once epidural sited. • New epidural chart with dermatome map and observation chart with space for sensory level monitoring. Surgical Morality and High • Modification of Early Warning Score algorithm to have critical Dependency Unit Admissions care response. Re‐audit • Launch of a ‘Choices Around Escalation and Resuscitation’ document (CARE)’ to be filled out on ward round with patient and consultant discussion. Mammographers performing • Implement staff training/new protocols/benchmarks magnification views in assessment clinics Transfusion indication codes • Targeted learning points provided. • Confidential individual feedback to staff to be offered to self assess training requirements. Platelet use regional audit • Major haemorrhage guidelines to be produced in 2011. • Further actions to be indentified from the National Comparative Platelet Audit in haematology (March 11). Re audit of sample labelling • Awareness has been raised through Trust Quality teams. errors detected at the pre‐ • Maternity staff training days introduced. testing stage • NPSA transfusion competency assessment to be monitored and reported quarterly. • Further actions tabled at Hospital Transfusion Committee. Audit of antibiotic • Staff trained in use of mini bag techniques administration (respiratory • Flow chart prepared and implementation planned illness workstream) Audit of Liverpool Care Pathway • Developed a dashboard of measures for the Dying Patient • Regular reporting to be introduced on the dashboard in from April ‘11 • Core skills training package developed and will be implemented from April ‘11
Research The number of patients receiving NHS services provided or sub‐contracted by Royal Bolton Hospital NHS Foundation Trust in April 2011‐March 2010 that were recruited during that period to participate in
research approved by a research ethics committee was 294. ‐ 52 ‐
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Participation in clinical research demonstrates Royal Bolton Hospital NHS Foundation Trust’s commitment to improving the quality of care we offer and to making our contribution to wider health improvement. Our clinical staff stay abreast of the latest possible treatment possibilities and active participation in research leads to successful patient outcomes.
Over the period Royal Bolton Hospital NHS Foundation Trust was involved in conducting:
27 clinical research Cancer studies in 10 clinical research Paediatrics studies in 8 clinical research Medicine studies in 3 clinical research Women’s studies in Health 2 clinical research Critical Care studies in 2 clinical research Diagnostics studies in 1 clinical research Orthopaedics studies in
The improvement in patient health outcomes in Royal Bolton Hospital NHS Foundation Trust demonstrates that a commitment to clinical research leads to better treatments for patients. There were 78 clinical staff participating in research approved by a research ethics committee at Royal Bolton Hospital NHS Foundation Trust during April 2010‐March 2011.
As well, in the last three years, 30 publications have resulted from our involvement in National Institute for Health (NIHR), which shows our commitment to transparency and desire to improve patient outcomes and experience across the NHS.
Our engagement with clinical research also demonstrates Royal Bolton Hospital NHS Foundation Trust’s commitment to testing and offering the latest medical treatments and techniques.
Goals agreed with commissioners A proportion of Royal Bolton Hospital NHS Foundation Trust’s income in 2010/11 was conditional upon achieving quality improvement and innovation goals agreed between Royal Bolton Hospital and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework. Further details of the agreed goals for 2010/11 and for the following 12 month period are available on request from the Trust
The amount of our income conditional upon achieving quality improvement and innovation goals in 2010/11 was £2,461,000. The amount we earned was £1,501,000 which is 61% of the available amount
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What others say about us The Trust is required to register with the Care Quality Commission and its current registration status is registered without conditions. The Care Quality Commission has not taken enforcement action against the Trust during 2010/11.
Data Quality
Royal Bolton Hospital NHS Foundation Trust will be taking the following actions to improve data quality
Production of the Data Quality Dashboard, this is produced monthly and presented to the Information Quality Assurance group, which reports to the Information Management and Technology (IMandT) Committee a sub‐committee of the Board. The Data Quality Dashboard is presented directly to the IM and T committee on a quarterly basis. The data quality dashboard includes data quality metrics including NHS number coverage, demographic coverage and data completeness.
The Trust also completes monthly data quality audits on patient data, comparing casenotes to data recorded on the Patient Administration System. Results of the audits and actions arising from the audits are discussed at the Information Quality Assurance Group which reports to the IM and T committee (sub committee of the board).
The Royal Bolton Hospital NHS Foundation Trust has recently produced a Data Quality Policy the purpose of which is to improve data quality within the Trust, by formalising the procedure for accountability for data quality.
On a daily basis the Trust has routines to check data recorded on the Patient Administration System for duplicate and missing data on data items such as GP details, patient address details and NHS numbers. The Trust submitted records during 2010/11 to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data which included the patient's valid NHS number was:
99.7% for admitted patient care; 99.9% for outpatient care; and 99.1% for accident and emergency care.
The percentage of records in the published data which included the patient’s valid General Medical Practice Code was: 100% for admitted patient care; 100% for outpatient care; and 100% for accident and emergency care
The Trust score for 2010/11 for Information Quality and Records Management, assessed using the Information Governance Toolkit was 72%
Royal Bolton Hospital NHS Foundation Trust was not subject to the Payment by Results clinical coding audit during the reporting period by the Audit Commission.
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Our priority objectives for safety and quality in 2010/11
Our Quality Account for 2009/10 described a number of objectives directly related to the safety and quality of our services for 2010/11. These objectives were agreed with governors, staff and external stakeholders as being key areas of priority for the coming year:
For Patient Safety
• Reducing the Trust’s mortality rate (please refer to page 36) • Preventing harm as a result of venous thromboembolism (blood clots) • Using the Patient Safety Checklist in theatres
For Effectiveness
• Improving patient communication and discharge planning (please refer to page 41) • Reducing the number of people who do not attend their outpatient appointments (please refer to page 39) • Improving levels of compliance with best practice guidelines
For Patient Experience
• Reducing cancellation of patients due for admission • Achieving “Exemplar” and “Model” ward standards across the Trust • Improving the appraisal and development of staff (please refer to page 43)
Earlier in this report we set out our priorities for the coming year. These were agreed following consultation with stakeholders who were keen to see us continue work on some of the priorities agreed in the previous year.
The priorities identified for 2011/12 are discussed in detail in the first section of this report, therefore to avoid repetition they have not all been included in this section. The other indicators remain important to the Trust and although not selected as one of the key priorities in this report we will continue to monitor in the coming year.
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Preventing harm as a result of venous thromboembolism (VTEs) – blood clots
Description of the issue and why it was selected as a priority
The development of venous thromboembolism (VTE) – blood clots ‐ is a major risk for hospitalised patients, with estimates that hospital‐associated VTE leads to around 40,000 deaths in England each year, of which 25,000 are preventable.
Our objective for 2010/11 We aimed to achieve 90% coverage of VTE assessment of all appropriate patients by the end of 2010/11.
Where did we start from?
In March 2010 a baseline audit was conducted in our three clinical divisions, of the number of all hospital in‐patients who had had a VTE risk assessment completed. This gave us a baseline position of overall Trust compliance.
What we did
− Used our IT systems to capture and share information with our clinical teams and colleagues about compliance with assessments to provide regular updates on progress − Monitored compliance against the Trust’s revised VTE Policy through the Trust’s Thrombosis Committee and Mortality Reduction Group, and work with individual areas to achieve improvements − Established a system to identify any hospital acquired cases of VTE so that a Root Cause Analysis (RCA) can be carried out for each case. This enabled wider sharing and learning to promote further improvements. − Continued to raise staff awareness through a range of different mediums to promote best practice and the importance and significance of risk assessment and the treatment of VTE.
Results
As can be seen from the graph some progress has been made although we have not reached the target we set ourselves. The ability to demonstrate that risk assessments have been completed has been challenging. Despite a steady and ongoing improvement more focus is still needed to improve to the standard we have set.
VTE is one of the four workstreams included in the Safety Express initiative to ensure appropriate impetus is given to this key area.
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% of eligible patients with VTE assessment
100.0%
90.0% 80.0%
70.0% patients 60.0% 50.0% 40.0% 30.0% 20.0% percentage of eligible 10.0% 0.0% Jun-10 Sep-10 Dec-10 Mar-11
% VTE Target ‐ 57 ‐
Royal Bolton Hospital NHS Foundation Trust Annual Report and Accounts 2010/11 Page 5 Quality Report – Performance in 2010/11
Using the patient safety checklist in theatre
Description of the issue and why it was a priority
The Surgical Checklist promotes the use of routine checks on items such as the availability of equipment, administration of antibiotics and the site of surgery. It is used before each procedure to assure the safety of patients undergoing surgery by improving communication and supporting effective team work in the operating theatre.
The implementation of this World Health Organisation Checklist became compulsory with the issue of a National Patient Safety (NPSA) alert. This alert required that an action plan for introduction of the Checklist should be agreed by February 2009, and be underway by June 2009 and completed by February 2010 in all hospitals.
An international study published in the “New England Journal of Medicine” showed a reduction in mortality from 1.5% to 0.8% and in complications from 11% to 7% (7,000 patients) as a result of using the Checklist.
Data from the NPSA (2007) shows that, nationally, there were 130,000 reported errors that could affect patient safety in theatres.
An audit of the Trust’s main theatre departments reported incidents for April 2008 to 2009 demonstrated that 41 could have been avoided by use of the Checklist.
In January 2010 the Trust’s initial work on use of the Checklist was recognised with a Distinction in the National Patient Safety Awards.
Objectives 2010/11
Following a decision to focus in 2009/2010 on the “Time Out” section of the Checklist We aimed for improvement to 100% in 2010/2011. This is considered to be the most important element in improving patient safety. The “Time Out” is the final team check before the patient is prepared for surgery – it is performed with the whole team present and confirms the procedure, the site (if appropriate) and that all required equipment is available and that the patient has the best care (antibiotics, warming, anticoagulation).
The Checklist also contains an Inbrief and Debrief. The Inbrief is undertaken before the start of the list with all the theatre team present. At the meeting each patient is discussed and any potential problems are identified and actioned at this time. The Debrief is undertaken at the end of the list. The team look at whether there have been any issues during the list, what went well and anything that didn’t not go well that require actions. It is also an opportunity to look at the surgeon’s next list and identify equipment, particular patient issues
These aim to improve the running of theatre sessions and avoid delays during the procedure by highlighting any relevant issues, and equipment needs, at the beginning of the list. We aimed for all theatres to be using the Inbrief and Debrief procedure routinely for all operating sessions by March 2011.
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Where did we start from?
An audit of care plans demonstrated that the use of the checklist is more widespread than the data collection forms alone would indicate – the April 2010 audit of 50 cases showed 80% compliance. The audit also demonstrated a number of potential errors avoided as a result of using the Checklist.
What we did
− Incorporated the checklist into each patient’s care plan − Continued to run awareness sessions for theatre staff on using the “Inbrief” and “Debrief” − Continued to publish audit data and work with staff to target improvements where required
Results
The Time Out continues to be audited monthly and is part of the nursing care indicators. Currently Time out is 100% compliant. The In brief has been somewhat more challenging. This is also audited monthly and is part of the nursing care indicators. Theatres are currently at 68% compliance. Debrief is 10%.
To increase compliance through the productive theatre modules, three theatres have been identified between now and July 2011 to roll out fully the in brief and debriefs. Following this the other five theatres will roll out in July.
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Improving levels of compliance with best practice guidelines (‘care bundles’)
Description of this issue
Evidence from Trusts which have significantly improved their hospital standardised mortality rate (HSMR) shows that they have done so, in part, by rigorous implementation of “care bundles”, in line with best practice guidelines. Care bundles are evidence‐based groups of interventions, which have been shown to improve outcomes associated with specific medical conditions. Best practice also extends to preventative management, such as the prevention of thrombosis (blood clots), and safety checklists, such as the World Health Organisation surgical checklists, used in the “Patient Safety First” campaign, both of which we are using and routinely monitoring as discussed elsewhere in this report
Objectives in 2010/11
Although we are aiming to have 100% compliance with all of the key care bundles, and best practice guidelines, the three that were prioritised and on which we were aiming for 100% compliance in 2010/11 are: • pneumonia
• heart failure
• sepsis We aimed to achieve 70% compliance with the remaining key care bundles, aiming for 100% in 2011/12.
What we did
We implemented a care bundle approach by using practice educators and clinical audit, with routine feedback of audit outcomes as the basis for improvement action
Results
We implemented the pneumonia and sepsis care bundles first and early audits show between 50 and 70% compliance so there remains more work to do here. The heart failure care bundle, though now designed has not yet been implemented though this remains in our plan for 2011/12.
We revised our plans in late 2010 regarding implementation of any other care bundles as we wanted to ensure satisfactory and sustained compliance with the first three and to reflect upon lessons learned from attempts to successfully implement them.
Our plans for 2011/12 are to successfully implement all three care bundles as described above and achieve 100% compliance with them. We will review our achievements later this year and if these are well embedded will proceed to design three further care bundles.
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Reducing the number of operations cancelled on the day of admission
Description of the issue
We recognise the anxiety and inconvenience caused to patients and their families when their operation is cancelled on the day of their admission. Cancelled operations also cause frustration to staff and lead to wasted effort. The Trust is committed to ensuring that no patient waits longer than a total of eighteen weeks from referral by their GP to treatment at the hospital. Cancellations make this more difficult. (All patients cancelled on the day of their admission have their admission rearranged within 28 days).
There are a number of reasons for cancellations including for instance, when there is an influx of emergency patients, complications occurring during operating sessions, and the availability of key staff. We work hard to avoid cancellations, but in 2009/10 the proportion of operations cancelled by the hospital was higher than our target of not more than 0.8%. Not surprisingly, this gives rise to complaints from patients. The issue of cancellation also arose in interviews with orthopaedic patients in our “Patient Experience‐Based Design” project. The reduction of cancelled operations is a national priority, it is a requirement of our 2010/11 contract with NHS Bolton, and it is an important priority for the Trust.
Objectives for 2010/11
In 2010/11 we aimed to reduce on‐the‐day cancellations to not more than 0.8% of planned operations.
Where did we start from?
The graph below demonstrates a worsening trend in cancellations in 2009/10 compared with the previous year, particularly during the winter months when weather conditions and emergency pressures affected our ability to admit booked patients.
Overall, the on‐the‐day cancellation rate in 2009/10 was 352 out of 28,498 (1.24%) patients cancelled on the day of, or after, the day of admission). ‐ 61 ‐
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What we did
After putting into place a number of improvements throughout the year, including making sure that patients receive the appropriate assessment and preparation for their admission and improving our booking and theatre scheduling processes, we achieved our objective.
The graph below compares last year’s performance with this year after the introduction of these improvements. In total 226 of 28,504 (0.79%) patients were cancelled on the day due to non‐clinical reasons.
The hospital does not take a decision to cancel a patient lightly because we recognize the anxiety it causes the patient and their family. We remain focused to reduce this number even further because we aspire to get it right the first time.
Results
Comparative Summary of Cancellations on the Day As Percentage of Elective Admissions 1.4%
1.2%
1.0%
0.8%
0.6%
0.4% Percentage Cancelled 0.2%
0.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month 2009/10 2010/11 Target ‐ 62 ‐
Royal Bolton Hospital NHS Foundation Trust Annual Report and Accounts 2010/11 Page 5 Quality Report – Performance in 2010/11
Achieving Exemplar and Model ward standards across the Trust
Description of the issue
Over the last two years the Trust has developed a rigorous framework for setting, achieving and monitoring a range of essential standards in each ward and clinical department. Each area that enters the Exemplar Programme undergoes a developmental/improvement phase and is then assessed for accreditation, with follow‐up revalidation reviews. The standards relate to patient care and safety, staff management and development, and efficiency. The results of regular monitoring are reported publicly in each area.
The Exemplar Programme Team actively support staff and report on performance using the Quality Framework Tool (QFAT) which is an effective way of promoting continuous quality improvement.
The principles of continuous quality improvement and patient safety underpin the Exemplar programme. Fundamental to this is the introduction of “standard work”, removing unnecessary variation in what we do, and aiming consistently to remove waste in all our processes.
Objective 2010/11
In last year’s Quality report we set ourselves the objective of:
• 80% of wards being validated to Exemplar standard • all areas to sustain standards achieved • 80% departments to achieve exemplar status by March 2011 • At least two ward areas to work towards and achieve “Model” status, which demands even higher levels of compliance and consistency in meeting all the required standards (and one ward validated).
Where did we start from?
In April 2010 70% of wards had achieved Exemplar status in the three clinical divisions which provide inpatient care – Anaesthetics and Surgery; Medicine and Emergency; and Women’s, Children’s and Outpatients. Of these, two wards had achieved revalidation.
Ninety percent of clinical departments were working through the Exemplar Programme with two of these areas for validation.
What we did
• funded a project team which supported the roll out and implementation of the Exemplar programme. • Developed an action learning approach to improving patient care and ensuring improving standards both in operational performance such as length of stay, planned patients discharges,
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• Introduced achievement boards whereby ward compliance audits, patient outcomes, Key Performance Indicators and staffing levels are publicly displayed • Strengthened leadership and service improvement skills for ward managers. • Provided dedicated training and development support from practice educators and professional development nurses and put in place a robust and sustainable audit and monitoring infrastructure. • Supported our ward managers to equip our staff with the skills to provide the highest and consistent standard of care, with 100% of their staff having accessed all relevant mandatory and clinical training. • in 2010 the clinical departments took up the challenge to develop relevant key performance indicators and standards for their various departments linked to their own professional and national standards
Results
We achieved our target 80% of wards achieving exemplar status. The remaining 20% have completed the programme and are working through conditions in order to be validated as exemplar wards. 54% of departments (18 out of 33) have completed the programme, 45% have achieved exemplar status and the other 10% working through conditions. 100% of departments have commenced the programme and the 80% target should be achieved by the end of June 2011 Model ward measures have been updated and four ward areas are working towards model ward status. ‐ 64 ‐
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Urgent Care
Description of the issue
The Emergency Department at the Royal Bolton Hospital, which opened in September 1996, serves the population of Bolton and the surrounding districts with an estimated population of 330,000. It is the busiest, single site Emergency Department in Greater Manchester and in 2010 new patient attendance was over 110,000.
We recognise that improvement in urgent care pathways and, the achievement of the four hour target, is essential to improving the quality and safety of care in the hospital. Although the Bolton Health Economy achieved the 95% target in 2010/11 the Trust did not achieve its own internal stretch target of 98%
Performance
2007/08 2008/09 2009/10 2010/2011 Trust 96 95% 97 94.4 Health 97.2 96.7% 98 96.4 Economy
Vision for Urgent Care
During March 2011 a week long event took place with over 40 key stakeholders with an interest in the urgent care pathway within Bolton, these included GPs, commissioners, staff from the hospital, the community, social services and mental health, patient representatives and governors. The Event used BICS methodology to develop a vision and plan for delivering the transformation of urgent care in 2011/12.
New Emergency department clinical quality indicators were introduced on 1st April 2011. These consist of five equally weighted headline indicators, and three supporting indicators. Time remains important in that 6 hours maximum time in the department has been introduced.
The main areas of work for 2011/12 will be: 1. Patient Engagement: Understanding demand and patient needs 2. Front End: Redesigning all access points to urgent care to standardise processes, systems and skills needed regardless of location, this also includes some redesign and enhancement of physical facilities. 3. Workforce: Development of skills and capability. 4. In Hospital: Continued work to redesign bed management and escalation processes and the development of arrangements for transitions between A&E and Ward areas. 5. Back to Independence – work to reduce the length of stay and handover processes from acute care to support flow into these services, keep patients from returning to hospital and reduce duplication between services. 6. Primary Care – work to improve primary care access for urgent care will be taken forward by the
GP Consortia Urgent Care Lead. ‐ 65 ‐
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Infection Control
What is infection control? Infection prevention and control is about protecting patients, workers and others from the identifiable risks of acquiring a healthcare‐associated infection (HCAI). Examples of HCAIs are Clostridium difficile (CDT) and meticillin‐resistant Staphylococcus aureus (MRSA).
Why is infection control important? Anyone can get an infection, but some people are more at risk because their immune systems are weak. In a hospital those vulnerable people may be at additional risk because they have had a procedure that, while it is an important part of their treatment it may increase their risk of infection. It is especially important to prevent infections to help patients recover quickly and stay as healthy as possible.
Performance
MRSA 35
30
25
20 cases
of
15 No 10
5
0 2007/08 2008/09 2009/10 2010/2011
C Difficile
350
300
250
200 cases
of 150
No. 100
50
0 2007/08 2008/09 2009/10 2010/2011
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What Have we Been Doing to Prevent Infections?
We have concentrated on those key areas that we know are critical to the prevention of infection, these include; • Stringent Hand hygiene practices • High standards of Decontamination and cleaning • Environmental Cleanliness • The controlled use of Antibiotics
These elements are incorporated into everyday clinical practice, this is underpinned by ongoing education and training of staff to ensure excellent practice.
A robust programme of Audit and surveillance is in place so that these key elements are monitored on a regular basis. Compliance with a range of metrics has remained high, such as hand hygiene and cleanliness of the environment. These audits also monitor the number of staff who are trained in Aseptic Non touch Technique and Blood Culture sampling, which are all reported monthly.
Staff have used Bed management systems very effectively to ensure that there is timely identification of side rooms for symptomatic patients.
Universal Screening and prompt decolonisation are important strategies to prevent infection, our compliance with this is monitored through monthly audits.
Root Cause Analysis is carried out for all cases of MRSA and C. difficile, this ensures there is learning and any themes that may require actions to be taken to address issues can be identified.
A process to monitor and report wider infections has been established. These infections now also result in a root cause analysis and being followed up by clinical teams and microbiology.
Sustaining and Growing
• Continue with Screening and Decolonisation Strategy • Identification of high risk patients so interventions can be taken to minimise risk of infection. • Careful monitoring of any invasive devices being used • Safety express group looking specifically at improving management of catheters and catheter associated urinary tract infections. • Education campaign to recognise and put necessary interventions in place to protect high risk groups
Next year the challenging Health Economy target for both MRSA and C. difficile, is:
• MRSA: 5 cases of Pre 48 hour and 4 cases of Post 48 hour: Total of 9 cases
• C. difficile: 29 cases of Pre 72 hour and 32 cases of Post 72 hours: Total of 61 cases
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Monitors’ Compliance Framework Performance against key measures, April 2010 ‐ March 2011
Target Must Achieve Achieved RAG
C difficile year on year reduction (to fit the 146 46 trajectory for the year, as agreed with PCT)
Maintaining the annual number of MRSA bloodstream infections at less than 50% of 6 4
the 2003/04 level1
Maximum waiting time of four hours in Health A&E from arrival to admission, transfer or Economy to 96.9%
discharge achieve 95.0%
Maximum waiting time of 31 days from 96.0% 98.1% diagnosis to treatment of all cancers
Maximum waiting time of 62 days from 85.0% 86.8% urgent referral to treatment for all cancers
People suffering heart attack to receive 68.0% 68.5% thrombolysis within 60 minutes of call
Maximum waiting time of two weeks from urgent GP referral to first outpatient 93.0% 98.9% appointment for all urgent suspect cancer referrals
Screening all elective in patients for MRSA 100% 100%
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Royal Bolton Hospital NHS Foundation Trust Annual Report and Accounts 2010/11 Page 6 Staff Survey
Results from the 2010 Staff Survey
The results from the staff survey show a position of significant improvement from 2009. The Trust is recording, average or above average ratings in 31 of the available 38 key factors
6.1 Overall Response Rate
2009 2010 Trust improvement or deterioration Trust National Trust National Average Average Response Rate 57% 51% 50% 50% Decrease of 7% from the 2009 survey, but average for acute Trusts
Staff 3.60 3.64 3.66 3.62 Improvement from 2009 and above Engagement the national average in 2010
6.2 Top 4 Ranking Questions
Top 4 Ranking 2009/10 Top 4 ranking scores 2010/11 Trust improvement or Scores Trust National Trust National deterioration Average Average Question KF2 Question KF14 Highest 20% (best) % of staff 91% 90% % of staff appraised 80% 66% increase of 29% from agreeing that with personal 2009. (Best NHS scores their role makes development plans 84%) a difference to in the last 12 Improvement from 2009 patients months QuestionKF10 Question KF12 Highest 20% (best) % of staff using 76% 70% % of staff appraised 90% 78% increase of 28% from flexible working in the last 12 2009. (Best NHS scores options months 92%) Improvement from 2009
QuestionKF18 Question KF17 Lowest 20% (best) % of staff 15% 17% % of staff suffering 12% 16% decrease of 3% from suffering work‐ from work‐related 2009. (Best NHS scores related injury in injury in the last 12 10%) the last 12 months Improvement from 2009 months QuestionKF30 Question KF3 Highest 20% (best) % of staff feeling 24% 26% % of staff feeling 81% 76% increase of 5% from 2009. pressure in last 3 valued by their work (Best NHS scores 84%) months to attend colleagues Improvement from 2009 work when feeling unwell
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Lowest 4 Ranking Questions
Bottom 4 Ranking 2009/10 Bottom 4 Ranking 20010/11 Trust improvement Scores Trust National Scores Trust National or deterioration Average Average Question KF6 Question KF23 Highest (worst) Work pressure felt 3.24 3.11 % of staff 11% 8% 20%. No change by staff experiencing physical from 2009 violence from patients/relatives in the last 12 months QuestionKF24 Question KF24 Highest (worst) % of staff 13% 11% % of staff 2% 1% 20%. Deterioration experiencing experiencing physical from 2009 physical violence violence from staff in from the last 12 months patients/relatives in the last 12 months
QuestionKF22 % of Question KF21 Lowest (worst) 20%. staff reporting 92% 95% % of staff reporting 93% 95% No change from errors, near misses errors, near misses or 2009 or incidents incidents witnessed in witnessed in the last the last month month QuestionKF14 Question KF20 40% 37% Highest 20% (worst) % of staff having a 24% 30% % of staff witnessing 20%. No change well structured potentially harmful from 2009 appraisal in the last errors, near misses or 12 months incidents witnessed in the last month
Summary of local actions undertaken in 2010/11
As a result of the “Conversation” events and the 2009 NHS Staff Survey, a comprehensive action plan was developed to reflect the top priorities for action in the context of the four NHS constitution staff pledges. An overview of the actions undertaken are as follows:
• Action plan progress monitored monthly by the Best Employer Group • Development of the “Engagement Spectrum” to support the ongoing measurement of engagement • Implementation of an 80% target for appraisal which is monitored monthly by the Board of Directors • Roll out of the acuity and dependency scoring system to gauge work load and staffing demands and the implementation of E Rostering • Implementation of on line incident reporting
6.3 Learning and Development
This year the Organisational Development and Learning Team have made considerable improvements in the ways we support our workforce in learning and continuous development, which we believe are key to delivering patient centred care in the Trust, a vital component of our workforce strategy.
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Improving the uptake of appraisal has been a central theme during the year and we hit a target of 80% appraisals completed across the Trust in December 2010. We are now concentrating both on maintaining this level of appraisal completion, and auditing the quality of the appraisals that have taken place.
There has been a complete review of mandatory training resulting in an updated policy which meets the requirements of NHSLA level 2. To support this, information and ensuring the integrity of data on the recording of training on ESR has been another challenge for the department, resulting in records that now reflect the range of training activity and attendance that are shared with managers to enable compliance with mandatory training targets.
We have been able to offer a range of education, training and development opportunities that underpin workforce and organisational development. These opportunities are available to all staff groups from medical to the non‐registered workforce, often in partnership with universities, colleges and other education providers.
We are still committed to the Skills Pledge – a voluntary public commitment to ensure we work towards having a fully qualified workforce by 2012. We have supported the introduction of apprentices into our workforce and provided learning opportunities for our future workforce through collaboration with our local Health Academy.
A new management development programme was launched in August 2010, with coaching as the key theme running through every programme, some of our programmes are accredited with the Institute of Leadership and Management. Midyear we also began to deliver our ‘Engaging Manager’ programme linking to the engagement events held within the Trust. The Trust has maintained strong links with the North West Leadership Academy, accessing its range of leadership development programmes.
Staff have access to excellent education facilities on site. The Education Centre has a number of classrooms, discussion and seminar rooms and a 120 seat lecture theatre, complete with video conferencing and touch pad interactive systems. There is a well stocked library and an information technology suite based in the main part of the hospital. Although blended learning is used extensively within the Trust, e‐learning is increasingly being used as a learning methodology and we expect use of this to continue to grow across a range of training topics.
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Royal Bolton Hospital NHS Foundation Trust Annual Report and Accounts 2010/11 Page 7 Regulatory Ratings
Regulatory Ratings
Monitor award NHS foundation trusts regulatory ratings based on self‐certification received from trusts in their annual plan, in‐year quarterly submissions and any exception reports, including any reports from third parties such as the Care Quality Commission (CQC).
These ratings for Royal Bolton Hospital over the last two years are summarised in the tables below.
The ratings awarded at the start of each year are based on expected performance at the time of the annual risk assessment in our annual plan. The quarterly ratings are based on actual performance reported to Monitor via the quarterly in‐year submissions.
Annual Plan Q1 2009/10 Q2 2009/10 Q3 2009/10 Q4 2009/10 2009/10 Financial risk 3 3 3 3 3 rating
Governance risk green amber amber amber green rating
Mandatory green green green green green services
The table above outlines the ratings received during 2009/10. The mandatory services rating relates to provision of services in line with our terms of Authorisation, the governance risk rating relates to ongoing compliance with healthcare targets and indicators.
Annual Plan Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 2010/11 2010/11 Financial risk 3 3 3 3 3 rating
Governance risk amber‐ amber‐ green green green rating green green
Mandatory green green green green green services
In 2010/11 the Trust received a green rating for the first two quarters of the year and an amber green rating for the second two quarters. The amber/green rating in both quarters three and four relates to a failure to achieve the 62 day target for GP referral to start of treatment for cancer. This is due to the complex nature of the treatment pathways where patients are often referred to a specialist tertiary centre e.g. the Christie for treatment.
The financial risk rating was as planned throughout 2010/11.
The Trust has not been subject to any formal interventions.
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Royal Bolton Hospital NHS Foundation Trust Annual Report and Accounts 2010/11 Page 8 Other disclosures in the public interest
8.1 Actions taken by Royal Bolton Hospital NHS Foundation Trust to maintain or develop the provision of information to, and consultation with employees
Central to best possible care for our patients are staff who are motivated to give of their best and who feel they are involved in key decisions that affect them.
Over the last year the Trust has undertaken a series of events in order to embed a culture of “Staff Engagement”, in order to continue to improve staff satisfaction, involvement and communications. From October 2009 through to March 2010 over 500 staff took part in a number of “Small” and “Big Conversations”. The events overwhelming demonstrated that staff who work at the Royal Bolton Hospital are highly committed to providing excellence in care and services and identified the need to develop the following key priorities:
• Development of a set of core Trust values • Improvements in staff communications • Improvements in associated leadership and management behaviours • Improvements to the appraisal process • An examination of staffing and sickness levels • Mechanisms for improving staff recognition and wellbeing • Improvements in team working
The priority work streams are now in place, membership of which is made up from staff who attended the “conversation” events and sponsored by key leaders and managers. Achievements from the work streams are as follows and work is continuing in all the work streams throughout 2011:
• Core values to be launched in the spring of 2011 • Staff wellbeing survey to be undertaken in 2011 • Leadership and management programme and appraisal process revised • Launch of the management forum and supporting masterclasses • Engaging Manager programme commenced in October 2010 • Roll out of conversation events to support the development of an Integrated Care Organisation (Transforming Community Services)
8.2 Royal Bolton Hospital NHS Foundation Trust policies in relation to disabled employees and equal opportunities
The Royal Bolton Hospital NHS Foundation Trust, serves an increasingly diverse population and it is important that everyone can access our services fairly. It is also important that our staff reflect our local community and have protected rights of equality.
The Trust has recently implemented an Equality, Diversity and Human Rights Policy which identifies the following Trust goals: • Royal Bolton Hospital NHS Foundation Trust will be a provider of first class services that are equally accessible to, and appropriate for, all who are entitled to use them. • Royal Bolton Hospital NHS Foundation Trust will be an organisation that is recognised as a great place to work, where people are encourages and enabled to make their best and distinct contribution to the services provided. • Royal Bolton Hospital NHS Foundation Trust’s patients, carers, visitors, staff and other workers, volunteers, and members of the general public will be treated with courtesy, respect and
empathy, and as individuals with specific beliefs, needs and preferences. Where reasonably ‐ 74 ‐
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practicable, the Trust will make arrangements to support those beliefs, needs and preferences. Their human rights will be protected and promoted. • Royal Bolton Hospital NHS Foundation Trust will be an excellent corporate citizen.
The Trust has a wide range of policies which ensure that we adhere to legislation regarding equality and diversity and human rights for both staff and patients. These include policies on equal opportunities, employment of people with disabilities, recruitment and selection, interpreting and translating and respecting religious and cultural beliefs. We also produce recruitment material in different languages and our staff continue to attend equality and diversity training.
Equality and Diversity which is led by the Director of Corporate Services is taken to the patient experience and inclusion committee and links into the assurance framework of the Trust to ensure that we are compliant with mandatory standards and that any developments are progressed in accordance with Trust plans.
The following table represents the diversity of the workforce of the Trust,
Workforce 31/03/2010 31/01/2011 Age 0‐16 0 0 17‐21 38 43 22+ 3593 3586
Ethnicity White 3064 3056 Mixed 27 26 Asian/Asian British 252 249 Black/Black British 21 23 Other 46 39
Gender Male 623 625 Female 3008 3004
Disability 125 122
N.B. Discrepancies in the totals in this table are as a result of not all staff and members declaring data for ethnicity and diversity monitoring.
The Trusts’ Single Equality and Human Rights Scheme has been replaced by the implementation of an Equality Performance Improvement Toolkit, which has been adopted to ensure all areas of equality and diversity are addressed from both a staff and a service user perspective.
8.3 Information on health and safety performance and occupational health Health and Safety Performance There have been no prosecutions or Health and Safety Executive (HSE) enforcement notices issued to the Trust during the reporting period. ‐ 75 ‐
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The Trust has had two HSE advisory visits during the period in regard to monitoring the HSE’s ‘national intervention plan’. These involved monitoring of asbestos removal contractors working on‐site and arrangements for managing Legionella risks. The total number of accidents reportable to the Health and Safety Executive reduced from 39 in 2009/10 to 23 in 2010/11. They remain on average 50% lower than similar NHS reporting organisations. Occupational Health The Workforce Health and Wellbeing department (formerly the Occupational Health Department) continues to carry out all legislative requirements regarding protection of staff health at work but is also promoting general health and wellbeing in line with the publication of the Boorman review.
The department provides an extensive range of health and wellbeing services to Trust staff and a number of service level agreements to external organizations, including Bolton PCT. The appointment of a mental health practitioner has made considerable impact upon supporting the management of stress which equates to 22% of sickness absence within the Trust, providing a range of interventions/services, training for managers and compliance with national requirements. As a result a business case has been submitted to increase the provision of mental health services to staff from 2011. Meditation and relaxation sessions continue to be offered by our Chaplaincy Department and staff can access aromatherapy and reflexology via Occupational Health. This winter’s influenza outbreak was a significant challenge for the Occupational Health Team, but by the end of January 2011, 39.4% of front‐line staff had been vaccinated against seasonal flu, in an effort to protect our patients and staff.
8.4 Information on policies and procedures with respect to countering fraud and corruption The Trust has a Counter Fraud and Corruption Policy in place. A counter fraud work plan is agreed with the Director of Finance and approved by the Audit Committee. The local counter fraud specialist is a regular attendee at Audit Committee meetings to provide an update on the ongoing programme of pro‐ active work to prevent any potential fraud and investigatory work into reported and suspected incidents of fraud.
8.5 a statement describing the better payment practice code, or any other policy adopted on payment of suppliers, and performance achieved together with disclosure of any interest paid under the Late Payment of Commercial Debts (Interest) Act 1998; The Trust is expected to pay 95% of all creditor invoices within 30 days of goods or a valid invoice (whichever is the later) unless other payment terms have been agreed with the supplier. The Table below shows performance against this target in 2009/10 and 2010/11
Year ended 31 March 2011 Year ended 31 March 2010 Number £'000 Number £'000 Total Non‐NHS trade invoices paid within the target 45,027 55,008 38,018 43,494 Total Non‐NHS trade invoices paid in the period 49,378 60,946 42,451 49,826 Percentage of Non‐NHS trade invoices paid within the target 91.2% 90.3% 89.6% 87.3% Total NHS trade invoices paid within the target 1,338 16,735 1,677 17,750 Total NHS trade invoices paid in the period 1,569 18,441 1,931 20,180 Percentage of NHS trade invoices
paid within the target 85.3% 90.7% 86.8% 88.0% ‐ 76 ‐
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8.6 Consultations In May 2010 following a consultation with its stakeholders, NHS Bolton chose the Trust as its preferred partner for the transfer of PCT provider services. This decision signalled the start of a process to consult with staff and stakeholders of both NHS Bolton and Royal Bolton Hospital into the future of the new integrated care organisation. This consultation included: • Discussion of the proposed case for integration with the Foundation Trust Governors both in public Council of Governor meetings and in private sub‐committee meetings. • “Big and Small Conversations” – 14 staff engagement events, involving staff of the acute trust and the PCT. • Two day stakeholder event on vision and strategy, including patient and public representatives, health, local authority and third sector staff. • Cross sector clinicians’ event on models of integrated care organisations. • Presentation on the future integrated care organisation to each of Bolton’s 18 neighbourhood area forums. • Planned consultation on the future vision and strategy of the new integrated care organisation. • Public “Medicine for Members” meeting to describe and discuss the planned integration and the proposed vision and strategy.
8.7 Disclosures in relation to “other income” where “other income” in the notes to the accounts is significant The “other income” figure in the accounts is not considered significant
8.8 a statement that the NHS foundation trust has complied with the cost allocation and charging requirements set out in HM Treasury and Office of Public Sector Information guidance; and The Trust remains compliant with cost allocation and charging requirements laid down by HM Treasury and the Office of Public Sector Information
8.9 Details of Serious Untoward Incidents (SUIs) involving data loss or confidentiality breach There have been no SUIs involving data loss or a confidentiality breach during the period April 2010 – March
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8.10 Sickness absence data We work hard to ensure our staff are healthy and enjoy work, and to see a year‐on‐year improvement in attendance. We have a comprehensive attendance management policy and encourage staff to seek support if needed. The table below highlights the levels of absence against a target of 4.5%. There has been an overall improvement when comparing quarter 3 against the previous year, but there is room for improvement in sustaining our target of 4.5%.
April 2009 4.11% April 2010 4.74% May 2009 4.57% May 2010 4.55% June 2009 4.27% June 2010 4.65% Quarter 1 4.32% Quarter 1 4.65%
July 2009 5.11% July 2010 4.44% August 2009 5.00% August 2010 4.47% September 2009 4.93% September 2010 4.71% Quarter 2 5.02% Quarter 2 4.54%
October 2009 5.26% October 2010 5.06% November 2009 5.40% November 2010 4.97% December 2009 5.69% December 2010 5.42% Quarter3 5.45% Quarter 3 5.15%
January 2010 5.94% January 2011 4.99% February 2010 5.05% February 2011 4.26% 4.29% 4.17% March 2010 March 2011 Quarter 4 Total 5.10% Quarter 4 Total 4.99%
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Royal Bolton Hospital NHS Foundation Trust Annual Report and Accounts 2010/11 Page 9 Statement of Accounting Officer’s Responsibilities
Statement of the chief executive's responsibilities as the accounting officer of Royal Bolton Hospital NHS Foundation Trust
The NHS Act 2006 states that the chief executive is the accounting officer of the NHS foundation trust. The relevant responsibilities of the accounting officer, including their responsibility for the propriety and regularity of public finances for which they are answerable, and for the keeping of proper accounts, are set out in the NHS Foundation Trust Accounting Officer Memorandum issued by the Independent Regulator of NHS Foundation Trusts (“Monitor”).
Under the NHS Act 2006, Monitor has directed Royal Bolton Hospital NHS foundation trust to prepare for each financial year a statement of accounts in the form and on the basis set out in the Accounts Direction. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of Royal Bolton Hospital NHS foundation trust and of its income and expenditure, total recognised gains and losses and cash flows for the financial year.
In preparing the accounts, the Accounting Officer is required to comply with the requirements of the NHS Foundation Trust Annual Reporting Manual and in particular to: • observe the Accounts Direction issued by Monitor, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis; • make judgements and estimates on a reasonable basis; • state whether applicable accounting standards as set out in the NHS Foundation Trust Annual Reporting Manual have been followed, and disclose and explain any material departures in the financial statements; and • prepare the financial statements on a going concern basis.
The accounting officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the NHS foundation trust and to enable him/her to ensure that the accounts comply with requirements outlined in the above mentioned Act. The Accounting Officer is also responsible for safeguarding the assets of the NHS foundation trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities.
To the best of my knowledge and belief, I have properly discharged the responsibilities set out in Monitor's NHS Foundation Trust Accounting Officer Memorandum.
Signed Date…31st May 2011………………………………. Lesley Doherty Chief Executive
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st st Statement on Internal Control – 1 April 2010 – 31 march 2011 1. Scope of responsibility As Accounting Officer and Chief Executive of this Board I have responsibility for maintaining a sound system of internal control that supports the achievement of the NHS Foundation Trust’s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the NHS Foundation Trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum.
2. The purpose of the system of internal control The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of Royal Bolton Hospital NHS Foundation Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place in Royal Bolton Hospital NHS Foundation Trust for the year ended 31 March 2011 and up to the date of approval of the annual report and accounts.
3. Capacity to handle risk 3.1 Leadership Responsibility of the Chief Executive The Chief Executive has overall responsibility and accountability for leading risk management arrangements on behalf of the Board. The Chief Executive holds each line manager accountable for setting objectives, relevant to the Board’s corporate objectives for their own staff. The Chief Executive chairs the Risk and Assurance Committee, is a member of the Finance and Investment Committee and attends other trust wide committees. The Chief Executive is also personally involved in the management of complaints against the Trust. Responsibility of the Director of Corporate Services The Director of Corporate Services has managerial responsibility for the health and safety and fire safety departments and for clinical governance with the Medical Director providing the professional lead. The Director of Corporate Services attends the Audit Committee and is a member of the Risk and Assurance Committee, and the Finance and Investment Committee. The Clinical Governance and Assurance Committee, the Health and Safety Committee and the Estates Strategy Committee are chaired by the Director of Corporate Services who is also responsible for the management of claims and complaints against the Trust. The post of Head of Clinical Governance, Patient Safety and Experience and Corporate Quality Manager support the delivery of the Governance and Quality agenda and the Head of Health and Safety is the competent person for the Trust in relation to health and safety management. Responsibility of the Director of Nursing and Performance Improvement (April 10 – June 10) The Director of Nursing and Performance Improvement is operationally responsible for the delivery of all clinical and operational services within the Trust through the divisions. This includes the achievement of key performance indicators on patient access and patient safety. ‐ 80 ‐
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The role also includes the professional leadership of nurses and midwives and providing advice to the Board on nursing issues in addition to representing Allied Health Professionals and healthcare scientists at Board level. The posts of Head of Performance, Senior Nurse (older people) and Head of Clinical Practice support the delivery and monitoring of key performance targets and developing and supporting clinical practice throughout the Trust. In June 2010 the Director of Nursing and Performance was split into two Director portfolios, an acting Director of Operations assumed responsibility for the operational performance (the post became substantive in January 2011) and an acting Director of Nursing for the professional leadership (a permanent appointment has been made with effect from 2nd May 2011) Responsibility of the Medical Director The Medical Director provides professional leadership for clinical governance and patient safety within the Trust. The Medical Director chairs the Clinical Safety and Quality Improvement Committee. The Medical Director also provides medical advice to the Board and is managerially and professionally responsible for the clinical effectiveness department, audit, research and development and medical education. The Medical Director is supported by the Associate Medical Directors and the Clinical Leads for clinical effectiveness, patient safety and post graduate education Responsibility of the Director of Finance, Information and Procurement The Director of Finance is the responsible officer for managing financial risk in the Trust and is also responsible for performance reporting, information and procurement. The Director of Finance provides professional financial advice to the Board. The Director of Finance attends the Audit Committee and sits on the Finance and Investment Committee. Responsibility of Director of Service Development The Director of Service Development is responsible for service planning, objective setting, Information Governance and IM and T issues. The Director of Service Development is the Senior Information Risk Owner (SIRO) for the Trust and is responsible for ensuring that organisational information risk is properly identified, managed and that appropriate assurance mechanisms exist
3.2 Committees The Board of Directors has overall responsibility for risk management in the Trust. The following formal Board sub committees and Trust wide committees provide additional assurance to the Board having explored relevant key issues in greater depth: Sub committees • Audit Committee • Risk and Assurance Committee • Remuneration and Nomination Committee • Finance and Investment Committee • Charitable funds Committee In February 2010 the Trust reviewed its governance structure in line with the Audit Commission publication “Taking it on Trust”. In order to streamline the risk and assurance process and provide effective assurance to the Board a new Risk and Assurance Committee was formed effective from 1st April 2010. All Executive Directors and three Non Executive Directors are members of the Risk and Assurance Committee which is chaired by the Chief Executive and receives reports from the following assurance providing committees: • IM and T committee
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• Health and Committee • Clinical Governance and Assurance Committee The Audit Committee continues to provide assurance and to review the establishment and maintenance of an effective system of integrated governance and internal control across the whole of the Trust’s activities both clinical and non clinical. The executive team is supported by a divisional management structure consisting of four divisions. Each division has a Divisional General Manager accountable for the delivery of key objectives in their areas of responsibility. Each division is supported by a divisional nurse (other than Diagnostics, Therapies and Facilities Division) and an Associate Medical Director who have specific responsibility for delivering on patient safety, quality and the governance agenda. Since June 2011, the four divisions have been accountable to the Director of Operations (prior to this they were accountable to the Director of Nursing and Performance Improvement). The remainder of the Trust’s business is managed by the following functional Directorates: • Finance Information and Procurement • Workforce and Organisational Development • Corporate Services • Nursing and Performance Improvement • Service Development • Medical Performance monitoring reports are provided to the Executive Board and Board of Directors on a monthly basis and, in addition to this the, Executive Directors review each division in depth on a quarterly basis. The minutes of all the Trust wide committees are also seen by the Executive Board. In addition one or two Non‐Executive Directors are attached to each Trust wide Committee. The Risk and Assurance Committee received the Board Assurance Framework (BAF) and Risk Register at each of its six meetings during 2010/11 and the Audit Committee received the Board Assurance Framework and the Trust Risk Register three times in this period. The Board of Directors received the BAF and Risk Register twice and also received quarterly CLIP reports combining complaints, litigation, incidents and PALS issues. The Finance and Investment Committee meets monthly and monitors the Trust’s operational budget position, cash balances and progress against the Trust’s investment, capital programme and savings plan. The Finance and Investment Committee also monitors and agrees any changes to the Trust’s capital programme. The minutes of the Finance and Investment Committee are received by the full Board of Directors. As Accounting Officer I have overall accountability for internal control. To support this role there are clear systems of accountability within the organisation with each Executive Director having specific areas of responsibility Arrangements are in place for the reporting of serious untoward incidents to the Strategic Health Authority (SHA) and other stakeholders through the Trust’s Incident Reporting Policy. The Trust also links to the National Reporting and Learning System (NRLS) of the National Patient Safety Agency.
3.3 Processes in place by which we work with partner organisations. The Trust’s principal partner organisation is NHS Bolton (Bolton Primary Care Trust) and a series of working arrangements are in place relating both to its role as commissioner and a co‐provider of ‐ 82 ‐
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services. During the latter part of the reporting period the two organisations have been working increasingly closely in preparation for integration of the PCT provider services with the Foundation Trust. This has involved work to harmonise policies and procedures and agree joint objectives in a new five year vision and strategy document. Other joint working includes: • Joint planning and development intentions are embodied in the contract • Strategic developments are regularly discussed including but not limited to urgent and emergency care, medicines management and respiratory pathways. Directors from both organisations are involved in these meetings • Members of the Executive teams of both the Trust and PCT meet on a regular basis. • Non‐Executives of both organisations meet and there are occasional Board to Board meetings • Joint contract review mechanisms are in place focusing on quality targets within the contract, other key contract deliverables and NHS plan target delivery. • An array of planning forums exist to focus professional advice and managerial action across a range of priority agendas, including services for cancer services, children’s services, coronary heart disease, diabetes, urgent care services, access, choice and booking. • Improvement teams using BICS routinely involve patients, and staff from partner organisations • A Clinical Effectiveness Group, Medicine Management Committee and a Clinical Standards Board are also in place to enable clinicians and managers to work together on a range of clinical issues such as clinical pathways, medicine management and clinical risk management. • A Health Economy Wide Safety Committee ensures that safety is addressed across the health economy. • NHS Bolton is represented on the Trust’s Clinical Governance and Assurance Committee and the Trust is represented on the PCT’s Clinical Governance Committee. Relationships and working arrangements with the SHA are conducted principally through: • SHA led Greater Manchester joint planning networks e.g. for Cancer, Women’s and Children’s Services, stroke, trauma and IT etc. • Routine contact between senior officers and their counterparts. Overarching partnership structures, embracing local authority, NHS and non statutory sector organisations provide a framework for borough wide strategic development and the Trust is an active member of the Vision Steering group and its partnership boards including the Children’s Trust, Health and Care Together, Local Safeguarding Children’s Board and local safeguarding adults board. Over the latter part of 2010/11 the Trust has established more formal arrangements with two of its neighbouring trusts to examine opportunities for collaboration on a range of services
3.4 Training To ensure the successful achievement of the Risk Management Strategy and implementation of the Risk Management Policy staff at all levels are provided with appropriate training in carrying out risk assessments and the reporting of incidents. The ongoing programme of training within the trust also includes: managing safety, incident reporting, risk assessment training, risk register training, fire safety training, manual handling, Safeguarding training, major incident training and conflict resolution training Medicine management training is delivered at doctors’ induction programmes and during educational and developmental sessions. Medication error reports are brought to the Clinical Governance and Quality Committee and disseminated to the divisions through the Clinical Quality Boards. Support and advice on medicine management is also provided at ward and departmental level by the Chief Pharmacist and link pharmacists. ‐ 83 ‐
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Risks and safety in respect of clinical equipment and devices is discussed and disseminated by the Medical Devices and Equipment Management Committee on which all divisions are represented and which also has a training sub group and each ward has a link nurse. General awareness raising on risk management issues is achieved through staff briefings, team brief, safety bulletins, induction and the intranet. The Trust has a Patient Experience group which is chaired by the Head of Clinical Governance and Patient Safety and Experience and includes the Customer Relations Co‐ordinator, PALS Officer, Quality Managers, Foundation Trust Governors, lay members, Head of Clinical Practice and matrons. The purpose of the group is to identify themes from complaints and PALS issues on a monthly basis and to agree lessons to be learnt and actions to be taken to improve patient experience and ensure this information is shared across the organisation. Work is also undertaken on audits or particular issues such as protected meal times, mixed sex accommodation, nutritional assessments, patient records and infection control
4. The risk and control framework The risk management policy outlines the responsibilities of the following executives: • Chief Executive • Director of Corporate Services • Director of Finance • Director of Nursing and Performance Improvement The responsibility for systems to manage clinical risks is incorporated into the post of Head of Clinical Governance and Patient Safety. Advising on the management of health and safety risks is the responsibility of the Head of Health and Safety. The post of Fire Safety Manager meets the requirements of the hospital technical memorandum 05‐01: Managing Healthcare Fire Safety and he reports to the Head of Health and Safety. The role of Head of Clinical Governance and Patient Experience plays a key role in advising and co‐ ordinating clinical governance, CQC registration and NHSLA Standards and is responsible for clinical governance, equality and diversity, complaints, litigation and clinical risk Directors and Divisional General Managers are responsible for ensuring that risks are identified and managed in their own areas of responsibility and escalated as appropriate and that their staff are appropriately trained. Responsibility for risk management for all levels of staff is fully outlined in the Trust’s policy on risk management responsibilities. A Board endorsed risk management strategy and policy is in place which describes the following: • Board Statement • aims • strategic objectives • philosophy of risk management • risk controls • risk management structure • risk management responsibilities • process of evaluating and prioritising risk ‐ 84 ‐
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• risk register • performance management • monitoring and review • risk management training and support • fair blame culture The risk management strategy also links to other Trust policies, e.g. risk management policy and protocols, e.g. accident/incident reporting and investigation and root cause analysis. The strategy is available to staff in all wards and departments via the Trust intranet. The risk management strategy was reviewed and approved in June 2010 to reflect the organisational structure and to meet the requirements of the new NHSLA Risk Management Standards and the revised governance arrangements
4.1 Risk management is embedded in the trust Risk management is embedded within the Trust through key committees: • Audit Committee • Finance and Investment Committee • Risk and Assurance Committee • Clinical Governance and Assurance Committee • IM and T Committee • Workforce Committee • Health and Safety Committee Minutes of these groups are exchanged and made available to staff through the intranet, meetings and bulletins. Other groups which cover risk issues include: • Radiation Protection Committee • Medical Devices and Equipment Management Committee • Divisional Quality Boards • Infection Control Committee (reports to Clinical Safety and Quality Improvement Committee) • Local Security Management Committee • Fire Safety Committee • Emergency Preparedness Steering Group The implementation of the Trust’s policies and procedures is the responsibility of Directors, divisional general managers, heads of service and departmental managers.
4.2 Board assurance framework A Board approved assurance framework was in place for the period 1st April 2010 – 31st March 2011. The framework: • covers all of the Trust’s main activities ‐ 85 ‐
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• identifies the corporate objectives and targets the Trust is striving to achieve and covers the core standards on which the Trust is required to declare its compliance during 2010/11 • identifies risks to achievement of these objectives and targets • identifies the system of internal control in place to manage the risks • identifies and reviews the assurance mechanisms which relate to the effectiveness of the system of internal control The Board also receives updates on high/significant risks and risks are documented in the Trust Risk Register. The Risk and Assurance Committee consider high and significant risks and recommends their inclusion on the Trust Risk Register. The Trust Risk Register and Assurance Framework go to The Risk and Assurance Committee three times a year, to the Audit Committee twice a year, to the Board twice a year and to the Executive Board twice a year. Risk prioritisation and action planning is informed by the corporate objectives of the Trust, incident reports, litigation claims, audit information, complaints, individual issues from divisions, Directorates and national requirements/guidance. Action plans are developed for unresolved risks and the scoring of risks is adapted from the Australian/New Zealand Risk Management scoring system. Lead managers and Directors are identified to deal with gaps in control and assurance and are responsible for developing action plans to address the gaps. The most significant issues on the Board Assurance Framework for 2010/11 were with regard to achieving the four hour health economy A&E target, sustaining the 18 week target by speciality and meeting the standards for clinical correspondence. Although the targets other than clinical correspondence were achieved these areas remain challenging and will be the Trust’s top priorities in 2011/12. The other key issue for the Trust in 2011/12 will be the integration of NHS Bolton provider services, this is expected to take place from 1st July 2011. The risks associated with this transaction are being managed through a separate risk register and Assurance Framework which will merge with the main Assurance Framework once the transaction has been completed. The Board received a significance assurance opinion from internal audit for its Board assurance process in 2010/11
4.3 Information governance controls In March 2010, the Trust adopted a new and overarching Information Risk Management Policy, setting out key principles, the legislative and good practice framework, revised information governance structures, and roles and responsibilities, including the concept of Information Asset Owners. The Trust’s IT security policy has been revised and approved to take into account new requirements. It is mandated that all new bulk flows of data must be registered with the Information Governance Group. Other flows of personal data have been documented and mapped as per the requirements of the Department of Health. The Trust has encrypted all laptops and desktop PCs. Centralised storage has been rolled out across the Trust to ensure that all critical and sensitive data is held securely, not on local equipment. All portable devices such as memory sticks that are plugged into PC’s and laptops have enforced encryption. Email encryption software has been procured which allows the encryption of emails containing sensitive information. An updated Email and Internet Access policy has been approved to reflect the capabilities that new security applications now give the Trust. Staff have been reminded that email should not be used to send personally identifiable data, unless it is encrypted or NHSmail is used and messages remain within the NHS. ‐ 86 ‐
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The Senior Information Risk Owner (SIRO) for the Trust is Ann Schenk, Director of Service Development. The Trust has submitted its Statement of Compliance and Information Governance toolkit (IGT) to Connecting for Health. The IGT records the status of a number of controls against Information Governance Standards. The overall score of 72% shows the Trust as in the top category of compliance. A programme of work has been developed, approved and is monitored by the IM and T Committee.
4.4 Public involvement The Trust engages with the public in a number of ways in relation to risk management. There is lay representation, in most cases through Foundation Trust Governors on the Clinical Governance and Assurance committee, the Ethics Committee, Emergency planning group, Patient Experience Group, Mortality group, Workforce Committee, Divisional Quality Boards and PEAT visits. Council of Governor meetings are held in public and publicised in the local media, performance reports are shared at these meetings and Governors and the Public are invited to discuss corporate objectives and performance.
4.5 Care Quality Commission Royal Bolton Hospital NHS foundation Trust is fully compliant with the requirements of registration with the Care Quality Commission
4.6 CNST/NHSLA Standards In February 2011 the Trust was re‐ assessed against the general NHSLA risk management standards and was successful at level 2. The Trust has level 1 against the maternity CNST standards and is aiming for accreditation at level 2 in 2011/12
4.7 As an employer with staff entitled to membership of the NHS Pension Scheme control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employee’s contributions and payments into the scheme are in accordance with the scheme rules and that member pension scheme records are accurately updated in accordance with the timescales detailed in the regulations. Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with. The Trust has undertaken risk assessments and is working with the Carbon Trust to ensure Carbon Reduction Delivery Plans are in place in accordance with UKCIP 2009 and to ensure that this organisation’s obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with. The Trust employs a Head of Emergency Planning who is responsible for ensuring compliance with emergency preparedness and civil contingency requirements. Policies are in place to deal with a major incident; in addition the Trust has a CBRN plan, a heatwave plan and a flood plan.
5. Review of economy, efficiency and effectiveness of the use of resources The Trust regularly reviews the economic, efficient and effective use of resources with robust arrangements in place for setting objectives and targets on a strategic and annual basis. These arrangements include: • ensuring the financial strategy is affordable
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• Co‐ordination of individual and departmental objectives with corporate objectives using lean methodology. Performance against objectives is monitored and actions identified through a number of channels • Approval of the annual budgets by the Board of Directors • Weekly review at Executive Director meetings • Quarterly reporting to the council of Governors • Monthly reporting to the Board of Directors and the Executive Board on key performance indicators • Monthly review of financial targets by the Finance and Investment Committee • Quarterly reporting to Monitor and compliance with terms of authorisation. The Trust also participates in initiatives to ensure value for money for example: • The Trust uses lean methodology to optimise the efficient and effective use or resources whilst enhancing the patient experience. • Procurement of goods and services is undertaken thorough professional procurement staff and through working with neighbouring organisations within a procurement hub. • In year cost pressures are rigorously reviewed and challenged, and alternatives for avoiding cost pressures are always considered.
6. Annual Quality Report The Directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual Quality Reports which incorporate the above legal requirements in the NHS Foundation Trust Annual Reporting Manual. In producing its Quality Account in 2010, the Trust identified key areas for improvement under the three headings of patient safety, clinical effectiveness and experience. To ensure a balanced view, the Board worked with Governors and other internal stakeholders to select the nine priorities on which the Trust would be reporting in 2010/11. The process for identifying priorities for 2011/12 included the Board, our Council of Governors, staff and other stakeholders. The final short list of priorities for inclusion in the report was agreed between the Non Executive Directors and the Council of Governors We have used existing performance management arrangements to track progress throughout the year on the targets selected and have reported at year end on these to both the Board and Governors. An External Audit report on our 2009/10 Quality Account provided assurance that the Trust has arrangements to ensure the accuracy of data.
7. Review of effectiveness As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, and the executive managers within the NHS foundation trust who have responsibility for the development and maintenance of the internal control framework. I have drawn on the content of the quality report attached to this annual report and other performance information available to me. My review is also informed by comments made by the external auditors in their management letter and other reports. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the board, the audit committee and the risk and assurance committee, and a plan to address weaknesses and ensure continuous improvement of the system is in place. ‐ 88 ‐
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Of particular relevance is the recently conducted review of governance arrangements against recommendations in the Audit Commission’s publication “Taking it on Trust”. This review prompted a change to the Trust governance arrangements and the formation of a new Board level Risk and Assurance Committee. These changes were approved at the Board of Directors meeting in March 2010 and implemented with effect from April 2010. The Assurance Framework itself provides me with evidence that the effectiveness of controls that manage the risks to the organisation achieving its principal objectives have been reviewed. My review has also been informed by o The Head of internal audit overall significant opinion on the system of internal control. o The Head of Internal Audit overall significant opinion on the Board Assurance Framework. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by: • The Board who receive monthly performance reports covering the Trust’s objectives, Improving Health, Best Possible Care, Value for Money, Joy and Pride in Work and Quarterly Reports on complaints, litigation, incident reporting, Serious Untoward Incidents and Patient Advice and Liaison Service (PALS) issues. • The Audit Committee who receive and review the Board Assurance Framework and Trust Risk Register three times a year, and also monitor progress and action taken in relation to external audit and internal audit reports. The Committee also review and monitor the Trust’s self‐ assessment against the Audit Commission’s Auditors Local Evaluation criteria and associated action plan. • The Finance and Investment Committee who monitor the organisations financial performance, review progress against the organisation’s investment, improvement and savings plan and recommend a capital programme to the Board and monitor and approve in year amendments. • The Risk and Assurance Committee who review and monitor the Board Assurance Framework and Risk Register, monitor progress on SUI action plans and receive formal reports from the divisions on their governance arrangements including incidents, and divisional risk registers. Training and Health and Safety monitoring reports are also reviewed by the Committee. • The Clinical Governance and Assurance Committee who review aspects of patient safety, patient experience and clinical effectiveness and clinical audit. The Committee review the Complaints, Litigation, Incidents and PALS report (CLIP) prior to consideration by the Board. • Executive Directors ‐ I have regular meetings with my Executive Directors, who advise me of actions they have taken to review the effectiveness of the system of internal control in their areas of responsibility.
8. Conclusion 8.1 Significant Control Issues
No significant control issues have been identified.
Signed
Date 31st May 2011
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Royal Bolton Hospital NHS Foundation Trust Annual Report and Accounts 2010/11 Page ROYAL BOLTON HOSPITAL NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2010/11
STATEMENT OF COMPREHENSIVE INCOME FOR THE YEAR ENDED 31 MARCH 2011
For the year For the year ended 31 ended 31 March 2011 March 2010 NOTE £000 £000 Revenue Operating revenue from continuing operations (patient care) 4 177,507 169,892 Other operating revenue 6 23,602 22,882 Operating expenses 8 (204,074) (192,937) Operating surplus (deficit) (2,965) (163) Finance costs: Finance Income 13 56 33 Finance costs 14 (381) (158) Finance expense - unwinding of discount on provisions (11) (13) Public dividend capital dividends payable (3,859) (4,491) NET FINANCE COSTS (4,195) (4,629)
Surplus/(Deficit) from continuing operations (7,160) (4,792)
Other comprehensive income Revaluation gains/(losses) and impairment losses property, plant and equipment 0 (16,355) Revaluations 3,485 0
Increase in the donated asset reserve due to receipt of donated assets 70 292 Other recognised gains and losses (156) (125) Total comprehensive income for the year (3,761) (20,980)
The notes on pages 6 to 38 form part of these accounts.
The Trust's reported deficit from continuing operations of £7,160k comprises a trading surplus of £1,946k, offset by a non cash impairment of £9,106k (see note 17.5) on revaluation of land and buildings.
Page 1 ROYAL BOLTON HOSPITAL NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2010/11
STATEMENT OF FINANCIAL POSITION AS AT 31 MARCH 2011
For the year For the year ended 31 ended 31 March 2011 March 2010 NOTE £000 £000 Non-current assets Intangible assets 18 602 724 Property, plant and equipment 17 128,095 120,667 Trade and other receivables 21 1,138 1,039 Total non-current assets 129,835 122,430 Current assets Inventories 20 1,094 1,160 Trade and other receivables 21 6,733 7,245 Cash and cash equivalents 22 7,643 6,191 Total current assets 15,470 14,596 Total assets 145,305 137,026
Current liabilities Trade and other payables 23 (11,697) (7,790) Borrowings 24 (545) (82) Provisions 27 (576) (565) Tax and social security costs payable 23 (2,338) (1,663) Total current liabilities (15,156) (10,100)
Total assets less current liabilities 130,149 126,926
Non-current liabilities Trade and other payables 23 0 0 Borrowings 24 (13,550) (6,535) Provisions 27 (312) (341) Total non-current liabilities (13,862) (6,876)
Total assets employed 116,287 120,050
Financed by taxpayers' equity: Public dividend capital 75,711 75,711 Revaluation reserve 29,640 28,875 Donated asset reserve 1,033 1,093 Retained earnings 9,903 14,371 Total Taxpayers' Equity 116,287 120,050
The financial statements on pages 1 to 5 were approved by the Board on 31 May 2011 and signed on its behalf by:
Signed: ……………………………… (Chief Executive) Date: 3rd June 2011
Page 2 ROYAL BOLTON HOSPITAL NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2010/11
STATEMENT OF CHANGES IN TAXPAYERS' EQUITY
Public Retained Revaluation Donated Other Total dividend earnings reserve asset reserves capital reserve (PDC) £000 £000 £000 £000 £000 £000 Balance at 1 April 2009 As previously stated 84,791 17,644 46,624 1051 0 150,110 Prior Period Adjustment 0 0 0 0 0 0 Restated balance 84,791 17,644 46,624 1051 0 150,110
Changes in taxpayers’ equity for 2009/10 Total Comprehensive Income for the year: Retained surplus/(deficit) for the year (4,792) (4,792) Impairments and reversals (16,230) (125) (16,355) Increase in the donated asset reserve due to receipt of donated assets 292 292 Other recognised gains and losses (125) (125) Transfers between reserves 0 PDC repaid in year (9,080) (9,080) Other reserve movements in year 1,519 (1,519) 0 Balance at 31 March 2010 75,711 14,371 28,875 1,093 0 120,050
Page 3 ROYAL BOLTON HOSPITAL NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2010/11
STATEMENT OF CHANGES IN TAXPAYERS' EQUITY
Public Retained Revaluation Donated Other Total dividend earnings reserve asset reserves capital reserve (PDC) £000 £000 £000 £000 £000 £000 Balance at 1 April 2010 As previously stated 75,711 14,371 28,875 1,093 0 120,050 Prior Period Adjustment 0 Restated balance 75,711 14,371 28,875 1,093 0 120,050
Changes in taxpayers’ equity for 2010/11 Total Comprehensive Income for the year Retained surplus/(deficit) for the year (7,160) (7,160) Revaluation gains/(losses) and impairment losses property, plant and equipment 3,459 26 3,485 Increase in the donated asset reserve due to receipt of donated assets 70 70 Other recognised gains and losses (156) (156) New PDC received 0 PDC repaid in year 0 Other reserve movements in year 2,692 (2,694) (2) Balance at 31 March 2011 75,711 9,903 29,640 1,033 0 116,287
Page 4 ROYAL BOLTON HOSPITAL NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2010/11
STATEMENT OF CASH FLOWS FOR THE YEAR ENDED 31 MARCH 2011
For the year For the year ended 31 ended 31 March 2011 March 2010 £000 £000 Cash flows from operating activities Operating surplus/(deficit) from continuing operations (2,965) (163)
Non-cash income and expense: Depreciation and amortisation 5,183 5,551 Impairments 9,106 6,172 Transfer from the donated asset reserve (156) (125) (Increase)/Decrease in trade and other receivables 413 (410) (Increase)/Decrease in inventories 66 (209) Increase/(Decrease) in trade and other payables 3,907 180 Increase/(Decrease) in provisions (18) (480) Tax (paid)/received 675 0 Other movements in operating cash flows (1,375) (1,038) Net cash generated from/(used in) operations 14,836 9,478
Cash flows from investing activities Interest received 56 33 (Payments) for Intangible Assets (123) 0 (Payments) for property, plant and equipment (15,531) (9,147) Sales of property, plant and equipment 6 9,085 Net cash generated from/(used in) investing activities (15,592) (29)
Cash flows from financing activities Public dividend capital repaid 0 (9,080) Loans received from the DH 6,997 6,407 Loans repaid to the DH 0 (1,500) Interest paid (228) (62) Capital element of finance leases and PFI (547) (79) Interest element of finance lease (53) (12) Dividends paid (3,961) (4,491) Net cash generated from/(used in) financing activities 2,208 (8,817)
Increase/(decrease) in cash and cash equivalents 1,452 632
Cash and cash equivalents at 1 April 2010 6,191 5,559 Cash and cash equivalents at 31 March 2011 7,643 6,191
Page 5 ROYAL BOLTON HOSPITAL NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2010/11
NOTES TO THE ACCOUNTS
1. ACCOUNTING POLICIES
Monitor has directed that the financial statements of Royal Bolton Hospital NHS Foundation Trust shall meet the accounting requirements of the NHS Foundation Trust Financial Reporting Manual which shall be agreed with HM Treasury. Consequently, the following financial statements have been prepared in accordance with the 2010/11 NHS Foundation Trust Financial Reporting Manual issued by Monitor. The accounting policies contained in that manual follow International Financial Reporting Standards (IFRS) and HM Treasury‟s Financial Reporting Manual to the extent that they are meaningful and appropriate to NHS Foundation Trusts. The accounting policies have been applied consistently in dealing with items considered material in relation to the accounts.
1.1 Accounting conventions
These accounts have been prepared under the historical cost convention modified to account for the revaluation of fixed assets at their value to the business by reference to their current costs. NHS Foundation Trusts are not required to provide a reconciliation between current cost and historical cost surpluses and deficits.
1.2 Acquisitions and discontinued operations
Activities are considered to be 'acquired' only if they are acquired from outside the public sector. Activities are considered to be 'discontinued' only if they cease entirely. They are not considered to be 'discontinued' if they transfer from one NHS body to another.
1.3 Critical accounting judgements and key sources of estimation uncertainty
In the application of the Trust accounting policies, management is required to make judgements, estimates and assumptions about the carrying amounts of assets and liabilities that are not readily apparent from other sources. The estimates and associated assumptions are based on historical experience and other factors that are considered to be relevant. Actual results may differ from those estimates. The estimates and underlying assumptions are continually reviewed. Revisions to accounting estimates are recognised in the period in which the estimate is revised if the revision affects only that period, or in the period of the revision and future periods if the revision affects both current and future periods.
1.4 Critical judgements in applying accounting policies
Critical judgements, apart from those involving estimations (see below), management has made in the process of applying the entity‟s accounting policies and that have the most significant effect on the amounts recognised in the financial statements.
1.5 Key sources of estimation uncertainty
The following are the key assumptions concerning the future, and other key sources of estimation uncertainty at the Statement of Financial Position date, that have a significant risk of causing a material adjustment to the carrying amounts of assets and liabilities within the next financial year:
Holiday pay accrual Incomplete spells (see revenue recognition note at 1.6) Depreciation (asset lives) Asset revaluations, impairments Provisions
Page 6 ROYAL BOLTON HOSPITAL NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2010/11
NOTES TO THE ACCOUNTS
1. ACCOUNTING POLICIES (CONTINUED)
1.6 Revenue recognition
Revenue in respect of services provided is recognised when, and to the extent that, performance occurs and is measured at the fair value of the consideration receivable. The main source of income for the Foundation Trust is contracts with commissioners in respect of healthcare services.
Where revenue is received for a specific activity which is to be delivered in the following financial year, that revenue is deferred.
Under Application Note G of FRS 5 and UITF 40, the Foundation Trust is entitled to recognise revenue for partially completed spells of activity at 31 March 2011. As the individual National Tariff price and procedure code is not known for partially completed spells, the Foundation Trust has based its calculation of such income on the average length of stay and the cumulative activity and price of individual specialties.
Revenue from the sale of non-current assets is recognised only when all material conditions of sale have been met, and is measured as the sums due under the sale contract.
The Foundation Trust receives income under the NHS Injury Cost Recovery Scheme, designed to reclaim the cost of treating injured individuals to whom personal injury compensation has subsequently been paid e.g. by an insurer. The Foundation Trust recognises the income when it receives notification from the Department for Work and Pensions' Compensation Recovery Unit that the individual has lodged a compensation claim. The income is measured at the agreed tariff for the treatments provided to the injured individual, less a provision for unsuccessful compensation claims and doubtful debts.
1.7 Employee benefits
Salaries, wages and employment related payments are recognised in the period in which the service is received from employees. The cost of annual leave entitlement earned but not taken by employees at the end of the period is recognised in the financial statements to the extent that employees are permitted to carry forward leave into the following period.
1.8 Pension costs
NHS Pension Scheme
Past and present employees are covered by the provisions of the NHS Pensions Scheme. The scheme is an unfunded, defined benefit scheme that covers NHS employers, general practices and other bodies, allowed under the direction of Secretary of State, in England and Wales. It is not possible for the NHS Foundation Trust to identify its share of the underlying scheme liabilities. Therefore, the scheme is accounted for as a defined contribution scheme.
Employer's pension cost contributions are charged to operating expenses as and when they become due.
Additional pension liabilities arising from early retirements are not funded by the scheme except where the retirement is due to ill-health. The full amount of the liability for the additional costs is charged to the operating expenses at the time the Foundation Trust commits itself to the retirement, regardless of the method of payment.
1.9 Expenditure on other goods and services
Expenditure on goods and services is recognised when, and to the extent that they have been received, and is measured at the fair value of those goods and services. Expenditure is recognised in operating expenses except where it results in the creation of a non-current asset such as property, plant and equipment.
Page 7 ROYAL BOLTON HOSPITAL NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2010/11
NOTES TO THE ACCOUNTS
1. ACCOUNTING POLICIES (CONTINUED)
1.10 Property, plant and equipment
Recognition
Property, plant and equipment is capitalised where:
• it is held for use in delivering services or for administrative purposes; • it is probable that future economic benefits will flow to, or service potential be provided to, the Foundation Trust; • it is expected to be used for more than one financial year; and • the cost of the item can be measured reliably; and individually has a cost of at least £5,000; or • collectively have a cost of at least £5,000 and individually have a cost of more than £250, where the assets are functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under single managerial control; or • items form part of the initial equipping and setting-up cost of a new building, ward or unit irrespective of their individual or collective cost. Where a large asset, for example a building, includes a number of components with significantly different asset lives e.g. plant and equipment, then these components are treated as separate assets and depreciated over their own useful economic lives.
Measurement
Valuation
All property, plant and equipment assets are measured initially at cost, representing the costs directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the manner intended by management. All assets are measured subsequently at fair value.
Subsequent expenditure
Where subsequent expenditure enhances an asset beyond its original specification, the directly attributable cost is added to the asset‟s carrying value. Where subsequent expenditure is simply restoring the asset to the specification assumed by its economic useful life then the expenditure is charged to operating expenses.
Depreciation
Freehold land, properties under construction, and assets held for sale are not depreciated.
Items of property, plant and equipment are depreciated over their remaining useful economic lives in a manner consistent with the consumption of economic or service delivery benefits. Freehold land is considered to have an infinite life and is not depreciated.
Property, plant and equipment which has been reclassified as „Held for Sale‟ ceases to be depreciated upon the reclassification. Assets in the course of construction and residual interests in off-Statement of Financial Position PFI contract assets are not depreciated until the asset is brought into use or reverts to the Foundation Trust, respectively.
Otherwise, depreciation and amortisation are charged to write off the costs or valuation of property, plant and equipment and intangible non-current assets, less any residual value, over their estimated useful lives, in a manner that reflects the consumption of economic benefits or service potential of the assets. The estimated useful life of an asset is the period over which the Trust expects to obtain economic benefits or service potential from the asset. This is specific to the Trust and may be shorter than the physical life of the asset itself. Estimated useful lives and residual values are reviewed each year end, with the effect of any changes recognised on a prospective basis. Assets held under finance leases are depreciated over their estimated useful lives.
Page 8 ROYAL BOLTON HOSPITAL NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2010/11
NOTES TO THE ACCOUNTS
1. ACCOUNTING POLICIES (CONTINUED)
Revaluation and impairment
Increases in asset values arising from revaluations are recognised in the revaluation reserve, except where, and to the extent that, they reverse an impairment previously recognised in operating expenses, in which case they are recognised in operating income.
Decreases in asset values and impairments are charged to the revaluation reserve to the extent that there is an available balance for the asset concerned, and thereafter are charged to operating expenses.
Gains and losses recognised in the revaluation reserve are reported in the Statement of Comprehensive Income as an item of „other comprehensive income‟.
De-recognition
Assets intended for disposal are reclassified as „Held for Sale‟ once all of the following criteria are met:
• the asset is available for immediate sale in its present condition subject only to terms which are usual and customary for such sales; • the sale must be highly probable i.e.: - management are committed to a plan to sell the asset; - an active programme has begun to find a buyer and complete the sale; - the asset is being actively marketed at a reasonable price; - the sale is expected to be completed within 12 months of the date of classification as „Held for Sale‟; and - the actions needed to complete the plan indicate it is unlikely that the plan will be dropped or significant changes made to it.
Following reclassification, the assets are measured at the lower of their existing carrying amount and their „fair value less costs to sell‟. Depreciation ceases to be charged and the assets are not revalued, except where the „fair value less costs to sell‟ falls below the carrying amount. Assets are de-recognised when all material sale contract conditions have been met.
Property, plant and equipment which is to be scrapped or demolished does not qualify for recognition as „Held for Sale‟ and instead is retained as an operational asset and the asset‟s economic life is adjusted. The asset is de- recognised when scrapping or demolition occurs.
1.11 Intangible fixed assets
Recognition
Intangible assets are non-monetary assets without physical substance which are capable of being sold separately from the rest of the Foundation Trust‟s business or which arise from contractual or other legal rights. They are recognised only where it is probable that future economic benefits will flow to, or service potential be provided to, the Foundation Trust and where the cost of the asset can be measured reliably.
Page 9 ROYAL BOLTON HOSPITAL NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2010/11
NOTES TO THE ACCOUNTS
1. ACCOUNTING POLICIES (CONTINUED)
Internally generated intangible assets
Internally generated goodwill, brands, mastheads, publishing titles, customer lists and similar items are not capitalised as intangible assets.
Expenditure on research is not capitalised.
Expenditure on development is capitalised only where all of the following can be demonstrated:
• the project is technically feasible to the point of completion and will result in an intangible asset for sale or use; • the Foundation Trust intends to complete the asset and sell or use it; • the Foundation Trust has the ability to sell or use the asset; • how the intangible asset will generate probable future economic or service delivery benefits e.g. the presence of a market for it or its output, or where it is to be used for internal use, the usefulness of the asset; • adequate financial, technical and other resources are available to the Foundation Trust to complete the development and sell or use the asset; and • the Foundation Trust can measure reliably the expenses attributable to the asset during development. Software
Software which is integral to the operation of hardware, e.g. an operating system, is capitalised as part of the relevant item of property, plant and equipment. Software which is not integral to the operation of hardware, e.g. application software, is capitalised as an intangible asset.
Measurement
Intangible assets are recognised initially at cost, comprising all directly attributable costs needed to create, produce and prepare the asset to the point that it is capable of operating in the manner intended by management.
Subsequently intangible assets are measured at fair value. Increases in asset values arising from revaluations are recognised in the revaluation reserve, except where, and to the extent that, they reverse an impairment previously recognised in operating expenses, in which case they are recognised in operating income. Decreases in asset values and impairments are charged to the revaluation reserve to the extent that there is an available balance for the asset concerned, and thereafter are charged to operating expenses. Gains and losses recognised in the revaluation reserve are reported in the Statement of Comprehensive Income as an item of „other comprehensive income‟.
Intangible assets held for sale are measured at the lower of their carrying amount or „fair value less costs to sell‟.
Amortisation
Intangible assets are amortised over their expected useful economic lives in a manner consistent with the consumption of economic or service delivery benefits.
Page 10 ROYAL BOLTON HOSPITAL NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2010/11
NOTES TO THE ACCOUNTS
1. ACCOUNTING POLICIES (CONTINUED)
1.12 Donated fixed assets Donated fixed assets are capitalised at their current value on receipt and this value is credited to the donated asset reserve. Donated fixed assets are valued and depreciated as described above for purchased assets. Gains and losses on revaluations are also taken to the donated asset reserve and, each year, an amount equal to the depreciation charge on the asset is released from the donated asset reserve to the income and expenditure account. Similarly, any impairment on donated assets charged to the income and expenditure account is matched by a transfer from the donated asset reserve. On sale of donated assets, the net book value of the donated asset is transferred from the donated asset reserve to the Retained Earnings.
1.13 Leases
Leases are classified as finance leases when substantially all the risks and rewards of ownership are transferred to the lessee. All other leases are classified as operating leases.
Finance leases
Where substantially all risks and rewards of ownership of a leased asset are borne by the NHS Foundation Trust, the asset is recorded as property, plant and equipment and a corresponding liability is recorded. The value at which both are recognised is the lower of the fair value of the asset or the present value of the minimum lease payments, discounted using the interest rate implicit in the lease. The implicit interest rate is that which produces a constant periodic rate of interest on the outstanding liability.
The asset and liability are recognised at the inception of the lease, and are de-recognised when the liability is discharged, cancelled or expires. The annual rental is split between the repayment of the liability and a finance cost. The annual finance cost is calculated by applying the implicit interest rate to the outstanding liability and is charged to Finance Costs in the Statement of Comprehensive Income.
Operating leases
Other leases are regarded as operating leases and the rentals are charged to operating expenses on a straight-line basis over the term of the lease. Operating lease incentives received are added to the lease rentals and charged to operating expenses over the life of the lease.
Leases of land and buildings
Where a lease is for land and buildings, the land component is separated from the building component and the classification for each is assessed separately. Leased land is treated as an operating lease.
The Foundation Trust as lessor
Rental income from operating leases is recognised on a straight-line basis over the term of the lease. Initial direct costs incurred in negotiating and arranging an operating lease are added to the carrying amount of the leased asset and recognised on a straight-line basis over the lease term.
Page 11 ROYAL BOLTON HOSPITAL NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2010/11
NOTES TO THE ACCOUNTS
1. ACCOUNTING POLICIES (CONTINUED)
1.14 Inventories
Inventories are valued at the lower of cost and net realisable value using the weighted average cost formula. This is considered to be a reasonable approximation to fair value due to the high turnover of stocks.
1.15 Cash and cash equivalents
Cash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than 24 hours. Cash equivalents are investments that mature in 3 months or less from the date of acquisition and that are readily convertible to known amounts of cash with insignificant risk of change in value.
In the Statement of Cash Flows, cash and cash equivalents are shown net of bank overdrafts that are repayable on demand and that form an integral part of the Foundation Trust‟s cash management.
1.16 Provisions
The NHS Foundation Trust provides for legal or constructive obligations that are of uncertain timing or amount at the Statement of Financial Position date on the basis of the best estimate of the expenditure required to settle the obligation. Where the effect of the time value of money is significant, the estimated risk-adjusted cash flows are discounted using HM Treasury‟s discount rate of 2.2% in real terms.
1.17 Clinical negligence costs
The NHS Litigation Authority (NHSLA) operates a risk pooling scheme under which the NHS Foundation Trust pays an annual contribution to the NHSLA, which, in return, settles all clinical negligence claims. Although the NHSLA is administratively responsible for all clinical negligence cases, the legal liability remains with the NHS Foundation Trust. The total value of clinical negligence provisions carried by the NHSLA on behalf of the NHS Foundation Trust is disclosed at note 27.
1.18 Non-clinical risk pooling
The NHS Foundation Trust participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the Foundation Trust pays an annual contribution to the NHS Litigation Authority and in return receives assistance with the costs of claims arising. The annual membership contributions, and any „excesses‟ payable in respect of particular claims, are charged to operating expenses when the liability arises.
1.19 Contingent liabilities
Contingent liabilities are not recognised, but are disclosed in Note 29, unless the probability of a transfer of economic benefits is remote.
Contingent liabilities are defined as:
possible obligations arising from past events whose existence will be confirmed only by the occurrence of one or more uncertain future events not wholly within the entity‟s control; or present obligations arising from past events but for which it is not probable that a transfer of economic benefits will arise or for which the amount of the obligation cannot be measured with sufficient reliability.
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NOTES TO THE ACCOUNTS
1. ACCOUNTING POLICIES (CONTINUED)
1.20 Financial assets
Financial assets are recognised on the balance sheet when the Foundation Trust becomes party to the financial instrument contract or, in the case of trade receivables, when the goods or services have been delivered. Financial assets are de-recognised when the contractual rights have expired or the asset has been transferred. Financial assets are initially recognised at fair value.
Financial assets are classified into the following categories: financial assets „at fair value through profit and loss‟; „held to maturity investments‟; „available for sale‟ financial assets; and „loans and receivables‟. The classification depends on the nature and purpose of the financial assets and is determined at the time of initial recognition.
Financial assets at fair value through profit and loss
Embedded derivatives that have different risks and characteristics to their host contracts, and contracts with embedded derivatives whose separate value cannot be ascertained, are treated as financial assets at fair value through profit and loss. They are held at fair value, with any resultant gain or loss recognised in the income statement. The net gain or loss incorporates any interest earned on the financial asset.
Loans and receivables
Loans and receivables are non-derivative financial assets with fixed or determinable payments which are not quoted in an active market. After initial recognition, they are measured at amortised cost using the effective interest method, less any impairment. Interest is recognised using the effective interest method. Fair value is determined by reference to quoted market prices where possible, otherwise by valuation techniques.
The effective interest rate is the rate that exactly discounts estimated future cash receipts through the expected life of the financial asset, to the net carrying amount of the financial asset.
At the balance sheet date, the Foundation Trust assesses whether any financial assets, other than those held at „fair value through profit and loss‟ are impaired. Financial assets are impaired and impairment losses recognised if there is objective evidence of impairment as a result of one or more events which occurred after the initial recognition of the asset and which has an impact on the estimated future cash flows of the asset.
For financial assets carried at amortised cost, the amount of the impairment loss is measured as the difference between the asset‟s carrying amount and the present value of the revised future cash flows discounted at the asset‟s original effective interest rate. The loss is recognised in the income statement and the carrying amount of the asset is reduced directly, or through a provision for impairment of receivables.
If, in a subsequent period, the amount of the impairment loss decreases and the decrease can be related objectively to an event occurring after the impairment was recognised, the previously recognised impairment loss is reversed through the income statement to the extent that the carrying amount of the receivable at the date of the impairment is reversed does not exceed what the amortised cost would have been had the impairment not been recognised.
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NOTES TO THE ACCOUNTS
1. ACCOUNTING POLICIES (CONTINUED)
1.21 Financial liabilities
Financial liabilities are recognised on the balance sheet when the Foundation Trust becomes party to the contractual provisions of the financial instrument or, in the case of trade payables, when the goods or services have been received. Financial liabilities are de-recognised when the liability has been discharged, that is, the liability has been paid or has expired.
Loans from the Department of Health are recognised at historical cost. Otherwise, financial liabilities are initially recognised at fair value.
Financial liabilities are classified as either financial liabilities „at fair value through profit and loss‟ or other financial liabilities.
Financial liabilities at fair value through profit and loss
Embedded derivatives that have different risks and characteristics to their host contracts, and contracts with embedded derivatives whose separate value cannot be ascertained, are treated as financial liabilities at fair value through profit and loss. They are held at fair value, with any resultant gain or loss recognised in the income statement. The net gain or loss incorporates any interest earned on the financial asset.
Other financial liabilities
After initial recognition, all other financial liabilities are measured at amortised cost using the effective interest method. The effective interest rate is the rate that exactly discounts estimated future cash payments through the life of the asset, to the net carrying amount of the financial liability. Interest is recognised using the effective interest method.
1.22 Value Added Tax
Most of the activities of the Foundation Trust are outside the scope of VAT and, in general, output tax does not apply and input tax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT.
1.23 Foreign exchange
The functional and presentational currencies of the Foundation Trust are sterling.
A transaction which is denominated in a foreign currency is translated into the functional currency at the spot exchange rate on the date of the transaction.
Where the Foundation Trust has assets or liabilities denominated in a foreign currency at the balance sheet date: monetary items (other than financial instruments measured at „fair value through income and expenditure‟) are translated at the spot exchange rate on 31 March; non-monetary assets and liabilities measured at historical cost are translated using the spot exchange rate at the date of the transaction; and non-monetary assets and liabilities measured at fair value are translated using the spot exchange rate at the date the fair value was determined.
Exchange gains or losses on monetary items (arising on settlement of the transaction or on re-translation at the balance sheet date) are recognised in income or expense in the period in which they arise.
Exchange gains or losses on non-monetary assets and liabilities are recognised in the same manner as other gains and losses on these items.
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NOTES TO THE ACCOUNTS
1. ACCOUNTING POLICIES (CONTINUED)
1.24 Third party assets
Assets belonging to third parties (such as money held on behalf of patients) are not recognised in the accounts since the NHS Foundation Trust has no beneficial interest in them. Details of third party assets are disclosed in Note 33 to the accounts.
1.25 Public dividend capital (PDC) and PDC dividend
Public dividend capital (PDC) is a type of public sector equity finance based on the excess of assets over liabilities at the time of establishment of the predecessor NHS Trust. HM Treasury has determined that PDC is not a financial instrument within the meaning of IAS 32.
A charge, reflecting the forecast cost of capital utilised by the NHS Foundation Trust, is paid over as public dividend capital dividend. The charge is calculated at the rate set by HM Treasury (currently 3.5%) on the average relevant net assets of the NHS Foundation Trust.
Relevant net assets are calculated as the value of all assets less the value of all liabilities, except for donated assets and cash held with the Office of the Paymaster General. Average relevant net assets are calculated as a simple means of opening and closing relevant net assets.
1.26 Losses and special payments
Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way each individual case is handled.
Losses and special payments are charged to the relevant functional headings in the Income and Expenditure Account on an accruals basis, including losses which would have been made good through insurance cover had NHS Foundation Trusts not been bearing their own risks (with insurance premiums then being included as normal revenue expenditure).
1.27 Accounting standards
No accounting standards have been adopted early.
1.28 Corporation tax
Royal Bolton Hospital NHS Foundation Trust is regarded as a Health Service body within the meaning of the Income and Corporation Tax Act (ICTA) 1988 and accordingly is exempt from taxation on its income and capital gains within categories covered by this. There is a power for the Treasury to disapply this exemption in relation to the specified activities of a Foundation Trust. Accordingly, Royal Bolton NHS Foundation Trust is potentially within the scope of corporation tax in respect of activities which are not related to, or ancillary to, the provision of healthcare and where the profits therefrom exceed £50,000 p.a.
There is no corporation tax liability for this financial period.
Activities such as staff and patient car parking and sales of food are considered to be ancillary to the core healthcare objectives of the Foundation Trust and therefore not subject to corporation tax.
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NOTES TO THE ACCOUNTS
1. ACCOUNTING POLICIES (CONTINUED)
1.29 Accounting standards that have been issued but have not yet been adopted
The following standards and interpretations have been adopted by the European Union but are not required to be followed until 2011/12. None of them are expected to impact upon the Trust's financial statements.
IAS 24 (Revised) Related Party Disclosures
Annual Improvements 2010
IFRIC 14 amendment
IFRIC 19 Extinguishing financial liabilities with Equity Instruments
2. OPERATING SEGMENTS
All activity for Royal Bolton Hospital NHS Foundation Trust is healthcare related. As the operating segments have similar characteristics there is no requirement to report segmentally.
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NOTES TO THE ACCOUNTS
3. INCOME GENERATION ACTIVITIES
The Trust undertakes income generation activities with an aim of achieving profit. The total income generation for the year ended 31 March 2011 was £101k. This is included within other income.
4. OPERATING INCOME FROM CONTINUING OPERATIONS
4a. Revenue from patient care activities - by point of delivery 2010/11 2009/10 £000 £000
Elective income 31,617 30,250 Non elective income 71,915 70,513 Outpatient income 30,684 27,559 A&E income 9,361 8,845 Other NHS clinical income 32,065 30,880 All Trusts Private patient income 140 178 Other non-protected clinical income 1,725 1,667 Total income from activities 177,507 169,892
4b. Revenue from patient care activities - by source 2010/11 2009/10 £000 £000
NHS Foundation Trusts 459 350 NHS Trusts 230 196 Strategic Health Authorities 0 767 Primary Care Trusts 172,510 166,670 Department of Health 665 105 NHS Other 1,778 0 Non-NHS: Private patients 131 144 Overseas patients (non-reciprocal) 9 34 Injury costs recovery 1,717 1,522 Other 8 104 177,507 169,892
Injury cost recovery income is subject to a provision for impairment of receivables of 9.6% to reflect expected rates of collection. 4c. Revenue from patient care activities - mandatory and non- mandatory 2010/11 2009/10 £000 £000
Revenue from mandatory patient care activities 175,642 168,047 Revenue from non-mandatory patient care activities 1,865 1,845 177,507 169,892
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5. PRIVATE PATIENT INCOME
Section 44 of the 2006 Act requires that the proportion of private patient income to the total patient related income of NHS Foundation Trusts should not exceed its proportion whilst the body was an NHS Trust in 2002/03 (the Private Patient Cap).
2002/03 2010/11 2009/10 (Base Year) £000 £000 £000 Private patient income 140 178 126 Total patient related income 177,507 169,892 118,421 Proportion as a percentage 0.08% 0.10% 0.11%
6. OTHER OPERATING REVENUE
2010/11 2009/10 £000 £000
Education, training and research 7,551 7,416 Charitable and other contributions to expenditure 0 141 Transfers from donated asset reserve 157 125 Non-patient care services to other bodies 5,876 7,693 Other revenue 10,018 7,507 23,602 22,882
Other Revenue 2010/11 2009/10 £000 £000 Car parking 864 899 Estates recharges 319 379 Staff recharges 2,304 1,993 IT recharges 54 44 Pharmacy sales 1,884 1,572 Staff accommodation rentals 100 67 Catering 326 132 Property rentals 166 179 Other 4,001 2,242 Total 10,018 7,507
7. REVENUE
Revenue is almost totally from the supply of services. Revenue from the sale of goods is immaterial.
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8. OPERATING EXPENDITURE
8a. Operating expenses 2010/11 2009/10 £000 £000 Services from Foundation Trusts 1,492 1,517 Services from other NHS Trusts 400 325 Services from other NHS bodies 1,189 1,402 Purchase of healthcare from non-NHS bodies 157 357 Employee expense - Executive directors 846 807 Employee expense - Non-executive directors 116 105 Employee expense - Staff costs 134,555 131,118 Drug costs 11,011 8,543 Supplies and services - clinical (excluding drug costs) 16,711 14,975 Supplies and services - general 6,362 6,384 Establishment 1,420 1,373 Transport 227 325 Premises 7,146 6,776 Increase/(Decrease) in bad debt provision 71 12 Depreciation on property, plant and equipment 4,938 5,311 Amortisation on intangible assets 245 240 Impairments of property, plant and equipment 9,106 6,172 Audit fees audit services - statutory audit 54 54 audit services - regulatory reporting 35 0 Other auditors' remuneration other services 18 7 Clinical negligence premium 4,822 4,287 Loss on disposal of land and buildings 40 345 Loss on disposal of other property, plant and equipment 14 4 Legal fees 174 126 Consultancy costs 732 501 Training, courses and conferences 492 476 Patient travel 49 49 Insurance 86 20 Losses, ex gratia & special payments 75 196 Other 1,491 1,130 204,074 192,937
8b. Audit remuneration 2010/11 2009/10 £000 £000 Other services: Board Review 7 Other services: IFRS Review 18 0 18 7
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9. OPERATING LEASES
9.1 As lessee
Operating lease payments include £127k for leased vehicles and £86k for equipment leases. The contracts for equipment leases are taken out for between 5 and 10 years, whilst vehicle leases are taken out for 3 years.
Payments recognised as an expense 2010/11 2009/10 £000 £000
Minimum lease payments 213 267 Contingent rents 0 0 Less sublease payments received 0 0 213 267
Future minimum lease payments due: 2010/11 2009/10 £000 £000
- not later than one year 119 168 - later than one year and not later than five years 140 160 - later than five years 0 0 Total 259 328
9.2 As lessor
Rental revenue 2010/11 2009/10 £000 £000
Contingent rent 171 184 Other 0 0 Total rental revenue 171 184
Total future minimum lease payments 2010/11 2009/10 £000 £000 Receivable: Not later than one year 171 184 Between one and five years 683 600 After five years 196 1,685 Total 1,050 2,469
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10. EMPLOYEE COSTS AND NUMBERS
10.1 Employee costs 2010/11 2010/11 2010/11 2009/10 Total Permanent Other Total
£000 £000 £000 £000
Salaries and wages 110,742 102,919 7,823 108,806 Social Security costs 7,843 7,843 0 7,536 Pension costs - defined contribution plans Employer's contributions to NHS Pensions 12,267 12,267 0 12,025 Agency/contract staff 4,549 0 4,549 3,558 Employee benefits expense 135,401 123,029 12,372 131,925
10.2 Average number of people employed 2010/11 2010/11 2010/11 2009/10 Total Permanent Other Total Number Number Number Number
Medical and dental 368 258 110 362 Administration and estates 751 748 3 746 Healthcare assistants and other support staff 627 627 0 636 Nursing, midwifery and health visiting staff 1,105 1,071 34 1,088 Scientific, therapeutic and technical staff 369 360 9 340 Bank & agency staff 182 0 182 221 Other 19 19 0 22 Total 3,421 3,083 338 3,415
10.3 Directors' remuneration 2010/11 2009/10 £'000 £'000 Directors remuneration 962 912 Employer contribution to a pension scheme in respect of directors 125 101
Number Number
The total number of directors to whom benefits are accruing under defined benefit schemes 9 7
10.4 Key management remuneration
Key management is defined as the executive and non-executive directors of the Foundation Trust. Further details of their remuneration can be found in the 2010/11 remuneration report published as part of the Foundation Trust's annual report.
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11. PENSION COSTS
Past and present employees are covered by the provisions of the NHS Pensions Scheme. Details of the benefits payable under these provisions can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions. The scheme is an unfunded, defined benefit scheme that covers NHS employers, GP practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The scheme is not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS Body of participating in the scheme is taken as equal to the contributions payable to the scheme for the accounting period.
The scheme is subject to a full actuarial valuation every four years (until 2004, every five years) and an accounting valuation every year. An outline of these follows:
a) Full actuarial (funding) valuation The purpose of this valuation is to assess the level of liability in respect of the benefits due under the scheme (taking into account its recent demographic experience), and to recommend the contribution rates to be paid by employers and scheme members. The last such valuation, which determined current contribution rates was undertaken as at 31 March 2004 and covered the period from 1 April 1999 to that date. The conclusion from the 2004 valuation was that the scheme had accumulated a notional deficit of £3.3 billion against the notional assets as at 31 March 2004.
In order to defray the costs of benefits, employers pay contributions at 14% of pensionable pay and most employees had up to April 2008 paid 6%, with manual staff paying 5%.
Following the full actuarial review by the Government Actuary undertaken as at 31 March 2004, and after consideration of changes to the NHS Pension Scheme taking effect from 1 April 2008, his Valuation report recommended that employer contributions could continue at the existing rate of 14% of pensionable pay, from 1 April 2008, following the introduction of employee contributions on a tiered scale from 5% up to 8.5% of their pensionable pay depending on total earnings.
On advice from the scheme actuary, scheme contributions may be varied from time to time to reflect changes in the scheme‟s liabilities.
b) Accounting valuation A valuation of the scheme liability is carried out annually by the scheme actuary as at the end of the reporting period by updating the results of the full actuarial valuation.
Between the full actuarial valuations at a two-year midpoint, a full and detailed member data-set is provided to the scheme actuary. At this point the assumptions regarding the composition of the scheme membership are updated to allow the scheme liability to be valued.
The valuation of the scheme liability as at 31 March 2011, is based on detailed membership data as at 31 March 2008 (the latest midpoint) updated to 31 March 2011 with summary global member and accounting data.
The latest assessment of the liabilities of the scheme is contained in the scheme actuary report, which forms part of the annual NHS Pension Scheme (England and Wales) Resource Account, published annually. These accounts can be viewed on the NHS Pensions website. Copies can also be obtained from The Stationery Office.
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11. PENSION COSTS (CONTINUED)
c) Scheme provisions
The NHS Pension Scheme provided defined benefits, which are summarised below. This list is an illustrative guide only, and is not intended to detail all the benefits provided by the Scheme or the specific conditions that must be met before these benefits can be obtained:
The Scheme is a “final salary” scheme. Annual pensions are normally based on 1/80th for the 1995 section and of the best of the last three years pensionable pay for each year of service, and 1/60th for the 2008 section of reckonable pay per year of membership. Members who are practitioners as defined by the Scheme Regulations have their annual pensions based upon total pensionable earnings over the relevant pensionable service.
With effect from 1 April 2008 members can choose to give up some of their annual pension for an additional tax free lump sum, up to a maximum amount permitted under HMRC rules. This new provision is known as “pension commutation”. Annual increases are applied to pension payments at rates defined by the Pensions (Increase) Act 1971, and are based on changes in retail prices in the twelve months ending 30 September in the previous calendar year.
Early payment of a pension, with enhancement, is available to members of the scheme who are permanently incapable of fulfilling their duties effectively through illness or infirmity. A death gratuity of twice final year‟s pensionable pay for death in service, and five times their annual pension for death after retirement is payable.
For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the liability for the additional costs is charged to the statement of comprehensive income at the time the trust commits itself to the retirement, regardless of the method of payment.
Members can purchase additional service in the NHS Scheme and contribute to money purchase AVCs run by the Scheme‟s approved providers or by other Free Standing Additional Voluntary Contributions (FSAVC) providers.
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12. RETIREMENTS DUE TO ILL-HEALTH
During 2010/11 there were 10 (2009/10, 8) early retirements from the NHS Trust agreed on the grounds of ill- health. The estimated additional pension liabilities of these ill-health retirements will be £903,316 (2009/10: £462,397). The cost of these ill-health retirements will be borne by the NHS Business Services Authority - Pensions Division.
These retirements represented 2.97 per 1,000 active scheme members.
13. FINANCE INCOME
2010/11 2009/10 £000 £000
Interest on loans and receivables 56 33 Interest on held-to-maturity financial assets 0 0 Total 56 33
14. FINANCE COSTS - INTEREST EXPENSE 2010/11 2009/10 £000 £000
Loans from the Foundation Trust Financing Facility 328 146 Interest on loans 0 0 Interest on obligations under finance leases 53 12 Total interest expense 381 158 Other finance costs 0 0 Total 381 158
15. THE LATE PAYMENT OF COMMERCIAL DEBTS (INTEREST) ACT 1998 2010/11 2009/10 £000 £000
Amounts included in finance costs from claims made under this legislation 0 0 Compensation paid to cover debt recovery costs under this legislation 0 0 Total 0 0
16. OTHER GAINS AND LOSSES 2010/11 2009/10 £000 £000
Gain/(loss) on disposal of property, plant and equipment (54) (349)
Page 24 ROYAL BOLTON HOSPITAL NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2010/11
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17.1 PROPERTY, PLANT AND EQUIPMENT Land Buildings Dwellings Assets under Plant and Transport Information Furniture & Total excluding construction machinery equipment technology fittings dwellings 2010/11: £000 £000 £000 £000 £000 £000 £000 £000 £000
Cost or valuation at 1 April 2010 23,273 96,891 1,881 5,670 17,220 138 4,817 414 150,304 Additions purchased 0 5,523 8 9,378 2,809 0 251 9 17,978 Additions donated 0 12 0 0 58 0 0 0 70 Reclassifications 0 4,715 (854) (3,861) 0 0 0 0 0 Revaluations 0 3,461 23 0 0 0 0 0 3,484 Impairments 0 0 0 0 0 0 0 0 0 Disposals 0 (40) 0 0 (1,418) 0 0 0 (1,458) At 31 March 2011 23,273 110,562 1,058 11,187 18,669 138 5,068 423 170,378
Depreciation at 1 April 2010 183 13,833 165 0 12,213 104 2,978 161 29,637 Disposals 0 0 0 0 (1,398) 0 0 0 (1,398) Impairments 0 9,106 0 0 0 0 0 0 9,106 Provided during the year 0 3,110 32 0 1,292 6 458 40 4,938 Depreciation at 31 March 2011 183 26,049 197 0 12,107 110 3,436 201 42,283
Net book value NBV - Owned at 31 March 2010 23,090 82,566 1,716 5,670 4,208 34 1,839 253 119,376 NBV - Finance lease at 31 March 2010 0 0 0 0 198 0 0 0 198 NBV - Donated at 31 March 2010 0 492 0 0 601 0 0 0 1,093 Total at 31 March 2010 23,090 83,058 1,716 5,670 5,007 34 1,839 253 120,667
Net book value NBV - Owned at 31 March 2011 23,090 84,095 815 11,187 4,891 28 1,632 217 125,955 NBV - Finance lease at 31 March 2011 0 0 0 0 1,107 0 0 0 1,107 NBV - Donated at 31 March 2011 0 418 46 0 564 0 0 5 1,033 Total at 31 March 2011 23,090 84,513 861 11,187 6,562 28 1,632 222 128,095
17.2 Analysis of property, plant and equipment at 31 March 2011
Net book value NBV - Protected assets at 31 March 2011 22,880 82,403 851 0 0 0 0 0 106,134 NBV - Unprotected assets at 31 March 2011 210 2,110 10 11,187 6,562 28 1,632 222 21,961 Total at 31 March 2011 23,090 84,513 861 11,187 6,562 28 1,632 222 128,095
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17.3 PROPERTY, PLANT AND EQUIPMENT (CONTINUED) Land Buildings Dwellings Assets under Plant and Transport Information Furniture & Total excluding construction machinery equipment technology fittings dwellings Prior year: 2009/10 £000 £000 £000 £000 £000 £000 £000 £000 £000
Cost or valuation at 1 April 2009 26,248 113,953 2,089 2,391 17,096 112 4,673 408 166,970 Additions purchased 0 3,625 12 5,050 686 26 144 0 9,543 Additions donated 0 127 0 0 159 0 0 6 292 Reclassifications 0 1,771 0 (1,771) 0 0 0 0 0 Impairments (1,533) (14,602) (220) 0 0 0 0 0 (16,355) Disposals (1,442) (7,983) 0 0 (721) 0 0 0 (10,146) At 31 March 2010 23,273 96,891 1,881 5,670 17,220 138 4,817 414 150,304
Depreciation at 1 April 2009 0 4,256 68 0 11,814 102 2,505 121 18,866 Disposals 0 0 0 0 (712) 0 0 0 (712) Impairments 183 5,989 0 0 0 0 0 0 6,172 Provided during the year 0 3,588 97 0 1,111 2 473 40 5,311 Depreciation at 31 March 2010 183 13,833 165 0 12,213 104 2,978 161 29,637
Net book value NBV - Owned at 31 March 2009 26,248 109,060 2,021 2,391 4,592 10 2,167 287 146,776 NBV - Finance Lease at 31 March 2009 0 0 0 0 277 0 0 0 277 NBV - Donated at 31 March 2009 0 637 0 0 413 0 1 0 1,051 NBV total at 31 March 2009 26,248 109,697 2,021 2,391 5,282 10 2,168 287 148,104
Net book value NBV - Purchased at 31 March 2010 23,090 82,566 1,716 5,670 4,208 34 1,839 253 119,376 NBV - Finance Lease at 31 March 2010 0 0 0 0 198 0 0 0 198 NBV - Donated at 31 March 2010 0 492 0 0 601 0 0 0 1,093 NBV total at 31 March 2010 23,090 83,058 1,716 5,670 5,007 34 1,839 253 120,667
17.4 Analysis of property, plant and equipment 31 March 2010
Net book value NBV - Protected assets at 31 March 2010 22,600 80,617 1,706 0 0 0 0 0 104,923 NBV - Unprotected assets at 31 March 2010 490 2,441 10 5,670 5,007 34 1,839 253 15,744 Total at 31 March 2010 23,090 83,058 1,716 5,670 5,007 34 1,839 253 120,667
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17.5 PROPERTY, PLANT AND EQUIPMENT (CONTINUED)
Assets totalling £70k have been donated by Bolton Hospitals NHS Charitable Trust. These are:
£'000 4 incubators 39 Bariatric hoist 6 M Turbo Ultrasound system 13 Various building enhancement works 12
Assets are depreciated evenly over the estimated life given in the table below:
Life (Years)
Software Licences 2 - 5 Buildings excluding dwellings 1 - 79 Dwellings 14 - 44 Land 41 - 100 Plant & Machinery 3 - 15 Transport Equipment 7 Information Technology 2 - 15 Furniture and Fittings 7 - 10
At 31 March 2011 no land, buildings or dwellings were valued at open market value.
The date of the latest revaluation of land and buildings was 1 January 2011. This was carried out by the District Valuer and the valuation was based on "modern equivalent assets".
The overall effect of the revaluation is a reduction in value of Land and Buildings of £5,645k. This is the total impairment on building for the year £9,106k and a revaluation up lift of £3,461k for buildings.
The revaluation resulted in an impairment of £1,782k during the year. In addition the Trust has revalued buildings which are not part of the Trust's long term strategy, this has resulted in an impairment of £7,324k on these buildings.
Analysis of property, plant and equipment:
31 March 2011 31 March 2011 31 March 2011 £000 £000 £000 Total Protected Unprotected Land, buildings and dwellings 108,464 106,134 2,330 Other plant and equipment 19,631 0 19,631 128,095 106,134 21,961
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18. INTANGIBLE ASSETS Computer Total software - 2010/11: purchased
£000 £000
Gross cost at 1 April 2010 1,300 1,300 Additions purchased 123 123 Gross cost at 31 March 2011 1,423 1,423
Amortisation at 1 April 2010 576 576 Provided during the year 245 245 Amortisation at 31 March 2011 821 821
Net book value Purchased 724 724 Donated 0 0 Government granted 0 0 Total at 31 March 2010 724 724
Net book value Purchased 602 602 Donated 0 0 Government granted 0 0 Total at 31 March 2011 602 602
Prior year: Computer Total software - 2009/10: purchased
£000 £000
Gross cost at 1 April 2009 1,280 1,280 Additions purchased 20 20 Gross cost at 31 March 2010 1,300 1,300
Amortisation at 1 April 2009 336 336 Provided during the year 240 240 Amortisation at 31 March 2010 576 576
Net book value Purchased 724 724 Donated 0 0 Government granted 0 0 Total at 31 March 2010 724 724
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19. CAPITAL COMMITMENTS
Contracted capital commitments at 31 March not otherwise included in these financial statements:
2010/11 2009/10 £000 £000
Property, plant and equipment 502 2,495 Intangible assets 0 0 Total 502 2,495
20a. INVENTORIES
2010/11 2009/10 £000 £000
Drugs 501 580 Consumables 189 198 Energy 125 111 Other 279 271 Total 1,094 1,160 of which held at net realisable value: 1,094 1,160
The Foundation Trust does not have any non-current inventories.
20b. INVENTORIES RECOGNISED IN EXPENSES 2010/11 2009/10 £000 £000
Inventories recognised in expenses 10,163 8,673 Write-down of inventories recognised as an expense 7 81 TOTAL Inventories recognised in expenses 10,170 8,754
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21. TRADE AND OTHER RECEIVABLES
21.1 Trade and other receivables Current Non-current 2010/11 2009/10 2010/11 2009/10 £000 £000 £000 £000
NHS receivables 1,052 516 0 0 Provision for the impairment of receivables (141) (102) (121) (88) Prepayments - other 909 807 0 0 Accrued income 2,638 3,522 0 0 PDC receivable 102 0 0 0 Other receivables 2,173 2,502 1,259 1,127 Total 6,733 7,245 1,138 1,039
88% of trade is with Primary Care Trusts, as commissioners for NHS patient care services. As Primary Care Trusts are funded by Government to buy NHS patient care services, no credit scoring of them is considered necessary.
21.2 Receivables past their due date but not impaired 2010/11 2009/10 £000 £000
By up to three months 209 146 By three to six months 15 31 By more than six months 4 64 Total 228 241
21.3 Provision for impairment of receivables 2010/11 2009/10 £000 £000
Balance at 1 April 190 178 Amount recovered during the year 0 0 (Increase)/decrease in receivables impaired 71 12 Balance at 31 March 261 190
Receivables impaired during the period relate to the movement in the provision for bad debt on the injury cost recovery scheme.
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22. CASH AND CASH EQUIVALENTS 2010/11 2009/10 £000 £000 Balance at 1 April 6,191 5,559 Net change in year 1,452 632 Balance at 31 March 7,643 6,191
Made up of Cash with Office of HM Paymaster General Cash with the Government Banking Service 7,611 6,125 Commercial banks and cash in hand 32 66 Current investments 0 0 Cash and cash equivalents as in statement of financial position 7,643 6,191 Bank overdraft - Commercial banks 0 0 Cash and cash equivalents as in statement of cash flows 7,643 6,191
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23. TRADE AND OTHER PAYABLES Current Non-current 2010/11 2009/10 2010/11 2009/10 £000 £000 £000 £000
NHS payables 2,580 1,597 0 0 Other trade payables - capital 2,868 1,448 0 0 Tax and social security costs 2,338 1,663 0 0 Other 5,102 3,058 0 0 Accruals 1,147 1,687 0 0 Total 14,035 9,453 0 0
Other payables include: There are 10 cases at a total of £903k of payments due in future years under arrangements to buy out the liability of early retirements over 5 years; and £1,574,567 outstanding pension contributions at 31 March 2011. Pension contributions are paid a month in arrears.
24. BORROWINGS Current Non-current 2010/11 2009/10 2010/11 2009/10 £000 £000 £000 £000
Loans from: Foundation Trust Financing Facility 0 0 13,404 6,407 Finance lease liabilities 545 82 146 128 Other 0 0 0 0 Total 545 82 13,550 6,535
The Foundation Trust has agreed a loan with the Department of Health of £19,998k. This loan is to fund the "Making it Better" developments within Women's and Children's. At 31 March 2011 the Foundation Trust had drawn down £13,404k of the £19,998k.
The loan is at a fixed rate of 3.75%. The loan has been taken out over a 20 year term and is due to be fully repaid by October 2029.
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25. PRUDENTIAL BORROWING LIMIT
The Foundation Trust is required to comply and remain within a prudential borrowing limit.
This is made up of two elements:
• the maximum cumulative amount of long-term borrowing. This is set by reference to the five ratio tests set out in Monitor‟s Prudential Borrowing Code. The financial risk rating set under Monitor‟s Compliance Framework determines one of the ratios and therefore can impact on the long term borrowing limit; and • the amount of any working capital facility approved by Monitor. Further information on the NHS Foundation Trust Prudential Borrowing Code and Compliance Framework can be found on the website of Monitor, the Independent Regulator of Foundation Trusts. The Foundation Trust has a prudential borrowing limit of £58,700k in 2010/11.
Approved Actual Ratios Actual Ratios Ratios For the Year For the Year to Ended 31 Ended 31 31 March March 2011 March 2010 2011
Minimum dividend cover 2.8 2.6 >1x Minimum interest cover 28.13 73.86 >3x Minimum debt service cover 11.55 6.71 >2x Maximum debt service to revenue 0.5% 0.9% <2.5%
The Foundation Trust has an actual committed working capital (bank overdraft) facility of £13,500k within its approved limit of £58,700k. The amount borrowed in the year was £6,997k balance outstanding being £13,404k.
The Foundation Trust has not drawn down on its working capital facility at 31 March 2011. This facility expires on 30 September 2011.
26. FINANCE LEASE OBLIGATIONS Finance leases are generally for medical equipment used within the Trust. The largest of these is for a Managed Facilities Service in radiology that commenced in July 2010. The capital value of the assets provided to date under this facility is £1,028,000. The facility is for a 15 year term. Other finance leases are taken out over 5 or 7 years, these include an automated haematology analyser used within pathology. This had a capital value of £310k, when taken out in 2006.
Amounts payable under finance leases: Minimum lease payments Present value of minimum lease payments 2010/11 2009/10 2010/11 2009/10 £000 £000 £000 £000
Within one year 592 90 592 90 Between one and five years 156 135 156 135 After five years 0 0 0 0 Less future finance charges (57) (15) (57) (15) Present value of minimum lease payments 691 210 691 210
Included in: Current borrowings 545 82 545 82 Non-current borrowings 146 128 146 128 691 210 691 210
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27. PROVISIONS Current Non-current 2010/11 2009/10 2010/11 2009/10 £000 £000 £000 £000
Pensions relating to other staff 2 5 62 64 Legal claims 143 141 250 277 Other 431 419 0 0 Total 576 565 312 341
Pensions Legal Agenda for Other Total relating to claims Change other staff
£000 £000 £000 £000 £000
At 1 April 2010 69 418 0 419 906 Change in the discount rate (1) (24) 0 0 (25) Arising during the year 0 126 0 431 557 Utilised during the year (5) (99) 0 (419) (523) Reversed unused 0 (38) 0 0 (38) Unwinding of discount 1 10 0 0 11 At 31 March 2011 64 393 0 431 888
Expected timing of cash flows: - not later than one year; 2 143 0 431 576 - later than one year and not later than five years; 10 48 0 0 58 - later than five years. 52 202 0 0 254 TOTAL 64 393 0 431 888
£24,042,520 is included in the provisions of the NHS Litigation Authority at 31 March 2011 in respect of clinical negligence liabilities of the Trust (31 March 2010 £18,088,726).
Legal Claims include £262,793 for Employer's and Occupiers' Liability cases and £130,258 for Permanent Injury Benefits. The items shown for Employer's and Occupiers' Liability cases relate to cases that have more than a 50% chance of being settled. Claims that have a remote chance of being settled are classed as contingent liabilities and disclosed in note 29.
In January 2009 the Trust signed an agreement with the NHSLA that in the event of the Trust (i) choosing to leave the CNST voluntarily and (ii) in the event of insolvency, the Trust would be required to compensate the NHSLA for all outstanding clinical negligence claims i.e. lump sum liability
28. MOVEMENTS ON REVALUATION RESERVE
Movements on reserves comprised the following: Revaluation Reserve £000
Revaluation reserve at 1 April 2010 28,875
Impairments 0 Revaluations 3,459 Asset disposals 0 Other reserve movements (2,694) Other recognised gains and losses 0 Revaluation reserve at 31 March 2011 29,640
Revaluation reserve at 1 April 2009 46,624
Impairments (16,230) Revaluations 0 Asset disposals (1,519) Other reserve movements 0 Other recognised gains and losses 0 Revaluation reserve at 31 March 2010 28,875
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29. CONTINGENT LIABILITIES
2010/11 2009/10 £000 £000
Equal pay cases 0 0 Amounts recoverable against liabilities 0 0 Other (Employer's and Occupiers' legal claims) (68) (73) Total (68) (73)
30. FINANCIAL INSTRUMENTS
30.1 Financial assets
At 31 March 2011, £7,642k of the Foundation Trust's financial assets were held at a floating rate.
30.2 Financial liabilities
At 31 March 2011, none of the Foundation Trust's financial liabilities are carried at a floating rate.
30.3 Financial assets by category At fair value Loans and Available Total through receivables for sale Income and Expenditure £000 £000 £000 £000
Receivables 0 7,270 0 7,270 Cash at bank and in hand 0 6,191 0 6,191 Total at 31 March 2010 0 13,461 0 13,461
Receivables 0 6,440 0 6,440 Cash at bank and in hand 0 7,642 0 7,642 Total at 31 March 2011 0 14,082 0 14,082
30.4 Financial liabilities by category At fair value Other Total through Income and Expenditure £000 £000 £000
Payables 0 5,700 5,700 Finance lease obligations 0 210 210 Other borrowings 0 6,407 6,407 Provisions under contract 290 0 290 Total at 31 March 2010 290 12,317 12,607
Payables 0 7,578 7,578 Finance lease obligations 0 691 691 Other borrowings 0 13,404 13,404 b Provisions under contract 0 263 263 Total at 31 March 2011 0 21,936 21,936 a
Notes a Fair value is not significantly different from book value since, in the calculation of book value, the expected cash flows have been discounted by the Treasury discount rate of 2.9% in real terms. b Borrowings from the Department of Health's NHS Foundation Trust Financing Facility where it is expected that book value will equal fair value.
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NOTES TO THE ACCOUNTS
30.5 Financial risk management
Financial Reporting Standard IFRS 7 requires disclosure of the role that financial instruments have had during the period in creating or changing the risks a body faces in undertaking its activities. Because of the continuing service provider relationship that the NHS Trust has with Primary Care Trusts and the way those Primary Care Trusts are financed, the NHS Trust is not exposed to the degree of financial risk faced by business entities. Also financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which the financial reporting standards mainly apply. The NHS Trust has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the NHS Trust in undertaking its activities.
The Trust‟s treasury management operations are carried out by the finance department, within parameters defined formally within the Trust‟s standing financial instructions and policies agreed by the Board of Directors. Trust treasury activity is subject to review by the Trust‟s internal auditors.
Currency risk
The Trust is principally a domestic organisation with the great majority of transactions, assets and liabilities being in the UK and sterling based. The Trust has no overseas operations. The Trust therefore has low exposure to currency rate fluctuations.
Interest rate risk
The Trust borrows from Government for capital expenditure, subject to affordability as confirmed by the Strategic Health Authority. The borrowings are for 1 – 25 years, in line with the life of the associated assets, and interest is charged at the National Loans Fund rate, fixed for the life of the loan. The Trust therefore has low exposure to interest rate fluctuations.
Credit risk
Because the majority of the Trust‟s income comes from contracts with other public sector bodies, the Trust has low exposure to credit risk. The maximum exposures as at 31 March 2011 are in receivables from customers, as disclosed in the Trade and other receivables note.
Liquidity risk
The Trust‟s operating costs are incurred under contracts with Primary Care Trusts, which are financed from resources voted annually by Parliament . The Trust funds its capital expenditure from funds obtained within its prudential borrowing limit. The Trust is not, therefore, exposed to significant liquidity risks.
31. EVENTS AFTER THE REPORTING PERIOD
There are no events after the reporting period.
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NOTES TO THE ACCOUNTS
32. RELATED PARTY TRANSACTIONS
Details of related party transactions with individuals are as follows:
Payments to Receipts from Amounts Amounts due Related Party Related Party owed to from Related Related Party Party £ '000 £ '000 £ '000 £ '000 Bolton MBC - The Chairman of the Foundation Trust is Leader of the Council 1,167 253 3 25
The Department of Health is regarded as a related party. During the period, Royal Bolton Hospital NHS Foundation Trust has had a significant number of material transactions with the Department, and with other entities for which the Department is regarded as the parent Department. These entities are listed below:
£ '000 £ '000 £ '000 £ '000 Department of Health 0 1 0 0
Bolton Primary Care Trust 1,090 143,283 233 1,400 Ashton, Leigh & Wigan Primary Care Trust 3 16,968 0 467 East Lancashire Primary Care Trust 262 5 0 Salford Primary Care Trust 70 12,198 0 215 Bury Primary Care Trust 1 3,746 130 0 Other Primary Care Trusts 1,355 6,840 145 913
Greater Manchester West Mental Health NHS Foundation Trust 305 2,717 53 393 Other Foundation Trusts 2,246 1,507 498 172
Other NHS Trusts 6,637 365 243 70
North West Strategic Health Authority 60 7,670 0 17 Other SHAs 10 337 9 0
In addition, the Foundation Trust has had a number of material transactions with other Government Departments and other central and local Government bodies. Most of these transactions have been with the NHS Pension Scheme and the National Insurance Fund in respect of employee contributions. These entries are listed below
£ '000 £ '000 £ '000 £ '000 NHS Blood & Transplant 1,312 111 15 1 NHS Litigation Authority 4,825 31 5 0 NHS Purchasing and Supply 5,386 0 1,192 0 NHS Pensions Agency 12,267 0 1,054 11 NHS Institute for Innovation and Improvement 0 10 0 0 Prescription Pricing Authority 26 0 0 0 NHS Business Services 69 0 50 0 Other WGA 3 1,486 2 31
The Foundation Trust has received revenue and capital benefit from purchases made by Bolton Hospitals NHS Trust Charitable Funds. The transactions are summarised below. The separate Trustees' Report and Accounts for Bolton Hospitals NHS Trust Charitable Funds are available on request.
Purchases made from Purchases Charitable made from Funds relating Charitable to capital Revenue Capital Funds relating assets Payments to Payments to to revenue transferred to Charitable Charitable items the Trust Funds Funds £ '000 £ '000 £ '000 £ '000
4 70
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NOTES TO THE ACCOUNTS
33. THIRD PARTY ASSETS
The Trust held £648 cash and cash equivalents at 31 March 2011 (£1,590 - at 31 March 2010) which relates to monies held by the NHS Trust on behalf of patients. This has been excluded from the cash and cash equivalents figure reported in the accounts.
34. ANALYSIS OF INTER WHOLE OF GOVERNMENT BALANCES Current Income Current Expenditure receivables Transactions payables transactions £000 £000 £000 £000
English NHS Foundation Trusts 565 4,224 551 2,551 English NHS Trusts 70 365 243 6,637 Department of Health 0 1 0 0 English Strategic Health Authorities 17 8,007 9 70 English Primary Care Trusts 2,995 183,297 513 2,519 RAB Special Health Authorities 28 94 2,317 22,575 NHS WGA bodies 15 111 1 1,312 Total NHS Receivable/Payables 3,690 196,099 3,634 35,664 Other WGA bodies 441 4,591 719 9,794 Total WGA Receivables/Payables at 31 March 2011 4,131 200,690 4,353 45,458
35. LOSSES AND SPECIAL PAYMENTS
There were 76 cases of losses and special payments (2009/10: 65 cases) totalling £145,370 (2009/10: £196,127) paid during 2010/11.
There were no cases exceeding £250,000. These amounts have been prepared on an accruals basis but exclude provisions for future losses.
36. LIMITATION ON AUDITORS' LIABILITY
There is no specified limitation in the Trust‟s contract with its external auditors, the Audit Commission, that provides for limitation of the auditors' liability.
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