spitals Providing high quality care for patients through your local ho Annual Report2010 / 11 Introduction . 2 Providing About the Trust . 4 The communities we serve . 5 Top Ten Facts . 6 high Chairman’s Report . 8 Chief Executive’s Report . 10 quality care Mission Statement and Values and Corporate objectives . 12 Coprorate Objectives . 13 for patients Service changes . 15 Key achievements . 16 Risks . 19 through Quality Accounts . 20 National Context . 20 Local Context . 21 your local Contents Statement on Quality on Behalf of the Board . 22 Review of quality performance . 25 Review of quality performance - Effectiveness . 38 hospitals Review of quality performance - Patient experience . 42 Service improvements . 50 Community Services . 59 Participation in Clinical Audit . 60 Research and Development . 68 Participation in CQUINs . 69 Advice, Liaison and Complaints . 72 Data Quality . 73 Care Quality Commission Statement . 74 Comments received on the Quality Accounts 2010/11 . 76 Personal Data . 80 Sustainability . 82 Emergency Preparedness & Flu response . 83 Valuing People . 84 Staff Feedback . 87 NHS Constitution . 88 Foundation Trust update . 89 Looking Forward . 90 Annual Accounts . 92 Statement of Directors’ Responsibilities in respect of the Accounts . 95 Independent Auditors’ report to the Board of Directors of the Pennine Acute Hospitals NHS Trust . 96 Statement on Internal Control 2010/11 The Pennine Acute Hospitals NHS Trust . 98 Notes to the Accounts . 107 Remuneration Report . 136 Charitable funds . 138 Finance Glossary . 140 Trust Board . 143 Contacting the Trust . 146 ANNUAL REPORT AND ACCOUNTS 2010/2011 1 Welcome to the 2010/11 Annual Report and The Trust’s mission Financial Accounts of The Pennine Acute statement is: Hospitals NHS Trust . The Trust’s mission statement is “to which was approved by the Department to provide provide the very best care to each patient of Health in August 2010, is due for on every occasion .” To achieve this, completion in December 2012 as part patient safety and quality are at the heart of Making it Better . It will be the biggest the very of everything we do . capital investment made by the Trust . best care We have continued to focus on improving We have also made a number of major patient safety, quality of care and the service changes this year as part of our to each patient experience through strong commitment to implement the Healthy clinical leadership . We have continued to Futures reconfiguration programme patient reduce significantly healthcare acquired across the north east sector of Greater Introduction infections, such as MRSA and Clostridium Manchester . These changes, agreed Difficile, across all our hospitals and in 2007 by the Secretary for State for on every reduce our hospital mortality rate further . Health at the time, aim to improve care to patients by centralising the skills and occasion Our performance and the improvements expertise of our doctors and nursing we have made across the areas of patient staff . This year we have invested millions safety, clinical effectiveness and patient of pounds in the development of new experience is reported within our Quality services, new equipment and new Accounts 2010/11 . These can be found in facilities . this Annual Report on p20 . The Care Quality Commission, in The Trust continues to work with introducing the new registration scheme partner agencies in implementing the across England, registered the Trust with ambitious programmes to reshape and no conditions from April 2010 . improve services to make them safer and Every patient has the right to receive sustainable for the future . high quality care that is safe, effective This year we were pleased to open our and respects their privacy and dignity . new purpose-built women and children’s Protecting a patient’s privacy and dignity development at North Manchester is an essential part of delivering high General Hospital in June . The new quality care . All NHS Trusts were required building, costing around £35 million, to make a Same-Sex Accommodation was delivered as part of Making it (SSA) declaration to confirm they are Better, the Greater Manchester-wide compliant ‘to eliminate mixed sex The Trust continues to work with NHS programme to improve services for accommodation except where it is in the partner agencies in implementing women, children and babies . overall best interests of the patient, or the ambitious programmes to Construction work on the Trust’s new reflects their patient choice’ by 31 March 2011 . We were able to confirm that purpose-built £44million women and reshape and improve services to we are compliant with the Government children’s development at The Royal requirement . This declaration is available make them safer and sustainable for Oldham Hospital, including a new on our website at www .pat .nhs .uk . specialist neonatal unit, is progressing the future . well and ahead of schedule . The facility, 2 THE PENNINE ACUTE HOSPITALS NHS TRUST ANNUAL REPORT AND ACCOUNTS 2010/2011 3 The Pennine Acute Hospitals NHS Trust is the largest The communities in the North West and largest non-teaching hospital we serve are in England . We employ around 10,000 staff and diverse in their provide high quality general and specialist hospital make-up, but services to around 800,000 residents across the are similar in that north east of Greater Manchester in Bury, Prestwich, they are generally North Manchester, Middleton, Heywood, Oldham less healthy and Rochdale . when compared The Trust manages four main hospitals across children, and diagnostic and clinical support, with the rest of the north east sector of Greater Manchester . which work together to provide integrated England, with a These include North Manchester General care across our five hospitals . Specialist clinical Hospital, The Royal Oldham Hospital, Fairfield areas within each division are overseen by higher proportion General Hospital in Bury and Rochdale one of 21 consultants who are senior doctors Infirmary, and services at Birch Hill Hospital . appointed as clinical directors responsible for of people who managing their own services . With an annual operating budget of over half have a long term About the Trust a billion pounds, we work with four Primary A range of support services, such as human Many areas suffer high levels of deprivation . Where there are Care Trusts – NHS Manchester, NHS Bury, NHS resources, education and training, IT, research illness . high rates of unemployment and deprivation, there tends to Oldham and NHS Heywood, Middleton and and development, finance, governance, be poorer health and a greater demand for health and social Rochdale - to plan, develop and commission facilities, estates and catering, are all essential care services . healthcare services for local people . for our hospitals to run smoothly and effectively . Rates of obesity, smoking, cancer and heart disease related Our clinical services are organised within four to poor general health and poor nutrition are significantly divisions: surgery, medicine, women and higher than the national average, whilst life expectancy at birth in some areas is one of the lowest in England . Common themes of ill health and death include circulatory diseases such as coronary heart disease and stroke, diabetes, cancer, and respiratory diseases such as pneumonia, asthma, bronchitis and emphysema . The local communities we serve are geographically and culturally diverse, but remain largely characterised by their The communities we serve industrial past . This has contributed to significant health inequalities among residents . Other issues facing our communities include proportionately larger numbers of younger and older people, large and growing ethnic minority populations whose health and access to healthcare have been poor, and heavy reliance on public transport and low levels of personal car ownership . 4 THE PENNINE ACUTE HOSPITALS NHS TRUST ANNUAL REPORT AND ACCOUNTS 2010/2011 5 In 2010/11 the Trust: 1) spent over half a billion pounds (about 5) saw 694,500 outpatients and 218,277 total £1.5m per day) ) on providing healthcare inpatients services for local people . 6) saw 78,240 day cases 2) invested £24.9million on capital programmes 7) delivered 10,384 births . and in maintaining and improving the physical estate and on smaller projects to 8) provided 1,749,068 meals develop front line clinical services . 9) laundered more than 4.4 million kilograms 3) spent £4million on medical and scientific of linen Top Ten Facts Ten Top equipment to support front line clinical 10) provided 75,249 episodes of training and services . learning activities to staff in-house 4) saw 310,688 A&E cases 6 THE PENNINE ACUTE HOSPITALS NHS TRUST ANNUAL REPORT AND ACCOUNTS 2010/2011 7 The first priority for the Trust Board in 2010/11 has been We have placed major emphasis this year on Haydn Griffith and Mike Holly were reconfirmed recognising the work of our staff and we instituted as Non Executive Directors for further terms of ensuring the continued safe and sustainable provision of the Pennine Staff Awards which culminated in office and Hugh Mullen took up post as Director of clinical services . a very successful awards ceremony at the City Operations . Haydn Griffith subsequently decided of Manchester Stadium in July 2010 . These to retire from the Board in April 2011 and we The two major reconfiguration schemes The Trust Board has also placed a significant were fully sponsored by a number of our major welcomed Chris Mayer in his