North Tees and Hartlepool
NHS Foundation Trust
Annual Report and Accounts 2011 – 2012
2
North Tees and Hartlepool
NHS Foundation Trust
Annual Report and Accounts 2011 – 2012
Presented to Parliament pursuant to Schedule 7, paragraph 25
(4) of the National Health Service Act 2006.
3
Contents
Page
1. Chairman’s Statement
8
2. Chief Executive’s Statement
9
3. About Us
10
4. Director’s Report incorporating both the Business and Operating Reviews
14
4.1 Business Review
15
4.1.1 Trust Strategic Direction
17
4.1.2 Development and Service Improvement
18
4.1.3 Stakeholder Relationships
26
4.1.4 Corporate and Social Responsibility
26
4.1.5 Environment, Sustainability and Climate Change
27
4.2 Operating Review
30
4.2.1 Performance and Development of the Trust’s Business
30
4.2.2 Business Planning and Linkages to Key Activities
32
4.2.3 Future Challenges to Performance Delivery
34
4.2.4 Risks and Uncertainties
35
4.2.5 Regulatory Ratings
37
4.2.6 Information Risks
38
4.2.7 Counter Fraud Arrangements
39
5. Quality Report – Our Commitment to Quality
40
6. Valuing Our Workforce
102
6.1 Commitment to Staff
103
6.2 Keeping Staff Informed
109
6.3 Supporting Staff
110
6.4 Development and Education of Staff
112
6.5 Equality and Diversity
114
6.6 NHS Staff Survey
115
7. Research and Development
118
8. Organisational Structure
122
8.1 Working Together – the Trust Board and Council of Governors
123
8.2 Council of Governors
124
8.2.1 Role and Composition
124
8.2.2 Elections – Public and Staff Governors
125
8.2.3 Meetings of the Council of Governors
126
8.2.4 Who’s Who – Council of Governors 128
8.2.5 Register of Interests – Governors
130
8.3 Membership of Our Trust
130
8.4 Board of Directors
131
8.5 Internal Control
131
8.6 Development and Performance 132
8.7 Register of Interests – Board Directors
135
8.8 Board Directors – Who's Who
136
Annual Report and Accounts 2011 – 2012
5
Page
9. Remuneration Report
138
10. Statement of the Chief Executive's responsibilities
144
11. Annual Governance Statement
146
12. Internal Audit Statement
156
12.1 Roles and responsibilities
157
12.2 The Head of Internal Audit Opinion
157
13. External Audit Opinion
160
14. Financial Performance 2011/12
164
14.1 Foreword to the Accounts
165
14.2 Financial Commentary and Metrics
165
14.3 Financial Performance against Plan 2011/12
166
14.4 Income and Contract Performance
166
14.5 Capital Investment
169
14.6 Financial outlook for 2012/13
170
14.7 Financial Key Performance Targets
170
14.8 Summary
172
14.9 Annual Accounts 2011/12 including Financial Statements and Notes
173
14.10 Going Concern
207
14.11 External Auditors
207
15. Contact Information 208
6
Annual Report and Accounts 2011 – 2012
Welcome to North Tees
and Hartlepool NHS
Foundation Trust
North Tees and Hartlepool NHS Foundation Trust provides hospital and
community-based healthcare to around 365,000 people living in East Durham,
Hartlepool, Stockton-on-Tees and surrounding areas including Sedgefield,
Easington and Peterlee. Our breast and bowel screening services extend
further, taking in a population of around 400,000. We also provide a number
of outpatient and outreach clinics at Peterlee Community Hospital, Hartlepool
Minor Injuries Unit (One Life Centre Hartlepool), and other community settings.
Excellence is at the heart of all our services and activities, with patients at the
forefront of everything we do.
Staff nurse Jenny Goodman and support worker Ann Manders.
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Annual Report and Accounts 2011 – 2012
1. Chairman’s
Statement
As Chairman of North Tees and Hartlepool NHS Foundation Trust
I am delighted to introduce this annual report. The Board of
Directors sets the direction, strategy and objectives for the Trust,
working closely with the Council of Governors and our staff from
across the Trust. Our assurance is not limited to the boardroom;
assurance often means seeing for ourselves what is happening on
the ground, and the Board and Council of Governors take pride in
engaging with staff, patients and carers of our Trust.
Paul Garvin
Chairman
Without exception Board members are welcomed in every corner of the Trust when
they carry out both announced and unannounced visits. Staff at the forefront of
patient care and those who provide essential support to front line staff are quite
rightly very proud of their work and, as a Board, we are always impressed and
inspired by the things we see. The Board to Ward culture is very well embedded and
we see consistently high levels of performance and quality as a result.
Even in this challenging financial climate quality remains our top priority; we are
not prepared as a Trust to compromise the performance and quality our patients
have come to expect. In fact what we have found is that getting it right first time
for patients is more economical. All of these things are set out in our strategy which
talks about high performance, high quality and excellent financial management.
Under the requirements set out by the external regulator we have deliberately kept
our planned surplus to the lowest levels possible because we want to use our income
for patient care not build up unwanted surpluses.
Our strategic direction continues to be that of transforming health and healthcare
services under the Momentum: pathways to healthcare programme. This programme
is explained in more detail in this report. Our aim is to provide early interventions
and care in or closer to people’s home. That infrastructure is being implemented
and 2011-2012 saw many of the changes materialise. We see the final piece of
the jigsaw as a new hospital. I expect 2012-2013 to be the time when we can
confirm this option can be realised, otherwise alternative transition plans will be fully
developed and implemented.
This year has been a very challenging one and we know there are more challenges
on the horizon. However, our strong Board and our commitment to quality, high
performance and financial stability will stand us in good stead for the future.
When Board members review quality, performance and finance at our meetings we
always remind ourselves that maintaining all of these aspects at a very high level
doesn’t happen on its own. Every member of the Board appreciates the talent,
skill, commitment and dedication of our staff. Whether working in front of or
behind the scenes they keep our patients at the forefront and consistently strive
for improvement. The Trust is the place it is because of these amazing people, our
staff, and I am absolutely delighted to be able to place the Board’s thanks and
appreciation on public record through this report.
I commend the Trust’s Annual Report and Accounts 2011-2012 to you, as an
opportunity to read the achievements and developments our Trust has made to
healthcare during 2011-2012.
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Annual Report and Accounts 2011 – 2012
2. Chief Executive’s
Statement
Once again this has been a successful year for the Trust.
We have continued to improve quality and achieve high levels of
performance while maintaining an excellent financial position.
It has been delivered not only by excellent leadership at all levels
throughout the organisation, but also by individual members of
staff who take great pride in their work, and who are committed
to providing high quality services for patients.
Alan Foster
Chief Executive
Although it has been a successful year, it has also had its challenges. In November
we launched our £40m challenge. This is the amount the Trust needs to save in the
next three years. I am delighted to report that we have achieved £16m of the savings
required of us in the first of the three-year programme. We have had to take some
difficult decisions but these have been taken to protect the best interests of our patients
and their families, who were and remain at the forefront of our minds throughout.
We know we have a similar amount to save in 2012-2013. However, I am confident
that our staff will do what they always do; rise to and meet this challenge with
determination, commitment and professionalism.
In August 2011 the Accident and Emergency Department at University Hospital
Hartlepool closed and the minor injuries part of that service was transferred into a
Primary Care developed purpose-built urgent care centre at One Life Centre Hartlepool.
Medical emergencies referred by GPs, which would have been taken to Accident and
Emergency, were taken straight to our existing Emergency Assessment Unit at the
University Hospital of Hartlepool. Whilst there have been changes it still means that
most people continue to have their urgent and emergency care needs met in the town
of Hartlepool. Patient satisfaction surveys show a high level of satisfaction with the
new services. Ambulatory care – a service set up for patients who need an emergency
medical assessment but do not need an overnight stay – has developed and flourished
throughout the year on both of our hospital sites. This service is growing and heralds a
change in the way emergency assessment services are provided. We acknowledge that
concern was expressed about the changes and appreciate the challenge brought, as it
ensured that we appraised our alternative model of care to also ensure that it provided
more tailored and enhanced medical provision to the people of Hartlepool.
We were the first Trust in the country to provide both acute and community
services when we began providing community services in December 2008. We were
then, and we are now, convinced of the value of this integration, which improves
pathways of care for patients. Integrated working has enabled staff to work together
in the interests of patients, and we have seen further increases in patients being
cared for at home where previously they would have been admitted to hospital.
This has happened because our community teams have increasingly had access to
new technologies such as hand-held toughbook computers and telehealth systems,
which patients can use to monitor their health in their own homes supported by
our community teams. Community teams have had support from the Trust’s IT team
and patients have benefited as a result. This is one of many shining examples of
backroom staff and systems improving frontline care.
This report contains details of the many developments which have improved services
for our patients. I am very proud of our achievements and I commend our staff for
their hard work and dedication throughout the year.
Annual Report and Accounts 2011 – 2012
9
3. About Us
10
Community midwife Sheila Robson.
North Tees and Hartlepool NHS Trust was formed when North Tees Health NHS Trust and Hartlepool
and East Durham NHS Trust merged on 1 April 1999. North Tees and Hartlepool NHS Foundation
Trust was authorised as a NHS Foundation Trust in December 2007. We provide a wide range of
health and healthcare services across and beyond our catchment area.
We have two hospitals:
•The University Hospital of Hartlepool;
•The University Hospital of North Tees in
Stockton-on-Tees.
We care for patients in a number of community
facilities including Peterlee Community Hospital
and One Life Centre Hartlepool, which is the
first of the integrated care centres to be created
under the Momentum: pathways to healthcare
programme. This programme is transforming the
shape of health services in our area by providing
care in clinics, sports centres, children’s centres,
schools and in people’s homes.
The combining of our acute and community
services has been a model which has proved very
successful in streamlining care for patients and
working with our primary care colleagues and
GP practices. Community and acute palliative
services are co-located, which facilitates the
provision of a more cohesive care pathway
for patients and their families. Other specialist
services such as the heart failure and community
respiratory teams are working more closely
with acute care staff to improve patient care.
Community staff have also seen benefits in
having the resources of a successful acute NHS
Foundation Trust to support their work.
We are the only Trust in the region to have
taken part in a national pilot project, using the
Panasonic Toughbook – a rugged wireless laptop
which is being used by community nurses and
matrons, speech and language therapists and
the community stroke team. Staff can use the
computers to check and update patient records
wherever they go – reducing paperwork, trips
back to the office and ensuring up to date
availability of information.
We have become one of three local health Trusts
to provide bariatric surgery to patients, after
the service was commissioned by the North East
Specialist Commissioning Group. Our breast screening services cover Teesside (the
local authority areas of Hartlepool, Stockton-onTees, Middlesbrough and Redcar and Cleveland),
South Durham and parts of North Yorkshire, and
we are the referral centre for bowel screening for
Teesside, South Durham and North Yorkshire.
We provide community musculoskeletal services
and community dental services for the whole of
Teesside.
Patients from a wider catchment area can, and
do, choose to use our services; our leading edge
spinal services at the University Hospital of North
Tees attract patients from other parts of the
country, and women who live out of our area
have chosen to use our midwife-led birthing
centre in Hartlepool.
We have continued to reduce mortality, which
has been achieved through our Board to Ward
Policy and by having a relentless determination
to drive quality. The culture in the Trust is very
much about team working from the domestic
staff cleaning the wards and the consultant
carrying out the World Health Organisation
(WHO) checklist before an operation begins:
every member of staff knows and understands
their contribution to safety, outcomes and
patient experience.
We were one of the original partner NHS Trusts
to embrace Lean methodology and this is now
truly embedded within our Trust, with a wide
range of staff understanding and applying the
principles in their every day work.
We have ambitious plans for the future to work
with our healthcare partners to transform health
and healthcare services under the Momentum:
pathways to healthcare programme. This
programme will help to keep people healthy,
intervene early and provide care in or closer
to people’s homes by an infrastructure of
integrated care centres, working with our
hospitals to provide excellent tailored healthcare.
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Annual Report and Accounts 2011 – 2012
The map below shows the extended catchment population of the Trust, reflecting
the service developments around screening programmes and bariatric surgery
collaboration. The general catchment population of the Trust is shown by the
darker shading.
Easington
Durham
Peterlee
Wheatley Hill
A181
Trimdon
Hart
A1M
A179
Hartlepool
A19
Sedgefield
Newton Aycliffe
Greatham
A689
Billingham
A1M
Stockton-on-Tees
Darlington
A66
A19
Key
General patient catchment area
Extended patient catchment area for service developments
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Annual Report and Accounts 2011 – 2012
We provide a diverse range of services from our two hospital sites and a range of community facilities.
Many services are inter-related and span across patient pathways. The following provides an overview
of our service profile:
Acute Services
Community Services
1
General Surgery
30
Asylum Seekers
2
Urology
31
Coronary Heart Disease Service
3
Trauma and Orthopaedics
32
Child Protection
4
Outpatients
33
Community Matrons
Breast and Bowel Screening
34
Community Respiratory Assessment and Management
Service
5
6*
Ophthalmology
35
Continence Advisory Service
7*
Oral Surgery/Orthodontics
36
Community Dental Services
8*
Plastic Surgery
37
Diabetes Team
9*
Dermatology
38
Diabetic Retinopathy Screening Service
10
Anaesthetics
(including Pain Management & Critical Care)
39
Discharge Liaison Service
11
Accident and Emergency
(including Trauma Unit Status/Minor Injuries Unit)
40
Falls Service
12
General Medicine
41
District Nursing
13
Care of the Elderly
42
Hand and Wrist Surgery
14
Gastroenterology
43
Health Visiting
15
Cardiology
44
Intermediate Care
16
Diabetic Medicine
45
Specialist Palliative Care/ Macmillan Nursing
17
Rheumatology
46
Skin/Minor Surgery
18
Respiratory Medicine
47
Musculoskeletal Services
19
Obstetrics (including Midwifery Led Unit)
48
Nurse Prescriber Advisor
20
Gynaecology
49
Phlebotomy Service
21
Children and Young People’s Services
50
Podiatry/Podiatry Surgery
22
Clinical Acute Oncology/Clinical Haematology
51
Rapid Response Team
23
Radiology
52
School and Specialist School Nursing
24
Pharmacy
53
Speech and Language Therapy
25
General Pathology
54
Community Stroke team
26
Bereavement Services
55
Tees Community Equipment Store (TCES)
27
Allied Health Professionals
56
Health Trainers
28
Endoscopy
57
Specialist Stop Smoking
58
Physiotherapy, Occupational, Therapy, Dietetics,
Audiology & Orthotics
59
Allied Health Professionals
29
Bariatric Surgery
* Visiting specialities. N.B. This list is not exhaustive.
GP Links and Community/Specialist Services
The Trust has established positive links with local GPs ensuring emerging Clinical Commissioning
Groups (CCGs) Chairs are members of the North of Tees Partnership Board. The Trust hosts bi-monthly
liaison meetings with Chairs of the four CCGs in the area it serves and participates in lunch and learn
sessions organised by CCGs in Hartlepool and Stockton.
We continue to work with the local Pathfinder CCGs to transform health and healthcare services under
the Momentum: pathways to healthcare programme. As mentioned earlier, this programme is aligned
to government policy, which aims to keep people healthy, intervene early and provide care in or closer
to people’s homes. This will be facilitated by an infrastructure of integrated care centres with the final
piece of the Momentum jigsaw being a new, state of the art district general hospital on a single site.
Annual Report and Accounts 2011 – 2012
13
4. Director’s Report
INCORPORATING BOTH THE BUSINESS AND OPERATING REVIEWS
14
Cardiac specialist nurse Liz Harbron.
4.1 Business Review
The Trust’s operational and financial performance continues to be strong despite
the challenging economic climate in which we work. Our staff understand the
need to provide excellent services to patients, putting safety and quality at the
heart of all that we do. We launched our £40m challenge, which has informed
staff and all our stakeholders of the financial challenge facing the Trust over the
next three years, and asked them to contribute ideas that would assist the Trust in
meeting this challenge.
The process we have used for undertaking
this and other staff engagement activities is
described in section 6, Valuing Our Workforce,
page 102-117, which also provides the
outcomes of the Trust’s annual staff survey
and identification of appropriate policies used
within the Trust in relation to staff. In respect
of other Trust policies and strategies these can
be found in section 4.1.1 page 17, section
4.1.5 page 27 and section 5 page 40. We have,
as part of this review, streamlined services,
reviewed costs, changed planned savings,
reduced management posts, and improved
our financial and planning assumptions. All
these important events and details surrounding
the Trust’s market value of assets, donations,
going concern etc can be found in section 14
Financial Performance, page 164. In addition,
an area of interest is the work and activity of
our Board, and all details surrounding the work,
committees and disclosures can be found in
section 8, page 122. The Trust values the work
of its Council of Governors, and recognises
the need to ensure good governance practices
are embedded throughout the Trust. Our
disclosures and activities associated with this
can be found in section 8, page 122. The Trust
has made provision for Governors and members
to communicate with each other, details of
which can be found in section 8, page 122. All
of this helps us with our achievements, quality
visits and external assessments. The Trust as a
whole is committed to its vision and our strategy
to achieve this and our Annual Governance
Statement to support this can be found in
section 11 page 146.
The Board has debated, discussed and
challenged many assumptions and plans
presented throughout this report. The robust
nature of this challenge may not be reflected,
but the outcomes presented are those approved
at the Board. The Chief Executive, on behalf
of the Directors, has ensured that the Trust’s
auditors have been provided with all required
information, this declaration is presented in
section 8.4 page 131 of the Report. In respect
of accounting policies for pensions and other
retirement benefits, these are set out in section
9 page 138 to the accounts and details of
senior employees’ remuneration can be found in
section 9 page 138 of the Remuneration Report.
Everything we do as a Trust puts Patients First,
this is our strapline and something we are very
proud of. Our services to patients focuses upon
patient safety and quality at every stage of their
interaction with the Trust. Our annual Quality
Report reflects the commitment to delivering
high quality patient care, and how we have
achieved this in 2011-2012, this can be found
in section 5, Quality Report – Our Commitment
to Quality, page 40. In addition our Annual
Governance Statement, reflecting our systems of
control, safeguarding risks etc can be found in
section 11 on page 146.
The Director’s Report is presented on behalf of
the Directors that served on the Board during
the year 2011-2012. The following sections set
out key activities of the Trust and the way the
Trust has embraced these. Working with all our
stakeholders to ensure the achievement of our
objectives and also providing the high quality
patient care is right at the heart of all we do.
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Annual Report and Accounts 2011 – 2012
16
Annual Report and Accounts 2011 – 2012
4.1.1 Trust Strategic Direction
Manage our Relationships
Our Vision
To ensure the Trust’s services, and the way we
provide them, meet the needs of our patients,
commissioners and other partners by proactively
engaging with all appropriate stakeholders,
which includes staff, through communications,
engagement and partnership working.
The Corporate Strategy was reviewed and
updated in 2011. Since that time the Board
of Directors has worked with Governors, key
clinicians, managers and staff to refresh the
Corporate Strategy as of January 2012. Details
of the Directors and Governors in post during
2011-2012 are presented in section 8.
The Corporate Strategy to 2016 can be
summarised in the triangular diagram opposite.
The Trust identified six key strategic themes,
which were translated into strategic aims:
Putting Patients First
To create a patient-centred organisational culture
by engaging and enabling all staff to add value
to the patient experience, which is demonstrated
through patient safety, service quality and Lean
delivery.
Maintain Compliance and Performance
To maintain performance and compliance with
required standards and continually strive for
excellence by good governance and operational
effectiveness in all parts of the Trust’s business.
The strategic aims are underpinned by objectives
and outcomes, which in turn are underpinned
by specific strategies and delivery plans. Overall
the Trust measures its performance against the
delivery of these objectives, and regularly the
Board receives updates on progress.
Momentum: Pathways to Healthcare
To develop and implement a new healthcare
system for the people of Easington, Hartlepool,
Peterlee, Sedgefield and Stockton.
Community Integration
To develop and expand the portfolio of
services to provide healthcare services to our
communities as close to home as possible.
Service Development
To improve and grow our healthcare services
to better meet the needs of our patients,
commissioners and the Trust.
A copy of the Trust's priorities and objectives can
be found in the Corporate Strategy, a copy of
which can be obtained from www.nth.nhs.uk
or by contacting the Trust directly, see page 208.
Libby Lynas demonstrates her brushing techniques on Alex the puppet with oral health
promotion advisor Nicola Cronin.
17
Annual Report and Accounts 2011 – 2012
Outline Business Case for New Single Site Hospital
Following an independent review of health services north of the Tees, it was
concluded that fully integrated provision of healthcare would provide improved and
sustainable care for our patients.
Over the course of the last 30 months, the Trust has developed a compelling case
for the replacement of its existing two sites with a new state of the art, single site
development. This is linked to the overarching Momentum: pathways to healthcare
programme; the new hospital will be pivotal in the plan to transform healthcare
services north of the Tees.
The Outline Business Case (OBC) received Department of Health and HM Treasury
(HMT) approval in March 2010, which paved the way for the planned procurement,
construction and opening of the new facility in 2017. The new hospital will afford
the Trust the opportunity to navigate the challenging financial environment facing
the NHS over the next five years, and provides the ability for the Trust to reduce
infrastructure and overheads in response to the Quality Innovation Productivity and
Prevention (QIPP) agenda and to emerge from the next five years lean, fit and with
a world class facility to maintain patient flows, enhance patient quality and further
attract patients.
The subsequent change in Government has seen the withdrawal of the publicly
funded solution. A revised £300m Private Finance Initiative was developed and is
awaiting final approval. Meanwhile, the Trust is pursuing alternative funding solutions
and hopes to have a scheme approved in the summer of 2012.
As part of the Trust’s desire to generate supplementary income it has established
a trading company, which is currently dormant. The subsidiary company is called
‘North Tees and Hartlepool Trading Company Limited’.
4.1.2 Development and Service Improvement
The following initiatives, service developments and improvements have been
instrumental in the delivery of our Corporate Strategy, each will be considered in
turn. They include:
•Momentum: pathways to healthcare;
•Healthworks – Annual Health and Wellbeing Report;
•Community Renaissance;
•Environmental Developments;
•Service Developments 2011-2012.
Momentum: pathways to healthcare programme
The Momentum: pathways to healthcare programme is a partnership of local
stakeholders made up of three key elements:
•Service transformation – covering all services and care pathways in the locality;
•Primary and community care capital planning – covering the design and
commissioning of new community based buildings and facilities;
•Hospital capital planning – covering the design and build of a new hospital to
replace the existing two hospitals, University Hospital of Hartlepool and University
Hospital of North Tees.
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Annual Report and Accounts 2011 – 2012
Delivery of the Momentum vision will mean that we have:
Better services
Better facilities
• Continued focus on prevention and appropriate self care;
• Great places to get better, work and visit;
• Extended roles for GP and primary care;
• Inspires confidence in our patients and helps them to
keep well;
• More locally based care, assessment, diagnostics,
treatment and care management;
• Supports our new healthcare model and hospital needs;
• Sustainable high quality emergency care services;
• Hospital with near 100% single rooms;
• Increased choice of service provision;
• Acute care provision using cutting edge technology,
fabric and equipment;
• Proactive management of long-term conditions;
• More integrated health and social care service provision;
• Reduced waste and improved access;
• Low carbon facilities that are efficient and cost effective;
• Spaces that are innovative, flexible and sustainable.
• Staff supported to care for patients.
The Momentum: pathways to healthcare
programme Capacity Plan was reviewed again
during 2011-2012 to confirm the forecast of
future demand that underpins the planning
assumptions for our new hospital facilities. These
are the delivery of the following:
•40,000 Accident and Emergency (A&E)
attendances will be seen at the community
integrated care centres, providing more care
locally and relieving pressure on the major A&E
department of the new hospital;
•Negligible increase in emergency admissions
and a reduction in emergency lengths of
stay by up to one third, ensuring that Trust
performance for emergency length of stay is at
or close to top decile nationally;
•160,000 outpatient appointments in the
community, including 90,000 physiotherapy
and occupational therapy;
•Move of up to 6,500 treatments that currently
take place in day case or inpatient facilities
to procedure rooms, possibly in a community
setting;
•Movement of inpatient treatments into a day
case setting to achieve an overall day case rate
of 78%;
•Reduction of 124 general and acute beds to
enable care closer to home to be achieved.
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Annual Report and Accounts 2011 – 2012
Service Transformation is the process of whole system business and service
change across care pathways to provide care closer to home and increase quality,
accessibility, integration, responsiveness and value for money across the patient
pathway, all of which results in more appropriate and more timely care and reduced
hospital admissions and length of stays.
Service Transformation
Whole System / Patient Pathway
Self Care
GP /
Practice
Nurse
Clinical
Nurse /
Community
Matron
Clinical Pathway Projects
Specialist
Community
Services
Hospital
Services
Enabling Projects
Reducing Unnecessary Admissions and Length of Stay
Service transformation is undertaken as mainstream business. Service changes have
already moved more care into the community with a resultant reduction of almost
10% in the use of acute beds across both hospital sites.
Some of the areas of change include:
•‘Think Glucose’ programme introduced to raise awareness of diabetes;
•Telehealth deployment in the community to support patients at home;
•Out of Hours District Nursing was implemented in Stockton in November 2011 to
better mirror the service in Hartlepool;
•Rapid response service in Stockton is now able to manage COPD patients better,
mirroring the service in Hartlepool and reducing the pressure on the Community
Respiratory Service;
•Rapid response services are now able to help patients with cellulitis needing IV
antibiotics;
•Toughbooks have been rolled out to adult community services;
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Annual Report and Accounts 2011 – 2012
•A new integrated Minor Injuries Unit,
alongside a GP led ‘Walk-In Centre’ and ‘Out
of Hours’ service was opened on 2 August
2011 at One Life Centre Hartlepool and has
been well used by local patients. This follows
an independent review into Accident and
Emergency Services in Hartlepool carried out
by the North East Strategic Health Authority
and Hartlepool Health Scrutiny Forum in March
2011, which recommended the closure of the
University Hospital of Hartlepool Accident &
Emergency Department based on the inability
to ensure continued clinical sustainability and
safety;
•Communication systems have been put in
place to support the provision of integrated
palliative care services across Stockton,
Hartlepool and East Durham;
•Coronary heart disease patients now receive
coronary care support directly on hospital base
wards;
•A General Practice Imaging (X-ray) and
Ultrasound Service became available at One
Life Centre Hartlepool from September 2011.
•Patients who have had a stroke are now
provided with a more integrated stroke
rehabilitation service across Stockton,
Hartlepool and East Durham;
•Acute oncology nurses have developed systems
to ensure patients on active chemotherapy
(or within 6 weeks post-treatment) receive a
prompt review by an appropriate specialist;
•Point of Care Testing has been extended;
•A review of patients admitted with problems
of the digestive system is being evaluated to
reduce admissions and improve care;
•ICE System (diagnostic reporting) is to be
upgraded and linked to the information system
at James Cook University Hospital;
•Electronic Document Management (pilot) has
been implemented to support communication
across the patient pathway;
•Nurse rostering system has been implemented
to ensure the most effective deployment of our
nursing workforce;
The continued alignment of the Momentum:
pathways to healthcare programme to other
issues, initiatives and areas of work is vital;
particularly QIPP and the commissioning
intentions of CCGs. A new body, the North of
Tees Partnership Board, has been established to
direct and oversee the service transformation
work. This Board includes representation from
local partners including the emerging CCGs
and provides a strong platform to maintain
relationships and support effective partnership
working.
Service transformation will become fully integrated with mainstream business of the Trust
from November 2012 and follows a review of management arrangements across the Trust.
This means that:
•The Momentum: pathways to healthcare programme ‘brand’ will continue as a focus for the work;
•Overall co-ordination will be fully mainstreamed into directorates with an overview being maintained
via a performance management approach;
•Service developments will be identified, planned and assessed as part of the Trust Directorate
Business Planning process, including production of business cases as required and performance
managed accordingly;
•Alignment will be overseen by the North of Tees Partnership Board;
•Communications and engagement with community groups will be undertaken by the clinicians
and managers across the service pathways involved, to meet the ‘4 tests’ outlined by the
Department of Health.
21
Annual Report and Accounts 2011 – 2012
Primary and Community Care Capital Planning Board led by the Tees Primary
Care Trust has led the redesign of community facilities in Stockton, Hartlepool, Yarm
and Billingham.
One Life Centre Hartlepool has continued to be used by local people and is a
new home for General Practice, Community Services and the integrated urgent
care service model. This facility was considered for a Building Better Healthcare
Award. Options to take forward healthcare provision in Billingham continue to be
considered. A new building development in Yarm has started and will facilitate the
work of a number of community clinics.
In summary, progress has been made throughout the year to transform services and
facilities for patients, carers and staff working across a range of patient pathways.
A transition plan has been developed throughout 2011-2012 to communicate
the changes involved in the transition to the new hospital in spite of the revised
procurement phase outlined above.
Hospital Capital Planning Board has led the process of design and procurement
for the new hospital at a site at Wynyard Business Park. As explained above, the
new hospital procurement is anticipated to commence during 2012-2013. To better
understand the processes to date, a summary of activity follows.
Following production of a revised OBC version 3.0 in December 2010, it received
support from the North East Strategic Health Authority in April 2011. The OBC has
subsequently been reviewed by the Department of Health (DH) capital investment
branch during summer 2011 and this process continues. This review by the DH has
taken longer than expected and has involved very high levels of governance and
scrutiny, directly related to the DH/HM Treasury policy position in relation to deed
of safeguard, the review of the PFI as a result of these delays the Trust has been
looking at different funding options, in the hope that a decision can be reached
during 2012.
Numerous clarifications have been provided, primarily in relation to affordability and
Value for Money (VFM) modelling. The outstanding issues are:
•Tier 2 borrowing requirements linked to the updated Long Term Financial Model
(LTFM);
•Hard Facilities Management (Hard FM) split and a VFM analysis demonstrating
both quantitative, qualitative, benefits and risk analysis;
•Pre Official Journal of the European Union (OJEU) documentation development;
•Refresh of the OBC (version 4.0) that will include the detail of the clarification
process.
It is expected the DH review will be completed in 2012-2013. This delay has provided
the opportunity to fine-tune the procurement documentation with a final quality
assurance process, which has refined the presentation of the scheme to the market
via a competitive dialogue process.
22
Annual Report and Accounts 2011 – 2012
Healthworks – The Annual Health and
Wellbeing Report
An additional strategic development has seen
the production of ‘Healthworks’ – an annual
report on the health and wellbeing of the
local population. ‘Healthworks’ supports the
continuous improvement in the health of the
population and details our contribution to this
work. It is not always recognised that the Trust
provides services from the cradle to the grave,
including health promotion, preventing ill health,
treating and supporting people through longterm conditions, right through to the end of life
itself. Specifically the Trust:
•Actively promotes healthy living and healthy
lifestyles through specific services geared to
this purpose, and also through our hundreds
and thousands of contacts with people
concerning their health every day of every year;
•Detects early signs of ill health and identifies
where actions, behaviours or symptoms may
result in illnesses developing at a later stage;
•Intervenes and treats people across a wide
range of specialties and conditions to return
people to a state of optimum health and
wellbeing;
•Where optimum functioning cannot be
achieved we support people to manage
their conditions to achieve the best possible
functioning and to prevent deterioration;
•When our patients reach the end of their lives,
we support them and their families and carers
to ensure that this time is as comfortable as
possible.
Respiratory nurse specialist Deborah Walls.
Community Renaissance
A key component in the delivery of the Corporate
Strategy is the ongoing service developments
and improvements that have been implemented
within community services.
The Community Renaissance programme will
radically reshape community care in line with
modern, 21st century evidence-based models
of care delivery with the creation of ‘Teams
Around the Practices’ and ‘Virtual Wards’. The
Community Renaissance programme is starting
to:
•Develop ‘Teams Around the Practice’ which will:
--Improve the way in which clinical care is
provided;
--Remove any duplication of service
provision;
--Utilise multidisciplinary teams organised
around GP practice populations;
--Ensure more seamless care for patients;
--Promote integrated working with local
authority colleagues.
•Develop the ‘Virtual Ward’ which will provide:
--A framework for service provision;
--Support in the community to people with
the most complex medical and social needs;
--Systems and clinical professionals on par
with that of hospital care but without the
physical building;
--Standardisation of care pathways based on
clinical evidence and safety.
Carrol Simpson receives intravenous antibiotics at home with community staff
nurse Nick Doughty and rapid assessment support worker Amanda Adamson.
Annual Report and Accounts 2011 – 2012
23
Environmental Developments
Throughout the year the Commercial Directorate continued to support the Trust in
achieving all of its objectives. It provided a comprehensive range of services covering
all aspects of management of the estate and facilities services over a wide range of
non-clinical support services.
During the year the estates and facilities management team has:
•Completed the capital programme for the period 2011-2012 delivering a wide
range of environmental, safety and service improvements across the Trust;
•Continued with the estates strategy, to rationalise the estate, including the plans
for demolition of the vacated Elderly Care Day Hospital on the Hartlepool site in
readiness for land disposals;
•Improved space utilisation which has enabled the Community Services
administration staff to vacate what was poor, expensive, leased accommodation,
and relocated to a vastly improved environment within the hospital setting,
at much reduced accommodation cost, supporting the Trust’s cost reduction
programme;
•Further developed ‘deep cleaning’ and 24-hour rapid response domestic cleaning
services, providing ward hygienists and deployment of hydrogen peroxide
vapour decontamination of the environment. The strategy has developed a
decant programme across all in-patient wards of the Trust, thus enabling full
decontamination to assist in the Trust’s initiatives to reduce hospital acquired
infections and environmental improvements;
•Undertaken major refurbishment of catering facilities across both sites, improving
quality, satisfaction and profitability of catering services, as well as maintaining a
5-star Environmental Health Award;
Ward hostess Claire Corking.
•Major investment has also taken place to provide the very best possible standards
of Legionella prevention systems, improving safety for users and delivering
innovative solutions that have been published nationally;
•Completed the digital breast screening expansion programme as the lead provider
organisation in the region;
•Completed the Access Lounge facilities at the University Hospital of North Tees.
Alongside the need to provide the highest quality of care for our patients we
want a clean and safe environment. We were, therefore, delighted to achieve a
Patient Environment Action Team (PEAT) score of 5 or ‘excellent’ for all three PEAT
areas, which assessed cleanliness and the environment, hospital food, and privacy
and dignity.
We also performed well against other targets upon which we were assessed. These
included the key standards recognised by the Care Quality Commission as being
most important for patients such as safety, cleanliness, dignity and respect, standards
of care and the delivery of accessible and responsive services.
Domestic Lam Swinbourne.
24
Annual Report and Accounts 2011 – 2012
Service Developments 2011-2012
The table below outlines the Trust’s main service developments implemented in-year. The Trust’s
planned priorities for 2012-2013 are reflected on page 33.
The following services were developed across elective, emergency and associated
pathways:
•Successful transformation of urgent and emergency care service delivery. Full transformation was
underway by August 2011 following an independent external review. The review supported the
Trust’s proposal to optimise safe and effective pathway management within the two hospital sites;
•Successful collaborative tender was won with South Tees and Durham & Darlington Acute
Trusts, for Bariatric Services to improve access for our local population;
•The introduction of Percutaneous Nephrolithotomy (surgical procedure to remove stones from
the kidney) (PCNL) and laser treatment within the Urology Service;
•The development of Acute Oncology Services in line with Cancer Peer Review measures for
patients within the emergency pathway;
•Appointment of a Dementia Specialist Nurse linked to the Trust’s patient safety agenda;
•Access lounge at the University Hospital of North Tees was redesigned to improve the elective
surgical pathway;
•Expansion of Ambulatory care pathways;
•Cardiology services developed across outpatient, diagnostics and inpatient pathways in line with
NICE guidance;
•Transient Ischemic Attacks (TIA) – GPs refer patients with a low risk TIA into the Trust’s daily TIA
clinic. The Trust operates a 7-day service for high risk TIAs with imaging;
•Electronic Document Management system (EDM) providing the Trust with an electronic view of
both historical and newly created patient records;
•Extension of the working day in the Chemotherapy Day Unit to enable patients to receive
chemotherapy early to reduce waiting times;
•Installed and tested an automated, electronic, biometrically accessed medicines storage
cupboard, as a prelude to a further roll out in 2012-2013;
•Antibiotic management has significantly decreased the expenditure on antibiotics, supporting
the work in Clostridium-Difficile reduction;
•Improved accommodation for relatives supporting patients nearing the end of their life;
•Continuous nurse prescribing competencies enabling further development of nurse led clinics.
In order to develop and integrate community services, overarching plans included:
•Rapid assessment and support for weekend discharge;
•A renewed focus with regard to the Discharge Liaison Team.
The above plans will assist in admission avoidance supporting care closer to home, supporting safe
and early discharge and patient safety by delivering improved care, which is clinically effective, and
innovative. The continued integration of community services remains one of the Trust’s key corporate
objectives and is seen in the context of ‘Transforming Community Services’ (2010).
25
Annual Report and Accounts 2011 – 2012
4.1.3 Stakeholder Relationships
Maintaining good relationships with all our partners, commissioners and local
stakeholders is a crucial element of the Corporate Strategy, and delivery of our
objectives and meeting the needs of our patients. Equally important in managing our
relationships is keeping staff informed along the way too.
The Trust has well established relationships with a number of stakeholders across the
area it serves, examples being:
•North of Tees Partnership Board, which replaced the Momentum Programme
Board. Membership includes the Chief Executives of the Trust and Tees and
County Durham PCTs, senior officers and the Chairs of the Pathfinder Clinical
Commissioning Groups;
Dementia nurse specialist
Carley Ogden.
•Local Involvement Networks (LINks) arrange ‘enter and view’ visits into the Trust
when concerns have been raised by the public. Following these visits, the LINk
members submit a report to the Trust including recommendations to improve
patient care and experience. A bi-monthly Multi LINk meeting with the Chairs of
the LINk has also been established;
•Local Health Overview and Scrutiny Committees scrutinise decisions made by the
Trust on behalf of the population it serves. The Trust meets with the Chairs of the
Health Scrutiny Forums on a regular basis;
•GP Lunch and Learn sessions are arranged by the Hartlepool and Stockton Clinical
Commissioning Groups. This is an opportunity for GPs and Consultants working in
the Trust to share good practice and improve communication between primary and
secondary care;
•The five universities for the North East (Newcastle, Northumbria, Sunderland,
Durham and Teesside) work with the Trust to provide our workforce with the right
knowledge and skills to provide a quality service;
•The Trust is a member of the Shadow Health & Wellbeing Boards for Hartlepool
and County Durham. The Trust also has representation on the Stockton Health and
Wellbeing Partnership;
•The Trust regularly attends various patient forums and community groups to
provide updates on service developments.
The Trust has forged alliances with neighbouring Trusts to improve existing care
pathways and initiate new pathways. The Bariatric Service is a new collaboration that
is provided by North Tees and Hartlepool NHS Foundation Trust, County Durham and
Darlington NHS Foundation Trust and South Tees Hospitals NHS Foundation Trust.
4.1.4 Corporate and Social Responsibility
North Tees and Hartlepool NHS Foundation Trust is committed to being a good
corporate citizen. During 2011-2012, it worked hard to strengthen its corporate
responsibility programme.
The Trust believes in Good Corporate Citizenship (GCC), which is demonstrated
throughout this report. Corporate social responsibility touches all areas of the Trust’s
activities including how the Trust trains and develops its workforce, how it purchases
goods and services, how it uses energy and how it conducts its relationships with its
patients, carers, members of staff, Governors and members of the public. The Trust
continues to improve its GCC rating on an annual basis and is positioned well above
national averages.
26
Annual Report and Accounts 2011 – 2012
During 2011-2012, the Trust has successfully
completed all stages of the Carbon Trust's
NHS Carbon Management Programme to seek
further improvements in corporate responsibility,
sustainability and reduction of carbon emissions.
The Trust has developed and embedded its
business values across the whole organisation,
through a programme of development and
customer care.
Trust’s Business Values
The Trust sees healthcare as a people business
and places great emphasis on all the people
associated with its business, such as patients,
carers, staff, Governors and members of the
public. This is recognised in our People First
Values which underpin service delivery.
The Trust expects People First Values to drive
behaviour when delivering care to patients
and their families as well as dealing with
colleagues and people within and external to the
organisation.
The Trust’s People First Values expect that we will:
•Be responsive to the needs of our patients as
individuals;
•Be responsive to the needs of our stakeholders;
•Treat all people with compassion, care,
courtesy and respect;
•Respect each person’s right to privacy, dignity
and individuality;
•Take time to be helpful;
•Respond quickly and effectively;
•Always give clear, concise explanations;
•Practise good listening skills;
•Develop and maintain an appropriate
environment;
•Look the part;
•Deal effectively with difficult situations;
•Perform as a team.
Fundamentally, ‘Putting Patients First’ is what the
Trust stands for and believes in.
4.1.5 Environment, Sustainability and
Climate Change
The Trust endorses the views of Saving Carbon,
Improving Health (2008), and Fit for the Future
(2009) Department of Health Sustainable
Development Unit, which highlights the need for
the NHS to reduce its carbon footprint to be a
good ‘corporate citizen’.
The NHS is responsible for 18 million tonnes
of carbon dioxide per annum and is one of the
largest public sector emitters in the world. It has
economic and ethical obligations to reduce its
impact on the environment not only for public
health, but also for its own health and long-term
survival. The reports conclude that a low carbon
NHS is a more efficient NHS and, if the service
is to provide the best quality of healthcare in
the future, it must build on both its efforts to
mitigate climate change and its resilience to
that change. This would require an investment
in the future to achieve this. Climate change is
regarded as the biggest global health threat of
the 21st century.
The NHS carbon footprint of 18 million tonnes
CO2 per year is composed of energy (22%),
travel (18%) and procurement (60%). Despite
increased efficiency, the NHS has increased its
carbon footprint by 40% since 1990. To meet
the Climate Change Act (2008), targets of 26%
reduction by 2020 and 80% reduction by 2050
are required, which is regarded by many as a
huge challenge. The Trust aims to reduce its
2007 carbon footprint by 10% by 2015 which
will require not only the current level of growth
of emissions to be curbed but the trend to be
reversed and absolute emissions reduced.
The Trust has developed an Environment,
Sustainable Carbon Governance Committee to
focus resources into deliverable short, medium
and long-term goals. The Trust aims to work
towards a low carbon environment across its
services that include transport, service delivery
and community engagement. The Trust has
participated in the Carbon Trust’s NHS Carbon
Management Programme, identifying an 18%20% reduction in carbon emissions over a fiveyear period through capital investment and staff
awareness campaigns. The Carbon Trust has fully
supported and approved this plan.
27
Annual Report and Accounts 2011 – 2012
As part of its governance, the Trust has established its current position by
participation in the ‘Good Corporate Citizen Assessment Model’ developed by
the Sustainable Development Commission and, in addition, is ahead of target in
achieving the 2015 goals.
Carbon Value at Stake
18,000
16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
Year
Actual
BAU (+0.7%)
Target
BAU - Business as usual
Strategic Objectives:
•Reduce emissions from energy, waste, procurement and transport;
•Realise fiscal savings through the implementation of the objectives and identified
projects;
•Promote the Trust as a ‘Good Corporate Citizen’ and develop a low carbon culture
among its workforce.
Targets
The Trust plans to reduce the level of carbon emissions from a baseline position at
2007 by a minimum of 20% by 2015. Embarking upon this strategy to reduce the
impact on the environment from emissions, enables the Trust to demonstrate how it
will meet these obligations and provide responsible leadership as a Good Corporate
Citizen within the communities we serve.
The Trust has:
•Successfully participated in the Carbon Trust NHS Carbon Management Programme
2010, which concluded in May 2011. Recognition of environmental success was
achieved through the ‘silver’ award from The Green Organisation;
•Continued to deliver the Estates Strategy, aimed to reduce the size of the occupied
estate from 2007 levels by 20% by 2015; currently this programme is ahead of
projections;
•Implemented a complementary Travel Plan, which aims to reduce the number of
single occupancy car journeys by 5%, by 2015;
•Achieved and maintained a minimum Display Energy Certificate (DEC) of ‘D’ for
both hospitals sites. It is pleasing to note the University Hospital of North Tees has
received its lowest ever DEC rating of ‘C’ and the University Hospital of Hartlepool
continues to evidence a downward trend of consumption whilst rated ‘D’;
28
Annual Report and Accounts 2011 – 2012
•Improved energy consumption (GJ/100m3)
with a 10% reduction from 2007 levels by
2015;
•Reduced carbon emissions by 20% between
2007 baseline and 2015, progress against this
target is ahead of schedule.
Carbon Governance Arrangements
The formation of an Environment, Sustainable
Carbon Governance Committee, chaired by an
Executive Director, will oversee performance and
governance issues. A comprehensive range of
measures will be implemented, measured and
reported on a quarterly basis with summary
being incorporated in annual reports on the
following:
•Compliance to estates strategy and occupied
space levels;
•Good Corporate Citizen Assessment Model
ratings and improvements;
•Reduction in single car journeys through the
application of the Trust’s Travel Plan;
•Progression through Carbon Trust NHS Carbon
Management Programme;
•Energy performance ratings utilising DEC
methodology;
•Utilities consumption and carbon emissions
utilising NHS Estates Returns Information
Collection (ERIC) reports;
•Monitoring and reporting of waste disposal to
landfill sites and recycling levels.
Reporting on progress of the plan will be
provided on a six-monthly basis to the North
East Strategic Health Authority.
•Benchmark of peer performance using the
Department of Health Premises Assurance
Model of space efficiency and effectiveness;
Specialist oncology nurse practitioners Tracy Nugent and Maggie Wright.
29
Annual Report and Accounts 2011 – 2012
4.2 Operating Review
This section provides an overview of the Trust activities,
developments and future challenges. The Trust ensures all risks are
effectively managed, and we ensure compliance with all regulatory
targets and performance indicators.
4.2.1 Performance and Development of the Trust’s Business
In August 2011 the emergency services provided by the Trust saw the final stages of
the development of a reconfigured model within the principles of the Momentum:
pathways to healthcare programme.
The service model, which became operational on 2 August 2011, included the
provision of a Minor Injuries Unit at One Life Centre Hartlepool, with 24 hours per
day availability, an extended Emergency Assessment Unit and Ambulatory Care Unit
at the University Hospital of Hartlepool; reconfigured Accident & Emergency Unit at
the University Hospital of North Tees, and a single point of access for patients at the
One Life Centre Hartlepool, to ensure patients access the right service the first time.
The Trust developed a robust evaluation framework and governance process to
enable informed operational and strategic decisions around the management and
future delivery of the new service model with successful evaluation to date. The Trust
will continue to further develop processes to ensure the organisation delivers safe,
reliable, efficient and cost effective services in keeping with the strong reputation of
the Trust in delivering urgent and emergency healthcare services.
The table below demonstrates Trust activity within 2011/12 against 2010/11. During
2011/12 the Trust saw a small decrease in elective activity across inpatient planned
admissions, with an increase in day case admissions. Outpatient attendances (New
and Review) saw a decrease, as a result of working with the PCTs and GPs to achieve
commissioning intentions of reducing ‘Consultant to Consultant’ referrals and ‘New
to Review’ ratios. Ward attender activity also saw a decrease against contract.
A&E attenders decreased following the reconfiguration of the Emergency Care Pathways
in August 2011 as described above and in line with the Trust's move to follow an
Ambulatory Care model. The admitted non elective activity also saw a decrease
against 2010/11, which was in line with the Trust move to more ambulatory care
provision where activity significantly increased in line with QIPP health economy plan.
The Annual Operating Plan negotiations to agree the 2012-2013 contractual activity
once again resulted in a detailed and robust process with rigorous challenge and
contest, with the end contract agreed in March 2012. The Board of Directors and
Finance Committee have been appraised of progress. The contract poses challenges
to system efficiencies, pathway delivery, and systems to forecast activity and finance
against plan. The detail of which will continue to be shared with the Board of
Directors to enable debate and challenges as to future risk and mitigation.
Point of Delivery
Sister Jacqui Downes with a patient in the
minor injuries unit at One Life Hartlepool.
2010/11 Actual
2011/12 Actual
% Variance
Accident and Emergency Attendances*
99,504
91,248
-8.30%
Day Case Admissions
30,735
32,967
7.27%
Inpatient Planned Admissions
Inpatient Emergency Admissions
Ambulatory Care Attendances
Outpatient Attendances (new and review)**
Ward Attenders
30
7,176
7,052
-1.55%
44,072
39,826
-9.63%
2,721
6,187
127.38%
227,677
219,245
-3.70%
27,276
25,059
-8.13%
* Reconfiguration of Emergency Care Pathways in August 2011. ** Consultant and nurse-led clinics.
Annual Report and Accounts 2011 – 2012
Service Line Management
Service Line Management (SLM) continues to
be implemented by all clinical, non-clinical and
community services. During the current difficult
economic climate with the challenges of cost
improvements, Quality, Innovation, Productivity
and Prevention (QIPP) and driving performance
improvement whilst maintaining and enhancing
quality and safety, clinicians are using SLM as
a model to deliver operational and financial
efficiencies, to improve patient experience
and enhance the quality and safety of services
delivered. Organisational structures have been
redesigned to ensure robust structures are in
place to deliver SLM. 2012-2013 will see the
continued development of service lines.
The Trust has commissioned the University of
Durham to deliver a leadership programme
specifically aimed at developing leadership
and management within the service lines.
Two cohorts have completed the programme
and the third cohort has commenced. The
programme is designed to develop the service
line’s leadership and equip them to manage
efficient and quality services.
A patient level information costing system
(PLICS) is being developed to support the
implementation of Service Line Reporting (SLR).
Operational Performance
The Trust is committed to developing and
improving service efficiency. In line with
commissioning agreements in the Integrated
Strategic Operating Plan (ISOP), Commissioning
for Quality and Innovation (CQUIN) and QIPP, the
Trust’s programmes concentrate on efficiency
indicators aimed at improving patient pathways
with care closer to home, where appropriate.
Progress is reported to the Board of Directors
within the Corporate Dashboard, together
with detailed indicators incorporated into the
specialty and sub-specialty dashboards, to enable
specialty focus.
The current economic climate with the
requirement of substantial efficiency savings
and with the overall objective of moving to a
new single site hospital, pose more challenging
requirements in 2012-2013 with penalties within
the ISOP, against locally agreed performance
standards and QIPP, to drive improvements in
efficiency.
The Trust will endeavour to continue with its
success in managing service improvements to
deliver the operational efficiencies through
projects such as, reducing the number of wasted
appointments through the implementation of a
telephone reminder service, enhanced recovery
in elective surgery, the operating theatre review,
the readmissions audit and admissions avoidance
where patients can be treated in an ambulatory
care setting. Additional projects will be identified
and implemented, where appropriate, using
Lean methodology to diagnose and drive change
in patient pathway management.
The Trust achieved Care Quality Commission
(CQC) registration without conditions in April
2011, which is a reflection of the safe, high
quality levels of care provided in the organisation
and continues to deliver against key standards
as reported by the unannounced CQC visits (16
November 2011).
Overall a relatively good year for operational
performance. The Trust continued to deliver
on key cancer standards throughout the year;
two week outpatient appointments; 31 days
diagnosis to treatment and 62 day urgent
referral to treatment access targets. The Trust
demonstrated a positive position with evidence
of continuous improvement against the cancer
standards introduced in the Going Further with
Cancer Waits guidance (2008).
Performance against key national priorities
for 2011/12 from the Department of Health,
Operating Framework Appendix B of the
Compliance Framework are provided on Page 86
of this report.
Effective surge management remains a priority
within the emergency preparedness agenda,
and as such the Trust had a well-developed
flexible capacity plan to accommodate surges in
demand, which was effective in managing the
challenges posed by the winter of 2011-2012.
31
Annual Report and Accounts 2011 – 2012
4.2.2 Business Planning and Linkages to Key Activities
The Trust has a robust business planning cycle which commences in July each
year, with a Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis.
Plans for the forthcoming year are submitted in October allowing initial relevant
information to be shared between services. In addition, the timely development
and focus afforded to directorates and departments through early planning
enables a robust and structured approach to contract negotiation.
Each Business Plan is accompanied by relevant Strategic Outline Cases (SOC),
which in turn are shared for consideration in the impending year’s contracting
negotiations with commissioners. Each SOC is progressed through the governance
route of the Trust and ultimately presented to the Capital and Service Development
Group for consideration as to alignment with strategic priorities, investment
potential and lifecycle payback.
The Trust continues to re-profile services and flex capacity to accommodate changes
in service demand, disease profile and patient needs. The resilience in capacity
management will continue into the future especially in the face of the limited public
spending and the need for further cost improvements and, more specifically, given
the planning assumptions expected on growth and efficiency.
The business planning cycle has enabled the Board, managers and clinicians to
review services with the aim of embracing technological advances, quality and safety
requirements in preparing for the development of the proposed new hospital.
Five main categories were identified within last year’s Annual Plan and given priority
throughout the year, these were:
1. Transformation of accident and emergency service delivery;
2. Integration of acute outpatient pathways into community;
3. Elective service developments;
4. Emergency service developments;
5. Transformation of community services.
These continue to be key to the delivery of our services. Achievement against these
activities for 2011-2012 can be found on page 25. Looking forward to the service
needs for 2012-2013, our priorities are identified opposite.
32
Annual Report and Accounts 2011 – 2012
The Trust is assessing the viability of provision of the following new services in 2012-2013 in
contributing to the improved safe provision of efficient and cost effective services:
Planned Service Development Priorities for 2012-2013:
•To further develop and review urology services to deliver care closer to home;
•Development and expansion of fat grafting for breast reconstruction for patients with cancer;
•Development of further hand and wrist day surgery;
•Progress with developing sports injury services pathway in conjunction with radiology, A&E and
surgery;
•To further develop the trauma unit within A&E and across pathways to manage improved clinical
outcomes;
•Development of stroke services enabling care for patients closer to home;
•To adopt an integrated approach to primary and secondary care respiratory pathway thus
providing a seamless service for patients;
•Further development of Endobronchial Ultrasound Services (EBUS) with continued development of
the unit as a centre of excellence in investigational bronchoscopy;
•Development and provision of bedside Thoracic Ultrasound Service by Chest Physicians for pleural
interventions;
•Development/support for Non Invasive Ventilation (NIV) at home preventing hospital admission;
•Development of telephone clinics for monitoring of certain haematological conditions which
currently require outpatient attendance;
•To develop a one-stop service for an Early Arthritis Clinic;
•To further develop a 24-hour specialist children’s emergency department;
•Implement telehealth enabling patient monitoring at home preventing admission/readmission to
hospital.
Clinical Support Services contribute to the Trust's overall plans by developing
the following:
•A strategic approach to implementing technology solutions to problems of efficiency,
patient safety, and waste by creating business cases for electronic prescribing and medicines
administration, robotic dispensing and electronic medicines cupboards;
•Delivery of a Microbiological Reporting Service from the Quality Control Laboratory on a funded,
pull, web platform and integrated into a Laboratory Information and Management System;
•Investment in a Cardiac Computed Tomography (CT) scanner to enable cardiac imaging thus
aiming to minimise intervention where possible.
33
Annual Report and Accounts 2011 – 2012
4.2.3 Future Challenges to Performance Delivery
The National Operating Framework 2012 outlines the performance expectations for
NHS services and organisations for 2012-2013. Improving access, quality, patient
safety and experience remains high on the performance agenda, with the national
performance measures falling into five domains of delivery that will be given
particular attention in 2012-2013:
•Preventing people from dying prematurely;
•Enhancing quality of life for people with long term conditions;
•Helping people to recover from episodes of ill health or following injury;
•Ensuring that people have a positive experience of care;
•Treating and caring for people in a safe environment and protecting them from
avoidable harm.
The national performance measures include the ongoing monitoring of Referral to
Treatment (RTT) pathways, focussing on the original 90% compliance for admitted
pathways and 95% for non admitted pathways, which will be measured at specialty
level. This will be further supported by the 95th percentile and median waits.
Incomplete RTT pathways are high on the national and local agenda and measures
have also been added into the performance indicators with a standard set at 92%
completed within 18 weeks. The operational performance, see page 31, highlights
the success of the Trust in managing incomplete pathways beyond the required 92%.
In addition to the RTT access measures the following key performance indicators will
be monitored closely to ensure the Trust fully complies with all the required domains:
•Reducing Diagnostic waiting times;
•Further reduction in the number of cases for both MRSA and C-diff;
•Reduction in MSSA and E-Coli cases;
•Total time in A&E supported by the shadow monitoring of the A&E Quality
Outcome Standards, including:
--arrival to discharge;
--arrival to treatment;
--arrival to assessment for ambulance admissions/attendances;
--left without being seen;
--unplanned re-attendance within 7 days.
In addition supporting indicators will also be monitored for improvement, including
the cellulitis management pathway and consultant review:
•Reduction in new to review ratios;
•Risk assessment of hospital related Venous Thromboembolism (VTE);
•Reduction in emergency readmissions within 30 days;
•Reducing avoidable hospital admissions for acute conditions;
•Managing increasing emergency pressures;
•Achieve operational efficiencies in line with the QIPP agenda.
34
Annual Report and Accounts 2011 – 2012
Surge management will continue to be a
priority to ensure emergency preparedness,
resilience and performance is robust. In addition,
balancing the equilibrium between operational
efficiency, financial performance and patient
safety and quality will pose new challenges in
the climate of cost reduction and ever increasing
efficiency requirements.
All but one of the required governance standards
were achieved, the exception being the required
annual reduction in hospital acquired Clostridium
Difficile cases which was disappointing for the
Trust. This is further expanded upon in section
4.2.5.
4.2.4 Risk and Uncertainties
The Board of Directors is aware of the risks on
operational performance and has continued to
assess associated risks with necessary actions
taken to mitigate against such risks. This will
contribute to the Board’s capacity to declare
assurance and capability to deliver the key
objectives within the Annual Plan.
Following the publication of the White Paper
“Equity and Excellence: Liberating the NHS”
in the summer of 2010, there was a pause
and listening exercise which led to further
clarifications of the scale of reforms expected
of the NHS. At the time of writing, some of
this policy is still emerging, however, the Trust
continues to follow its strategic direction, which
sets out an ambitious programme of work for
the next five years aimed at providing the best
possible healthcare for the people that we are
here to serve.
The backdrop of risks and uncertainties against
which the Corporate Strategy is to be delivered,
are predominantly those of economic downturn
and financial pressures, changing policy and
structures within the NHS and Local Authorities,
and the realisation of a new hospital to complete
the service transformation journey to develop
and implement a new healthcare system. Taking
each in turn:
Economic Downturn and Financial
Pressures
Worldwide and the United Kingdom economic
situation provides the context for the NHS in
general and for the Trust in particular.
The requirement for the NHS to release
£20billion savings for reinvestment, which
led to the Department of Health establishing
the QIPP programme with its emphasis on
Quality, Innovation, Productivity and Prevention,
continues to be the economic backdrop in which
the NHS is operating. For the Trust, this equated
to a Cost Improvement Programme (CIP) totalling
£16 million through 2011-2012 and similar
challenges in the following two years, which
the Trust has called its £40million challenge. In
order to manage the pressures locally, the North
of Tees Partnership Board was established with
Executive membership from the Foundation
Trust, the local Primary Care Trusts, and local
CCGs. One of the key tasks of the Board is
to “oversee the delivery of the shared QIPP
objectives of the constituent organisations” with
a range of other tasks, which include ensuring
high quality clinical services are maintained
whilst protecting the financial stability of the
local heath economy, overseeing the delivery of
capital developments in community locations
and service changes associated with the new
hospital, and acting as a director-level reference
group during the contracting period.
The Trust’s financial risk rating remains at
3. The current planned rating of 3 results
from deliberate reductions in surplus and the
Earnings Before Interest, Taxes, Depreciation
and Amortisation (EBITDA) margin. The Board
took a conscious decision to reduce the planned
income and expenditure surplus to ensure an
appropriate balance between the challenging
financial efficiency agenda and the desire to
continue to improve quality, patient experience
and service performance. This decision was
taken with due cognisance to an EBITDA margin
percentage at the lower end of the spectrum
for the acute sector, which is a function in the
main of the impact of having no major leases or
PFI and being the first NHS Foundation Trust to
integrate community provider services.
35
Annual Report and Accounts 2011 – 2012
Other matters that have impacted upon the Trust include:
•The technical changes to tariff whereby the costing and pricing for services could
be impacted if the Trust has provided more services than the contract will pay for,
therefore insufficient funding could follow core activity;
•The Trust saw the realignment of services following a tendering process with some
services transferring to private sector providers;
•Centralisation/regionalisation of services to provide patients with care delivered
by specialist units that are designed to treat the minimum number of patients to
maintain expertise. The impact would be for the Trust to potentially lose services or
become a key provider;
•Funding for the proposed new hospital has not yet been secured even though a
strong case has been made. It is anticipated that 2012-2013 will be the time when
a final decision will be made about the new hospital;
•National and local pay, and terms and conditions of service, a proposal to change
nationally has not materialised, therefore a local review will be required. The impact
of no change would have an impact upon the proposed efficiency saving targets.
All of the above are being considered in the light of their impact upon local and
national policy, best practices and services the Trust can invest in and secure.
Changing Policy and Structures
The two most significant structural changes have been the creation of CCGs and
the movement of Public Health from the NHS to Local Authorities. With it the
establishment of Health and Wellbeing Boards to bring together the key NHS, public
health and social care leaders to work in partnership to improve the health of the
population. With respect to CCGs, in addition to the establishment and membership
on the North of Tees Partnership Board outlined above, other activities are carried
out in order to maintain strong relationships with clinical commissioners and GPs in
the form of GP Lunch and Learn sessions, which provide an opportunity for GPs and
Consultants working in the Trust to share good practice and improve communication
between primary and secondary care.
Following the changes to Public Health the Trust is a member of the Shadow Health
& Wellbeing Boards for Hartlepool and County Durham and has representation on
the Stockton Health and Wellbeing Partnership. It should be noted that managing
our relationships is one of six key strategic themes for the organisation.
The introduction and further development of competition within the system through
Any Qualified Provider (AQP) poses a risk to reduced income through patients
exercising choice for treatment elsewhere. However, the management of the Trust
reputation through clinical governance, good performance, marketing and close
relations with commissioners and GPs should ensure that market share is not
lost, furthermore it is these attributes that the Trust is exploiting in order to grow
business, in particular through patient repatriation.
Another area related to structures and systems is the drive for the centralisation/
regionalisation of some regional services coupled with the geographic location of
Trust sites, the range of services provided and the recruitment/retention of scarce
staff. This could lead to the loss of key services through movement to other Trusts
and impact on our ability to recruit to key posts to deliver services.
The Trust is positioning itself to take on the central/regional services that may be
under threat through positive promotion of the Trust.
36
Annual Report and Accounts 2011 – 2012
In the short-term this should at least maintain
the status quo with a longer term view to ensure
that we provide at least one of the central/
regional services.
Service Transformation and the New
Hospital
Service transformation continues to deliver the
bed reductions required in the capacity plan,
provide care closer to home and increase quality,
accessibility, integration, responsiveness and
value for money across the patient pathway.
Service changes have already delivered almost
a 10% reduction in the use of acute beds
across both hospital sites and better pathways
for patients. The Trust has continued to work
with the Department of Health and other key
stakeholders regarding our aspirations for the
provision of a new hospital, the current position
is described on page 18. We expect that 201213 will see the final decisions made regarding
these plans, which will enable the service
transformation plans to be completed.
4.2.5 Regulatory Ratings
The Trust has continued to strive to achieve
clinical and financial success during 2011-2012,
which has resulted in overall adherence to the
Terms of Authorisation.
The quarter 4 position is tentatively reported at
a risk rating of 3 for finance, 'Amber/Red' for
governance and 'Green' for mandatory services
(pending final assessment by Monitor).
Table 1 and 2 overleaf provides an analysis of
actual quarterly rating performance compared
with the expectation in the Annual Plan 20112012, together with a comparison of the
previous years’ (2010-2011) rating performance.
Almost all of the key indicators against which the
Trust is judged relate to clinical care, managerial
standards, efficiency and effectiveness. The Board of Directors is committed to reducing
clostridium difficile infection (CDI) across both
acute and community settings. The challenge in
reducing the hospital acquired CDI numbers is
not to be underestimated and it is recognised
that with a legacy of successful performance,
further and continued focus will assist with
controlling and managing potential numbers.
The Infection Prevention and Control Team
continue to work closely with clinical teams
and estates colleagues to ensure that all staff
are aware of the measures needed to reduce
the risk of CDI, and maintain high standards of
environmental cleanliness, whilst ensuring that
those patients who do become symptomatic are
managed appropriately, resulting in best patient
outcomes and optimum patient safety.
All Trusts are required by the Department of
Health to deliver a year-on-year reduction in
CDI cases, based on the previous year’s baseline
period (Oct-Sept).
The Trust is over trajectory for the year end
(2011/12) position.
•2009-2010 target set at 168 –
reported 136 cases
•2010-2011 target set at 127 –
reported 53 cases
•2011-2012 target set at 59 –
reported 68 cases
The Trust recognised in early June 2011 that
performance against the CDI target was
challenging and subsequently adopted both
internal and external collaborative actions to
recover the position. The Trust worked closely
with colleagues from the Commissioning PCT
and the Health Protection Agency to take action
to improve the CDI performance. Whilst the Trust
was not alone in the trend of increased cases
of CDI, with the overall SHA seeing a reduction
in performance against trajectory during 20112012, reassurance was obtained following peer
review that the organisation was working in
line with other organisations and undertaking
appropriate actions. The Trust has implemented
robust mitigation plans and governance
processes, which have seen a reduction in
reported CDI cases during quarter 4 period. This demonstrates that once again, despite the
benchmark getting more difficult each year,
the Trust continues to perform well in both the
national and regional arena.
The Trust triggered Monitor’s ‘3 amber/greens
to red rule’ in respect of its CDI performance in
quarter 3. This led to a potential red governance
risk rating (GRR) whilst Monitor considered
whether to escalate and intervene with the Trust. 37
Annual Report and Accounts 2011 – 2012
Following a further review and meeting of Monitor’s Executive Committee on
13 February 2012, Monitor decided not to escalate the Trust at this stage, with an
interim GRR given of amber-red for Quarter 3. Table 1
Annual Plan
2010/11
Quarter 1
2010/11
Quarter 2
2010/11
Quarter 3
2010/11
Quarter 4
2010/11
3
3
3
3
3
Governance Risk Rating
Green
Green
Green
Green
Amber/ Green
Mandatory Services
Green
Green
Green
Green
Green
Annual Plan
2011/12
Quarter 1
2011/12
Quarter 2
2011/12
Quarter 3
2011/12
Quarter 4*
2011/12
3
3
3
3
3
Governance Risk Rating
Green
Amber/ Green
Amber/ Green
Amber/ Red
Amber/ Red
Mandatory Services
Green
Green
Green
Green
Green
Finance Risk Rating
Table 2
Finance Risk Rating
* tentative awaiting Monitor final assessment quarter 4.
4.2.6 Information Risks
The Trust is required to assess and report information risk and data losses in a
standard format provided by the independent regulator, Monitor. The table below
contains a summary of reported incidents, which relates to the loss of electronic
equipment or documents that contained personal data from outside secured NHS
premises. We take all incidents very seriously and these are investigated in the same
way as clinical incidents so that we learn lessons and take action to prevent similar
issues occurring.
Summary of Information Incidents
Category
38
Annual Report and Accounts 2011 – 2012
Nature of Incident
Total
1
Loss of inadequately protected electronic equipment, devices or paper
documents from secured NHS premises
2
2
Loss of inadequately protected electronic equipment, devices or paper
documents from outside secured NHS premises
0
3
Insecure disposal of inadequately protected electronic equipment,
devices or paper documents
0
4
Unauthorised disclosure
2
5
Other
1
4.2.7 Counter-fraud Arrangements
The Trust has an established counter-fraud policy and response plan to minimise the risk of fraud or
corruption, together with a code of conduct and whistle-blowing policy to be followed in the event of
any suspected wrong-doing being reported. The policies and related materials are available on the Trust’s
intranet and counter-fraud information is prominently displayed on the Trust’s premises. The Trust’s Local
Counter-Fraud Specialist (LCFS) reports to the Audit Committee and performs a programme of work
designed to provide assurance to the Board with regard to fraud and corruption. The LCFS gives regular
fraud awareness sessions to the Trust’s staff, investigates concerns reported by staff and liaises with the
police. If any issues are substantiated, the Trust takes appropriate criminal, civil or disciplinary measures.
39
Security Andrew Spindloe.
Annual Report and Accounts 2011 – 2012
5. Quality Report –
Our Commitment
to Quality
ANNUAL QUALITY REPORT 2012-2013
40
Non-executive director Steve Hall and staff nurse Melissa McKie.
Our approach to Quality: A statement on quality from the Chief Executive
The Trust welcomes the opportunity to present our annual quality report to demonstrate our
continued commitment to delivering high quality patient care. Whilst there has been much
publicity about the quality of care provided to some patients in hospitals in England and Wales
over the last year, I am always pleased to receive excellent feedback from our patients and their
relatives across both the community and hospital services we deliver, which demonstrates to me
that we strive to ensure that our patients receive high standards of clinical care, delivered by
caring, compassionate staff.
Despite the challenging economic climate during
2011-2012, we are committed to maintaining
quality and protecting frontline teams. We have
continued to invest in and expand our training
and development opportunities to provide staff
with the skills, technology and knowledge they
need to meet the needs of patients.
Our quality strategy and our quality report
indicate our priorities for the coming year.
These have been developed with patients,
carers, staff, Governors, commissioners and
with key stakeholders including health scrutiny
committees, local involvement networks (LINks)
and hospital user groups.
This, our second combined community and
hospital service quality report, demonstrates
some of the actions we have taken during
2011-2012, and highlights actions we will
be taking over the forthcoming year to ensure
our continued commitment to ensuring and
improving quality of care for our patients
wherever they receive treatment.
We believe and commit to Putting the Patient
First by making patient safety and experience our
number one priority every day.
41
Annual Report and Accounts 2011 – 2012
Contents:
Part 1:
Statement on Quality from the Chief Executive
Part 2:
Priorities for Improvement
2A Performance against quality improvement priorities for 2011-2012
2B Quality improvement priorities for 2012-2013
2C Statement of Assurance from the Board
Part 3:
3A Performance against additional quality improvement priorities 2011-2012
3B Performance against key national priorities from the Department of Health
Operating Framework, Appendix B of the Compliance Framework
ANNEX:
1 Third party statements
2 Statement of directors’ responsibilities in respect of the quality report
3 Independent Auditors’ Limited Assurance Report to the Council of Governors
42
Annual Report and Accounts 2011 – 2012
PART 1: STATEMENT ON QUALITY FROM THE CHIEF EXECUTIVE
Our quality pledge
Quality standards and goals
In 2008, our Board and our staff pledged
patient safety and experience as their
number one priority supported by a four year
quality strategy developed in 2009. Our clear
commitment to improving the quality of our care
and service quality for our patients continues
to be our number one priority. It is prevalent at
every level of our organisation and is generating
excellent performance results.
Values, standards and goals
Our Board of Directors receive and discuss
quality, performance and finance at every Board
meeting. We use our Patient Safety and Quality
Standards Committee and our Audit Committee
to assess and review our systems of internal
control and to provide assurance in relation to
patient safety, effectiveness of service, quality
of patient experience and to ensure compliance
with legal duties and requirements. The Patient
Safety and Audit Committees are each chaired by
non-executive directors with recent and relevant
experience, these in turn report directly to the
Board of Directors.
The Board of Directors seek assurance of the
Trust's performance at all times and recognises
that there is no better way to do this than by
talking to patients and staff. During 2011-2012,
the Board of Directors undertook their first
night-time review of services. This unannounced
visit enabled members of the Board of Directors
to witness for themselves how well our staff
manage patient care during the out-of-hours
period. This approach of unannounced visits at
varied times will be continued and enhanced
during 2012-2013.
The Trust greatly values the contributions made
by all members of our organisation to ensure
we can achieve the challenging standards and
goals which we set ourselves in respect of
delivering high quality patient care. The Trust
also works closely with the primary care trusts
who commission the services we provide to
set challenging quality targets. Achievement of
these standards, goals and targets form part of
the Trust’s four year strategic quality aims.
Listening to patients and meeting their
needs
Associate practitioner Sue Holmes shows Paul Kinnersley the
guide to coming into hospital with support worker Phil Dale.
We recognise the importance of understanding
patients' needs and reflecting these in our values
and goals.
Our patients want and deserve excellent clinical
care delivered with dignity, compassion, and
professionalism and these remain our key
quality goals.
Over the last year we have spoken with
over 1,000 patients in their own homes, in
community clinics and in our inpatient and
outpatient hospital wards and departments and
have asked patients how we are doing and what
we could do better.
We understand from patients that great
healthcare is defined in the way that we treat
patients, family members, carers and staff.
Annual Report and Accounts 2011 – 2012
43
Chief nurse of NHS North of England Jane Cummings with director of nursing, patient safety and quality Sue Smith, matron
Gail Fincken and ward manager Gail Johnson on the emergency assessment unit.
As a result of this we launched a consultation on our RESPECT nursing and
midwifery strategy in summer 2011. Our RESPECT strategy aims to promote the
importance of involving the patient and carer in every aspect of healthcare. The
strategy, developed by nurses and midwives with patients and stakeholders, was
formally launched by Jane Cummings, the Chief Nurse from the North of England
Strategic Health Authority in December 2012. The strategy encompasses the
fundamental elements of what we believe underpins great patient care. These are:
Responsive
Timely
Equipped
Patients
Carers
Staff
Care and
Compassion
Evidence
Based
44
Annual Report and Accounts 2011 – 2012
Safe and
Secure
Person
Centred
Achievements
Unconditional CQC Registration
During 2011-2012 the Trust met all standards
required for successful and unconditional
registration with the Care Quality
Commission (CQC) for services across
community and acute services.
The Trust also had two unannounced CQC
inspections, one at University Hospital of
Hartlepool in April 2011 and the other at
University Hospital of North Tees in November
2011, both of which resulted in the Trust being
assessed as achieving full compliance with
essential standards.
Finalists for HSJ Awards
We were particularly pleased to be a finalist for
two National Health Service Journal Awards
in 2011 as follows:
•Workforce development award for
our Modern Apprentice in nursing
programme. This programme provides a
career pathway for potential nurses of the
future whilst implementing defined clinical and
care standards and training for all unregistered
nursing staff entering hospital employment.
The programme has led to reduced reliance on
bank and agency provided nursing staff, with
consequential savings of over £0.5million
during 2011-2012;
•Acute healthcare organisation of the year.
The Trust was delighted to be a finalist in this
category and recognised for the great clinical
leadership and teamwork across all areas
of practice. This teamwork and leadership has
resulted in improvements in patient and staff
satisfaction, improved quality outcomes and
reduced mortality rates.
Our overall results in improving patient safety
and quality of care continue to be recognised
nationally and internationally with our clinicians
and clinical teams being featured in numerous
journals and conferences over the last year.
Introduction to Parts 2 and 3 of our
Quality Report
Part 2 of this quality report indicates it should
be performance over the year and priorities for
the future. Part 3 demonstrates and reviews
additional performance over the past year. This
quality report allows us to demonstrate our
commitment to continuous, evidence-based
quality improvement, to draw your attention to
the standards achieved and the progress we have
made and the approach we intend to continue.
It enables you the opportunity to assess the
quality of our performance across the healthcare
services we offer.
The areas we have chosen as our quality
improvement targets for 2012-2013 have once
again been set following consultation with
our Council of Governors, local health scrutiny
committees, local involvement networks, with
our commissioners and importantly, by talking to
staff, patients and carers.
Progress described within this document is
based on data and evidence collected locally and
nationally, much of which is presented as part
of our performance framework each month and
in our public board meetings, in our Council of
Governors meetings and to our commissioners.
To the best of my knowledge the information
given in this document is accurate.
Governance Rating
All Foundation Trusts are subject to assessment
by Monitor which was set for us under its
compliance framework. We achieved top ratings
for our high standards of clinical care, however,
we did not achieve our challenging clostridium
difficile target. Part 3, page 79 describes actions
we have taken to manage this.
Alan Foster
Chief Executive
45
Annual Report and Accounts 2011 – 2012
PART 2: PRIORITIES FOR IMPROVEMENT IN OUR COMMUNITY AND
HOSPITAL SERVICES 2012-2013
2A Performance against quality improvement priorities for 2011-2012
Introduction to our key priorities
In our 2011-2012 quality report, we identified a number of quality improvement
priorities that patients, staff and stakeholders agreed we should focus on over the
last year.
Priority 1 = Patient safety: reduce deaths and prevent deterioration
Priority 2 = Effectiveness of Care: clinical documentation and communication
Priority 3 = Patient experience: care with compassion
Part 2A of the quality report provides an opportunity for the Trust to report on
progress against quality priorities that were agreed with external stakeholders the
previous year. We are very pleased to be able to report some significant achievements
during the course of the year.
The outcomes reported in Part 2A are those that were requested and agreed
with external and internal stakeholders during the (2010-2011) consultation
period for 2011-2012 priorities. We would like to thank our stakeholders for their
continued engagement and involvement in setting our quality priorities but also in
reviewing progress during the year.
Some of our ambitions for 2011-2012 were more complex than anticipated and
took us longer than expected to achieve. For example, developing an early warning
score for use by community nurses took longer than expected because we could
not find a tool that was already available anywhere else. That meant that we had
to develop and test a new product before we could introduce it for use by
community staff.
Our teams did manage to develop a tool linked to Telehealth, however and during
the last few months of 2011-2012, we have been collecting baseline data. We
intend to continue this work during 2012-2013 and aim to report progress on this
outcome next year.
Where possible, we have provided additional sources of (external) data to
provide members of the public with as much information as possible.
Our progress against the above and the action plans for each of the priorities have
been regularly monitored via the Patient Safety and Quality Standards Committee,
the Council of Governors and by the Trust Board. Progress is described below for
each of the priorities.
We would like to acknowledge the hard work and commitment of our staff, both
clinical and non-clinical across all healthcare settings. It is their hard work and
dedication to putting patients first that delivers positive results.
46
Annual Report and Accounts 2011 – 2012
Throughout the quality report we will
include examples of changes made in
response to comments made by patients
and visitors. They will be described
through ‘you said; we did’ bubbles
as requested by one of our external
stakeholders during the consultation
period.
You said:
I would like to see a cancer specialist nurse
working on the EAU at North Tees to ensure that
cancer care is effective and joined up.
Why/How we chose this as a priority:
We want to reduce our mortality so that it is one
of the best in England. We have been reporting
on our progress to external and internal
stakeholders, for example to our commissioners,
Council of Governors, to health scrutiny
committees and to local involvement networks.
During the consultation period everyone agreed
that this must remain our number one priority.
Stakeholders also asked that we develop a
process that can be used in patients' own homes
to prevent escalation of care for patients with
chronic conditions.
We did:
We recruited a cancer specialist nurse to see all
cancer patients admitted to the EAU and to coordinate care across all teams.
We provided bespoke training for all nurses on
the EAU and introduced the carer's diary early.
Priority 1
Patient safety: reducing mortality
In 2008 the Trust, in partnership with external
and internal stakeholders agreed that its first
priority should be to reduce mortality. Through
our quality strategy, we set out a five-year plan
to achieve this. Patient safety remains the first
priority of every member of staff from ward to
board.
Our first patient safety priority identified
by external and internal stakeholders as well as
well as our staff was to reduce the number
of patients that die in our hospitals and this
year we continued to reduce opportunity
for avoidable deterioration at home or in
hospital.
47
Annual Report and Accounts 2011 – 2012
What we said we would do: Reduce deaths and prevent deterioration
Hospital Healthcare
Overview of how we
said we would do it
Overview of how we said
we would measure it
Overview of how we
said we would report it
How did we do?
• Collect information when
things don’t go according to
plan.
• Use of the Dr Foster mortality
database which predicts the
number of deaths that should
be expected in our hospital
based upon local demographic
information and case mix.
• Dr Foster mortality data to
be presented at every public
meeting of the Board of
Directors.
• Reported at
every Board
and Council
of Governors
meetings.
✔
• Reported by
CHKS and SHA as
most improved
mortality.
✔
• Over 600 sets
of observation
charts reviewed.
✔
• Audits of EWS
undertaken.
✔
• Number of
cardiac arrests
in hospital has
reduced.
✔
• Report and analysis incidents.
• Patient observations to be
carried out in a timely way.
• Any deterioration to be dealt
with quickly and by somebody
with the right level of
knowledge and skill.
• Review every patient who
suffers a cardiac arrest so that
we can be sure that there was
nothing more that we could
have done in the previous 48
hours to reduce the risk of it
happening.
• Communicate and embed
guidelines for the treatment of
sepsis (infection in the blood)
to ensure quick treatment.
• Work with key stakeholders
to develop and implement
a pathway for patients with
dementia. We aim to minimise
risk and ensure patients receive
specialist support where
needed.
• Monitoring Dr Foster data every
month to track our progress
against our target.
• Review in full, the CHKS data
supplied by the North East
Quality Observatory System to
benchmark mortality in our Trust
against other Trusts in the North
East.
• Mortality data to be presented
to the Council of Governors on
a quarterly basis.
• A copy of the quality report
to the Board of Directors to
be sent to our commissioners
every month.
• Monitor management of the
deteriorating patient by reviewing
observation charts on at least 50
patients every month.
• Undertake a Trust-wide audit of
early warning scores (the score
provided upon completion of a
set of patient observations) on
all patients in our hospitals twice
a year.
Community Healthcare
Overview of how we
said we would do it
Overview of how we said
we would measure it
Overview of how we
said we would report it
How did we do?
• Develop a Telehealth Early
Warning System (EWS) for
use in patients own homes
to support early identification
and management of
worsening of chronic illness,
reducing the need for hospital
admission, but maintaining the
appropriate level of care.
• Audit the use of the Telehealth
early warning score system and
evaluate the effectiveness of this
approach to early intervention.
• Monitor progress on a
quarterly basis in the quality
report to the Board of
Directors and to the Council of
Governors.
• Pilot the
Telehealth EWS
to establish
appropriateness
of use in the
community.
✔
• Development
of first known
community
Telehealth EWS
resulting in
supported early
discharge.
✔
• Monitor the impact on avoiding
hospital admissions, on reducing
length of stay and on patient
satisfaction.
• A copy of the quality report to
the Board of Directors will be
sent to our commissioners.
You said:
Then you said:
I attended rheumatology and because it was very
windy, I walked through the hospital which is a
long walk. I have rheumatoid arthritis. I would like
you to put a handrail on the left hand side up the
steep banks please. Thank you for reading this.
I am the lady who asked for hand rails as I walked
back from rheumatology. I have used them today
and it made a big difference to me going up the
slope. Thank you.
48
Annual Report and Accounts 2011 – 2012
As can be seen below, the outcome of Priority 1 was achieved. The following evidence provides more
detail to demonstrate how these improvements effect direct care.
Hospital healthcare – evidence in practice
1. A significant reduction in cardiac arrests – a cardiac arrest is what happens when a patient’s
heart stops beating. We believe (and the evidence supports) that this reduction is linked to a reduction
in the number of patients that deteriorate whilst in our care. The number of patients experiencing
cardiac arrest reduced by over 30% when compared to the previous year (129 cardiac arrests in
2010-2011 down to 91 in 2011-2012).
Quarter/Year
Apr- Jun
Jul- Sept
Oct-Dec
Jan- Mar
2010 – 2011 cardiac arrests
22
28
38
41
2011 – 2012 cardiac arrests
29
12
28
22
2. Lower risk of Pulmonary Embolism (PE) or Deep Vein Thrombosis (DVT) following
surgery.
The Trust has one of the highest rates of assessing patients for risk of PE or DVT in the country.
The rate of PE or DVT is (well) under the national average value. For 100 patients that suffer
from a post-operative PE or DVT in the average hospital in England, only 64.9 patients acquire one
after surgery in our hospitals.
Dr Foster database 2/3/12.
The Trust continues to monitor all mortality data including raw mortality data (all actual deaths)
weekly as well as looking at monthly and quarterly trends. This data is benchmarked regionally and the
overall trend remains positive.
3. Lower than average rate of mortality – Our hospital standardised mortality ratio (ratio of
deaths) continues to be lower than average with 94 patients dying in our hospitals compared to 100
patients in the average hospital in England. This is a great improvement on the Trust's highest mortality
ratio of 131 in 2008. The Trust was even featured in Dr Foster’s 2011 Good Hospital Guide for
reducing mortality ratios; evidence in practice. Members of the public can read the Good Hospital
Guide via the following link:
http://drfosterintelligence.co.uk/wp-content/uploads/2011/11/Hospital_Guide_2011.pdf
The 2011 Dr Foster Good Hospital Guide uses four mortality indicators and identifies the Trust mortality
ratio ‘as expected’ in relation to all of the indicators. Indicators used include hospital standardised
mortality ratio (HSMR) which reflect deaths in hospital and adjusts (makes allowance) for palliative
care; summary hospital mortality-level indicator (SHMI) which measures deaths in hospital and within
30-days of discharge and does not adjust for palliative care; deaths after surgery; and deaths in low
risk conditions.
49
Annual Report and Accounts 2011 – 2012
Community healthcare – evidence in practice
1. Development and use of bespoke Telehealth early warning system (EWS)
tool for use in community services. We could find no nationally developed early
warning system for use in community settings. Our community staff therefore tested
the hospital EWS for use in the community. The hospital EWS did not work in the
community therefore staff developed and tested their own system linked to Telehealth.
The EWS track and trigger tool measures patient blood pressure, temperature, pulse
and oxygen levels and a trigger (of worsening condition) results in a speedy review
of medication and care. The system supports real-time flow of information from
patient to clinical staff, supporting continuous evaluation of care needs, risks
and appropriate and timely interventions. We believe that the system designed
by staff will avoid crisis or deterioration resulting in a need for unscheduled care
(unplanned intervention or admission to hospital).
The key measurable benefits to patients using this system include:
•Supported early discharge;
•Improved confidence because patients know that their condition is being closely
monitored;
•Rapid response to any change in condition;
•Improved clinical risk management for a group of patients known to a service;
•Fewer unplanned admissions or readmissions to hospital;
•Convenience and comfort of being monitored at home.
The Telehealth EWS track and trigger system was implemented in December 2011
and baseline outcomes will be measured and reported in the 2012-2013 Quality
Report. Introduction and early success of this ground-breaking work had resulted in
our staff aim of developing a virtual ward in the community and this has been built
into the quality objectives described in this document for 2012-2013.
Clinical lead Paula Swindale with patient Alan Crooks who is using telehealth.
50
Annual Report and Accounts 2011 – 2012
Priority 2
Effectiveness of care; clinical
documentation and communication
Upon admission to our hospital patients will
be asked to provide certain information. Such
information is important to us to ensure our
patients receive the best possible care. This
information may be needed across various
clinical teams, however it can be frustrating to
patients when the same questions are asked by
many people.
One of our key priorities for 2011-2012 was
to reduce repetition of information and to
ensure that communication and documentation
between and across clinical teams is up to
date and complete, ensuring every healthcare
professional has all of the information they need
to make decisions speedily and effectively.
This goal was shared across our community and
hospital services and although it may not be
possible to eliminate all repetition, we believe
that working this way will result in more time
for healthcare staff to spend delivering direct
patient care.
We introduced contemporaneous
documentation so that all healthcare
professionals write in the same record, which is
easier to use, reduces paperwork and improves
communication between doctors and nurses.
Why/How we chose this as a priority:
The quality of documentation and
communication was a priority that a number of
our stakeholders believed should be a priority for
2011-2012 and it was also recognised as an area
for improvement in our 2010 staff patient safety
culture survey.
Amy Wetherell and Steve Badger with daughter Georgia at the assisted reproduction unit celebrations.
51
Annual Report and Accounts 2011 – 2012
What we said we would do: Improve quality of documentation and communication
Hospital Healthcare
Overview of how we
said we would do it
Overview of how we said
we would measure it
Overview of how we
said we would report it
How did we do?
• All healthcare professionals
write in the same document
as and when things happen
or decisions are made.
• Measurement will be carried
out using the number of
communication-related clinical
incidents, complaints and claims.
• Progress to be reported
through the Patient Safety and
Quality Standards committee
to the Board of Directors.
• Reported to Ps
and Qs.
✔
• The importance of good
communication will be
part of the training and
development of staff, starting
at induction.
• The Trust will audit the quality
of documentation and measure
the impact of these changes on
patient satisfaction.
• Monthly audits
completed. Over
600 patient records
reviewed.
✔
• SBAR
communications
tool in use and is
taught to clinical
staff at induction.
✔
• Introduction of
multi-professional
contemporaneous
documentation,
resulting in
healthcare
professionals
documenting their
care as they deliver
it in one shared
document. This
reduces the risk of
staff missing an
important piece of
information.
✔
• Reduction in
the amount of
paperwork that
doctors and nurses
have to complete.
✔
• We worked in
partnership with
South Tees Hospital
NHS Foundation
Trust, to agree how
both organisations
would use the same
documentation,
making transfers
better and easier
for patients and for
staff.
✔
• Promoting and embedding
the use of the Situation,
Background, Assessment and
Recommendation (SBAR)
communication tool across
clinical and non-clinical
teams to ensure that when
important discussions are
taking place, there is a clear
understanding between
staff of the situation,
background, assessment and
recommendation.
Community Healthcare
Overview of how we
said we would do it
Overview of how we said
we would measure it
Overview of how we
said we would report it
How did we do?
• Increase in the number of
Toughbooks used to treat
patients in their own homes.
• Measurement will be carried
out using the number of
communication related clinical
incidents, complaints and claims.
• Progress to be reported
through the Patient Safety and
Quality Standards committee
to the Board of Directors.
• 145 Toughbooks
in use.
✔
• Training provided
to all staff using
mobile working
solutions.
✔
• 35% reduction in
potential hospital
admissions
✔
• The importance of good
communication will be
part of the training and
development of staff, starting
at induction.
52
• The Trust will audit the quality
of documentation and measure
the impact of these changes on
patient satisfaction.
Detail of the impact of the improvements linked to Priority 2 and how they improve patient care are demonstrated
further opposite:
Annual Report and Accounts 2011 – 2012
Hospital healthcare – evidence in practice
1. High standards evident following audit
of quality of documentation –
The standard we expect is extremely high.
In relation to document completion, 25% of
a ward/department score can be lost if there
is one missing date or entry or page number.
The standard of observations we expect is
similarly high with 25% of a ward/department
score being deducted if one patient has one
observation missed at one point in their entire
episode of care with us. The Patient Experience
and Quality Standards (PEQS) scores highlighted
showed reviewers inspected every observation for
every day of care for over 777 patients. A good
average score of 90% was achieved across all
wards and departments reviewed in relation to
accuracy and quality of documentation.
The CQC reviewed documentation during its
unannounced review of services and reported
that people were receiving appropriate care
and treatment and that clear plans were
in place, which was continually updated
throughout people’s hospital stay.
2. Overall patients tell us that they are
satisfied with communication –
Our Governors and non-executive board
members spoke to 777 patients to ask
among other things, whether our healthcare
professionals communicate well with them.
They were asked if they understood what the
plan of care is and whether they have been
involved in decisions about them with staff
communicating in a way they understand, using
language they understand.
Patients and relatives were asked if they knew
what their medications were for and if they knew
what tests they were having and why. They were
also asked if our staff treat them with dignity
and respect, with kindness and compassion
(97% said yes) and whether or not they would
recommend our Trust (99% would). These
questions continue to be asked on a regular
basis and whilst recognising that we don’t get
it right every time, we have learned from the
national survey that patients are satisfied with
the following aspects of communication:
•We are involving people in decisions about
their care;
•People can find someone to talk to about their
worries and fears;
•Patients believe they are given enough privacy
when discussing their condition or treatment;
•Although we score well when compared to
Trusts nationally in relation to telling people
about medication side effects to watch
out for when they go home, there are still
improvements we can make. We will present
the data at directorate and professional
meetings and training days and promote this
aspect of communication, monitoring the
impact on our score;
•Our patients gave us a good score when they
were asked if they knew who to contact if they
were worried about their condition.
Trends over three years can be seen in the
table below (data taken from the 2011-2012
inpatient survey used for CQUIN).
Question
2009
2010
2011
68
71.2
73.7
Did you find someone to talk to about worries and fears?
59.9
59.1
63.9
Were you given enough privacy when discussing your condition or treatment?
79.3
82.7
82.6
45
57.4
52.2
76.2
80.3
82.9
Were you as involved as you wanted to be in decisions about your care and treatment?
Were you told about medication side effects to watch out for when you went home?
Were you told who to contact if you were worried about your condition after you left hospital?
53
Annual Report and Accounts 2011 – 2012
Community staff nurse Helen Butler.
3. Community healthcare – evidence in practice
Use of the toughbooks allows staff to electronically and contemporaneously
update patient information at the point of care, resulting in timely and accurate
documentation and clinical decision-making.
Being one of only eleven national pilot sites who have introduced mobile working
(toughbooks), we have undergone independent evaluation by the NHS Information
Centre for Health and Social Care (NHS IC) on this use and approach. Staff using
toughbooks are able to electronically and contemporaneously update patient
information at the point of care. This improved access to high quality information
has improved staff confidence when working across teams. A number of key
improvements were evident during the evaluation including:
•145 toughbooks have been introduced, funded by the Department of Health
with the further success in a (locally funded) bid for 154 additional devices for use
in adult services;
•5% decrease in referrals (633 referrals made with 33 referrals avoided) to other
clinicians/services in Hartlepool;
•19 patients were admitted with 10 potential admissions avoided, resulting in a
35% reduction in potential hospital admissions;
•An overall 8.5% reduction in retrospective and duplicate data entry. The reduction
in duplication across services varied and individual results can be seen in the table
below:
Service
54
Annual Report and Accounts 2011 – 2012
Baseline
Period 1 benefit
measurements
Period 2 benefit
measurements
Change
District nursing
9.6
7.5
7.7
-19.8%
Speech and language
therapy
0.5
0.1
0.0
-100%
Stroke team
7.5
6.8
7.4
-1.3%
Specialist nursing
2.7
2.2
1.6
-40.7%
•The number of patient contacts for each
clinician has increased by 15% from an
average of 5.85 contacts to 6.7 contacts per
day for each clinician;
•Staff have immediate access to corporate
and clinical policies at the point of contact
because they are immediately available on the
toughbook;
•Toughbooks provide patients with an
opportunity to book further appointments
at the time care is being delivered therefore
improving patient choice and access to services;
•Using the toughbooks provides important
performance data that can be used as evidence
that care standards are being met, for
example, we can now demonstrate, through
record audits that, during 2011-2012, to time
of writing the Quality Report, 100% of all
palliative care patients in the community
were contacted within one hour of
needing the service and this is now 24-hours a
day across all of our service provision;
•Toughbooks can be used to record patient
views as well as clinical care. To date, although
one client expressed a negative view regarding
IT systems, feedback from most clients has
been very positive;
•Staff satisfaction has improved because
information is immediately available and
records can be completed immediately,
reducing risk of errors or omissions.
This work has been showcased regionally
and nationally.
Further Development
In line with the strategic priority of the NHS
Operating Framework, further deployment of
technology and the electronic clinical record
is planned. The deployment of mobile devices
will be key to the accurate reporting of the
forthcoming national Community Information
Data Set. A further evaluation of the longer term
benefits of mobile working is to be undertaken
by the Department of Health.
The Trust will continue to audit the quality
of records, both paper and electronic, by
completing monthly healthcare record audits
and by continuing to monitor the quality of
patient’s records as part of the monthly Patient
Experience and Quality Standards Panel.
Scores from these are disseminated across the
teams and action plans devised if required.
You said:
It would be nice to have an easy chair when we
were staying overnight with mum.
We did:
We bought easy chairs for relatives who need to
stay overnight.
Priority 3
Patient experience; care with compassion.
We believe that patients have a right to be
treated in an environment that makes them
feel safe, secure and cared for. During 2011
and 2012 we continued to work hard to ensure
that every member of staff understands the
impact of a smile, a kind word and taking
time to listen. We aim to deliver a healthcare
service that people remember for the
right reasons. Linked to this, we hope that
patients and their carers will have a very positive
experience whether treated in the community or
in hospital and that they would recommend us
to people they know.
Feedback from CQC, patients and Local
Improvement Networks (LINks) as well as from
our commissioners has shown that the work
undertaken so far within the Trust continues
to result in overall high levels of patient
satisfaction.
We appreciate that on the few occasions that
we get things wrong, it could have a devastating
effect on those involved. We therefore aim to
reinforce and embed a culture where every
patient receives care delivered with compassion
no matter which service they use.
Why/how we chose this as a priority:
The quality of documentation and communication
was a priority that a number of our stakeholders
believed should be a priority for 2011-2012 and it
was also recognised as an area for improvement
in our 2010 staff patient safety culture survey.
Although we continue to improve it remains a
theme in both formal and informal complaints.
55
Annual Report and Accounts 2011 – 2012
You said:
We would like to see somebody with specialist skills to provide support and
training for staff caring for patients with dementia.
We did:
Appointed a clinical nurse specialist for dementia and provided training for all staff.
We also appointed a safeguarding adult nurse specialist to provide training and
assurance that staff can deal compassionately and effectively with the needs of
all vulnerable adults. We ran a learning disability awareness campaign and
have provided access to specialist training at Teesside University as well as to
online training.
What we said we would do: Care with compassion
Hospital & Community Healthcare
Overview of how we said we
would do it
Overview of how we said
we would measure it
Overview of
how we said we
would report it
How did we do?
• Speak to at least 50 patients on a
monthly basis, in their own homes, in
community premises and in hospital
departments to find out:
• Use of a patient experience scoresheet to record a quality score.
• The aggregated
score for patient
experience will be
reported in the
public Board of
Directors meetings.
• We spoke to over
600 patients
and carers in
community
clinics. In
patients' own
homes and in
hospital wards
and departments.
✔
• Results of the
PEQS reviews
were reported
at every Board
and Council
of Governors
meetings.
✔
• Feedback from
the carer's
diary has been
provided to
wards and
departments.
✔
• Bespoke training
on use of the
carer's diary has
been provided
and will continue
in 2012-2013.
✔
-- if we have treated them well;
• Quality scores to be given to
staff according to the feedback
received from patients.
-- if we have treated them with dignity
and respect;
• Positive comments will be fedback as well as recommended
areas for improvement.
-- if we have treated them with
kindness and compassion.
• Aggregated scores will be
provided to give a total quality
score for the Trust.
-- what we have done well and what
we can improve
• Invite our Governors to join our quality
review panels as independent members
of the quality review panel team to speak
to patients and carers.
• Every month the results will be discussed
with the senior clinical team and we
will use the feedback given by patients
to make the improvements that are
important to them.
• Feedback will be shared with
departmental teams so that they know
what they are doing well and what they
can do to improve.
• Teams will be supported to achieve the
high standards that they aspire to and
we will recognise and thank them when
patient feedback is great.
• The Trust to provide the support and
resources required when improvement
is needed.
56
• Findings will be compared
against the Trust's own
discussions with patients, the
results of visits by patient-user
groups such as those undertaken
by our commissioners and by
local involvement networks to
make sure that the Trust really
understands how it is doing.
• Members of the Board of
Directors to regularly speak to
patients and staff and their
findings will be discussed and
reviewed against other forms of
evidence.
• Use of carer's diaries to enable
relatives to comment on the
quality of clinical care (pain,
nausea and agitation) as well
as the personal support and
compassion provided during the
last hours or days of life. These
diaries will also be provided to
patients who suffer from chronic
conditions to ensure that the
Trust is meeting their clinical and
emotional needs.
• Results will also
be reported to the
Council of Governors
on a quarterly basis.
• Individual
department patient
experience scores
will be reported to
the department/
ward manager and
to the directorate
management teams
(senior doctor, nurse
and manager).
• Feedback from
the carer’s diaries
will be provided to
each department
and to the Board
of Directors
and Council of
Governors.
The impact of treating patients with compassion has a direct link to what patients and relatives/carers think about our
organisation.
Annual Report and Accounts 2011 – 2012
Carer's diary
During the year our carers diary was provided to the family or carers of 185 hospital
patients placed on the end of life care pathway. The diary provided an opportunity for family/
carers to score the quality of end of life care in relation to a number of key quality domains, these
being; pain, breathlessness, nausea (sickness), restlessness, staff care of the patient and staff care of
the carers. The comments made in these diaries provided staff with a vital opportunity to quickly
understand what they are doing well and how they might improve actual and perception of care
for each individual patient and their carers. Any score below 25 would indicate that the relative/
carer perceived that a suboptimal quality of symptom control or experience of care was provided.
Use of the carer's diary will enable the Trust to review scores and trends over time. It provides
an opportunity for staff to put things right and where appropriate for additional support
and training to be put in place to enable to Trust staff to influence perception of care so that we
continuously meet patient and carer expectations.
We have received no complaints at all about end of life care from patients where the carer’s
diary has been used.
Hospital healthcare – evidence in practice
1. Over the year, during our scheduled PEQS
visits, our Governors and Non-Executive
Directors visited 209 wards and departments
in our hospitals, speaking to 777 patients and/
or relatives as well as reviewing standards in
community clinics, in patients own homes.
In 2011 the Care Quality Commission joined
senior nursing staff on a PEQS visit and reported
how impressed they were by the robust process
and the benefits that this evaluation brings to
patients and staff alike.
In response to issues identified in the Airedale
Enquiry (2010), the Trust has been evaluating
standards of care and patient experience
during the out-of-hours period (nights
and weekends). The corporate nursing team
perform quarterly unannounced reviews of
standards and patient experience during
these hours. The Board of Directors have
also visited the hospitals at night to review
standards of care and to derive assurance that
our standards are high no matter what time
or day patients are treated in our hospitals. To
date, four such reviews have been undertaken.
The Board of Directors also intend to attend
community PEQS during 2012 so that they can
see how care is delivered for themselves. Patients
have reported good experiences throughout
these reviews and a number of actions have
been taken to further improve quality of care.
For example a small number of wards were late
in commencing their night-time medication
rounds. This has been improved and is now
regularly monitored.
The Trust is recruiting a practice development
nurse to deliver bespoke work training
programmes to nursing staff at night and the
post-holder will commence in 2012.
Following their unannounced inspection
in November 2011, the CQC reported that
‘we found that people’s care and treatment
is provided by competent staff who are
appropriately trained, supervised and appraised’.
They also commented that the Trust has very
good systems in place to regularly audit and
monitor the quality of service it provides.
57
Governor Carol Ellis speaks to a patient.
Annual Report and Accounts 2011 – 2012
58
Nurse consultant in cancer and palliative care Mel McEvoy speaks to ward manager Jayne Corbey about the carer's diary.
3. Carer's diary - The diary was rolled out in 2011 and at time of writing, 185 diaries have been
completed (April 2011-Feb 2012) and the results have demonstrate that high standards of care has
been provided. The table below demonstrates the overall marks afforded to each ward/department
across the Trust.
Marks are awarded on a scale of 1 (poor) to 5 (excellent) for each of 6 key quality indicators, these
being; pain, nausea, breathlessness, restlessness, how the nurse is with the patient and how the nurse
is with the family or carer. The maximum score that can be achieved is 30.
Ward
Average score
Ward
Average score
28 surgery
29/30
27 gastroenterology
26.6/30
29 surgery
29/30
24 acute elderly
26.4/30
26.3/30
1 stroke/rehab
28.5/30
7 cardiology
25 cardiology
28.4/30
9 acute elderly
SSU medicine
28.4/30
11 respiratory
25.6/30
26 respiratory
27.6/30
5 gastroenterology
25.4/30
EAU NT
27.3/30
30 surgery/gynae
25.1/30
42 elderly rehab
27.1/30
31 surgery/gynae
25.1/30
41 acute stroke
26.7/30
EAU UHH
26/30
23/30
Understanding this data helps the Trust to understand how we are doing and to develop and target
training in end of life care for wards where scores are lower. In 2012 we will send our trainers to
work with and support staff in developing knowledge and skill to bring all scores up to match or
exceed the best.
The table below highlights how scores (1 being poor and 5 being excellent with a maximum total
score of 30 showing excellence in every aspect of care) and comments made in one diary helped staff
to address issues in a timely way. The improvement in score each day demonstrates how this important
feedback can influence quality of care resulting in a peaceful death for a patient and the best possible
experience for the next of kin.
Day
Pain
Nausea
Calmness
Breathing
Staff/Patient
Staff/Carer
Total score
1
3
3
3
3
4
3
19/30
2
4
4
5
4
5
5
27/30
3
5
5
5
4
5
5
29/30
4
5
5
5
5
5
5
30/30
3. Community Healthcare – evidence in practice
Roll out and use of Carers Diary has now commenced. Introduction of the first three Carer’s
Diaries for community patients on the Liverpool End of Life Care Pathway was introduced on 14
November 2011. Baseline data is being collected and we aim to report against this indicator for
community and hospital care in the 2012-2013 quality report. We need to identify resources to
support training and roll-out of the diary to families in the community.
In order to achieve an optimum roll out of the carer’s diaries we focussed on the use of the diary for
end of life patients in our hospitals and introducing it for similar patients in the community. In light of
the positive results demonstrated above, rolling out this diary for patients with chronic conditions has
not commenced yet however it continues to be a priority of the Trust.
59
Annual Report and Accounts 2011 – 2012
The latest data available from the (March 2012) North East Quality Observatory
System reports the 2010-2011 overall inpatient experience measure for the Trust as
77.7 against a national mean score of 74.9.
2B Quality improvement priorities for 2012-2013
Key priorities for improvement for 2012-2013 have been agreed through
consultation with patients, staff, Governors, local involvement networks,
commissioners, health scrutiny committees and other key stakeholders. We started
the consultation period at the beginning of September 2011, which allowed
us to consult widely and provide stakeholders with a significant opportunity to
consider and suggest the priorities that they would like to see us address. Feedback
and third party declarations have been received from formal stakeholders.
Full details of stakeholder feedback can be found in Annex 1, page 88-94. Our
Governors have also been actively involved in assisting us in setting our priorities.
We would like to thank all of those involved in setting priorities for 2012-13 which
are linked to patient safety, effectiveness of care and patient experience. We all
agree that our priorities for improvement should continue to reflect three key
principles, namely:
Treat me
right the
first time
Don’t
harm me
Be nice
to me
Stakeholder priorities
The quality indicators that our external stakeholders said they would like to see
included were:
Patient Safety
Effectiveness of Care
Patient Experience
Infection Control
Communication
Mortality
-
Discharge Arrangements
-
-
Nutrition
Dementia
Rationale for the selection of priorities
All of the quality indicators selected by external stakeholders have been incorporated
into the quality priorities for 2012-2013.
The tables over the following pages will describe each priority, the rationale for
including it along with a summary of how we aim to achieve the outcome, measure
the impact and reporting arrangements.
We have incorporated feedback from patients, staff and visitors through our
consultation on the Trust’s RESPECT strategy and through feedback from our dignity
day campaign in February 2012.
We have aligned indicators where possible to quality indicators requested by
commissioners.
60
Annual Report and Accounts 2011 – 2012
Priority 1: Patient Safety
In Hospital
How will we do it?
How will we
measure it?
How will we
report it?
Monitoring patient
safety; mortality.
• We will undertake monthly
mortality reviews using the
global trigger tool.
• We will monitor HSMR
(hospital standardised
mortality ratio) on the Dr
Foster database.
• We will report HSMR at
our Board and Council of
Governor meetings.
• 95% of all staff will receive
infection control training.
• We will monitor rates of
clostridium difficile.
• The number of e-coli
infections will continue to
be reported.
• The number of e-coli
infections will be reported.
• Quarterly to the Infection
Prevention and Control
Committee.
Rationale: Staff,
patients and key
stakeholders agree that
reducing mortality ratio
should continue to be
our first patient safety
objective.
Infection Control:
Rationale: Key
stakeholders asked us
to report on clostridium
difficile because we did
not achieve a reduction
in 2011-2012.
Trust commissioners and
clinicians would like to
understand if there are
any trends that would
help understand, prevent
and control e-coli
infections.
• Senior doctors and nurses
will continue to review all
incidents on a weekly basis.
• Every hospital-acquired
clostridium difficile and
e-coli infection will be
investigated to establish
cause and potential
actions required.
• We will report any trends
and actions.
• At meetings with our
commissioners.
In the
Community
How will we do it?
How will we
measure it?
How will we
report it?
Monitoring patient safety
• We will roll out use of
the new community early
warning system allied to
Telehealth to more areas.
• We will monitor admissions
to hospital from the
community.
• We will report results at
the Integrated Nursing and
Midwifery Board meetings.
Rationale: Stakeholders
were pleased that we
managed to develop an
early warning score into
the community. They
would like to understand
the impact of this over a
period of time.
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Annual Report and Accounts 2011 – 2012
Priority 2: Clinical Effectiveness
In Hospital
How will we do it?
How will we
measure it?
How will we
report it?
Communication:
• We will roll out intentional
rounding to listen to what
patients and relatives have
to say about standards of
care and experience.
• We will monitor what we
are told and take actions to
address any concerns.
• We will continue to ask
patients about their
experience of clinical care
and experience during our
PEQS (patient experience
and quality standards)
panels.
• We will monitor and
report the impact of this
on complaints relating to
nursing communication.
• Ward/department leaders
will feedback daily results
of intentional rounding to
their staff.
• Themes of compliments
and concerns will be
reported to the Integrated
Nursing and Midwifery
Board six monthly.
• Complaints relating to
nursing communication
will be reported to the
Integrated Nursing and
Midwifery Board six monthly.
• Complaints trends are
reported quarterly to the
Patient Safety and Quality
Standards Committee.
• We will develop improved
communication processes
to GPs.
• We will enhance the
current discharge letter
format to allow audit of
the quality of complex
discharge arrangements.
Rationale: Stakeholders
said they would like
us to listen to patients
and provide improved
opportunities for
concerns to be heard
and acted on.
Staff believe that
intentional rounding will
provide an opportunity
to understand and act on
patient needs in a timely
way that is meaningful
to them.
Discharge
Arrangements:
Rationale: Quality and
monitoring of complex
discharge arrangements
remains a focus for
commissioners and key
stakeholders.
• We will collect baseline
data about complex
nursing discharge.
• We will report results of the
baseline audit data along
with any actions that are
agreed to the Patient Safety
and Quality Standards
Committee at the end of
the year.
• We will continue to
promote referral of every
hospital patient that is
placed on the Liverpool
Care (end of life) Pathway
to the chaplaincy team for
spiritual and/or emotional
support.
• We will audit the rate of
referral and of repeat visits.
• We will monitor the impact
of this service on carer,
staff and chaplaincy job
satisfaction.
• Results of audit data will
be reported six monthly to
the Director of Nursing and
Patient Safety for inclusion
in the annual Quality
Reports.
In the
Community
How will we do it?
How will we
measure it?
How will we
report it?
Development of
virtual ward:
• We will use the Telehealth
early warning system to
escalate and de-escalate
specific patient cohorts for/
from care on a virtual ward
(hospital at home).
• We will monitor the
number of patients treated
this way.
• Six monthly to the Patient
Safety Team.
• Training and deployment
of initial 40 toughbooks
to be completed within
first three-months of 2012
(April-June).
• The number of units in use
will be reported.
End of life care; spiritual
and emotional care
Rationale: Hospital
chaplains play an
important role in the
spiritual and emotional
support of patients and
their relatives during
end of life care. A high
percentage of patients
request repeat visits.
This service supports
the patient, the family
and supports the clinical
team.
Rationale: Staff believe
that the impact of the
early warning system in
Telehealth provides an
opportunity to develop
virtual wards enabling us
to provide some aspects
of hospital care in the
home for a defined
cohort of patients
supported by doctors
and nurses.
Communication: expand
deployment of tough
books (mobile working):
62
• We will record the results
of PEQS panels.
Rationale: Toughbooks
were introduced in 20112012 with successful
bids to enable the Trust
to double the number
in use.
Annual Report and Accounts 2011 – 2012
• 154 additional units to
be deployed during the
remainder of 2012-2013.
• We will ask patient views
about the service.
• The impact of mobile
working (toughbooks) on
admission to hospital rates
and on length of stay in
hospital of patients with
chronic conditions will be
monitored.
• Annually to Patient Safety
and Quality Standards
Committee.
• Progress will be reported
twice yearly to the
Patient Safety and Quality
Standards Group.
• The Trust executive
management team will
receive a progress report
twice a year.
Priority 3: Patient Experience
In Hospital
How will we do it?
How will we
measure it?
How will we
report it?
Dementia:
• We will conduct an initial
dementia screen on all
patients aged 65 and over.
• We will undertake a
prevalence study on a
quarterly basis.
• Quarterly to the Integrated
Nursing and Midwifery
Board.
Rationale: As the
population becomes
older, dementia is
becoming more
common. Dementia is a
priority for stakeholders,
commissioners and staff
alike.
End of Life Care:
Rationale: Patients and
their carers/families are
very vulnerable and can
find it difficult to explain
what they want. In
2011, the use of carer’s
diaries was successful
in improving quality of
care and experience.
Monitoring the impact
of diaries on quality
standards results in
better care for patients,
better experience for
carers/family and better
job satisfaction for staff.
Stakeholders asked for
this to be included in this
year’s priorities.
Nutrition:
Rationale: Good
nutrition plays an
important contribution
to recovery from
illness or injury. Our
stakeholders and our
commissioners are joined
by our staff in agreeing
that nutrition should
be a priority for all
patients. We have good
standards of nutrition for
adult inpatients so we
will focus on nutrition
for children and in the
outpatient setting.
• Quarterly to our
commissioners.
• Where indicated, we will
carry out an abbreviated
mental health test on
patients that fit the
dementia criteria.
• If required we will refer
patient for specialist review.
• We will ask carers/families
to score their perception
of the quality of care in
relation to:
• Pain;
• Nausea (sickness);
• Dyspnoea
(breathlessness);
• Restlessness;
• Ward nurses will review
the diaries during each visit
and respond to the score to
ensure we meet the needs
of the patient and the
carer/family.
• Diaries will be audited
corporately and themes
used to inform learning
and training needs.
• Local results will be fed
back to every ward and
department.
• Corporate data along
with themes, learning
and recommendations for
training will be reported
to the Integrated Nursing
and Midwifery Board on a
quarterly basis.
• Nursing care of patient;
• Nursing care of carer/
family.
• Introduce the malnutrition
universal screening tool
(MUST) that we use for
adult inpatients into the
outpatient setting.
• Introduce the screening
tool for the assessment of
malnutrition in paediatrics
(STAMP) into inpatient
paediatric wards.
• We will train staff to use
the MUST and STAMP
tools.
• We will introduce the
tools into outpatient and
paediatric inpatient areas.
• We will collect baseline
audit by June 2012.
• Results of audits will be
reported to the Integrated
Nursing and Midwifery
Board every six months for
both new audits as well
as for the adult inpatient
MUST tool audits.
• We will audit use twice a
year.
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Annual Report and Accounts 2011 – 2012
Priority 3: Patient Experience continued
In the
Community
How will we do it?
How will we
measure it?
How will we
report it?
Dementia:
• If the Department of
Health (DH) recommend
a dementia test for use
by community nurses, we
will adopt it and monitor
compliance.
• We will evaluate the
accuracy of the early
warning score by reviewing
the number of patients
requiring onward referral
for further tests and the
outcome of the tests.
• We will report whether we
have adopted a national
test or alternatively,
managed to develop a
dementia early warning
score for use by community
nurses.
Rationale: District
nurses are in a strong
position to pick up
early signs of dementia.
Dependent on funding,
we will develop a
dementia early warning
score for use by district
nurses (if the Department
of Health do not
recommend one).
End of Life Care:
Rationale: Patients and
their carers/families are
very vulnerable and can
find it difficult to explain
what they want. In 2011,
the use of carer’s diaries
was introduced in the
community. Monitoring
the impact of diaries
on quality standards
results in better care
for patients, better
experience for carers/
family and better job
satisfaction for staff.
Stakeholders asked for
this to be included in this
year’s priorities.
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Annual Report and Accounts 2011 – 2012
• If not, we will evaluate
dementia screening tools
used in other healthcare
sectors and.
• We will report how many
patients we use the early
warning scores on and the
outcome.
• We will develop and test
a dementia early warning
score for district nurses.
• We will ask carers/families
to score their perception
of the quality of care in
relation to:
• Pain;
• Nausea (sickness);
• Dyspnoea
(breathlessness);
• Restlessness;
• Nursing care of patient;
• Nursing care of carer/
family.
• Community nurses will
review the diaries during
each visit and respond to
the score to ensure we
meet the needs of the
patient and the carer/
family.
• Diaries will be audited
corporately and themes
use to inform learning and
training needs.
• Local results will be fed
back to every team.
• Corporate data along
with themes, learning
and recommendations for
training will be reported
to the Integrated Nursing
and Midwifery Board on a
quarterly basis.
2C Statement of Assurance from the Board
1. Review of Services
During 2011-2012 the North Tees and
Hartlepool NHS Foundation Trust provided and/
or subcontracted 64 NHS services. The majority
of our services were provided on a direct basis,
with a small number under sub-contracting or
joint arrangements with others.
We have reviewed all of the data available to us
on the quality of care in all of these services. The
income generated by the NHS services reviewed
in 2011-2012 represents 86% of the total
income generated from the provision of NHS
services by the Trust for 2011-2012.
The data reviewed aims to cover the three
dimensions of quality - patient safety, clinical
effectiveness and patient experience. In a
number of areas there has been no benchmark
data available. Where benchmark data has been
available, it has been included.
This represents 100% of all mandatory national
clinical audits and 100% of all mandatory
national confidential enquiries. We did not
participate in all non-mandatory audits as we
have a small audit team.
The national clinical audits and national
confidential enquiries that we were eligible to
participate in during 2011-2012 are listed below.
This list also identifies those national clinical
audits and national confidential enquiries that
the Trust participated in during this period.
The national clinical audits and national
confidential enquires that the Trust participated
in, and for which data collection was completed
during 2011-2012, 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.
2. Participation in clinical audits
All NHS Trusts are audited on the standards of
care that they deliver and our Trust actively and
positively participates in all relevant national
audits and national confidential enquiries. The
CQC quality risk profile rated the Trust as green
in relation to assessing and monitoring the
quality of service provision throughout 20112012. The CQC quality risk profile is included in
section 5.
The Department of Health provides a
comprehensive list of national audits which
collected audit data during 2011-2012 and this
can be found on the following link:
www.dh.gov.uk/qualityaccounts
During 2011-2012, 51 national clinical audits
and five national confidential enquiries covered
the NHS services that we provide. During that
period we participated in all (51 national clinical
audits and five national confidential enquiries)
of the national clinical audits and national
confidential enquiries which we were eligible to
participate in.
65
Annual Report and Accounts 2011 – 2012
Audit title
66
Participation
M=mandatory
N=non-mandatory
% cases submitted
Perinatal mortality (MBRRACE-UK)
Yes (N)
100%
Neonatal intensive and special care (NNAP)
Yes (M)
100%
Paediatric pneumonia (British Thoracic Society)
Yes (N)
Data collection ongoing
Paediatric Asthma (British Thoracic Society)
Yes (N)
100%
Pain Management in Children (College of Emergency Medicine)
Yes (N)
100%
Childhood epilepsy (RCPH National Childhood Epilepsy Audit)
Yes (M)
100%
Paediatric intensive care (PICANet)
Not applicable
Paediatric cardiac surgery (NICOR Congenital Heart Disease Audit)
Not applicable
Diabetes (RCPH National Paediatric Diabetes Audit)
Registered to participate
(M)
Audit to commence later
in 2012
Emergency use of oxygen (British Thoracic Society)
Yes (N)
100%
Adult community acquired pneumonia (British Thoracic Society)
Yes (N)
Data collection ongoing
Non invasive ventilation (NIV) - adults (British Thoracic Society)
Yes (N)
Data collection ongoing
Pleural procedures (British Thoracic Society)
Yes (N)
100%
Cardiac arrest (National Cardiac Arrest Audit)
Yes (N)
Data collection ongoing
Severe sepsis & septic shock (College of Emergency Medicine)
Yes (N)
100%
Adult critical care (ICNARC CMPD)
Yes (N)
100%
Potential donor audit (NHS Blood & Transplant)
Yes (N)
100%
Seizure management (National Audit of Seizure Management)
Yes (N)
100%
Diabetes (National Adult Diabetes Audit)
Yes (M)
100%
Heavy menstrual bleeding (RCOG National Audit of HMB)
Yes (M)
46%
(national estimate only)
Chronic pain (National Pain Audit)
Yes (M)
100%
Ulcerative colitis & Crohn’s disease (UK IBD Audit)
Yes (M)
100%
Parkinson’s disease (National Parkinson’s Audit)
Yes (N)
100%
Adult asthma (British Thoracic Society)
Yes (N)
100%
Bronchiectasis (British Thoracic Society)
Yes (N)
100%
Hip, knee and ankle replacements (National Joint Registry)
Yes (N)
100%
Elective surgery (National PROMs Programme)
Yes (N)
80.3% (patient
questionnaire return rate)
Intra-thoracic transplantation (NHSBT UK Transplant Registry)
Not applicable
Liver transplantation (NHSBT UK Transplant Registry)
Not applicable
Coronary angioplasty (NICOR Adult cardiac interventions audit)
Not applicable
Peripheral vascular surgery (VSGBI Vascular Surgery Database)
Not applicable
Carotid interventions (Carotid Intervention Audit)
Not applicable
CABG and valvular surgery (Adult cardiac surgery audit)
Not applicable
Acute Myocardial Infarction & other ACS (MINAP)
Yes (M)
100%
Heart failure (Heart Failure Audit)
Yes (M)
100%
Acute stroke (SINAP)
Yes (M)
100%
Cardiac arrhythmia (Cardiac Rhythm Management Audit)
Not applicable
Renal replacement therapy (Renal Registry)
Not applicable
Annual Report and Accounts 2011 – 2012
Audit title
Participation
M=mandatory
N=non-mandatory
Renal transplantation (NHSBT UK Transplant Registry)
% cases submitted
Not applicable
Lung cancer (National Lung Cancer Audit)
Yes (M)
100%
Bowel cancer (National Bowel Cancer Audit Programme)
Yes (M)
100%
Head & neck cancer (DAHNO)
Not applicable
Oesophago-gastric cancer (National O-G Cancer Audit)
Yes (M)
100%
Hip fracture (National Hip Fracture Database)
Yes (M)
100%
Severe trauma (Trauma Audit & Research Network)
Yes (N)
100%
Prescribing in mental health services (POMH)
Not applicable
National Audit of Schizophrenia (NAS)
Not applicable
Bedside transfusion (National Comparative Audit of Blood
Transfusion)
Yes (N)
100%
Medical use of blood (National Comparative Audit of Blood
Transfusion)
Yes (N)
100%
Risk factors (National Health Promotion in Hospitals Audit)
Yes (N)
100%
Care of dying in hospital (NCDAH)
Yes (N)
100%
The Trust participated in all five national confidential enquiries (100%) that it was eligible to participate
in, namely:
National Confidential Enquiry
NCEPOD "Are we there yet?" (Surgery in Children)
NCEPOD “Knowing the risk” (Peri-operative Care Study)
NCEPOD Cardiac Arrest Procedures (not yet published)
NCEPOD Bariatric Surgery Study (data collection ongoing)
NCEPOD Alcohol Related Liver Disease Study (data collection ongoing)
Commendations on our participation and performance
In the National Outpatient Survey 2011, the Trust achieved the top score against all other Trusts
for the questions, “How long after the stated appointment time did the appointment start?” and
“Was the reason for changing your medication explained in a way you could understand?”
Once again, the Trust was commended this year for the high quality of audit data submitted
as part of the continuous audit looking at the care of patients who suffer a heart attack, the
myocardial ischaemia national audit project (MINAP).
The Trust performed well in the National Care of the Dying Audit and Professor Edwin Pugh and
the chaplaincy team were recognised for their role in caring for the spiritual and emotional
needs of patients placed on the (end of life) Liverpool Care Pathway. This work has been
featured in numerous national journals and our team were featured in a national television
programme.
Nurse consultant Mel McEvoy has also been published widely during the year for his innovative
research into the impact of asking carers to provide scores on our management on key aspects of
care for patients who are dying.
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Annual Report and Accounts 2011 – 2012
National Clinical Audits
The reports of 10 national clinical audits were reviewed by the Trust in 2011-2012 resulting in the
following actions to improve the quality of healthcare provided:
Audit title
Actions taken
National Familial
Hypercholesterolaemia Audit
Report
We are reviewing available patient information and developing a local patient
information leaflet.
An information pack has been developed for use by ward staff and training on the
management of dementia is now mandatory for clinical staff.
National Dementia Audit
An alert system on PAS is being used to flag patients with a definitive diagnosis of
dementia.
An Abbreviated Mental Test Score (AMTS) has been implemented for use with patients
over the age of 65 years.
National Audit of Falls and Bone
Health
An Osteoporosis Fracture Liaison Nurse has been appointed.
A falls group is in place and includes representation from both the acute and community
teams.
Audit of Feverish Children
A patient information leaflet is being developed.
Audit of Renal Colic
Targeted teaching is being organised for staff in relation to assessment of pain and reevaluation of pain scores.
Audit of Vital Signs in Majors
National Sentinel Stroke Audit
We have improved speed of triage times in A&E and we will repeat the audit to measure
effect.
We are providing training for staff so that they understand the repeat observation
protocol.
We are improving continence planning.
Volunteers have been employed to help patients at meal times. Productive ward rollout
has helped staff to focus on proactive patient support during meal times.
National Inpatient Survey 2010
In order to ensure staff offer choice of admission dates, the review script used by
booking clerks now includes the word “choice” in the dialogue to ensure patients are
aware that they are being offered a choice of admission dates.
We have improved communication with women to promote knowledge and
understanding of choices for birth.
National Maternity Survey 2010
Midwives are encouraging skin-to-skin contact after delivery for both vaginal and
caesarean section and take time to ensure women are aware of the benefits.
Sonographers are working to ensure all women know the reason for scans. Leaflets are
being given at pre booking.
National Cancer Patient
Experience Survey 2010
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Annual Report and Accounts 2011 – 2012
Cancer nurse specialists are providing patients with information about support groups
and are ensuring that ward areas have posters and leaflets about support. We will
include support group detail in information pathways as per key worker policy and
ensure that this is audited annually.
We are working closely with the George Hardwick Foundation to ensure information
about financial help is included in patient information packs. We aim to offer the
Macmillan publication (Helping with the Cost of Cancer) to every patient.
Local Clinical Audits
The reports of 52 local clinical audits were reviewed by the provider in 2011-2012 and the Trust
intends to take the following actions to improve the quality of healthcare provided as follows:
Local audit title
Actions taken/in progress
Acute Severe Asthma
Establish process to better identify children who require closer monitoring
once discharged. A background admission sheet is to be put in place to
record vital information and to act as a screening tool.
Laparoscopic Cholecystectomy Audit of
Practice
Introduction of more morning lists and additional training for staff.
Consent prior to elective treatment
Improvements made to the patient consent form.
Antibiotic prescribing
Redesign of the Trust prescribing kardex and review of the antibiotic strategy.
Arthroscopic ACL Reconstructions using
Hamstring Tendons
Proposal submitted to perform this procedure as a standard day case
procedure.
Management of Patients Presenting with
Acute Urinary Retention
Introduction of education sessions for EAU and on-call surgical staff who
deal with cases of acute urine retention. Protocol updated to increase staff
awareness and understanding.
Discharge summary audit
Working with local commissioners and GPs in order to improve the level
of patient information shared when patients move between primary and
secondary care.
The Trust continues to perform well in audit activity and positive points to note include:
Local audit title
Good practice
NICE Clinical Guideline for Acutely Ill
Patients in Hospital (NICE CG 50)
Six cycles of audit have been completed which have demonstrated significant
improvement in documentation of regular observations and evidence of
acting upon abnormal early warning scores. The team undertaking these
audits were initially winners of the Trust Clinical Audit Prize in 2009 for the
significant improvement in patient care as a result of the audits and the audit
continues to demonstrate local improvements. This work was entered for the
NICE shared learning awards and the outcome is awaited.
NICE Clinical Guideline for inadvertent
peri-operative hypothermia in adults (NICE
CG 65)
Three cycles of audit have been completed in order to demonstrate significant
improvement in managing hypothermia in patients presenting for surgical
procedures. The team won the Trust Clinical Audit Prize in 2011 for the
significant improvements made and the continued work being undertaken to
improve patient care.
NICE Clinical Guideline for the management
of patients with dementia (NICE CG 42)
The Trust successfully took part in the national dementia audit and
subsequently improved the level of education and information available to
staff on the management of patients with dementia. A mental test score and
flagging system was also put into practice.
NICE Clinical Guideline for the management
of diabetes in pregnancy (NICE CG 63)
Shared Diabetes Pregnancy clinics now in place, following a shared care
pathway between Obstetrics and the Diabetes Service.
NICE Clinical Guideline for surgical site
infection (NICE CG 74)
The surgical directorates of Gynaecology, Orthopaedics and General Surgery
worked together to undertake a shared audit around the local management
of surgical site infection, looking at patients over a 12 month period. All areas
showed excellent levels of compliance with the NICE standards.
All national audit reports are considered by the Audit and Clinical Effectiveness (ACE) Committee which
reports to the Patient Safety and Quality Standards (Ps&Qs) committee. Ps&Qs reports directly to the
Board of Directors.
The Care Quality Commission national outpatient survey 2011-2012 identified that improvements have
been made in relation to patient experience across a number of areas measured, with 44% (up from
40% in 2009) of all results being in the top 20% nationally. The full report can be found at
http://www.nhssurveys.org/Filestore/documents/OP11_RVW.pdf
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Annual Report and Accounts 2011 – 2012
3. Participation in Research
Patient John McGarva takes part in a breathing test, observed by staff nurse Julie Lindberg.
Research activity continues to expand within the Trust. We have 158 active
studies, 106 (67%) of which are National Institute for Health Research (NIHR)
portfolio studies. The total number of patients receiving NHS services provided or
subcontracted by the Trust in 2011-2012 who were recruited during that period to
participate in research approved by a research ethics committee was 1,052 (portfolio
and non-portfolio studies).
Data for April 2011-March 2012 indicate the number of patients recruited into
(NIHR) portfolio studies has continued to increase with 993 patients recruited in this
11 month period compared with 459 for the whole of the previous year. Having
exceeded the ambitious target of 900 patients this year, our total represents a
116% increase on the recruitment figures for the preceding year. The table below
demonstrates the increases seen in portfolio recruitment over the last four years and
highlights the Trust’s commitment to supporting research as part of core business.
Patients recruited into NIHR portfolio research
Year
Number of patients
recruited
% increase on
previous year
2008-2009
159
N/A
2009-2010
412
159%
2010-2011
458
10.7%
2011-2012
993
116%
The research and development (R&D) team have worked with departments across the
Trust to promote the importance of healthcare professionals being involved in research.
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Annual Report and Accounts 2011 – 2012
Through the Trust’s provision of an R&D
Incentive fund of £50,000 we have been able
to help to develop staff knowledge and skills
to enable them to lead and/or be involved in
research studies through provision of:
•Bi-annual Good Clinical Practice (GCP) training;
•R&D fellowship and small grant scheme;
•R&D seminar series;
•R&D Conference.
We currently have 111 members of staff
with valid GCP training. Four research nurses/
scientists are enrolled to undertake Master of
Science (MSc) degrees in health service research
and three Doctors of Medicine (MDs) have been
funded through the R&D Incentive Fund.
The range of specialisms now participating in
research is notable, encompassing paediatrics
and family health, respiratory medicine,
gastroenterology, diabetes, stroke medicine,
rheumatology, surgery, orthopaedics,
anaesthetics and critical care and accident and
emergency. Our clinical teams are involved in a
substantial number of complex National Cancer
Research Network (NCRN) trials and we are the
second highest recruiter to these trials within
the Comprehensive Local Research Network.
There are 63 members of staff acting as principal
investigators/local collaborators in research
approved by a research ethics committee
within the Trust, some of whom have up to
ten studies in their research portfolio. We
have nine CLRN (comprehensive local research
network) funded research nurses within the Trust
with an additional six nurses who undertake
supplementary research work as additional
hours. We have initiated an active bi-monthly
research nurses working group to provide
professional support and mentorship.
Trust sponsored research projects are being
developed across a number of specialties and
we believe that this approach to developing
understanding through research will contribute
significantly to our quality strategy and
outcomes in relation to safety, effectiveness
of care and patient experience. Four Trust
researchers were recipients of CLRN FSF
(flexibility and sustainability funding) to develop
NIHR applications for funding of their proposed
research studies.
We have continued to streamline our research
governance processes and to formalise them
through standard operating procedures
disseminated to all research active staff. We have
recently been inspected by the MHRA (medicines
and healthcare products regulatory agency) which
helped us to further develop our quality systems.
Our paediatric and neonatology research teams have established themselves in a very short
space of time as nationally recognised high recruiters to sometimes complex trials. For two
neonatal studies (I2S2 and BOOST II), we were the 3rd and 5th highest recruiters respectively
nationally. BOOST II is a study of the effect of varying concentrations of inspired (inhaled)
oxygen in pre-term (a baby born at less than 37 weeks gestation) infants. This study
recruited 59 babies (82% of all potentially eligible) which is a reflection of the hard work by the
research team in identifying and consenting patients for recruitment.
There has been excellent commitment to recruitment into a paediatric study to examine the
effect of nebulised magnesium (a nebuliser converts liquid into droplets that can be
breathed in) in acute severe asthma in children (MAGNETIC Study). In this study the team
were the second highest recruiters nationally. This directorate have established regular directorate
research meetings that are well attended with updates and newsletters to staff to inform them of
progress in active research studies, which has further embedded research within the core values of
the directorate.
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Annual Report and Accounts 2011 – 2012
4. Commissioning for quality and innovation (CQUIN)
As for all Trusts, a proportion of the Trust income in 2011-2012 was conditional
upon achieving quality improvement and innovation goals agreed with our
commissioners and administered through the CQUIN payment framework. The total
income received through achievement of CQUIN goals in 2011-2012 is £3,168,181
which includes £2,793,077 for acute services and £375,104 for community services.
The total payment received through achievement of CQUIN goals in 2010-2011 was
£2,730,716 for acute and £399,866 for community services.
Further details of the agreed goals for 2011-2012 and the following 12 months'
CQUIN schemes are available electronically at: http://www.institute.nhs.uk/world_
class_commissioning/pct_portal/cquin.html
5. Care Quality Commission (CQC)
North Tees and Hartlepool NHS Foundation Trust is required to register with the
Care Quality Commission and its current registration status is registered without
conditions for all services provided.
Results of unannounced CQC inspections
The Trust received two unannounced CQC reviews in 2011.
In April, the University Hospital of Hartlepool was assessed for compliance with the
following essential standards:
•Outcome 01: Respecting and involving people who use services; and
•Outcome 05: Meeting nutritional needs.
In November 2011, it was the turn of the University Hospital of North Tees, which
was assessed for compliance in relation to five essential standards, these being:
Diet chef Joanne Speight.
•Outcome 01: Respecting and involving people who use services;
•Outcome 04: Care and welfare of people who use our services;
•Outcome 07: Safeguarding people who use services from abuse;
•Outcome 14: Supporting staff;
•Outcome 16: Assessing and monitoring the quality of service provision.
Both inspections comprised a comprehensive visit with assessors checking records,
observing how people were being cared for, looking at records of people who use
services, talking to staff and people who use our services. They visited numerous
clinical areas including the accident and emergency department, emergency
assessment units, surgical wards and wards providing care to older people.
Both reviews resulted in the Trust being found to be compliant against all key
standards reviewed. The Trust was found to have very good systems in place to
regularly audit and monitor the quality of services it provides.
Confirmation of no enforcement action
We are happy to confirm that the Care Quality Commission (CQC) has not taken
enforcement action against the Trust during 2011-2012.
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Annual Report and Accounts 2011 – 2012
Participation in CQC reviews
On 23 March 2012, the Secretary of State asked the CQC to conduct inspections into standards of
documentation in relation to all providers of termination of pregnancy (TOP) services. Inspectors were
specifically asked to review whether signatures relating to consent met legal requirements. Inspectors
have visited a number of providers in the North of England and this Trust has undergone its inspection.
We are awaiting formal feedback on the outcome of the inspection and will report results to the public
Board and Council of Governors meetings.
The CQC will publish the outcome of their investigation on all providers in due course.
The Trust has not participated in any other special reviews and investigations by the CQC during the
reporting period.
Trust CQC Quality Risk Profile
The CQC provides a quality risk profile (QRP) for all NHS Trusts. The QRPs are updated on a regular
basis and take into consideration all information, internal and external, which is collected in relation
to the relevant Trust. They are used to help monitor compliance against the CQC Essential Standards
of Quality and Safety. More information on the essential standards and other CQC assessments can be
found on the following link: www.cqc.org.uk.
The Trust (current and previous) QRP ratings can be seen below and shows that the Trust is performing
very well across all areas.
Outcome
Number
Outcome Description
Previous
Risk
Estimate
Current
Risk
Estimate
1
(R17) Respecting and involving
people who use services
High Green
Low Green
2
(R18) Consent to care and
treatment
High Green
4
(R9) Care and welfare of people
who use services
5
Total
Number
of Items
No. of
Qualitative
Items
No. of
Quantitative
Items
110
23
87
High Green
5
0
5
High Green
Low Green
186
24
162
(R14) Meeting nutritional needs
Low Neutral
Low Neutral
21
6
15
6
(R24) Cooperating with other
providers
High Green
Low Green
12
2
10
7
(R11) Safeguarding people who
use services from abuse
Insufficient
Data
High Green
2
1
1
8
(R12) Cleanliness and infection
control
Low Neutral
Low Neutral
58
4
54
9
(R13) Management of medicines
Low Neutral
High Green
15
0
15
10
(R15) Safety and suitability of
premises
Low Neutral
Low Neutral
46
2
44
11
(R16) Safety, availability and
suitability of equipment
Low Neutral
Low Neutral
13
1
12
12
(R21) Requirements relating to
workers
Low Green
Low Green
5
0
5
13
(R22) Staffing
Low Green
Low Green
30
0
30
14
(R23) Supporting staff
Low Green
Low Green
63
1
62
16
(R10) Assessing and monitoring
the quality of service provision
Low Green
Low Green
40
1
39
17
(R19) Complaints
Low Green
Low Green
8
0
8
21
(R20) Records
Low Green
Low Green
73
0
73
February 2012 data
Annual Report and Accounts 2011 – 2012
73
There are 8 ratings that can be assigned to Trusts. The highest possible (best) rating
is low green and the lowest (worst) possible rating is high red. An additional two
criterion for no data or insufficient data are also used.
You said:
Some elderly patients have no visitors and can be lonely and bored.
We did:
We recruited nine volunteers specifically to visit, read to and support elderly
patients with nobody to visit. We aim to recruit more volunteers in 2012.
CQC outpatient survey results
In 2011, the CQC ran a national outpatient survey. Thirty-nine questions were
asked with the Trust being within the top 20% scoring Trusts nationally for 17
questions (43.59%) and in the lowest 20% for only one question (2.56%). This is an
improvement against the previous (2009) national outpatient survey when 40% of
our scores were in the top 20% and 7% in the lowest 20%.
The Trust achieved the highest score nationally for two questions (5.13%), these
being; ‘How long after the stated appointment time did the appointment start?’
and ‘Was the reason for changing your medication explained in a way you could
understand?’.
The table below shows how the Trust score relates to the scores for other Trusts
nationally in relation to scores for each section of the national outpatient survey.
Section heading
Score out of 10 for
your Trust
How this score
compares with
other Trusts
Before the appointment
8/10
about the same
Waiting in the hospital
5.66/10
better
Hospital environment and facilities
8.9/10
about the same
Tests and treatments
8.38/10
about the same
Seeing a doctor
8.89/10
about the same
Seeing another professional
8.83/10
about the same
Overall about the appointment
8.42/10
about the same
Leaving the outpatients department
7.65/10
better
Overall impression
8.82/10
about the same
6. Quality of Data
Good quality information underpins the effective delivery of patient care and helps
staff to understand what they do well and where they might improve.
The Board of Directors attend regular development sessions and seminars to ensure
that every member of the Board is equipped to interpret data, challenge and oversee
improvements where necessary. They consider data provided with other intelligence
including listening to what patients are saying. Our executive and non-executive
directors can often be seen in clinical areas talking to patients and staff to ensure a
fully informed and well rounded approach to decision making.
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Annual Report and Accounts 2011 – 2012
Non-executive directors review and monitor
complaints data and review a sample of
complaints on a quarterly basis to ensure that
complaints are dealt with appropriately and that
lessons are learned and actions taken when we
get things wrong.
Training staff in critical appraisal is a vital part
of ensuring that evidence is considered in an
objective and balanced way. We develop clinical
staff so that they have the skills and knowledge
to use evidence in a way that supports them to
make good clinical decisions.
Clinical effectiveness advisor, John Blenkinsopp
has been training staff in critical appraisal
for nearly 10 years. His courses have been
recognised and adopted by the British Medical
Association (BMA) and are now used in the UK,
Europe and the United States of America.
He is the highest ranked trainer authorised by
the BMA.
Additional assurance in relation to data quality
is provided independently by Audit North. This
provides rigorous and objective testing of data
collection and reporting standards.
Results of these independent audits are
reported to the audit committee and provide
the Trust with independent appraisal of
clinical, financial and business governance
standards. This process of internal audit
enables the Trust to test quality assumptions
and pursue its philosophy of continual
improvement. In order to test and improve
quality of data the Trust will continue to
commission independent audits of its key
business.
Smarter Board Reporting Tools
A data quality indicator set has been further
developed by the Trust to include as part of
the Trust Board reporting system. This offers a
real-time view of the current status of clinical,
operational and financial performance and an
opportunity to forecast and mitigate risk in
relation to data quality. This ensures executive
and non-executive directors are empowered
to challenge, scrutinise and derive appropriate
levels of assurance.
The same quality indicator set is used at
directorate level through service line
management to ensure timely and accurate
data is available at all times.
NHS number and general medical practice validity
The Trust submitted records during 2011-2012 to the national Secondary User Service (SUS) for
inclusion in the national Hospital Episodes Statistics (HES) for inclusion in the latest published data.
The percentage of records in the published data is shown in the table below:
Which included the patient’s
valid NHS number was:
%
Which included the patient’s valid
general medical practice code was:
%
Percentage for admitted patient care
98.9
Percentage for admitted patient care
100
Percentage for outpatient care
99.4
Percentage for outpatient care
100
Percentage for accident and emergency care
98.5
Percentage for accident and emergency care
100
(April 11 – Dec 11 data included)
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Annual Report and Accounts 2011 – 2012
7. Information governance (IG)
Information governance means keeping information safe. This relies on good
systems, processes and monitoring. Every year we audit the quality of specific aspects
of information governance through the national information governance toolkit
report. In 2011-2012 we had to ensure that 95% of all of our staff had received
information governance training. This target was challenging and few NHS Trusts
have achieved this. We made significant progress with a total of 95% of all staff
undertaking mandatory IG training.
Annual ratings of green (pass) or red (fail) are assigned to Trusts each year. The
following table shows progress with ratings when compared to the previous year.
Requirement
2010-2011
rating
2011-2012
rating
Comparison
Information governance management
Green - 93%
Green - 93%
The same
Corporate Information Assurance
Green - 66%
Green - 66%
The same
Confidentiality and Data Protection
assurance
Green - 83%
Green - 83%
The same
Clinical information assurance
Green - 73%
Green - 73%
The same
Secondary use assurance
Red - 83%
Green - 87%
Better
Information security assurance
(pseudonymisation)
Red - 73%
Red - 73%
The same
The Trust Information Governance Assessment Report score overall for 2011-2012
was 79% and this was graded red. A red rating is achieved where Trusts do not
achieve level 2 or above on all requirements (see above). Pseudonymisation is the
name given to the process where patient identifiable information is removed from
data held by the Trust. Pseudonymisation is a challenge for many NHS Trusts due to
capabilities of current information technology systems and interfaces.
We continue to provide assurance to the Trust Board that we are constantly assessing
and improving our systems and processes to ensure that information is safe.
We receive a number of Freedom of Information (FOI) requests every year. In
order to be transparent about information we have been asked to provide, we have
developed a virtual reading room on our internet site. Since 1 January 2012, we
have been posting responses to Freedom of Information requests on the site and
these can be viewed by the public on: www.nth.nhs.uk/foirr
8. Actions to Improve Data Quality Going Forward
The Trust is also taking the following actions to further improve data quality:
•Expanded number of PAS
(patient administration system) data quality audits by 50%;
•Intend to extend data quality auditing to SystemOne (community data system);
•Develop current staff to become qualified auditors.
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Annual Report and Accounts 2011 – 2012
9. Clinical coding error rate
You said:
The Trust was subject to the Payment by Results
clinical coding audit during the reporting period
by the Audit Commission and the error rates
reported in the latest published audit for that
period for diagnosis and treatment coding
(clinical coding) was:
Some community clinics are in a poor state of
repair.
•Primary diagnoses incorrect
•Secondary diagnoses incorrect
14%
We did:
We made improvements to paths, décor and
signage in a number of community buildings.
10.8%
•Primary procedures incorrect
6.7%
•Secondary procedures incorrect
4.9%
Trust Actions
The Trust is also taking the following actions to
further improve data quality:
•Expanded number of PAS
(patient administration system) data quality
audits by 50%;
•Intend to extend data quality auditing to
SystemOne (community data system);
•Develop current staff to become qualified
auditors. The services reviewed within the
sample were 100 finished consultant episodes
(FCEs) in trauma and orthopaedics and 100
FCEs sampled at random from all other
specialties.
The results should not be extrapolated further
than the actual sample audited.
Depth of coding and key metrics are monitored
by the Trust in conjunction with mortality data.
Monthly coding audits are undertaken to
provide assurance that coding reflects clinical
management.
Our coders work so that they are closer
to the clinical teams resulting in sustained
improvements to clinical documentation,
clinical coding and a reduction in the number of
Healthcare Resource Group changes made (it is
the methodology which establishes how much
we should get paid for the care we deliver).
We will continue to work hard to improve quality
of information because it will ensure that NHS
resources are spent effectively.
Community lead midwife Karen Stevens with mum Janette Weegram
and daughter Suranne in the birthing centre at the University Hospital
of Hartlepool.
Annual Report and Accounts 2011 – 2012
77
PART 3: REVIEW OF QUALITY PERFORMANCE
You said:
There are long waiting lists for
community physiotherapy.
We did:
Changed the way we work
and reduced waiting times
from 6 weeks to 2 weeks.
3A Performance against additional quality improvement priorities
2011-2012
Part 3 of this quality report provides an opportunity for the Trust to report on
progress against the quality priorities that were agreed with stakeholders last year.
We are very pleased to be able to report some significant achievements. Performance
relating to clostridium difficile was disappointing however, and we describe some of
the actions we took during the course of the year to manage this.
Where possible, we have provided additional sources of external data in Section
3A to provide members of the public with as much useful information as possible.
Part 3A of this report will describe Trust performance against local quality indicators.
Part 3B will describe Trust performance against national priorities from the
Department of Health Operating Framework, Appendix B of the Compliance
Framework.
Part 3A
Trust performance against additional Quality Performance Indicators
In addition to the 3 local priorities outlined in Part 2, the indicators below further
demonstrate the quality of the services provided by the Trust over 2011-2012 has
been positive.
In keeping with the format of the quality report, additional indicators will be
presented under the headings of patient safety, effectiveness of care and patient
experience.
Patient Safety
1. MRSA bacteraemia
Actions taken by the Trust:
The importance of personal hygiene is fully understood by all staff and is visible
through the bare below the elbow policy and the presence of alcohol gel
dispensers and hand-washing facilities. Further improvements to our environment
and practices are constantly being implemented and evaluated.
Many patients carry MRSA on their skin, this is called colonisation. It is important
that we screen patients when they come in to hospital so that we know if they are
carrying MRSA. Screening involves a simple skin swab. If positive, we can provide
special skin wash that helps to get rid of MRSA.
Our rate of screening for MRSA is very high and we believe that this has helped us to
achieve the excellent results reported during the course of the year.
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Annual Report and Accounts 2011 – 2012
How did we do?
In 2011-2012, our organisation performed very well against regional and national standards in relation
to almost all aspects of infection prevention and control and this reflects the hard work of all staff,
both clinical and non-clinical, in ensuring that high standards are maintained all of the time. For the
first year ever, there were no hospital-acquired MRSA bacteraemia during 2011-2012. The trend
over the last 4 years can be seen below.
Year
2008/09
2009/10
2010/11
2011/12 Apr-Feb
9
5
4
0
MRSA bacteraemia
The (March 2012) North East Quality Observatory System benchmark data reports the Trust at 5.6
cases of MRSA bacteraemia per 1,000,000 bed days compared to a national mean of 12.2.
2. Clostridium difficile
Actions taken by the Trust:
During 2011-2012, we did not achieve our
clostridium difficile target. We continued to
work hard to control and reduce opportunity for
infections to spread when we treat people in our
clinical premises or in their own homes. There
is no one way in which clostridium difficile can
be eliminated but a consistent approach across
the three important areas of cleanliness of the
environment; appropriate antibiotic prescribing
and strict hygiene at the point of care are
vigorously pursued. We continue to invest in
new equipment which is easier to clean and
which is less likely to harbour infections.
We established a task and finish group in
June 2011 to concentrate on reducing risk of
patients acquiring clostridium difficile in hospital.
The group has examined the quality of antibiotic
prescribing practice, isolation practices and the
on going decant process for deep cleaning all of
our inpatient wards throughout the year. We have
also developed an electronic whiteboard system
to help key staff to monitor and manage cleaning
and allocation of isolation facilities in a robust and
speedy way. A detailed report relating to infection
prevention and control is also reported at every
public Board of Directors meeting.
The application of this service is delivered
through a multi-disciplinary team implementing
an annual decant and decontamination
programme and process to all clinical areas.
The Trust was commended at a national
cleaning award ceremony for our work in
raising standards of cleanliness.
We changed the way that the patient experience
and quality standards panels monitor cleanliness
in clinical areas every month throughout the
Trust. If any problems are found, they are dealt
with immediately, which has contributed to
consistent improvements in environmental
cleanliness and infection prevention and control
practices. The directors responsible for infection
prevention and control and for estates and
facilities undertake regular walkabouts to provide
support to staff and assurance to the Board of
Directors that any environmental issues are dealt
with speedily and effectively.
Hygienists have been employed to deep clean
clinical areas, wards and equipment and we
purchased additional hydrogen peroxide
fogging systems. Fogging with hydrogen
peroxide is found to kill the spores responsible
for people getting clostridium difficile.
Assistant matron for Infection Prevention and Control
Lynn Blackwood and nurse Elizabeth Warde.
Annual Report and Accounts 2011 – 2012
79
How did we do?
In 2011-2012, we had a challenging clostridium difficile target of 59 set by our
commissioners which we did not achieve. Over the last few months of the year we
were able to bring our quarterly rate in line with our quarterly trajectory, however
the larger numbers in the early part of the year resulted in our breaching the end
of year target. The table below identified the numbers of hospital acquired cases of
clostridium difficile cases reported by the Trust against the target for that period. The
table also identifies the number of community acquired cases of clostridium difficile
reported by our laboratory.
Quarter
Q1
Q2
Q3
Q4
Target for hospital-acquired cases
13
13
15
18
Number of hospital-acquired cases
19
19
17
13
Number of community-acquired cases
21
30
33
22
We took definitive and timely actions in order to address this and our task and finish
group led this work.
At our request, our commissioners organised an independent review at the Trust
and this provided assurance to NHS Tees and to our Board of Directors that we were
taking all appropriate steps to reduce numbers of clostridium difficile infections.
Monitor, our regulator has also reviewed actions taken by the Trust and (at the time
of writing) is satisfied that the Trust has done and continues to do all that we can
to reduce opportunity for patients to acquire clostridium difficile while in hospital.
Monitor will review the position at the end of the year.
The CQC commented specifically on their observation of the high standards of
infection prevention and control practice that they observed during their
unannounced inspection of the University Hospital of North Tees in November 2011.
The trend in hospital acquired clostridium difficile over four years can be seen in the
table below:
Year
Clostridium difficile
2008/09
2009/10
2010/11
2011/12
158
136
53
68
3. Medication errors
During the last year, staff have reported 372 medication related incidents across
hospital and community services. Some of these will have been actual incidents
and some will have been near misses. A near miss is the name for a situation when
the error did not actually happen but the circumstances were such that there was
potential for an error.
Medication errors can happen at a number of steps in the process for example, by
the Doctor prescribing the medication, by the pharmacist dispensing it or the
nurse administering it.
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Annual Report and Accounts 2011 – 2012
There are many thousands of contacts made by
our hospital and community teams every day.
We estimate there could be around 12 million
staff interactions with medications during a year,
which results in a very low risk of error when
the reported incidents are considered against the
proportion of:
•The number of bed days last year (around
400,000);
•The number of drugs a patient might be given,
possibly five different drugs three or four times
a day;
•The steps in the process (prescribing by the
doctor, dispensing by the pharmacist and
being administered by the nurse).
We have a culture of encouraging all staff
to report actual medication errors as well as
opportunities for error. The figures above show
that our staff are doing an excellent job and that
patient safety is paramount.
The reason for encouraging reporting is
not to look for blame; it is very much about
understanding why these rare things happen,
learning from them and putting in systems
which will improve things in the future.
Actions taken by the Trust:
We have undertaken a number of actions this
year to raise awareness of opportunity for
making medication errors.
The pharmacy department has introduced ward
pharmacists in a number of wards. These ward
based pharmacists work with medical and
nursing staff to ensure that prescription sheets
are checked and that drugs and interactions are
picked up and managed well. This system of
checks reduces opportunity for prescribing and
administration errors.
Nursing staff have introduced uninterrupted
drug rounds. Our nurses are often disturbed
when they are in the middle of taking the drugs
trolley round for the wards. Nurses identified
that there would be fewer administration errors
if they could do this very important aspect of
their role without being interrupted.
Our positive reporting culture enables staff
to understand what contributes to actual or
potential error and helps them to come up
with solutions to continually review and reduce
risk. This is the reason why we have checks and
balances in place across the Trust to improve
patient safety and help to our staff in any
situation, whether they are caring for patients in
our hospitals or in the community.
The latest benchmarking data published by the
North East Quality Observatory System
(NEQOS Acute Trust Quality Dashboard 2.10
Winter 2011) demonstrates that the Trust rate
of medication errors is 50% lower than the
national mean rate with 3.29 per 1,000 bed
days against the national rate of 6.59.
All trainee doctors who come to work for us
undertake a practical prescribing test. If they
do not achieve a pass, they are not allowed to
prescribe, however their clinical educator will
work with them to ensure that they are given an
opportunity to achieve the required standard.
This system of assessment reduces opportunity
for prescribing errors.
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Annual Report and Accounts 2011 – 2012
Effectiveness of Care
1. Selected quality performance indicators and national benchmarks from
the North East Quality Observatory System (NEQOS).
NEQOS collects benchmark data on Trusts for a number of clinical indicators. The
following (latest reported data) indicators provide an indication of Trust performance
when compared to other NHS Trusts nationally (March 2012 dashboard).
Effectiveness indicator
Period
Trust
value
National
Mean
95th percentile wait for elective inpatient treatment (weeks)
Nov 11
18.1
21.9
Median wait for elective inpatient treatment (weeks)
Nov 11
8.77
8.63
Delayed transfer of care per 1,000 occupied beds – NHS
responsibility
Q2
11/12
21.2
21.0
% of all admissions who have had venous thromboembolism
risk assessment
Nov 11
94.4
91.3
Medication errors per 1,000 bed days
Oct 10Mar 11
3.29
6.59
Admitted patient care – % valid data (average for all fields)
Nov 11
99.1%
97.77
Outpatient – % valid data (average for all fields)
Nov 11
91.4%
93.35%
Accident and emergency – % valid data (average for all fields)
Nov 11
99.9%
94.21%
Admitted patient care – % records submitted with valid HRG on
first submission
Oct 11
99.8%
97.5%
Staff recommendation of the Trust as a place to work
(last CQC survey)
2010
61.8%
54.6%
Staff recommendation of the Trust as a place to receive
treatment (last CQC survey)
2010
65.6%
63.8%
Overall medical trainees global satisfaction score (last GMC survey)
2010
78.8
75.7
Consultant clinical supervision trainers given to its trainees
2010
66.4
60.7
2. External reviews
The Trust continues to value the opportunity for external reviews providing an
opportunity to meet staff and review the quality of our environment, clinical care
and patient experience. Over the last year, we have been subject to a number of
formal and informal visits including:
•Two unannounced CQC inspections; as previously described;
•Assessment for risk management standards (Clinical Negligence Scheme for
Trusts) in maternity services. The Trust achieved a pass in the assessment according
to latest standards and was accredited at Level 1 for maternity services.
Additionally, we have undergone thirteen enter and view visits undertaken by
LINks where, amongst other things, they monitored standards of cleanliness and
asked patient and staff views in relation to key aspects of patient care.
LINks are independent volunteers who reach out and involve hundreds of local
people in public and patient involvement in health and social care. The independence
of LINks reviews and feedback is important to us as a Trust because it helps us to
understand other people’s views of how we are doing. Feedback is provided in a
constructive way and helps staff to understand what works well and whether there
are any areas that could be improved. More information about the work of the LINks
can be found on their website.
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Annual Report and Accounts 2011 – 2012
How did we do?
During 2011-2012, there have been a number
of external reviews and we continue to value the
ongoing feedback relating to the levels of care
and compassion our staff provide to elderly
patients and patients with dementia. It has been
particularly rewarding for staff to receive so
much positive feedback regarding the care they
take in ensuring that patient hygiene, nutrition
and personal needs are met by caring and
competent staff.
The Healthcare User Group (HUG) also
undertakes regular visits to both clinical and nonclinical areas, providing valuable feedback from
a user perspective. LINKs and HUG members sit
on key Trust quality committees enabling them
to contribute to setting and monitoring quality
standards and goals.
3. Decubitus ulcer (pressure sores)
Reducing opportunity for pressure sores has
been a high priority for all healthcare staff in the
community and in hospital.
Actions taken by the Trust:
Over the year, training in the prevention and
management of pressure ulcers has been
enhanced. Every single pressure ulcer that is
acquired whilst in our care is subject to a full
root-cause analysis to help us to understand
whether it was avoidable or not and importantly,
whether there is anything that we can learn. At
the end of 2011-2012 a new body-mapping
process was introduced. The Integrated Nursing
and Midwifery Board oversee actions to pursue
continuous improvement in performance.
The relative risk is 84.4 which means that for
100 patients that acquire a pressure ulcer in
the average hospital in England, 84.4 patients
acquire one in our care.
Dr Foster data March 2012
Patient Experience
1. Spiritual and emotional care of patients
at the end of their life
In November 2011, the National Institute of
Health and Clinical Excellence (NICE) published
guidance describing importance of providing
spiritual and religious support to patients
approaching end of life. The guidance specifically
referred to role of chaplains in end of life care.
We were very pleased to read the guidance
because it promotes the approach that our Trust
has taken over the last two to three years to
meet the needs of patients and families when
faced with the knowledge that end of life is near.
Actions taken by the Trust:
For two to three years, this Trust has referred
every patient on the end of life care pathway
to the chaplaincy team. During 2011-2012,
621 patients were referred by our staff to
this pioneering service provided by the Trust
chaplains. They provide spiritual, pastoral and
emotional support to patients, families and
staff. Only 18 patients declined their support
during the year. 380 patients welcomed and
received multiple visits. This service offers
added value to the quality of overall care
provided to patients and their loved ones and
has highlighted the importance of this aspect of
support to the dying patient.
Data on community acquired pressure ulcers
is being collected. In the hospital, data has
been collected for a number of years. Our
specialist nurses support bespoke training and
support clinical teams to maximise treatment
options. In 2012-2013, we will continue to
focus on decubitus ulcers in hospital and in the
community.
How did we do?
Dr Foster data for Jan - Dec 2011 demonstrates
that the Trust performs well when benchmarked
nationally in relation to rate of hospital acquired
decubitus ulcers in patients discharged from
surgical and medical wards/departments.
Chaplain Paul Salter.
83
Annual Report and Accounts 2011 – 2012
End of life referrals to chaplains
Number of referrals
70
61
60
50
40
52
53
51
51
47
35
30
52
53
Referrals
34
29
54
48
45
38
34
54
34
30
31
29
31
28
27
20
More than
1 visit
Declined
10
0
2
Jan
11
2
Feb
11
2
3
0
0
Mar Apr May Jun
11 11 11
11
1
2
4
Jul
11
0
Aug Sep
11
11
Oct
11
1
1
Nov Dec
11 11
Month/Year
This innovative and ground breaking approach was honoured at the Trust’s Shining
Star Awards.
When this service is allied to the use of the carer’s diary, we believe that our
philosophy of care results in a better experience for patients and relatives and
better job satisfaction for clinical staff and chaplains.
2. Formal complaints and compliments
Actions taken by the Trust:
The Trust continues to work hard to improve customer satisfaction through patient
experience. As part of our ongoing commitment to resolving complaints locally we
introduced intentional rounding in 2011-2012. Intentional rounding involves the
nurse or midwife in charge of a ward or department visiting all patients (and visitors
where they are present) regularly throughout the day to ask whether everything is
satisfactory; whether there is anything they would like to ask or that they would like
us to do.
Intentional rounding provides an opportunity for staff to pick up worries or concerns
in a proactive way and importantly, enables staff to pick up issues quickly and
effectively deal with them at source. We believe that this approach will reduce cause
for complaint and provide patients and staff with a better experience. An unexpected
advantage of this approach is the satisfaction that our staff derive from hearing
many positive comments about our overall standards of care and compassion.
In 2009-2010 we started to also record the number of compliments received
centrally. The number of thank you and complimentary comments has increased year
on year. The trends in complaints and compliments can be seen in the table below.
We do recognise that we don’t always get things right and this is why we have
a dedicated patient relations team to listen and investigate any concerns or
complaints.
We continue to work hard to provide high standards of clinical care delivered with
dignity and compassion for everyone. Feedback from patients is important because it
helps us to understand what we do well and what we can improve further.
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Annual Report and Accounts 2011 – 2012
How did we do?
The number of formal complaints received over
the last 3 years is shown in the table below:
Year
2009
2010
2011
358
341
371
2,212
3,786
5,097
Complaints
Compliments
External feedback
The latest national CQC inpatient survey (20092010) reported the Trust as being in the top
20% nationally when asked ‘did you see any
posters or leaflets explaining how to complain
about the care you received’. We also achieved
the highest score in the North East region
for this score. This question was not asked
in the 2011 national outpatient survey. The
question ‘overall how would you rate the care
you received in the outpatient department’ was
asked and again the Trust was in the top 20%
nationally.
The (March 2012) North East Quality
Observatory System benchmark data reports
the Trust at 2.98 written complaints per
1,000 episodes of care which is significantly
lower than the national mean of 3.9.
In 2011 the CQC undertook an unannounced
review of services which included Outcome 16:
Assessing and monitoring the quality provision.
The full CQC report describes the observations
and evidence reviewed. The CQC provided
positive feedback regarding the numerous ways
the Trust evaluates patient care and reported
that any issues raised or complaints made
by people had been dealt with promptly
and appropriately.
The latest data available from the (March 2012)
North East Quality Observatory System
report the 2010-2011 overall inpatient
experience measure for the Trust as 77.7
against a national mean score of 74.9.
3. Catering services
Following patient feedback the catering
team has implemented further improvements
following the successful introduction of the
ward hostess service throughout all wards in
our hospitals. Our hostesses have a specific aim
of improving the patient enjoyment
of food.
This ward hostess strategy continues to prove an
extremely successful catalyst for improvements
in patient experience by ensuring patients always
get their meal of choice, well presented and
hot. This initiative has also greatly assisted the
reduction of food waste to enable re-investment
in improved offerings on the menu, modified
consistency meals and other important patientfocused issues.
We have fully refurbished restaurants and
coffee shops which now offer much improved
and appreciated facilities for staff, patients and
visitors. The national in-patient survey results of
2011 have indicated these improvements have
delivered noteable improvement.
4. Delivering same sex accommodation
The Trust is committed to delivering the highest
standards of privacy and dignity for its
patients. The Director of Nursing and Patient
Safety has overseen a dedicated same sex
accommodation working group that looks at
ways to improve standards and care for patients
in same sex accommodation. To improve the
quality of services to patients, bathrooms and
toilets have been built and upgraded in
some clinical areas and information technology
methods have aided staff to be alerted when
bays are suitable for men or women. The Trust
communicates the importance of same sex
accommodation and staff awareness of this
is high. As a result, inappropriate mixed sex
accommodation events have been eliminated
and work will continue to maintain a zero
tolerance. All patient accommodation has been
assessed and deemed compliant. Assessment
was based on the 17 principles developed
by the Department of Health to ensure each
organisation delivers the highest standards of
privacy and dignity within all areas of a hospital.
The process of assessment has been scrutinised
by the Board on a monthly basis. Each month
senior nurses ask at least 50 patients if
they feel they have been treated with
dignity and feedback remains very good. In the
2011 national inpatient survey, patients rated the
Trust in the top 20% nationally in relation to
delivering same sex accommodation. The North
East Quality Observatory report the Trust mixed
sex accommodation breach rate as zero (Jan
2012 data from Acute Trust Quality Dashboard
2.10 accessed May 2012).
Annual Report and Accounts 2011 – 2012
85
And finally...
You said:
This frightening experience was made bearable by the wonderful staff and systems
I experienced...I can hardly believe their (staff) efficiency and outstanding level
of patient care they achieved for me...The levels of dedication and competence I
witnessed during my (hospital) stay were vastly in excess of anything I have seen
in industry. I hope you are proud of your people and your hospital.
We said:
Thank you – we are very proud of our staff.
3B Performance against key national priorities from the Department of
Health Operating Framework, Appendix B of the Compliance Framework.
Compliance Framework key priorities
The compliance framework forms the basis on which the Trust's Annual Plan and
in year reports are presented. Regulation and proportionate management remain
paramount in the Trust to ensure patient safety is considered in all aspects of
operational performance and efficiency delivery. End of year Performance against
national priority, existing targets and cancer standards are displayed in the table
below with comparisons to the previous year.
Existing commitments
National
Standard
Performance
2011-2012
Performance
2010-2011
Achieved
95%
98.13%
98.34%
√
Inpatient waiting time
26 weeks
0
0
√
Outpatient waiting time
13 weeks
0
0
√
100%
100%
100%
√
Year on year
improvement
0.29%
0.40%
√
Readmission within 28 days of non medical cancellation
100%
100%
100%
√
Delayed Transfers of Care
3.5%
2.43%
1.45%
√
18 weeks maximum wait referral to treatment (RTT) –
admitted pathways
90%
94.07%
94.23%
√
23 weeks
19.0
N/A
√
95%
99.22%
98.66%
√
18.3 weeks
11.6
N/A
√
92%
(Operating Framework
2012-2013)
97.16%
N/A
√
28 weeks
16.6
N/A
√
(1) 4
0
4
√
59
68
53
X
0
0
N/A
√
Full Compliance
Full Compliance
N/A
√
4 hour emergency care target
Access to rapid access chest pain clinics within 2 weeks of
referral from GP
Cancelled operations for non medical reasons
RTT 95th percentile wait – admitted pathways
18 weeks maximum wait referral to treatment (RTT) –
non admitted pathways
RTT 95th percentile wait – non admitted pathways
18 weeks maximum wait referral to treatment (RTT) –
incomplete pathways
RTT 95th percentile wait – incomplete pathways
MRSA (post 48 hours)
C. Diff. (post 48 hours)
Eliminating Mixed Sex Accommodation
86
Compliant with access to healthcare for patients with
learning disabilities
Annual Report and Accounts 2011 – 2012
National
Standard
Performance
2011-2012
Performance
2010-2011
Achieved
14 day maximum wait for a first outpatient appointment
following urgent GP referral
93%
95.37%
94.93%
√
14 day maximum wait for a first outpatient appointment for
breast symptomatic referral
93%
94.71%
94.02%
√
31 day maximum wait to decision to treat
96%
99.27%
99.01%
√
31 day maximum wait decision to treat to subsequent
treatment (drug therapy)
98%
100%
99.81%
√
31 day maximum wait decision to treat to subsequent
treatment (surgery)
94%
96.00%
98.61%
√
62 day maximum wait referral to treatment - all cancers
85%
88.29%
87.64%
√
62 day maximum wait from screening recall to treatment
90%
95.96%
95.13%
√
Cancer standards
87
Assistant matron for infection, prevention and control Julie Olsen with Non-Executive Director Ken Lupton.
Annual Report and Accounts 2011 – 2012
Annex 1
Part 3C: Third Party Declarations
We have invited comments from our key stakeholders. Third party declarations from
key groups are outlined below:
Council of Governors (third party declaration) - 8 March 2012
This statement aims to provide evidence that the Governors of North Tees and
Hartlepool NHS Foundation Trust (the Trust) have been involved in the formation
of the Trust’s Quality Account throughout 2011-2012. Governors were consulted
regarding the Quality Account at Council of Governors meetings throughout the
year, and have been continuously involved in refreshing the Trust’s strategic plans
with their involvement at the Strategy Sub-committee, Advisory and Guardianship
Sub-committee and Council of Governors meetings.
In April 2011 a workshop was held with Governors and members of the Board
to discuss the requirements for the 2011-2012 Quality Account. This followed a
presentation that had been given by the Director of Nursing, Patient Safety and
Quality at the Strategy Sub-committee to engage with Governors of that group. In
addition, a small working group of Governors assisted by the Associate Director of
Patient and Public Involvement met in November 2011, to discuss key priority areas
to be included in the Quality Account. The information obtained from Governors
from these sessions was used to inform the Quality Account for 2011-2012. The
Trust regularly updates its Governors at quarterly meetings. Quality and Patient Safety
remains high on the Board and Governor agenda with reports delivered to them by
the Director of Nursing, Patient Safety and Quality.
The Quality Report aims to meet one of the Trust’s strategic aims of ‘Putting Patients
First’ and displays evidence from the Patient Experience and Quality Standards panels,
which Governors have attended on a regular basis since January 2011. The panels
take place at each hospital site and community locations. This has enabled Governors
to speak directly with patients, their carers and visitors to specifically ask about the
patient experience, including privacy and dignity, care and compassion, quality of
communication and if there were any improvements that could be made. Governors
have received additional assurance from their involvement in this process to date, and
from their observations of how thorough the review process has been. In addition,
a number of Governors are involved in some of the Trust’s informal groups including
the Patient Information Evaluation Group and Menu Review Group which provide the
opportunity to review specific services or functions provided for patients.
At each of the Council of Governors meetings during 2011-2012, a range of reports
have been presented, which enable Governors to receive and discuss quality and
patient safety matters, including the ongoing focus, scrutiny and associated actions
surrounding healthcare acquired infections and in particular clostridium difficile.
In June 2011, the Trust implemented internal and external collaborative actions
to improve performance in this area. The Quality Report includes findings from
the Patient Experience and Quality Standards panels, which assess patients’ first
impressions, nursing support and patient experience. The report also details the
Trust’s mortality rates, and other updates regarding improving patient safety and
dignity within the organisation.
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Annual Report and Accounts 2011 – 2012
At the September 2011 and January 2012 Council of Governors meeting, the lead Governor presented
feedback from the Patient Experience and Quality Standards panels on behalf of the Governors who
had attended the panels, and this will become a standing item. The panels enable Governors to truly
embed and engage in discussion regarding the quality of patient care. The Governors have been
assured that the Trust’s commitment and delivery of quality has not diminished at all in the current
climate of financial restraint.
Governors also receive information on resilience management with regards to the Trust’s plans on
seasonal pressures, operational resilience, and risks and mitigation plans with regards to the winter
2011-2012, the Emergency Care Strategy and Service Reconfiguration Proposals. The Advisory and
Guardianship Committee, a sub-committee of the Council of Governors, met on four occasions during
2011-2012 and at these meetings Governors were specifically informed about and discussed the care
provided to patients, including safeguarding children, cancer pathways, and dementia strategy, and
outlined the annual plan requirements, updated on compliance and service performance particularly
around clostridium difficile, 18 week targets, 4 hour emergency target, and resilience and emergency
preparedness. This Committee has considered quality, patient safety and service developments
throughout the year and has had an opportunity to comment and include a refocus in plans where
necessary.
The Governors at a meeting on 15 September 2011 received a presentation regarding the newly
produced Nursing and Midwifery Strategy, RESPECT which is explained further in the Quality Report,
section 5.
89
Sewing room assistant Edith Neary.
Annual Report and Accounts 2011 – 2012
Hartlepool LINk response to Annual Quality Account of North Tees
and Hartlepool NHS Foundation Trust - 24 April 2012
Following receipt of the draft quality account, Hartlepool LINk wish to make a formal
response to the approach taken by the Trust with regards to quality. This response
encompasses the views of Hartlepool LINk members, which have been relayed to
both the Trust via direct correspondence and also encompassed within our published
‘Enter and View’ statutory reports. Please note this opinion is based on factual ‘Enter
and View’ visits undertaken, referrals received into Hartlepool LINk and actual patient
experience of LINk members.
Our view of future priorities would be of agreement in particular the detail
surrounding Mortality, Effectiveness and Patient Experience. We firmly believe that key
recommendations borne out of our collaborative working with the Trust fit within the
priorities and focus of the quality account.
We have carried out a number of visits to Hartlepool and North Tees Hospital Wards
and Departments and we have been impressed by what was observed and what we
have been told. All visits have been underpinned by what we believe to be openness
and honesty with information freely given, which in turn has allowed Hartlepool LINk
to produce meaningful and robust reports. On occasion, as with every demanding and
resource intensive service delivered, we have on occasion found the need to revisit areas
of concern, following receipt of additional data around further patient experiences.
At the moment we would further recommend an extension to some of the
improvements made, in that they cover both hospital sites, in particular the Cancer
Specialist Nurse, Dementia Specialist nurse and the volunteers recruited to visit elderly
people who have no visitors. Whilst it is such an emotive subject regard must also be
given to ‘End of Life’ care as it is collectively felt within Hartlepool LINk, patients
receive a higher level of care should they die in hospital. Our experience has been that
palliative care is of an inferior standard and fails consistency within the community.
One area Hartlepool LINk is keen for the Trust to reconsider is the issue of transport.
Year on year, as a move towards improving meaningful communication we have
formerly requested the Trust adhere to its obligation in notifying patients of the NHS
Healthcare Travel Costs Scheme. In this current economic climate we feel some
patients are choosing to disengage from treatment purely because they do not have
the funds to attend appointments.
Rather than the hospital introducing the automated scheme, as an austerity measure,
to check on whether patients will be attending appointments, resource should be
directed at giving those most vulnerable members of our community the guidance
and means to seek financial assistance to attend. Year on year appointment letters are
being issued advising of the automated scheme, yet failing to advise patients of the
Travel Cost Scheme.
Overall, Hartlepool LINk welcomes the opportunity to respond to the Draft Quality
Account and would hope it will continue to reflect the views we present as the sole
statutory consultation body for the people of Hartlepool.
Yours Faithfully,
Christopher Akers-Belcher, LINKs Co-ordinator
Email: c.akersbelcher@hvda.co.uk
Website: www.hartlepoollink.co.uk
90
Annual Report and Accounts 2011 – 2012
Health Scrutiny Forum, Hartlepool
- 30 March 2012
Members of Hartlepool’s Health Scrutiny
Forum are pleased to be asked to contribute
to North Tees and Hartlepool NHS Foundation
Trust’s Quality Account for 2012/13. Despite
a challenging year which saw the closure of
the Accident and Emergency Department at
the University Hospital of Hartlepool, Members
have appreciated the continued improvement
in communication between the Trust and
the Forum, which has enabled more detailed
discussions to take place over the direction of
the Trust’s Quality Account for 2012/13.
The Health Scrutiny Forum were pleased with
the continued excellent reduction in MRSA
infections, however, Members were somewhat
concerned at Clostridium Difficile levels and the
fact that there has been a rise in these numbers
since last year. The Forum urges the Trust to
continue to find a way to ensure that hospital
acquired infections are at negligible levels or
eliminated entirely.
Although initially not included in this year’s
Quality Account, the Forum was aware of
the number of medication errors that have
occurred within North Tees and Hartlepool NHS
Foundation Trust’s service provision. Though
Members acknowledge that these medication
errors are small when compared to the number
of medicines dispensed by the Trust, the Forum
emphasises the importance of ensuring that
these are kept to a minimum and that for each
individual case, lessons are learnt to reduce any
risk to patient safety.
Members also congratulate the Trust in its
improvements in reducing mortality which
resulted in North Tees and Hartlepool NHS
Foundation Trust being recognised through
inclusion in the 2011 Dr Foster Good Hospital
Guide.
Councillor Stephen Akers-Belcher
Chair of Hartlepool’s Health Scrutiny Forum
Healthcare User Group (HUG)
- 1 April 2012
The main role of the Healthcare User Group
(HUG) is to assist the Trust in achieving the
Patient and Public Involvement (PPI) agenda.
The Trust has afforded the right level of support
to allow HUG to carry out its independent
visits to inpatient wards and outpatient clinics.
None of our visits during the past year have
highlighted any concerns that would affect the
Trust’s commitment in improving the quality of
care and service quality for patients, as outlined
in the Chief Executive’s Statement on Quality.
All recommendations from HUG have been
acknowledged and acted upon promptly.
HUG will continue to be an objective and
supportive party and provide input not only
through hospital visits but also with our
participation at Trust meetings such as the
Quality Standards Steering Group and High
Impact Action Groups.
Members of the Forum welcomed and support
the development of a early warning test for
dementia suffers in community settings and
although recognises that some of this work
is aspirational, encourage the Trust to look at
opportunities within communities that may
enable this roll-out to be achievable.
The Forum continues to be pleased at the usage
of Carer’s Diaries and how well received these
have become, particularly for those families who
are experiencing loved ones on an end of life
pathway.
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Annual Report and Accounts 2011 – 2012
NHS Tees and Stockton on Tees Clinical Commissioning group
(lead commissioner) - 8 May 2012
NHS Tees is the collaborative commissioner of NHS services across Teesside and
consists of NHS Hartlepool, NHS Stockton on Tees, NHS Middlesbrough and
NHS Redcar and Cleveland. NHS Tees has actively engaged the nascent Clinical
Commissioning Groups (CCGs) on the quality agenda and welcomes the opportunity
to submit a joint statement on the Annual Quality Account for North Tees and
Hartlepool NHS Foundation Trust.
NHS Tees and NHS Hartlepool and Stockton on Tees Clinical Commissioning Group
can confirm that to the best of its ability, the information provided within the
Annual Quality Account is an accurate and fair reflection of the Trust's performance
for 2011/12.
During 2011/12 we have continued to provide joint robust challenge through our
Clinical Quality Review Groups (CQRGs) to drive improvements in the quality of
services and outcomes for patients. The CQRGs involve key stakeholders who focus
on a significant range of topics including all aspects of safety, clinical effectiveness
and patient experience. North Tees and Hartlepool NHS Foundation Trust have been
open and transparent in their approach to working with commissioners and have
responded positively to constructive clinical challenge.
During 2011/12, clinical members of NHS Tees were invited to participate in multi
disciplinary mortality reviews using the IHI global trigger tool. In addition to this,
open invitations have been extended by North Tees and Hartlepool NHS Foundation
Trust to attend a number of key committees in relation to the patient safety agenda,
including the Adult Safeguarding Committee.
As part of their continued desire to be transparent providers, to improve care and
reduce harm, North Tees and Hartlepool NHS Foundation Trust have involved the
commissioners in the sharing of lessons learned following serious incidents. A key
learning outcome has led to the CCGs working collaboratively with the Trust to
further reduce Clostridium difficile. The Trust has also worked extremely hard across
acute and community settings in working with NHS Tees and CCG representatives
in agreeing, implementing and delivering a challenging Commissioning for Quality
and Innovation (CQUIN) scheme in 2011/12. This approach will be maintained in
2012/13.
NHS Tees and CCGs will continue to work very closely with relevant key staff groups
during the transition period to facilitate a seamless handover of commissioner
responsibilities at the end of March 2013. This will involve working with North Tees
and Hartlepool NHS Foundation Trust in ensuring that the commissioning, provision
and monitoring of safe clinical care for the people of Teesside remains a key priority.
The hard work and dedication of staff across acute and community settings are
recognised and the overall commitment of the Trust to “Put Patients First” by making
patient safety and experience their number one priority every day is very much
welcomed.
NHS Tees and NHS Hartlepool and Stockton on Tees CCG look forward to continuing
to work in partnership with North Tees and Hartlepool NHS Foundation Trust during
2012/13 to further improve the quality of services that the Trust provides for the
people of Teesside.
92
Annual Report and Accounts 2011 – 2012
Stockton Council’s Adult Service and
Health Select Committee and Stockton
LINk - 2 April 2012
Members of both the Select Committee and LINk
welcome the opportunity to comment on this
year’s Quality Account, and once again provide a
joint statement.
Both the LINk and Committee support the
priorities that have been selected for 2012-13
and these are clearly expressed in table form.
The Committee is pleased to note that all of its
suggestions will be addressed in some way.
Communication continues to be a key priority for
all those with an interest in the work of the Trust.
It is right that it remains as an improvement
target for the coming year, building on the good
work during 2011-12, and indeed it runs as a
theme throughout the Account.
The introduction of contemporaneous
documentation is innovative and it is pleasing
to see the joint working with South Tees
Foundation Trust in order to further standardise
documentation, given the numbers of patients
that transfer between Trusts for treatment.
Further joint working is proposed with GPs in
relation to discharge communication.
As part of the action plan for the forthcoming
year, in relation to tracking feedback on
communication and end of life care (including
compliments and complaints) there is a
concentration on reporting feedback to nursing
oversight boards; however the important role of
all other medical staff in this regard should not
be underestimated.
In relation to communication during 2011-12,
the Committee and LINk feel that the Trust has
been open in communicating with local partners,
including awareness raising about the Trust’s
need to achieve substantial savings over the next
three years. However, it is also felt that the Trust
could have done more in advance to inform
stakeholders, and users, of the introduction of
charging for disabled car park users.
Dementia has been selected as a priority for the
coming year. This has been a key public issue of
concern in the health service over the past few
years and its inclusion is supported.
However, it is important to recognise that the
Trust is building on a strong base in relation to
dementia care. Improvements in recent years
have included the appointment of specialist
dementia nurses, and improved joint working
with the Tees, Esk and Wear Valleys NHS
Foundation Trust including increased capacity
in the acute liaison team. It will be important to
build on this work as the proposed changes in
relation to TEWV’s Lustrum Vale older people’s
mental health unit and related community
services are embedded.
The Trust has also run a Learning Disability
awareness course for staff which is welcome,
and Learning Disability services are increasingly a
priority for the LINk and Committee, and will be
the subject of forthcoming enter and view visits.
Better community services can only assist in
improving patient experiences and reducing the
need for hospital-based treatment. The Trust is
to be congratulated on the development of the
community services early warning system, the
first in the country, and it is sensible to keep this
as a priority for the coming year in order to allow
the system to bed in further.
The LINk is particularly pleased to see the
introduction of volunteers to spend time with
elderly patients who have no visitors, and this
follows on from a clear recommendation in the
LINk’s Care and Dignity Report.
Both the Committee and LINk were pleased
to note the assurances of service quality from
external organisations, in particular the result
of a CQC inspection of the University Hospital
of Hartlepool; as part of its national review of
dignity and nutrition, the Trust was found to be
meeting the essential standards.
In terms of presentation of the document
itself, the introduction of a glossary will help
wider understanding. In addition, the LINk and
Committee are pleased to note that the Trust
intends to provide a more accessible summary
document for a wider public readership,
although this was not available for review at the
time of writing.
The Trust’s use of ‘you said, we did’-style
examples of patient feedback is welcome, and
follows on from a suggestion we made last year.
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Annual Report and Accounts 2011 – 2012
It may be appropriate to include a summary of the changing face of healthcare
and the increased focus on community healthcare and related new technologies,
together with references to the financial challenges, as this would set the detail
contained in the Account within the wider context of the Trust’s work.
The Trust’s inclusive approach to involving stakeholders in the development of the
Quality Account is to be commended once again. The opportunity to respond to the
consultation on the forthcoming year’s priorities during the autumn is appreciated.
In order to improve further, it is suggested that it would be useful to have
additional information during the consultation; for example, information on in-year
performance, in order to provide consultees with progress against that current year’s
priorities to aid the selection of the next year’s priorities.
94
Assistant matron for infection, prevention and control Debra Jenkins and ward manager Pauline Jiggins.
Annual Report and Accounts 2011 – 2012
Annex 2
Statement of Directors’ Responsibilities in Respect of the Quality Report
The Directors are required under the Health Act
2009 and the National Health Service (Quality
reports) Regulations 2010 as amended 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
for the quality report.
In preparing the quality report, Directors are
required to take steps to satisfy themselves that:
•The content of the quality report meets the
requirements set out in the NHS Foundation
Trust Annual Reporting Manual 2011-2012.
•The content of the quality report is not
inconsistent with internal and external sources
of information including:
--Board minutes and papers for the period
April 2011 - May 2012;
--Papers relating to quality reported to the
board over the period April 2011 May 2012;
--Feedback from the Council of Governors 8 March 2012;
--Feedback from the Hartlepool LINk 24 April 2012;
--Feedback from the Hartlepool Health
Scrutiny Forum, Hartlepool 30 March 2012;
--Feedback from the Healthcare User Group
(HUG) - 1 April 2012;
--Feedback from NHS Tees and Stockton on
Tees Clinical Commissioning Group (lead
commissioners) - 8 May 2012;
--The latest national staff survey April 2012;
--The Head of Internal Audit’s annual opinion
over the Trust’s control environment May
2012;
--CQC quality and risk profiles February 2012.
•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 are
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
reports regulations) (published at www.
monitor-nhsft.gov.uk/ annualreportingmanual)
as well as the standards to support data
quality for the preparation of the quality
report available at www.monitor-nhsft.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
--Feedback from the Stockton Council's Adult
Service and Health Select Committee and
Stockton LINk - 2 April 2012;
--The Trust’s complaints report published
under regulation 18 of the local authority
social services and NHS complaints
regulations 2009 dated April 2011 December 2011;
--The latest national patient survey April
2012;
Paul Garvin
Chairman
28 May 2012
Alan Foster
Chief Executive
28 May 2012
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Annual Report and Accounts 2011 – 2012
Annex 3
Independent Auditors’ Limited Assurance Report to the Council of
Governors of North Tees and Hartlepool NHS Foundation Trust on
the Annual Quality Report
We have been engaged by the Council of Governors of North Tees and Hartlepool
NHS Foundation Trust to perform an independent assurance engagement in respect
of North Tees and Hartlepool NHS Foundation Trust’s Quality Report (the ‘Quality
Report’) and specified performance indicators contained therein.
Scope and subject matter
The indicators in the Quality Report that have been subject to limited assurance
consist of the national priority indicators as mandated by Monitor:
•Clostridium difficile (page 79-80); and
•62 day maximum wait referral to treatment – all cancers (page 87).
We refer to these national priority indicators collectively as the “specified indicators”.
Respective responsibilities of the Directors and auditors
The Directors are responsible for the content and the preparation of the Quality
Report in accordance with the assessment criteria referred to on pages 96-97 of the
Quality Report (the "Criteria"). The Directors are also responsible for their assertion
and the conformity of their Criteria with the assessment criteria set out in the NHS
Foundation Trust Annual Reporting Manual (“FT ARM”) issued by the Independent
Regulator of NHS Foundation Trusts (“Monitor”). In particular, the Directors are
responsible for the declarations they have made in their Statement of Directors’
Responsibilities.
Our responsibility is to form a conclusion, based on limited assurance procedures, on
whether anything has come to our attention that causes us to believe that:
•The Quality Report does not incorporate the matters required to be reported on as
specified in Annex 2 to Chapter 7 of the FT ARM;
•The Quality Report is materially inconsistent with the sources specified below; and
•The specified indicators have not been prepared in all material respects in
accordance with the Criteria.
We read the Quality Report and consider whether it addresses the content
requirements of the FT ARM, and consider the implications for our report if we
become aware of any material omissions.
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Annual Report and Accounts 2011 – 2012
We read the other information contained in
the Quality Report and consider whether it is
materially inconsistent with:
•Board minutes for the period April 2011 to
May 2012;
•Papers relating to Quality reported to the
Board over the period April 2011 to May 2012;
•Feedback from the Commissioners dated
8 May 2012;
•Feedback from LINKS dated 24 April 2012;
•The trust’s complaints report published under
regulation 18 of the Local Authority Social
Services and NHS Complaints Regulations
2009, dated April to December 2011;
•The latest national patient survey dated
April 2012;
•The latest national staff survey dated
April 2012;
•Care Quality Commission quality and risk
profiles dated February 2012;
•The Head of Internal Audit’s annual opinion
over the trust’s control environment dated
21 May 2012;
•Feedback from the Health Scrutiny Forum,
Hartlepool dated 30 March 2012; and
•Feedback from the Healthcare User Group
dated 1 April 2012.
We consider the implications for our report if we
become aware of any apparent misstatements
or material inconsistencies with those
documents (collectively, the “documents”).
Our responsibilities do not extend to any other
information.
We are in compliance with the applicable
independence and competency requirements
of the Institute of Chartered Accountants in
England and Wales (ICAEW) Code of Ethics. Our
team comprised assurance practitioners and
relevant subject matter experts.
This report, including the conclusion, has been
prepared solely for the Council of Governors of
North Tees and Hartlepool NHS Foundation Trust
as a body, to assist the Council of Governors
in reporting North Tees and Hartlepool NHS
Foundation Trust’s quality agenda, performance
and activities. We permit the disclosure of
this report within the Annual Report for the
year ended 31 March 2012, to enable the
Council of Governors to demonstrate they have
discharged their governance responsibilities by
commissioning an independent assurance report
in connection with the indicators. To the fullest
extent permitted by law, we do not accept or
assume responsibility to anyone other than
the Council of Governors as a body and North
Tees and Hartlepool NHS Foundation Trust for
our work or this report save where terms are
expressly agreed and with our prior consent in
writing.
Assurance work performed
We conducted this limited assurance
engagement in accordance with International
Standard on Assurance Engagements 3000
‘Assurance Engagements other than Audits
or Reviews of Historical Financial Information’
issued by the International Auditing and
Assurance Standards Board (‘ISAE 3000’).
Our limited assurance procedures included:
•Evaluating the design and implementation of
the key processes and controls for managing
and reporting the indicators;
•Making enquiries of management;
•Limited testing, on a selective basis, of the
data used to calculate the indicator back to
supporting documentation;
•Comparing the content requirements of the FT
ARM to the categories reported in the Quality
Report; and
•Reading the documents.
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Annual Report and Accounts 2011 – 2012
A limited assurance engagement is less in scope than a reasonable assurance
engagement. The nature, timing and extent of procedures for gathering sufficient
appropriate evidence are deliberately limited relative to a reasonable assurance
engagement.
Limitations
Non-financial performance information is subject to more inherent limitations
than financial information, given the characteristics of the subject matter and the
methods used for determining such information.
The absence of a significant body of established practice on which to draw allows for
the selection of different but acceptable measurement techniques which can result
in materially different measurements and can impact comparability. The precision
of different measurement techniques may also vary. Furthermore, the nature and
methods used to determine such information, as well as the measurement criteria
and the precision thereof, may change over time. It is important to read the Quality
Report in the context of the assessment criteria set out in the FT ARM and the
Directors’ interpretation of the Criteria on pages 96-97 of the Quality Report.
The nature, form and content required of Quality Reports are determined by
Monitor. This may result in the omission of information relevant to other users,
for example for the purpose of comparing the results of different NHS Foundation
Trusts/organisations/entities.
In addition, the scope of our assurance work has not included governance over
quality or non-mandated indicators in the Quality Report, which have been
determined locally by North Tees and Hartlepool NHS Foundation Trust.
Conclusion
Based on the results of our procedures, nothing has come to our attention that
causes us to believe that,
•The Quality Report does not incorporate the matters required to be reported on as
specified in annex 2 to Chapter 7 of the FT ARM;
•The Quality Report is materially inconsistent with the sources specified above; and
•The specified indicators have not been prepared in all material respects in
accordance with the Criteria.
PricewaterhouseCoopers LLP
Chartered Accountants
Newcastle upon Tyne
28 May 2012
The maintenance and integrity of the North Tees and Hartlepool NHS Foundation
Trust’s website is the responsibility of the directors; the work carried out by the
assurance providers does not involve consideration of these matters and, accordingly,
the assurance providers accept no responsibility for any changes that may have
occurred to the reported performance indicators or criteria since they were initially
presented on the website.
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Annual Report and Accounts 2011 – 2012
Alcohol specialist nurses Kirsty Willis and Helen Clay.
99
Glossary
A&E
Accident and Emergency
ACE Committee
Audit and Clinical Effectiveness Committee - the committee that oversees both clinical audit (i.e. monitoring
compliance with agreed standards of care) and clinical effectiveness (i.e. ensuring clinical services implement the
most up-to-date clinical guidelines).
ACL
Anterior Cruciate Ligament - one of the four major ligaments of the knee
CABG
Coronary Artery Bypass Graft (or “heart bypass”)
Cancer – maximum waiting time,
eg 62 days from urgent GP referral
for first treatment for all cancers:
criteria for reporting
• The indicator is expressed as a percentage of patients receiving first definitive treatment for cancer within
62 days of an urgent GP referral for suspected cancer;
• An urgent GP referral is one which has a two week wait from date that the referral is received to first being
seen by a consultant (see http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/
digitalasset/dh_103431/pdf);
• The indicator only includes GP referrals for suspected cancer (i.e. excludes consultant upgrades and
screening referrals and where the priority type of the referral is National Code 3 – Two week wait);
• The clock start date is defined as the date that the referral is received by the Trust; and
• The clock stop date is the date of first definitive cancer treatment as defined in the NHS Dataset Set
Change Notice (A copy of this DSCN can be accessed at: http://www.isb.nhs.uk/documents/dscn/dscn2008/
dataset/202008.pdf). In summary, this is the date of the first definitive cancer treatment given to a patient
who is receiving care for a cancer condition or it is the date that cancer was discounted when the patient
was first seen or it is the date that the patient made the decision to decline all treatment.
CHKS
Comparative Health Knowledge System
Clostridium Difficile (infection)
An infection sometimes caused as a result of taking certain antibiotics for other health conditions. It is easily
spread and can be acquired in the community and in hospital.
Clostridium Difficile: criteria for
reporting
• Patients aged two or more;
• A positive laboratory test result for Clostridium Difficile recognised as a case according to the Trust's diagnostic;
• Positive results on the same patient more than 28 days apart are reported as separate episodes, irrespective
of the number of specimens taken in the intervening period, or where they were taken; and
• The Trust is deemed responsible. This is defined as a case where the sample was taken on the fourth day or
later of an admission to that trust (where the day of admission is day one).
100
CLRN
Comprehensive Local Research Network
CQC
The Care Quality Commission - the independent safety and quality regulator of all health and social care
services in England.
CQUIN
Commissioning for Quality and Innovation - a payment framework introduced in 2009 to make a proportion of
providers’ income conditional on demonstrating improvements in quality and innovation in specified areas of
care.
DAHNO
Data for Head and Neck Oncology (Head and Neck Cancer)
Dr Foster
A major provider of healthcare information and benchmarking
EAU
Emergency Assessment Unit
e-coli (infection)
An infection sometimes caused as a result of poor hygiene or hand-washing.
EWS
Early Warning Score - a tool used to assess a patient’s health and warn of any deterioration
FCE
Finished Consultant Episode - the complete period of time a patient has spent under the continuous care of
one consultant.
FOI (act)
The Freedom of Information Act - gives you the right to ask any public body for information they have on a
particular subject.
Global trigger tool (GTT)
Used to assess rate and level of potential harm. Use of the GTT is led by a medical consultant and involves
members of the multi professional team. The tool enables clinical teams to identify events through triggers
which may have caused, or have potential to cause varying levels of harm and take action to reduce the risk.
GCP
Good Clinical Practice
HCAI
Healthcare Acquired Infection
HES
Hospital Episode Statistics
HMB
Heavy Menstrual Bleeding
HRG
Healthcare Resource Group - a group of clinically similar treatments and care that require similar levels of
healthcare resource.
HSMR
Hospital Standardised Mortality Ratio - an indicator of healthcare quality that measures whether the death rate
in a hospital is higher or lower than you would expect.
HUG
Hospital User Group
IBD
Inflammatory Bowel Disease
ICNARC
Intensive Care National Audit and Research Centre
Annual Report and Accounts 2011 – 2012
IG
Information Governance
Intentional rounding
A formal review of patient satisfaction used in wards at regular points throughout the day.
Kardex (prescribing kardex)
A standard document used by healthcare professionals for recording details of what has been prescribed for a
patient during their stay.
LINks
Local Involvement Network - a group established in order to give local people a stronger voice in how their
health and social care services are run.
Liverpool End of Life Care Pathway
Used at the bedside to drive up sustained quality of care of the dying patient in the last hours and days of life.
MBRRACE-UK
Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries in the UK.
MHRA
Medicines and Healthcare products Regulatory Agency
MINAP
The Myocardial Ischaemia National Audit Project
Monitor
The independent regulator of NHS foundation trusts
MRSA
Meticillin-Resistant Staphylococcus Aureus - a type of bacterial infection that is resistant to a number of widely
used antibiotics.
MUST
Malnutrition Universal Screening Tool
NCEPOD
The National Confidential Enquiry into Patient Outcome and Death
NCRN
National Cancer Research Network
NEQOS
North East Quality Observatory System
NICE
The National Institute of Health and Clinical Excellence
NICOR
The National Institute for Cardiovascular Outcomes Research
NIHR
National Institute for Health Research
NNAP
National Neonatal Audit Programme
PAS
Patient Administration System
Patient Safety and Quality
Standards (Ps&Qs) Committee
The committee responsible for ensuring provision of high quality care and identifying areas of risk requiring
corrective action.
PEQS
Patient Experience and Quality Standards
PICANet
Paediatric Intensive Care Audit Network
PROMs
Patient Reported Outcome Measures
Pseudonymisation
A process where patient identifiable information is removed from data held by the Trust
Quality Risk Profile (QRP)
A CQC tool for monitoring compliance with essential standards of quality and safety that helps to identify
where risks lie within an organisation.
R&D
Research and Development
RCOG
The Royal College of Obstetricians and Gynaecologists
RCPCH
The Royal College of Paediatric and Child Health
RESPECT
“Responsive, Equipped, Safe and secure, Person centred, Evidence based, Care and compassion and Timely” - a
nursing and midwifery strategy developed with patients and Governors aimed at promoting the importance of
involving patients and carers in all aspects of healthcare.
Same sex accommodation
(delivery): criteria for reporting
• Any instance of more than 5 minutes inappropriate mixed sex accommodation is treated as an exception;
and
• An instance of mixed sex accommodation may be treated as appropriate if it is, for example, at the request
of a married couple.
SBAR
“Situation, Background, Assessment and Recommendation” - a tool for promoting consistent and effective
communication in relation to patient care.
SHA
Strategic Health Authority
SHMI
Summary Hospital Mortality-level Indicator - a hospital-level indicator which reports inpatient deaths and
deaths within 30-days of discharge at trust level across the NHS.
SINAP
Stroke Improvement National Audit Programme
SSU
Short Stay Unit
STAMP
Screening Tool for the Assessment of Malnutrition in Paediatrics
Toughbooks
Piloted in 2010, these mobile computers aim to ensure that community staff has access to up-to-date clinical
information, enabling them to make speedy and appropriate clinical decisions.
UHH
University Hospital of Hartlepool
UHNT
University Hospital of North Tees
VSGBI
The Vascular Society of Great Britain and Ireland
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6. Valuing Our
Workforce
102
Theatre worker Stephen Petch.
North Tees and Hartlepool NHS Foundation Trust is a vibrant and successful provider of hospital
and community based healthcare services. We cannot achieve this success without our most
valuable and important resource, our staff. The value of our staff cannot be over-emphasised.
Quality, value and recognition are the themes which run through all our activities, to enable us
to attract, retain, reward and develop our current and potential future staff.
The corporate strategy can only be achieved
through a competent workforce, which
is supported by effective management
and leadership practices. To this end, all
staff through our People and Organisation
Development Strategy will be provided with
opportunities to acquire the skills to do their
current job, and skills to equip them with
leadership and management opportunities to
promote career enhancement and to address
the changing needs of the Trust. The Trust aims
to support staff to achieve the highest levels of
performance in pursuit of the mission, vision
and values of the Trust, and enable the Trust to
be recognised as a high quality employer and
be their employer of choice.
The People and Organisation Development
Strategy builds upon good practices and new
opportunities and ensures our staff have an
understanding of the Trust’s purpose and aims.
It provides opportunities to give our staff the
energy and commitment levels to support the
strategic aims and enable this Trust to be one
of the best in the country, both as a provider of
healthcare and as an employer.
The four aims identified within the strategy
ensure:
•We have the right staff in the right jobs at the
right time;
•Our staff continue to develop the skills they
need to meet the Trust and their directorate/
department requirements and to achieve their
resulting development goals;
•Our staff are supported to achieve the highest
levels of performance in pursuit of our aims
and objectives;
•Our staff are recognised and rewarded for
their achievements and commitment.
6.1 Commitment to Staff
Putting people first is our Trust strapline, this
applies equally to all our staff. One key group is
our staff, without whom we could not provide or
deliver our healthcare services. The Trust cannot
over-emphasise the value of our staff, and our
People and Organisation Development Strategy
reflects the value, quality and recognition we
place upon our staff.
We recognise that we need to attract, retain,
reward and develop our current and future
staff, to do this we must, and do, place great
emphasis on the support we give to our staff, in
helping support their ambitions and we provide
substantial opportunities for staff to acquire the
skills to do their jobs and also equip them with
leadership and management skills to promote
career enhancement and meet the ever changing
needs of the Trust. The Trust has enhanced its
appraisal and development processes to ensure
all staff are provided with development to
support them in their job and career ambitions.
We were very proud in 2011-2012 when we
achieved all our mandatory training targets.
It is important for the Trust to engage with
staff, to seek their views, thoughts and ideas
about how we can improve our services and
activities for patients, and employment activities
and prospects for all staff. We take time to
listen, we provide opportunities for staff to
discuss and communicate their views, and
by doing this we improve our services and
activities. This has enabled the Trust to be truly
recognised through the awards and accolades
achieved during 2011-2012.
The Trust recognises the need to reward staff
for their contribution to making North Tees and
Hartlepool NHS Foundation Trust an excellent
place for: patient care; delivering our Trust vision
and people first values; and to work.
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Annual Report and Accounts 2011 – 2012
We recognise that rewarding and recognising our staff can be accomplished in a
number of ways. The Trust established a Trust Annual Awards (‘Shining Stars’) event,
which allows staff, including volunteers, to be recognised by their colleagues for the
contribution they have made to their work and that of the Trust in putting patients
at the forefront of everything we do.
Awards and Accolades
The Trusts first 'Shining Stars' Awards recognising our staffs contribution.
The Trust supports its staff in seeking both internal and external recognition for its
excellent work. The Awards and Accolades achieved in 2011-2012 recognised the
hard work, commitment and contribution staff make to enable North Tees and
Hartlepool NHS Foundation Trust to be a successful provider of healthcare services.
The Trust developed and held its first recognition event in 2011-2012, the Shining
Stars Awards, which enabled the Trust to recognise and acknowledge the amazing
staff and volunteers who go above and beyond the call of duty to help patients.
All nominees in each category were put forward by staff and volunteers of the Trust.
There were ten categories, and the winners are identified below:
•Developing excellent services: The Stroke Team;
•Dedication to quality improvement: The Chaplaincy Team;
•Learner of the year: Associate Practitioner Linda Fleet;
•Working in partnership with other agencies: The Weight Management Service;
•Commitment to equality and diversity: Human Resource Managers Michelle Taylor
and Tracy Minns;
•Working behind the scenes: Patient Safety Administrator Sue Turner;
•Unsung hero: Physiotherapist Amy Wynne;
•Team of the year: The Ward Hygienists;
•Leadership award: Theatre Support Worker James Sullivan;
•Outstanding contribution to volunteering: Jacob Dent.
This event generated over 100 nominations which resulted in awards being
presented in each category at the event on the 7 October 2011, which was attended
by 235 members of staff.
The event was a great success, with very positive feedback from staff. It is envisaged
that this will become an annual event within the Trust.
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Annual Report and Accounts 2011 – 2012
There was also recognition of staff achieving 40
years service with the Trust: those staff receiving
this celebration were:
•Pauline Stark
•William Henderson
cleaning and chemically disinfecting wards
to help reduce the risk of hospital acquired
infections spreading.
Trust recognised on the 10th anniversary of
PACES
•Shirley Peel
•Janet Robinson
•Linda Merryweather
The following awards and accolades were
presented to staff during 2011-2012.
Five star catering service
Professor Ash, chair examiner presents the plaque to
chief executive Alan Foster with consultant physicians
Deepak Dwarakanath and Basant Chaudhury.
Executive chef Craig Hooker, chef Ian Cannon, store
person Christine Owens, picker and packer Lucy
Littlewood and head of catering Colin Chapman.
A food hygiene inspection by Stockton Borough
Council awarded five stars for the fourth year to
the University Hospital of North Tees, as part of
the Tees Valley Food Hygiene Award.
To mark the 10th anniversary of the PACES
examination, the Trust was presented with a
commemorative plaque in recognition of its
continuing commitment to PACES. The MRCP
(UK) part 2 clinical examination, commonly
known as PACES has been running for 10 years.
During that time MRCP(UK) has assessed over
22,800 candidates in 256 examination centres
and 11 countries.
Endoscopy services accredited by Royal
College of Physicians
Trust commended at national cleaning
awards
The endoscopy team show their delight after
being accredited by the Joint Advisory Group on
Gastrointestinal Endoscopy.
Domestic Healthcare Team receive their
commendation from the Health Business Awards.
The Trust was given a clean bill of health for its
efforts in raising standards of cleanliness. The
commendation came at the Health Business
Awards for the hospital cleaning award, where
the Trust was short listed along with two other
hospitals in recognition of its work in deep
Endoscopy services at the Trust were under the
close scrutiny of the Joint Advisory Group on
Gastrointestinal Endoscopy (JAG) and passed
with flying colours. JAG is a group set up under
the Royal College of Physicians which sets
standards for endoscopy units and looks at
the quality of training and services, awarding
accreditation to those that meet the standards.
Annual Report and Accounts 2011 – 2012
105
Trust wins green apple award for carbon
management plan
Chief engineer Stuart Watkin with Shadow Health
Minister Liz Kendall.
IT/systems management award – Anaesthetic
systems manager Steve Blundell (pictured) won
the IT/systems management award for his work
which makes systems in the department more
efficient and is a massive benefit to patients.
The Trust achieved further recognition for efforts
to reduce carbon emissions and protect the
environment.
The green apple silver award was presented in
recognition of the Trust’s carbon management
programme which sets out how we plan to
reduce our emissions, how we can influence
other organisations to do the same, and how we
are preparing for the effects of climate change.
Staff recognised for their contributions to
patient care at the Hartlepool Mail Best of
Health awards
Many Trust staff were recognised for their
amazing contributions to patient care at the
Hartlepool Mail’s Best of Health awards.
106
Team of the year – The University Hospital
of Hartlepool’s chemotherapy day unit made
it a double when they were awarded team of
the year for the second year running. Rosie
Livingston, third right receives the award from
Marie Dollin, head of school, health and care
Hartlepool College of Further Education watched
by fellow nurses Julie Saint, Pam Hauxwell,
Pauline Wallace, Joanne Thomson and Karen Bird.
Annual Report and Accounts 2011 – 2012
Special achievement award – Clinical site
manager Val Wells (pictured with non executive
director Stephen Hall) received the special
achievement award. Val has spent more than
half a century in the health service having started
as a nursing cadet. Colleagues told how she
fulfils her role as a senior nurse in the hospital
with dignity and respect and her professionalism
for excellent healthcare is a driving force.
Judges award – The judges made a special award
for the district nursing team in Hartlepool as they
had been nominated in many categories and the
judges decided they deserved a special mention.
Apprentices celebrate their success
Specialist nurse nominated for national
award
Award winners Jordan Pearson (left) and Kurt
Blythman pictured with associate director of estates
Peter Mitchell (centre) and engineers Keith Walker
(left) and Ian Taylor.
Two apprentices at the Trust were awarded
top prizes for their achievements in hospital
engineering.
Electrical apprentice Jordan Pearson, 18, was
awarded the J R (Jack) Fletcher award for the
first year apprentice of the year and medical
engineer Kurt Blythman, 19, was awarded the
Bill Murray OBE award for the second year
apprentice of the year.
Staff given the VIP treatment for going the
extra mile
Lyndsey Cross, Clinical nurse specialist, inflammatory
bowel disease (IBD) nominated by a patient in the IBD
Nursing Awards.
Clinical nurse specialist, inflammatory bowel
disease (IBD) Lyndsey Cross was nominated by a
patient in the IBD Nursing Awards after Crohn’s
and Colitis UK invited their 31,000 members
living with IBD to nominate their specialist nurse
for the award.
Trust wins parking award for 8th year
running
Eight staff were treated to a VIP night out at the
Mayor of Stockton’s charity ball as a thank you
from the Trust, after directors and their teams
were asked to nominate staff who deserved extra
recognition for the efforts and achievements.
The Trust was presented with the Park Mark
award for the eighth year running for the safety
and quality of the car parking facilities. The Trust
is constantly improving lighting and security so
staff and visitors can be assured they are safe
while they are at our hospitals.
The Occupational Health Department have led
the Trust to success in achieving the Silver Level
of the North East Better Health at Work Award.
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Annual Report and Accounts 2011 – 2012
This award is given to organisations who successfully maximise opportunities for
health improvement and wellbeing, which in turn contribute to:
•Improved workplace health;
•Improved corporate image;
•Contributes to the achievement of the highest standards of patient care and
experience;
•Improved staff morale and loyalty;
•Reduced absenteeism;
•Reduced staff turnover;
•Compliance with NHS standards and quality frameworks.
Trust celebrates its safety success
Gillian Johnson from NHS Diabetes
receives the award for safer prescribing
and administration of insulin from Dr
Hilary Jones.
The Trust scooped three of the ten regional awards at the NHS North East Patient
Safety Awards, winning the drug safety category for leading a regional project to
ensure safer prescribing and administration of insulin, and the reducing mortality
category for reducing mortality in intensive care through improved communication,
patient pathways and influential consultant leadership.
Also winning the safe surgery category, the Trust’s innovative new day case foot
surgery service means patients no longer need to undergo general anaesthetic or stay
overnight in hospital, but instead can be discharged home within one hour of surgery
to recover in familiar surroundings, reducing the risk of blood clots and infection.
Deep Cleaning
The Trust were ‘commended’ at the Health Business Awards for hospital cleaning
standards in the application of decontamination processes including hydrogen
peroxide fogging, ward hygienists and deep cleaning initiatives. The team was also
short listed in the Healthcare Estates Facilities Management Association (HefmA)
national awards under the Innovation category for implementation of the Hydrogen
Peroxide cleaning systems.
Podiatric surgeon Sharon Bell receives
the award for the trust’s innovative
new day case foot surgery service from
Dr Hilary Jones.
Sustainability
In November 2011, the Trust won a silver award at a ceremony held in the House of
Commons in recognition of its carbon reduction and sustainability achievements.
Patient Environment Action Team
The Trust achieved Patient Environment Action Team (PEAT) Score of ‘5’, which
demonstrates excellent in all three PEAT areas assessed (cleanliness & environment,
patient catering, privacy & dignity).
Other key achievements during 2011-2012 were:
The Trust received 5-star Environmental Health Awards for both hospital catering
facilities and significant improvements in patient catering performance from the
national in-patient survey.
Consultant anaesthetist Farooq Brohi
receives the award for improvements
in intensive care from chief executive
of Northumbria Healthcare NHS
Foundation Trust and chairman of the
North East Patient Safety Strategic
Forum Jim Mackey.
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Ongoing accreditation to the ISO 9001: 2000, ISO 13485:2003 & MDD 93/42/
EEC Quality Standards within both Sterile Services Departments and also including
reprocessing of endoscopy scopes.
Space utilisation, occupancy ratios, occupancy
costs and carbon emissions, all being
benchmarked extremely favourably compared to
regional peers.
Park Mark award for the 8th consecutive year
- for safe and secure car parking arrangements.
6.2 Keeping Staff Informed
Key to this approach is to ensure that staff are
fully informed of, and engaged in, the business
of the Trust. The Trust continues to use well
established forums to keep staff informed on
issues that concern them. Regular departmental
meetings and forums such as the Trust Directors
Group, Local Medical Committee, Staff Council
and the Joint Negotiating and Consultative
Forums have continued throughout the
year. In addition, a monthly Chief Executive
briefing takes place where managers are
given information to cascade throughout the
workforce to ensure that staff are informed of
developments, quality, operational and financial
performance and plans. The opportunity for
staff to question and discuss such issues is
provided at each of the forums mentioned.
As well as being well informed the workforce
needs to be fully engaged in the aims of the
Trust. It was at one of the Chief Executive
briefings that the Trust launched its £40million
challenge. This informs staff of the financial
challenge facing the Trust over the next three
years and asks them to put forward ideas that
would contribute to the Trust successfully
meeting this challenge. A dedicated email
address was established to collate these ideas
and suggestions.
Progress towards the achievement of the
£40million challenge is reported through all
communication channels mentioned above as
well as the staff council, which was established
in 2010, and which provides a forum for
communicating, discussing and exchanging
views. Membership of the council includes
representatives of each directorate/department
within the Trust and gives staff the opportunity
to hear and discuss important issues from the
appropriate executive directors.
The Trust has a constructive working relationship
with its recognised trade unions, which is
demonstrated through the effective working of
the Joint Negotiating and Consultative Forums,
which meet regularly to discuss employment
matters. Subgroups of the main committee are
established as required, for example to consider
policy developments and changes to conditions
of service.
The Trust was affected by the industrial action
which took place on the 30 November 2011.
485 members of staff withdrew their labour
on this day, which resulted in reduced clinical
activity. However, due to good working
relationships with Staff Side, plans were put
in place to ensure all essential and emergency
services were maintained.
To constantly improve the services we deliver,
the Trust uses Lean Production Systems, which
embrace a process of continual improvement,
striving for zero defects and elimination of waste
and inefficiency in processes that are part of the
healthcare experience. Underlying this approach
is the recognition that staff working within the
process, know how they can be improved, and
therefore, supports true staff engagement. Using
the tools and techniques of Lean Production
Systems this encourages and supports staff
to constantly seek ways to deliver the highest
quality and safest patient care. It provides a
relentless focus on the patient experience and
increases the amount of value added time
patients experience with staff.
Consequently:
•Patients benefit from greater safety, less delay
in getting to see the appropriate staff for care
resulting in more timely results and treatments;
•Staff benefit by having less rework due to
errors and defects in the system and hence
greater opportunities to care for patients;
•The organisation benefits by operating
more efficiently and improving processes
that are a part of any healthcare experience
which ultimately contributes to North Tees
and Hartlepool NHS Foundation Trust in
its endeavour to improve the health and
wellbeing of its patients.
The Trust is implementing the work on Lean by
alignment with the NHS Institute for Innovation
and Improvement Productive series of Lean
interventions to enhance the outcomes and give
greater coverage within the organisation.
Annual Report and Accounts 2011 – 2012
109
6.3 Supporting Staff
The Trust has a well established Improving Working Lives Group with representatives
from each directorate. This group takes forward and implements all initiatives that
relate to Improving Working Lives, Investors in People, the annual Staff Survey and
health and well being at work agenda. This group was instrumental in the Trust
achieving a 62.71% response rate to the 2011 staff survey.
Staff with caring responsibilities continue to be supported through the provision of
flexible childcare facilities on both sites. These facilities are also offered to the local
communities.
The Trust’s Flexible Working Arrangements and Achieving a Work Life Balance Policy
provides support to staff and managers.
We have also improved our staff policies to reflect support for staff with other caring
responsibilities and end of life support.
Community staff nurse Jay Pattinson.
The Trust has in place various policies offering support to our staff throughout their
employment with us. These include policies such as the Work Life Balance Policy,
which covers flexible working, career breaks, time off for domestic emergencies,
bereavement leave, and the promotion of good mental health and management of
stress policy. The Trust also has in place a procedure for supporting staff involved in
traumatic or stressful situations.
The Trust takes a zero tolerance approach to violence and aggression and bullying
and harassment of staff whether that is from patients, relatives, visitors or staff.
The Trust Prevention of Bullying and Harassment policy is supported by training and
general awareness raising for staff. The Trust has in place the First Stop Contact
Officer scheme, which provides informal and confidential support to staff that may
have concerns.
Staff Health and Wellbeing
The health and wellbeing of our staff continues to be a high priority and all
activities relating to this agenda have been developed with cognisance of the Trust’s
Corporate Strategy and People and Organisation Development Strategy.
Health and wellbeing of our staff is crucial to the provision of our patient care as
2011-2012 has seen an increase in absence compared to 2010-11, the Trust has
seen a very variable sickness absence rate in 2011-2012.
Sickness absence rates throughout the year ranged from 4.12% to a high of 5.11%
in October 2011, with an overall annual rate of 4.67% against a target of 3.75%.
Absence has been subject to a review as 2011-2012 has seen a similar level of absence
compared to 2010-2011, 4.70%. We have engaged managers and staff side, which
has seen in the latter months of the year our absence rates reducing. Although we
are seeing an improvement in absence/attendance it remains above the Trust’s target.
Managing and reducing sickness absence is a key objective for the Trust and much
activity has been undertaken to ensure policies, tools and services are available to
support managers in the management of attendance.
The Trust recognises that the regular attendance of staff at work is crucial and
continuously strives to reduce absence levels and thereby maximise the level of
resource available to ensure that we deliver high quality services and patient care.
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Annual Report and Accounts 2011 – 2012
The Trust has a responsibility to monitor and
manage sickness absence and there are a
number of drivers for ensuring that sickness
absence is monitored and managed effectively,
these are patient care; staff health/morale and
finance.
Sickness absence levels are reported to the
Trust Board through the Human Resources and
Organisation Development quarterly reports and
include a range of key performance indicators.
As a Trust our aim is to ensure that all long term
sickness absence, defined currently as a period
in excess of four weeks absence, is effectively
managed to ensure staff are supported
throughout in order to minimise the length of
their absence and proactively manage a return
to work. In terms of short term sickness absence,
the aim is to manage frequent episodes that
exceed the agreed trigger points, proactively to
ensure a reduction in levels.
Our staff side are working with us to identify
ways that actions can be implemented to
improve attendance. They fully support the
need to reduce sickness absence, not only as a
means for the Trust to make significant savings
but also recognising the benefits that can be
gained including reduced agency spend, reduced
turnover, improved patient satisfaction, reduced
patient mortality and improved staff satisfaction.
The Trust also recognises that, at times staff
may experience situations or incidents that
are traumatic. The Procedure for Supporting
Staff involved In Traumatic/Stressful Incidents,
Complaints and Claims is in place to ensure staff
are provided with appropriate support prior,
during and following the event, as required.
The services include: work-based health
screening of new and existing staff; workrelated health checks; health and wellbeing
awareness events and production of information
sheets; sickness absence management advice;
supporting managers, Human Resources and
others in the reduction programmes of the Trust,
supporting the delivery of the management
standards and the Health and Safety Executive
needs; staff fitness programmes; 2012 challenge;
access to psychological therapies; physiotherapy,
vaccination and immunisation programmes;
and group and personal advice around reducing
health risks in the workplace.
Occupational health is a flexible team that
ensures all legislative screening of staff and the
activities they undertake are thorough and in
accordance with risk assessment requirements.
Occupational Health has continued to provide
specific health screening required by legislation
through health surveillance of certain staff
groups continuing on a regular basis and in
accordance with risk assessment, to ensure that
as far as reasonably possible their work does not
have an adverse affect on their health and where
health issues exist and may be exacerbated
through work, these have been properly assessed
and appropriate action taken. The Service works
closely with Human Resources and managers
to minimise the amount of sickness absence
taken by individual employees. The service aims
to ensure appropriate and prompt referrals for
advice are made and through doing so provides
early access to support services for staff, and
specialist advice to managers.
The Trust’s Occupational Health Service
employs a range of specialists: doctors; nurses;
physiotherapists; counsellors and support staff
that provide comprehensive occupational health
services to all our staff, as well as contracted
services to a number of local businesses and
other NHS organisations.
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Annual Report and Accounts 2011 – 2012
The Trust’s health and safety team has provided professional advice, support and
training in all aspects of fire, health and safety including manual handling, security
management and environmental safety to support the Trust’s responsibility of duty
of care to safeguard its patients, staff and visitors.
The effective management of non-clinical risk is achieved via the implementation and
continual review and improvement of Health and Safety policies following regulatory
body guidance and utilising Department of Healthcare Quality Commission and
NHS Litigation Authority Risk Management Standards requirements. This continual
improvement has led to the development and Introduction of a Managers’ Health
& Safety Manual available on the Corporate Health and Safety and Non Clinical Risk
website, which details all non clinical risk assessment guidance and requirements,
utilising simple flow charts and all relevant documentation to assist mangers in
effectively managing non-clinical risk locally. Since its introduction in July 2011,
subsequent health and safety audits have shown an increase in risk assessment
compliance to over 90% in all areas audited.
The Trust’s Local Security Management Specialists continued to work in partnership
with the Police and Crown Prosecution Service to ensure that offenders who assault
and abuse staff, cause criminal damage to Trust property or theft of staff or patient
belongings are brought to justice, which reinforces the Trust’s message of zero
tolerance towards this type of criminal behaviour. During 2011-2012 we raised
awareness of staff via the delivery of Conflict Resolution Training with 89% (over
3,200) of front line staff trained to date, we have seen an increase in the number
of incidents of violence and aggression reported, demonstrating that staff will no
longer tolerate this type of abuse and behaviour.
Working with Occupational Health and Procurement & Supplies, significant
improvement has been made regarding the risk management of Latex and
Occupational Skin Diseases. This improvement was confirmed following an
inspection by the Health & Safety Executive that resulted in some very positive
feedback on progress to date.
6.4 Development and Education of Staff
Education, learning and development for all staff remains high on the Trust’s
agenda. Education Learning and Development have continued to contribute to the
Trust’s strategic and national obligations by offering high quality education and
training, which is available to all.
The Directorate has undergone a major restructure and fundamentally changed the
work of the directorate’s teams and developing cross team working; key outcomes of
this process were to ensure value for money, further development of the educational
team, streamline quality standards and processes and develop the directorates
responsiveness to the needs of the Trust.
Healthcare apprentice Billy Rock assists
staff nurse Carmelita Bagangan on ward.
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Annual Report and Accounts 2011 – 2012
We have developed strong working relationships with three local colleges to deliver
apprenticeship programmes in care and business administration. There is now closer
liaison between the key Trust leads for care and administration helping to ensure that
we have an appropriately qualified and competent support workforce, which is vital
to the patient experience and to the smooth running of services. The forging of these
links with three further education providers will enable us to utilise education providers
flexibly in the future and commission programmes from a variety of providers.
We remain committed to the education of both
Undergraduate and Post Graduate Doctors.
Our success in these areas was evidenced in a
number of reports. The Trust received the results
of two surveys relating to medical education and
training, Your School, Your Say (YSYS) and GMC
Trainee and Trainer surveys.
The response rate for YSYS was very high (91%)
and the Trust was thanked for supporting
Northern Deanery Foundation School (NDFS)
with the survey. In response to the YSYS
survey, 97% of trainees said that they would
recommend this Trust to a friend that was
thinking of applying. Additionally, 87% of
trainees felt prepared for post foundation
training. Very few trainees felt that they
were dealing with problems beyond their
competencies and enabled the Trust to be shown
particularly well compared to other Trusts.
F1 doctor Stephen Brennan completes patient
documentation with staff nurse Leanne Clamp.
Within the GMC survey a number of areas
were identified as achieving a green triangle
(indicating the score is very high compared to
national mean) in both 2010 and 2011 surveys.
For example, Anaesthetics not only scored the
highest out of all of the Trusts in the region in the
areas of handover and hours of education per
week the trainees receive but were 2nd and 3rd
respectively in the country. They were also within
the top three in the region for the following
areas:•Other learning opportunities;
•Educational Supervision;
•Clinical Supervision;
•Workload;
•Work intensity;
•Local induction and feedback.
There has been a significant drive to achieve
compliance with mandatory training across the
organisation resulting in a Trust-wide aggregated
achievement rate of 96%. The Directorate has
implemented several alternatives to comply
with mandatory training including workbooks
and e-learning which have been successful. The
organisation has a robust policy for planning,
implementing and monitoring mandatory
training across all areas of the minimum data
set required by the NHS Litigation Authority and
other regulatory bodies such as the Care Quality
Commission.
All Directorates are aware of the targets for each
area of mandatory training and compliance is
monitored monthly at executive director level
ensuring that robust action plans are in place
for areas of concern. The Trust has achieved all
its mandatory training targets for 2011-2012.
The Trust Education Strategy Group, which is
chaired by the Director of Human Resources
and Education/Company Secretary and also has
a Non-Executive Director on the membership,
meets bi-monthly and considers education,
development (undergraduate/postgraduate and
nurse training), workforce and Lean activity and
developments across the Trust.
The Trust also supports the training of nonmedical clinical professionals by providing high
quality placements and workplace assessment
opportunities in conjunction with local and
regional Universities, acting as a home Trust to
nursing students from the University of Teesside
Postgraduate development opportunities are
catered for through funding provided by the
Strategic Health Authority to the Schools of
Health at Teesside and Northumbria Universities
from Diploma to Masters Degree level. The
portfolio is developed and revised annually by
education leads across the region and monitored
throughout the year for achievement rates,
attendance and quality.
The Trust also supports existing staff with their
Continuous Professional Development (CPD) to
ensure they maintain and enhance competence.
Trust policy supports the availability of
appropriate development of all staff based upon
the business objectives of the organisation, the
core skills of the position that they hold and their
individual development needs that are identified,
prioritised and planned for at appraisal.
Annual Report and Accounts 2011 – 2012
113
The Trust works in partnership with Higher and Further Education Providers to ensure
that educational and development opportunities exist to meet the needs of our staff.
During the year the Trust invested in leadership development by first of all identifying
the key leadership behaviours required, and then assessing our current capability
against these behaviours. The results were utilised to develop leadership programmes
for senior management teams within the directorates and departments of the Trust.
Mechanisms are now being developed to identify our leaders of the future through
a talent management process, thus enabling leadership and management skills to be
embedded at every layer of the organisation.
Key to the success of education, learning and development activities is that the
content meets the current and future needs of the Trust and its patients. To this
end, the functions of Education, Learning and Development and, Organisation
Development and Workforce Planning have been brought together under the
Education and Organisation Development Directorate to ensure that all planned
developments are underpinned by a detailed workforce plan which will drive the
content of education and learning plans. A yearly workforce planning cycle has been
developed and introduced through the Trust’s business planning cycle, this ensures
that we have a workforce, which is fit for purpose, and also cognisance is taken of
future service delivery needs.
6.5 Equality and Diversity
We are committed to ensuring diversity is recognised and equality is embedded at
the heart of everything we do, whether this be for staff, patients, carers or visitors
to our Trust. This statement explains our current position in relation to our Trust
meeting the statutory requirement with the Public Sector Equality Duty (PSED), which
arises from the Equality Act 2010 (Specific Duties) Regulations 2011.
Equality, Diversity and Human Rights issues have always been firmly on the agenda
of the Trust. The Trust has in place an Equality Strategy (currently being reviewed
for 2012), which sets out our commitment and direction in relation to our whole
equality, diversity and human rights agenda. Through the work we do on equality
and diversity we seek to:
•Eliminate unlawful discrimination, harassment and victimisation;
•Advance equality of opportunity between different groups;
•Foster good relations between different groups;
•Seek to improve existing practices and embed new initiatives and enhance our
equality and diversity activity.
The Trust’s commitment to this agenda starts right at the top of the organisation,
with the Trust’s Equality and Diversity Steering Group being chaired by Julie Gillon,
Executive Director of Operations and Performance. Paul Garvin, Chair of the Trust
and Clare Curran, Director of HR and Education/Company Secretary are also active
members of this committee.
The Equality and Diversity Steering Group has a cross section of representation from
across the Trust. Representatives from each directorate are invited to this meeting to
provide an update on equality issues pertinent to their area, and present new ideas
and developments they have embraced.
The Steering Group is supported by the Equality and Diversity Working Group which
comprises leads from each protected characteristic.
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Annual Report and Accounts 2011 – 2012
The Trust is a member of the Regional Equality,
Diversity and Human Rights Group that meet
monthly. Therefore ensuring any Regional/
National issues are fed directly from this group
to the Trust Working and Steering Groups.
The Trust is a ‘two ticks’ employer and is proud
to display the positive about disabled people
logo which shows our commitment to ensuring
fairness and equality in relation to recruitment
and then ongoing throughout a member of
staffs employment.
Our Recruitment and Selection policy makes it
clear that our processes are fair and consistent,
regardless of any protected characteristic. Managers are trained in good recruitment
and selection practices, ensuring they are
aware of equality issues in the recruitment and
selection processes. Workforce statistics relating
to recruitment are monitored by protected
characteristic to ensure fairness of application
of processes.
In 2011-2012 we continued to train our staff in
equality and diversity with a total of 1,747 staff
receiving training during this period.
The Trust published its third and final Single
Equality Scheme (SES) Annual Report in June
2011, highlighting the good practice ongoing
in relation to equality and diversity. With the
national change in approach in relation to
equality and diversity saw the end of the SES and
the introduction of the Equality Delivery System
(EDS). As a Trust we engaged with staff, patients
and service users in order to agree grading in
relation to the 18 outcomes included in the EDS.
Working with staff, patients and service users
the Trust has also worked with staff patients and
service users in order to identify our Equality
Objectives. These equality objectives were
published in line with the Public Sector Equality
Duty on 6 April 2012 and will be reviewed
annually.
The Trust reports annually on progress made in
relation to meeting the Public Sector Equality
Duty (PSED) which includes reporting on
workforce statistics. This information can be
accessed via the Trust website www.nth.nhs.uk.
The Trust is currently developing the Equality
Annual Report 2011-2012, with a view to this
document being ratified by the Trust Board.
This will be published on the Trust website from
June 2012. The Trust continues to ensure policies
and services are appropriately equality impact
assessed via the equality impact assessment
processes within the Trust. Managers across the
Trust have been trained to be able to undertake
this assessment.
6.6 NHS Staff Survey
The Trust took part in the ninth annual survey of
NHS staff. These results will inform improvements
in working conditions and practices and provide
evidence for self assessments and health checks.
The Care Quality Commission will use the results
as measures of performance in the annual health
check, whilst the Department of Health and other
national bodies will use the outcomes to help
assess the effectiveness of national NHS staff
policies, as well as influence future developments
in these areas.
The Trust recognises that engaging with and
listening to our staff is crucial as we aim to
achieve excellence. We have in place robust
partnership working with our staff side via
various forums including the Joint Consultative
Forum and Joint Negotiating Forum. We
also have the Staff Council, which includes
representation from each Directorate across
the Trust. The Trust has in place an established
Improving Working Lives Group that comprises
directorate leads from each directorate and staff
side membership. Members of both the staff
council and IWL group have responsibility for
cascading information to staff within their areas
of work, with the aim of achieving consistency
in information flows and gaining feedback from
staff. We also ensure our staff are provided with
feedback on survey outcomes and achievements
against previous years surveys.
In the staff survey an overall indication of staff
engagement is calculated from using findings
from a number of questions covering areas such
as staff ability to contribute to improvements at
work, their willingness to recommend the Trust
as a place to work or receive treatment and the
extent to which they feel motivated and engaged
in their work. The Trust score of 3.67 was above
average when compared with other Acute Trusts.
The Trust scored 3.76 in the 2010 staff survey.
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Annual Report and Accounts 2011 – 2012
The Trust response rate for 2011 was 62.71%, which was a significant improvement
from previous years.
2010/2011
Response rate
2011/2012
Trust
National
Average
Trust
National
Average
51%
52%
63%
52%
Trust
Improvement/
Deterioration
+12%
The overall results the Trust achieved in the 2011 staff survey were positive. Of the
38 key findings contained within the staff survey, the Trust were ranked in the best
20% of acute Trusts in 20 of these 38 key findings. The Trust also scored better than
average when compared to other acute Trusts in a further 12 key findings.
The Trust experienced better results than last year in five of the key findings:
•Percentage of staff appraised in the last 12 months;
•Percentage of staff appraised with personal development plans in the last 12
months;
•Percentage of staff receiving health and safety training in the last 12 months;
•Percentage of staff saying hand washing materials are always available; and
•Percentage of staff having equality and diversity training in the last 12 months.
However in relation to the three key findings below, the Trust saw a reduction in staff
responses:
•Percentage of staff reporting good communication between senior management
and staff;
•Staff recommendation of the Trust as a place to work or receive treatment.
Although on both the above key findings we were ranked better than average when
compared to other acute Trusts, and;
•Staff motivation at work (where we where ranked average when compared to
other acute Trusts).
The Trust’s top four ranked scores in the 2011 staff survey, when compared to other
acute Trusts in England were:
2010/2011
Top 4 ranked scores
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Annual Report and Accounts 2011 – 2012
2011/2012
Trust
Improvement/
Deterioration
Trust
National
Average
Trust
National
Average
Fairness and effectiveness of
incident reporting procedures
3.69
3.45
3.65
3.46
No Change
Percentage of staff working
extra hours
57%
66%
55%
65%
No Change
Perception of effective
action towards violence and
harassment
3.74
3.56
3.75
3.58
No Change
Work pressure felt by staff
2.92
3.11
2.96
3.12
No Change
The Trust’s bottom 4 ranked scores in the 2011 staff survey, when compared to other acute Trusts in
England were:
2010/2011
Bottom four ranked scores
2011/2012
Trust
Improvement/
Deterioration
Trust
National
Average
Trust
National
Average
Percentage of staff experiencing physical violence
from patients, relatives or the public in the last 12
months
7%
8%
9%
8%
No Change
Percentage of staff experiencing physical violence
from staff in the last 12 months
2%
1%
2%
1%
No Change
Percentage of staff suffering work-related injury in
the last 12 months
16%
16%
17%
16%
No Change
Effective team-working
3.75
3.69
3.69
3.72
No Change
As a Trust we monitor the responses received
from the NHS Staff Survey through the
Improving Working Lives (IWL) working group
with reports and action plans being prepared,
presented, discussed and approved at the Trust
Executive Management meetings, and presented
to the Trust Board. Results are also discussed
with the Staff Council and Council of Governors.
Areas of good practice that are identified via the
survey are communicated across the organisation
to celebrate achievement and to share widely
with a view to enabling the cascade of learning
and improvement opportunities. Action plans are
developed and continuously updated to address
any shortfalls identified via the staff survey, these
are shared with staff and they are monitored via
the IWL working group.
Directorate leads are responsible for the
development and implementation of action
plans within their own service areas, identifying
and addressing specific areas of concern raised
within the staff survey. Progress against both
the corporate and directorate action plans are
discussed at the IWL working group.
The Trust priority areas in 2012-2013 will include
the bottom four ranked scores when compared
to other acute Trusts in England. In addition,
priorities will also include any areas where there
is a significant deterioration from last years score
and also any areas where we are significantly
lower than other acute trusts nationally.
In particular, these areas of concerns to be
addressed via the IWL action plan will include
actions to address our priorities and targets.
Actions have been developed to:
•Reduce the percentage of staff experiencing
physical violence from patients, relatives or the
public;
•Reduce the percentage of staff experiencing
physical violence form staff;
•Reduce the percentage of staff suffering work
related injury;
•Improve effective team working;
•Improve staff motivation at work;
•Improve communication between senior
management and staff;
•Improve staff views of the Trust as a place to
work or receive treatment.
Progress on actions addressing these priorities
and targets will be monitored via the Trusts IWL
working group both at a directorate level and
also at a corporate level. Targeted focus groups
will be arranged within directorates or with a
particular staff group where a specific concern
is more prevalent than in other areas or staff
groups.
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Annual Report and Accounts 2011 – 2012
7. Research and
Development (R&D)
118
Consultant paediatricians Anil Tuladhar and Venkata Paturi discuss a patient’s treatment using the paperless handover sheet.
The R&D Department continues to embed research into the culture of the Trust through more
patients being recruited into the National Institute for Health Research (NIHR) portfolio studies,
additional staff benefiting from the R&D Incentive Fund and increased numbers of staff trained
in Good Clinical Practice (GCP).
We remain committed to actively encouraging participation into NIHR portfolio adopted research
studies as part of our membership agreement with County Durham & Tees Valley Comprehensive
Local Research Network (CDTV CLRN). We have 158 active studies registered with the department (an
increase of 21% on the figures for last year), 106 of these (67%) are NIHR portfolio studies.
Overall, the NIHR target of “doubling the number of patients recruited into portfolio studies between
2008 - 2013” has been exceeded in this Trust ahead of target with a 400% increase seen in the
numbers of patients recruited into studies between the 2008-2009 baseline (159 patients) and 2012
(993). The table below shows the year on year increases seen in this Trust for these portfolio study
recruitment figures.
Figure 1: NIHR Portfolio Recruitment
NIHR portfolio Study recruitment
993
1,000
900
800
700
600
500
412
400
458
300
200
159
100
0
2008/09
2009/10
2010/11
2011/12
Other achievements to date are summarised below:
•In addition, to our core CLRN funding allocation of £463,685 we received additional mid-year
allocations of £30,750 leading to a total budget of £494,435 for 2011-2012 from the CLRN. This
core allocation is lower than the previous year as we were unable to appoint to some research nurse
posts funded in 2010-2011, these costs were therefore carried forward into this financial year;
•The Trust R&D Incentive fund has funded £33,000 of training, research support and course fees
within the Trust over the last year. Funding was used for additional nurse time for a palliative care
study, plasma analysis kits for a Mammoglobin breast cancer research study, Trust based GCP
training, Medicines and Healthcare Products Regulatory Agency (MHRA) inspection fees and MSc
course fees;
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Annual Report and Accounts 2011 – 2012
•Through the R&D Incentive Fund, we were able to deliver two training sessions in
Good Clinical Practice for Research (GCP) since the last annual report with another
planned for March 2012. In total, 60 members of staff attended this training in
March and November 2011 and an additional 30 are registered for March 2012.
166 members of staff are currently trained in GCP. The course is intended as a
refresher every two years for staff who currently already hold a GCP certificate and
an introductory course for those new to research;
•There are 63 members of staff acting as Principal Investigator/local Collaborators
in research within the Trust, some of whom are contributing to 10 studies. We
now have 10 CLRN funded Research Nurses within the Trust, and an additional
13 nurses who undertake supplementary research work as additional hours. We
have initiated an active bi-monthly Research Nurses Working group to provide
professional support and mentorship in what can sometimes be an isolated role;
•We currently have two members of staff progressing external applications for NIHR
funding of their research projects (Respiratory Medicine and Colorectal Surgery).
These have been developed in close collaboration with the Research Design Service
from Durham University. One of which has progressed past the first round of
funding onto formal scientific peer review;
•The 2011 R&D conference was once again a huge success with notable interest in
the keynote lecture from Professor Sir John Burn. Overall, of the 99 people who
attended, 98% rated it as either excellent (59.6%) or good (38.3%) in terms of
overall opinion of the day;
•An MHRA inspection of the R&D department in December 2011 required a great
deal of preparatory work and collaboration from many departments in the Trust.
We were however, able to still maintain high levels of support for ongoing studies
and approval of new studies. Overall we found the inspection an extremely
informative and educational process. Recommendations from the MHRA were
made to the Trust and a final response from us has now been submitted. We
hope to incorporate lessons learned from this inspection into our planned quality
systems review and areas of work plan and our seminar series will target particular
areas where further training is needed;
•Participation in commercially sponsored portfolio research is an NIHR priority. Last
year there were four commercially sponsored studies active within the Trust. This
year we have approved another three with three more planned for approval before
the end of the financial year. We plan to use the revenue created through overhead
fees in these studies to create additional self-funded research posts within the
relevant directorates;
•The R&D seminar series for 2011 has been re-scheduled due to workload pressures
incurred from the MHRA inspection. We intend to run this course in Autumn 2012;
•We have appointed a new CLRN funded R&D Data Assistant to help alleviate some
of the administrative burden of research projects so that time can be devoted by
the research teams to active patient recruitment, treatment and follow-up. We
have also appointed a Deputy Director of R&D to assist the R&D director and help
further increase research capacity in the Trust;
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•Over the last year there has been increased collaboration with primary care colleagues predominantly
for studies within respiratory medicine, paediatrics and gastroenterology. GP practices have been
involved with the active identification of suitable patients for Trust based research studies. This will
become increasingly important over the next year to help achieve the recruitment to “time and
target” metrics for all portfolio studies.
The Trust has responded well to the need to see increased research capacity and participation in NIHR
portfolio research. In the forthcoming years we need to consolidate on this progress and further
develop research active staff in directorates where activity to date has been limited, increase our
participation in commercially sponsored research and increase the number of Trust initiated studies.
Vascular surgeon Andrew Parry carries out his 100th case of pioneering varicose vein surgery on patient Dawn Musgrave.
Annual Report and Accounts 2011 – 2012
121
8. Organisational
Structure
122
Julie Gillon talks to Governors at the Council of Governors meeting.
The Trust is a Foundation Trust, which requires specific statutory duties to be met. These include
the composition of Council of Governors and the Board of Directors. The Trust values the
contribution, which the Council of Governors and Board of Directors provide, their engagement
in reviewing and assessing Trust services, patient safety and quality is invaluable to enable the
Trust to both grow and enhance its healthcare reputation. This section provides an overview
of the structures and responsibilities which the Council of Governors, Board of Directors and
Executive Management team undertake. It also provides an overview of key committees of the
Trust and how they work in partnership with the Board, Council of Governors and Executive
Management Team. The Trust values the contribution of its staff into the development and
delivery of our health and healthcare services.
The Trust was authorised as a Foundation Trust in
December 2007. It is led by a Board of Directors
responsible for the exercise of the powers and
the performance of the Trust, for ensuring the
highest standards of corporate governance,
patient safety and quality, and that the Trust
operates within a framework of prudent and
effective controls, which enables risk to be
assessed and managed.
They also receive the Annual Report and
Accounts and hold to account the Board of
Directors for its management and leadership
of the Trust, the performance of the Trust, and
ensure the Trust does not breach its terms of
authorisation.
It is responsible for ensuring compliance
with the terms of authorisation, including
the constitution, with mandatory guidance
issued by Monitor, and with relevant statutory
requirements and contractual obligations.
The Board of Directors and Council of Governors
engage regularly, there are four Council of
Governor meetings each year, and the Board of
Directors attend each of these meetings.
The responsibilities of the Board of Directors
and the Council of Governors are set out in the
Trust’s Constitution, and the approved Standing
Orders and a Scheme of Delegation, which sets
out the powers reserved to the Board, and those
powers delegated to individuals.
The Board of Directors, composition and its
meeting structures are described on pages
131-137.
The Council of Governors is responsible for
representing the interests of NHS Foundation
Trust members and stakeholder organisations
in the governance of the Trust. They exercise
statutory powers, as laid down in Monitor’s
Code of Governance, these include the
appointment and terms and conditions of
the Chairman and Non-Executive Directors,
ratification of the appointment of the Chief
Executive and approval of the appointment of
the Trust’s External Auditors.
8.1 Working Together – the Trust Board
and Council of Governors
Before each formal Council of Governor
meeting, the Trust hosts a development
and information session, where the Council
of Governors and Board of Directors come
together to learn and develop ideas to
support the work of the Trust. Following each
development and information session, the
formal Council of Governors meeting occurs.
The Board of Directors have overall responsibility
for running the Trust, the Council of Governors
receive regular reports and updates from the
Board of Directors covering all aspects of Trust
business. Thus ensuring statutory requirements
are achieved and monitored.
In addition, members of the Board also attend
various sub-committees of the Council of
Governors, and therefore engage with members
of the Council of Governors on specific issues.
There is a Senior Independent Director, who is
available to Governors and members for contact
and communication in the event of any concerns
or difficulties.
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The Board of Directors approve the directions and decisions agreed. The Council
of Governors receive the decisions and directions made by the Board of Directors,
and hold the Board to account and seek justification of its decisions. Such examples
include:
•Patient safety and quality developments/initiatives;
•Changes to service configurations;
•Proposed developments including the proposals for the new hospital;
•£40m challenge launch;
•Workforce restructuring;
•Reconfiguration of the estate;
•Medical developments;
•Financial performance;
•Quality report.
The Board of Directors and the Council of Governors ensure the application of the
NHS Foundation Trust Code of Governance.
8.2 Council of Governors
The members of the Council of Governors are very committed to support and serve:
the Trust; its members, both public and staff; patients and their carers. The Trust
values the contribution of its Governors and in particular the perspectives that they
bring to the Trust’s development of services.
In particular, members of the Council of Governors have engaged with the Trust’s
Patient Experience, and Quality Standards monthly panels, these are described in
section 5, and this enables Governors to meet patients and carers and assess the
quality of our Trust’s services. The Trust's lead Governor is Pat Upton.
The Council of Governors working group have reviewed the Quality Report and
provided the third party declaration that has also been endorsed by the Council of
Governors.
8.2.1 Role and Composition
During 2011-2012 the Trust improved its guidance on the roles of Governors, which
was approved and used as part of the election process in 2011, and the subsequent
induction of our new Governors.
The Trust has:
•11 public Governors from Stockton;
•6 public Governors from Hartlepool;
•1 public Governor from Sedgefield;
•3 public Governors from Easington;
•7 Appointed members;
•6 Staff Governors.
The Council of Governors has five sub-committees, which are described on page 126.
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Annual Report and Accounts 2011 – 2012
During 2011, the Trust developed more
opportunities for Governors to meet and have
time to discuss on a more informal basis their
work and activities in support of the Trust. These
informal meetings have proved successful and
two meetings each year are to be established.
8.2.2 Elections –
Public and Staff Governors
Public and staff members are elected to
the Council of Governors from the Trust’s
membership. Governors for both public, staff,
and patient/carer constituencies are elected to
office on varying terms of up to three years and
may seek re-election for further terms of up to a
maximum of three terms (nine years). Elections
are held on an annual basis for Governors.
The last round of elections were held in
December 2011, and were conducted by the
Electoral Reform Services (ERS) who were
satisfied they were held in accordance with
good electoral practice and constitutional
requirements. The ERS managed the whole
process, from seeking nominations from
members, to producing the election sheets,
receiving the votes and announcing the results.
The Trust required to fill the following vacancies
at its elections in December 2011:
•2 public Governors – Hartlepool;
•6 public Governors – Stockton;
•2 public Governors – Easington;
•4 staff;
•1 patients and carers (no candidates were
received for this vacancy).
The outcomes of elections are detailed in the
table below.
Elections to Council of Governors 2011-2012
Date of Election
Constituency
Number of
Votes Cast
Turnout %
25 November 2011
Number of Eligible
Voters
Hartlepool
348
25.7
1,353
25 November 2011
Stockton
626
25.3
2,470
25 November 2011
Easington
263
22.4
1,172
25 November 2011
Staff
630
11
5,731
Head of catering Colin Chapman talks to members and governors as they taste some of the food which is served to patients.
Annual Report and Accounts 2011 – 2012
125
8.2.3 Meetings of the Council of Governors
The Council of Governors meetings are public meetings, and there were four
meetings in 2011-2012. The Trust values the contribution, experience and skills
of the Governors and, in addition to the formal meetings, has a number of
committees and groups which Governors support, lead and engage in, and these
focus on specific issues:
Strategy Committee – its aim is to advise on the direction of the Trust, and reflect
the interests of patients and members.
Membership Strategy Committee – its aim is to raise awareness of the Trust, to
enable greater engagement with current members and also develop and implement
a strategy to increase the membership of the Trust.
Advisory and Guardianship Committee – its aim being to receive, review and
update information relating to: patient treatment pathways; service performance;
compliance; patient experience, involvement and environment.
Travel and Transport Group – its aim being to draft and implement a travel and
transport strategy for the Trust.
External Audit Working Group – its aim being to appoint the external auditors of
the Trust
Nominations Committee
The Nominations Committee is responsible for the recruitment, appointment
and retention of the Chairman and Non-Executive Directors, including matters of
remuneration and conditions of appointment. The Committee also has oversight of
the appraisal system for the Chairman and Non-Executive Directors.
During 2011, the Nominations Committee, and approved by the Governors, agreed
to extend the term of office of a Non-Executive Director whose tenure would
otherwise have ceased in 2011.
The Senior Independent Director led the appraisal review of the Chairman, this was
achieved by asking all members of the Council of Governors and all Board Directors
to complete a questionnaire relating to the Chairman’s performance. The results
were assessed with the outcome being reported to the Nominations Committee who
subsequently took their decision to the Council of Governors for noting.
There were no increases to the Chairman’s or Non-Executive Directors’ remuneration
or allowances in 2011-2012.
Nominations Committee
Name
126
Total Number of
Meetings Attended
Total Number of
Meetings Held
Paul Garvin (Chair)
1
1
John Rhodes
1
1
Kenneth McCreesh
1
1
Maureen Rogers
1
1
Tom Lennard
1
1
Lynn Hughes 1, 2
1
1
Clare Curran
1
1
1
Attends to advise the Committee 2 Left the Trust 13 November 2012
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Annual Report and Accounts 2011 – 2012
Lead governor Pat Upton at a member event.
127
8.2.4 Who’s Who – Council of Governors
Public Governors
Constituency
Appointment
Year term of
office ends
Total number
of meetings
attended
Christopher Broadbent
Hartlepool
3 years from 2010
2013
4
Roger Morrow
Hartlepool
2 years from 2007 re-elected for 3 years 2009
2012
3
Maureen Rogers
Hartlepool
1 year from 2007 re-elected for 3 years 2008 & 2011
2014
3
Thomas Sant
Hartlepool
3 years from 2010
2013
4
Keith Thomas
Hartlepool
2 years from 2007 re-elected for 3 years 2009
2012
4
Margaret Stacey
Hartlepool
3 years from 2011
2014
1
Ron Watts
Hartlepool
3 years from 2008
2011
2
Janet Atkins
Stockton
3 years from 2009
2012
4
Geoffrey Bulmer
Stockton
2 years from 2011
2013
1
Stockton
3 years from 2011
2014
1
Maurice Critchley
Stockton
3 years from 2009
2012
0
Carol Ellis
Stockton
3 years from 2010
2013
3
Stockton
1 year from 2010
2011
2
Jonathan Fletcher
Stockton
3 years from 2007 re-elected for 3 years 2010
2013
2
Cathrine Linford
Stockton
1 year from 2011
2012
1
Kenneth McCreesh
Stockton
2 years from 2007 re-elected for 2 years 2009
2011
3
Mary Morgan
Stockton
3 years from 2007 re-elected for 3 years 2010
2013
4
James Newton
Stockton
2 years from 2007 re-elected for 3 years 2009
2012
4
Dawn Robinson
Stockton
3 years from 2011
2014
1
Richard Sidney
Stockton
3 years from 2008 re-elected for 3 years 2011
2014
3
Pat Upton12
Stockton
1 year from 2007 re-elected for 3 years 2008 & 2011
2014
4
Kate Wilson
Stockton
3 years from 2009
2012
4
John Cairns
Easington
3 years from 2008 re-elected for 3 years 2011
2014
3
Mary King
Easington
3 years from 2010
2013
3
Easington
1 year from 2011
2012
1
Easington
3 years from 2009
2012
2
Sedgefield
3 years from 2010
2013
4
Carol Alexander
Staff
3 years from 2011
2014
1
4
Hasan Bandi
Staff
2 years from 2007 re-elected for 3 years 2009
2012
2
Nina Bedding
Staff
1 year from 2011
2012
1
Pat Ferguson
Staff
3 years from 2011
2014
1
Ian Fraser
Staff
1 year from 2007 re-elected for 3 years 2008
2011
3
Deborah Gardener
Staff
3 years from 2010
2013
3
Siva Kumar
Staff
1 year from 2007 re-elected for 3 years 2008
2011
2
Cathrine Linford5
Staff
3 years from 2007 elected unopposed for 3 years 2010
2013
1
John Rhodes
Staff
2 years from 2007 re-elected for 3 years 2009
2012
4
Matthew Wynne
Staff
2 years from 2011
2013
1
Ann Cains
1
Patricia Ferguson
2
Denise Rowland MBE
Maureen Taylor-Gooby
Wendy Gill
3
Staff Governors
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Annual Report and Accounts 2011 – 2012
Council of Governors Who’s Who
Total
number of
meetings
held
Member of
committee
(see key)
4
SC
4
AGC
4
NC
4
MSC
4
EAWG, SC
1
*
3
EAWG, SC
4
MSC, AGC
1
*
1
*
2
EAWG, MSC, SC
4
MS
3
-
3
EAWG
1
*
3
NC, MSC
4
MSC, AGC
4
AGC
1
*
4
AGC, SC
4
MSC, AGC, SC
4
AGC
1
Maurice Critchley resigned 9 September 2011
4
TTG
2
Jonathan Fletcher resigned 3 November 2011
4
MSC
3
Maureen Taylor-Gooby resigned 5 October 2011
1
-
4
Hasan Bandi resigned 31 August 2011
3
SC
5
Cath Linford resigned 5 June 2011
MSC
6
Tim Blackman appointment ended 31 August 2011
7
Robin Coningham appointed from 1 September 2011
8
Lucy Hovvels appointed from 11 May 2011
9
Eunice Huntington appointment ended 10 May 2011
4
1
2
1
*
*
1
*
3
TTG
4
-
3
AGC
1
NC, MSC
4
NC, SC
1
*
Appointed
Members
Representing
Total
number of
meetings
attended
Total
number of
meetings
held
Member of
committee
(see key)
Jim Beall
Stockton-on-Tees
Borough Council
4
4
MSC, AGC
Tim Blackman6
University of
Durham
0
3
SC
Robin Coningham7
University of
Durham
0
2
ACG
Gerard Hall
Hartlepool
Borough Council
0
4
EAWG
Lucy Hovvels8
Durham County
Council
2
3
-
Eunice
Huntington9
Durham County
Council
0
1
NC
Tom Lennard
University of
Newcastle upon
Tyne
3
4
NC, SC
Alan Oliver
University of
Teesside
0
4
EAWG
Graham Prest10
NHS Stockton
1
3
-
Stephen Wallace
NHS Tees
0
4
-
Key
NC – Nomination Committee
MSC – Membership Strategy Committee
TTG – Travel And Transport Group
AGC – Advisory And Guardianship Committee
SC – Strategy Committee
EAWG – External Audit Working Group
10
Graham Prest appointment ended 5 December 2011
11 *
12
New Governors, Committee membership to be finalised
Pat Upton, Lead Governor
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Annual Report and Accounts 2011 – 2012
8.2.5 Register of Interests - Governors
A register of Governors’ interests that may conflict with their responsibilities at the
Trust is maintained and available for inspection by members of the public. If anyone
wishes to inspect the Register they can view it by contacting the Director of Human
Resources and Education /Company Secretary, North Tees and Hartlepool NHS
Foundation Trust, University Hospital of North Tees, Hardwick, Stockton, TS19 8PE or
email: membership@nth.nhs.uk.
8.3 Membership of Our Trust
The Trust members support the activity of the Trust, and the Trust has some 11,783
members, which comprise:
Paul Garvin at a member event.
•5,743 public members;
•165 patient/carers;
•5,875 staff.
Public members – are those aged 16 years and above that reside in the Trust’s
constituent areas of Hartlepool, Stockton-on-Tees, Easington and Sedgefield.
Patient/carer members – these can be people aged 16 years and above who have
been a patient or carer at the Trust in the last seven years.
Staff members – employees of the Trust who hold an employment contract with
the Trust of at least one year. In addition, staff who are based at the Trust but
work for a partner organisation, registered volunteers. Members that meet these
requirements are automatic members within the staff constituency unless they
choose to inform the Trust that they do not wish to be a member. This is outlined in
detail within the Trust’s constitution.
The Trust keeps in touch with all its members through our internal magazine
‘Anthem’, a special email account for members to contact the Trust and its Governors
has been established. Information relating to all forms of communication with
members is provided to them at the time of them becoming a member and at
regular events thereafter. Member events were held five times during 2011-2012.
These events provided opportunities for members to receive and discuss information
relating to our patient services, these included:
•Management of hearing loss;
•New hospital update;
•Community Services – current and future transformations;
•Parkinson's Disease;
•Hospital Catering;
•Anaesthetics and pain management;
•Trust finance and commissioning responsibilities;
•Chest disease in the north east;
•Back, neck and spinal problems;
•Telehealth.
The Trust recognised the need to enable members to communicate with the Trust,
the Board and the Governors for their constituencies. To do this we have established
a member email account, which is reviewed by the Trust’s Private Office daily and
any communications are forwarded to the relevant person for response.
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Annual Report and Accounts 2011 – 2012
We also ensure that at our member events there
are members of the Board, Governing body and
Trust staff present to communicate with and
discuss matters with our members. The Trust
recognises the need to enhance its work with
members and will be updating its Membership
Strategy during 2012-2013. The Trust’s current
membership strategy was produced in 2011 and
provides: targets for increasing Trust membership,
this was 5% for 2011-2012, this target was
achieved; members with information relating to
how they can engage with the Trust; explanations
about the various constituencies; and how we
plan to increase our membership base.
The Trust recognises the benefits members bring
to the work and activity of the Trust, many of
whom are volunteers and supporters, we have
in 2011-2012 provided members with the
same benefits as staff for catering and external
discounts facilities negotiated by the NHS.
8.4 Board of Directors
The NHS Foundation Trust Codes of Governance
was published by Monitor and updated in 2010,
based upon the combined Code of Corporate
Governance. Effective corporate governance
is a fundamental cornerstone for the success
of organisations. The Trust is committed to
high standards of corporate governance as
set out in the NHS Foundation Trust Code
of Governance. The Trust meets all the main
principles of the Code, especially those relating
to the development and management of patient
services, information provision and accountability
for the use of public services.
The role of the Board of Directors is to exercise
all powers when managing the Trust by
providing effective and proactive leadership
through setting the overall strategic direction
of the Trust, regular monitoring of performance
against objectives, ensuring the integrity of
financial control and planning, the quality
of patient care and safety through clinical
governance. The Board ensures it meets
all its obligations as set out in the Code of
Governance.
Membership of the Board of Directors and
biographical details of Board Members are
displayed on pages 136-137. The Trust
recognises the need for balance with regard to
its Board Members and believes this is provided
and shown in the Directors’ experience section
pages 136-137.
One Non-Executive Director (NED) Ken Lupton's,
independence was under constant review due
to his senior elected role from 1 April - 25
May 2011. He brought a breadth of expertise
to the Board and he is independant of the
Executive. The test of independence for NED’s
is made both at interview and again annually at
appraisal meetings. The Trust can confirm the
full independence of all Chief and Non Executive
Directors. The Chief Executive on behalf of all
directors can confirm that each director has
confirmed:•So far as the director is aware, there is no
relevant audit information of which the NHS
foundation trust’s auditor is unaware; and
•The directors’ have taken steps to make
themselves aware of any relevant audit
information and ensured that the Trust’s
auditor is aware of that information.
The Trust Directors’ have taken all reasonable
steps to ensure that the auditors have been
provided with all information required and have
executed reasonable care, skill and diligence.
8.5 Internal Control
The Board of Directors is responsible for the
Trust’s system of internal control and for
reviewing its effectiveness, which is designed to
manage risk to achieve the Trust’s objectives. It
provides reasonable but not absolute assurance
against material misstatement or loss. The Board
has established a process which is demonstrated
in the Trust’s Risk Management Policy that covers
identification, evaluation and management of
significant risks the Trust may encounter. Further
details of the Trust’s risk management process
can be found within the Annual Governance
Statement section 11 page 146.
The Board of Directors comprises: a NonExecutive Chairman, five Non-Executive
Directors, all of whom are independant; five
voting Executive Directors and three non-voting
Executive Directors.
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Annual Report and Accounts 2011 – 2012
8.6 Development and Performance
The Board recognises the benefit of development and taking the time to debate and
discuss the impact of governance and legislation matters. At its development event
in February/ March 2012 the Board discussed a range of matters and undertook
a governance survey to assess any gaps, following which a development plan was
produced. The Trust can confirm that there are no significant development gaps,
and the plan produced enables on-going learning and improved practices for the
Board and ultimately the Trust. The Board also held seven seminars (including a
night time panel) during 2011-2012, all of which provide on-going learning for all
Board members in the debates and discussions regarding Trust activities and new
developments.
The Board held 12 meetings in 2011-2012 comprising five public, five in-committee
and two extra ordinary open to the public, had agendas and minutes which are
published on the Trust’s website together with dates of future meetings.
The following table reflects those meetings:
Board of Directors Attendance
Name
Total No. of
Meetings
Attended
Total No. of
Meetings
Held
Paul Garvin (Chair)
12
12
Brian Dinsdale
10
12
Deputy Chair
Rita Taylor
12
12
Senior Independent Director
Stephen Hall
12
12
Kenneth Lupton
10
12
7
12
Alan Foster
12
12
David Emerton
10
12
Lynne Hodgson
1
1
Carole Langrick
11
12
Sue Smith
12
12
Julie Gillon
10
12
Kevin Oxley
12
12
Clare Curran
12
12
Neil Atkinson
6
6
Acting Director of Finance,
1 November 2011 – 25 March 2012
Angela Lamb
n/a
n/a
On secondment from 1 December 2007
5
5
Left the Trust 31 October 2011
Michael Bretherick
John Maddison
Notes
Joined 26 March 2012 as Director of
Finance and Information Technology
The Non-Executive Directors are appointed by the Governors for terms of office
of three years, which can be renewed subject to satisfactory performance. The
appointment and reviewing of performance is undertaken by the Nominations
Committee. In the event that the Council of Governors felt that the Chairman or
a Non-Executive Director’s position was untenable and should be removed from
position, the Trust would follow the provisions as set out in the Trust’s constitution.
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Annual Report and Accounts 2011 – 2012
The Nomination Committee would consider such situations and would make proposals to take to a
general meeting of the Council of Governors of which 75% shall be in agreement. The performance
evaluation of the Board, its activities and committees is presented throughout this section, and
assurance is provided in section 11 page 146. In addition, the Non-Executive Directors all undertake
an annual appraisal, the outcomes of which are presented to the Nominations Committee. Also the
Executive Directors engage in an annual appraisal relating to both their operational and Board roles.
Board Sub-Committees and Membership
Committee Name
Membership
In attendance
Board In-committee
Paul Garvin (Chairman) including all
members of the Board of Directors
Remuneration Committee
Paul Garvin (Chair), Rita Taylor, Michael
Bretherick, Stephen Hall
Audit Committee
Brian Dinsdale (Chair), Stephen Hall,
Michael Bretherick
1
John Maddison/Neil Atkinson /John Whitehouse/
Stuart Fallowfield/Carole Pearson/Jean Freund
Finance Committee
Brian Dinsdale (Chair), Stephen Hall,
Michael Bretherick
1
Investment Committee
Brian Dinsdale, (Chair), Paul Garvin,
Stephen Hall
1
Charitable Funds Committee
Brian Dinsdale (Chair), Paul Garvin, Rita
Taylor, Kenneth Lupton, Alan Foster
1
Patient Safety and Quality
Standards Committee
Stephen Hall (Chair), Rita Taylor, Kenneth
Lupton, David Emerton, Sue Smith
John Maddison/Neil Atkinson
John Maddison/Neil Atkinson
John Maddison/Neil Atkinson
1 Left the Trust 31 October 2011.
Trust Committee Structure
Audit Committee
The Audit Committee is authorised by the
Board of Directors and provides the Board with
independent and objective review of financial
and corporate governance risk management
in the Trust. The membership comprises three
Non-Executive Directors and is outlined below,
the Chair is Brian Dinsdale who is a chartered
accountant. The Committee provides independent
assurance for external and internal audit and
ensures the standards are set and compliance
monitored for all financial, non-financial and nonclinical areas and activities of the Trust.
The Audit Committee investigates any activity
within its terms of reference and seeks
information as required from any member
of staff of the Trust. In discharging these
responsibilities the Committee approved internal
and external audit work plans, their final reports
and sought assurance from the Trust that
outcomes were implemented.
The Audit Committee met five times during the
year to assess and critically review both the key
risks facing the Trust and to ensure that the key
financial controls were in place and operating
effectively.
The Trust’s Risk Manager attended meetings
and briefed members on the red corporate risks
and the overall level of risk from the risk register.
Internal audit progress reports were reviewed
at meetings throughout the year, with a focus
on any high level recommendations. Directors
and managers attended meetings to provide
assurance, as required.
Documents presented included annual plans
for external audit, internal audit and the
local counter fraud service, annual reports
for internal audit and the local counter fraud
service, Annual Quality Report for 2010-2011,
Annual Accounts for 2010-2011, external
audit report on the 2011 audit and the
Annual Governance Statement. The assurance
framework and the compliance report to
Monitor were presented quarterly.
The Audit Committee terms of reference were
reviewed and amended in order to comply with
the new Audit Committee Handbook, the draft
proposals are to be presented to the Board of
Directors in April 2012 for approval.
A self assessment was undertaken by the Audit
Committee and as a result a business plan has
been produced for 2012-2013.
133
Annual Report and Accounts 2011 – 2012
Audit Committee
Name
Total No. of Meetings
Attended
Total No. of Meetings
Held
Brian Dinsdale (Chair)
5
5
Stephen Hall
5
5
Michael Bretherick
4
5
Remuneration Committee
The Remuneration Committee considers and approves the pay and allowances and
other terms and conditions of service of the Chief Executive and Executive Directors.
The Committee meets annually and the membership is reflected below, and it is
chaired by the Trust’s Chairman.
Name
Total No. of
Meetings Attended
Total No. of
Meetings Held
Paul Garvin
2
2
Rita Taylor
2
2
Michael Bretherick
2
2
Stephen Hall
2
2
Kenneth Lupton1
1
1
In addition to the above-named individuals the Trust Board Secretary, Lynne Hughes (left the Trust 13
November 2011) attended the meeting to provide advice and services.
1
The Committee took account of the overall performance of the Trust, and although
recognised that all achievements had been met, due to the current economic
climate and taking account of national pay restraints agreed that no pay increases or
bonuses would be paid in 2011-2012.
Finance Committee
The Finance Committee ensures that the Trust’s resources are managed efficiently
and effectively.
The Finance Committee met five times during the year to review the financial
affairs of the Trust; the long term financial strategy; granular level/directorate cost
improvement action plans; fundamental business appraisal project and the monthly
finance report to the Board of Directors, with attendance by senior managers to
inform and provide assurance in relation to financial control. The 2011-2012 annual
plan review stage 2 was received and the terms of reference were updated to include
the provision of rigorous scrutiny of cost improvement programmes. Revenue
budgets and financial plans for 2012-2013 were reviewed and evaluated by the
Finance Committee.
Investment Committee
The Investment Committee met twice during the year to ensure a competitive return
on surplus cash with an acceptable risk profile was being delivered; to manage the
financial risk associated with operational activities and to ensure the availability of
competitively priced funding for working capital with an acceptable risk profile.
134
Annual Report and Accounts 2011 – 2012
Approval was given to add an additional
bank to the list of counterparties and to split
the investment between two banks in order
to mitigate risk. A tendering exercise was
undertaken and the Trust’s bankers changed
with effect from 27 January 2012.
Charitable Funds Committee
The Charitable Funds Committee met twice
during the year to monitor arrangements for
the control and management of the Trust’s
charitable funds and to make decisions involving
the sound investment of charitable funds in
a way that both preserved their capital value
and produced a proper return, consistent with
cautious and sensible investment. The charitable
funds accounts were approved and were
submitted to the Charities Commission. Work
on the consolidation of funds is ongoing and
publicity relating to expenditure from charitable
funds is to be taken forward.
Patient Safety and Quality Standards
Committee
The Patient Safety and Quality Standards
Committee measures standards of clinical
practice throughout the Trust to ensure that
they are of the highest possible standard. The
Committee meets on a monthly basis and
ensures that the Trust has in place the systems
and processes to support individuals and teams
in the delivery of safe, patient-centred, high
quality care. It also ensures the Quality Report/
Accounts are discharged and that lessons are
learned and disseminated to all professionals
within the Trust to ensure patient outcomes
do not demonstrate the Trust as an outlier. The
Committee ensures a corporate understanding
and accountability for the delivery of high quality
patient care across the Trust.
The team contributes to the development of the
Trust’s corporate and operational strategy and
monitors the delivery of both, including financial
objectives. It also develops and monitors
the implementation of plans to improve the
efficiency, effectiveness and equality of the
Trust’s services.
Trust Directors Group
The Trust Directors Group’s membership includes
members of the Executive Team and Clinical
Directors, the Group discussed Trust and clinical
developments and has responsibility towards the
achievement of corporate objectives identified by
the Board of Directors.
8.7 Register of Interests – Board of
Directors
A Register of Directors’ Interest that may
conflict with their responsibilities at the Trust
is maintained and available for inspection by
members of the public. If anyone would like
to inspect the Register they can view it on
the Trust’s website: www.nth.nhs.uk or by
contacting the Director of Human Resources,
Education and Organisation Development/
Company Secretary, North Tees and Hartlepool
NHS Foundation Trust, University Hospital of
North Tees, Hardwick, Stockton, TS19 8PE or
email: membership@nth.nhs.uk.
Executive Team
Executive Team consists of Executive Directors
and other senior managers upon invitation.
Meetings are held on a weekly basis throughout
the year. The role of the Executive Team is to
monitor the management of risk, which includes
the agreement of any action plans or resources
and reviews, and agrees detailed business plans
and performance contracts.
135
Annual Report and Accounts 2011 – 2012
8.8 Board of Directors –
Who's Who
1.
2.
3.
1. Paul Garvin QPM, DL, Chairman
Appointed as Chairman from 1 November
2009, Acting Chairman from 26 November
2008. Appointed as Non-Executive Director on
1 January 2006. Term of office as Chairman
concludes on 31 October 2012.
Current commitments include:
Member Home Office Police Appeals Tribunals
Deputy Lord Lieutenant for County Durham
Chair Durham Association of Clubs for Young People
Former positions:
Chief Constable of Durham Constabulary,
Chair County Durham Strategic Partnership,
Chair Victim Support County Durham,
Non-Executive Director Police Information Technology
Organisation (NDPB).
2. Brian Dinsdale OBE,
Non-Executive Director
Appointed 30 November 2007, Deputy
Chairman from 9 March 2010. Term of office as
NED until 30 November 2014.
Former positions:
Chief Executive for Hartlepool Borough Council from 1988
Chief Executive for Hartlepool (unitary) Council from 1996
Chief Executive for Middlesbrough Council from 2003
Efficiency Adviser for ‘Office of Government Commerce’
2005 – 2007
Four interim Chief Executive positions for other Councils
throughout UK 2006 – 2011
Chief Executive of Yorkshire Purchasing Organisations 2009
Former Non-Executive Director of Government North East
and Clerk to Cleveland Fire Authority
Member of Chartered Institute of Public Finance and
Accountancy; and Batchelor of Arts – Social Sciences.
136
Annual Report and Accounts 2011 – 2012
4.
5.
6.
3. Rita Taylor, Non-Executive Director/Senior
Independent Director
Appointed 1 January 2006 until 31 December
2009. Term of office until December 2012.
Previous Board level experience as Non-Executive Director of
County Durham and Tees Valley Strategic Health Authority
Youth Offending Manager at Darlington Borough Council
Former teacher at schools, colleges and prison service.
4. Stephen Hall JP, Non-Executive Director
Appointed 1 March 2007. Term of office until 28
February 2014.
Current commitments include Justice of the Peace (JP).
Former positions: Director within the Compass Group and
Managing Director Hallmark Catering Management.
Fellow of Royal Society of Public Health (FRSPH).
5. Michael Bretherick,
Non-Executive Director
Appointed 1 August 2010 until 31 July 2013
Principal and Chief Executive, Hartlepool College of Further
Education, Chair of National Strategic Skills Group for
Construction. Regional Lead for UK Skills, North East Chair
of National Skills, Academy for Environmental Technologies.
Former Positions: Senior roles in Further Education.
6. Kenneth Lupton, Non-Executive Director
Appointed 1 August 2010 for term of three
years, concluding 31 July 2013.
Leader of the Conservative Group on Stockton Borough
Council (since 2005), representing Hartburn Ward since
1999. Board member of Tees Active Leisure Trust.
Former positions:
Leader of Stockton Borough Council (2007-2011)
Vice Chairman - Association of North East Councils
Director of Contract Services for Stockton Borough Council
and a number of managerial roles in other North East
Authorities
Previously a referee for 16 years on the Football League.
7.
8.
9.
10.
11.
12.
13.
14.
7. Alan Foster, Chief Executive
Former positions: NHS and Strategic Health Authority positions as
Director of Finance and first Chief Executive of a Foundation Trust to
integrate Acute and Community Services.
Member of the Chartered Institute of Public Finance and Accountancy.
Date of commencement as Chief Executive 1 April 2007.
12. Clare Curran, Director of Human Resources and
Education/Company Secretary
Extensive experience in human resource management and organisational
development in both the private and public sector, and has worked at
Board level at the NCSC. Currently Chair of National JNC (SAS) Medical.
8. Carole Langrick, Director of Strategic
Development/Deputy Chief Executive
Former positions: Director of Human Resources at: Newcastle upon Tyne
NHS Foundation Trust; Northumbria and Teesside Universities; National
Care Standards Commission (NCSC) and held other positions in both the
public and private sector.
Extensive experience at regional, district and acute level with over 10
years NHS Board level experience.
Fellow of Chartered Institute of Personnel and Development and Masters
in Business Administration (MBA).
Registered General Nurse. Registered Health Visitor.
Date of commencement 31 March 2009.
Date of commencement 1 July 2007.
13. Julie Gillon, Director of Operations and
Performance
9. Lynne Hodgson, Director of Finance, Information
& Technology
Extensive experience in NHS finance from both a provider and
commissioning perspective and has worked at Board level within the NHS
since April 2007 at both Gateshead NHS FT, and NHS North of Tyne.
Member of the Chartered Institute of Management Accountants.
Date of commencement 26 March 2012.
10. David Emerton, Medical Director
Appointed to Medical Director position on 15 February 2010 for a term of
three years. Consultant in Accident and Emergency.
Former positions: Clinical Director in Accident and Emergency Associate
Medical Director for Clinical Governance.
MBChB (LEEDS), D.R.C.O.G, F.R.C.S. (Glasg), F.R.C.S. Ed (A & E), F.C.E.M.
11. Sue Smith, Director of Nursing, Patient Safety
and Quality
Extensive NHS experience of nursing and patient safety, Lead nurse on national
work streams including; International Nurse Recruitment, Hospital at Night,
New Ways of Working in Surgery and New Ways of Working in Anaesthesia.
One of the lead nurses responsible for developing the national Safer Nursing
Care Tool and has had work widely published in Health Journals.
Former positions: working at Nottingham University Hospitals, University
Hospitals of Coventry and Warwickshire and Morecambe Bay Hospitals.
MSc Leadership through HR Management; BSc Health Service
Management; PG Cert in Managing Health Services; PG Cert Leadership;
RN and Member of the Institute of Health Management.
Extensive NHS experience at regional and acute level, leading on a
range of complex portfolios, which have included: compliance; quality;
financial and operational performance.
Former positions: Registered General Nurse; Senior Sister; Senior Nurse;
Assistant Director and Head of Strategic Planning.
BSc Nursing; MSc Research & Statistics, Certificate in Management.
Date of commencement 10 June 2008.
14. Kevin Oxley, Commercial Director
Extensive NHS Board level experience. Commercial and NHS background.
Fellow of Chartered Institute of Building.
Date of commencement 13 August 2007.
15. Neil Atkinson, Acting Director of Finance
Acting Director of Finance from 1 November 2011 – 25 March 2012.
Appointed to the Trust June 2008.
Extensive NHS experience of financial management. Member of the
Chartered Institute of Public Finance and Accountancy.
16. John Maddison, Director of Finance
Extensive experience in regional and district level NHS Finance. Member
of the Chartered Institute of Public Finance and Accountancy.
Left the Trust 31 October 2011.
137
Date of commencement 8 September 2008.
Annual Report and Accounts 2011 – 2012
9. Remuneration
Report
138
Clinical lead for wheelchair services Judy Ruddle (right) speaks to chief health professionals officer for the Department of Health Karen Middleton.
This report sets out the salaries, allowances and pension entitlement of the Chief Executive and
Executive Directors (senior employees) of the Trust. In addition, the remuneration and expenses
of the Chairman and Non-Executive Directors will also be presented.
The following information is required by part
2 of schedule 8 to the regulations and is not
subject to audit.
The Trust’s Remuneration Committee
membership and roles are reflected in section
8.6, page 134, this Committee sets the salaries,
allowances and terms and conditions for the
Chief Executive and Executive Directors. During
2011-2012, the Trust saw the Director of
Finance, Information and Technology leave the
Trust, the individual left with immediate effect
on 31 October 2011, and received contractual
notice pay.
The Trust’s Nomination Committee sets the
remuneration and expenses for the Chairman
and Non-Executive Directors. Details of the
Nomination Committee can be found in section
8.2.3, page 126. The remuneration and expenses
remained unchanged in 2011-2012.
The process the Trust uses for assessing
performance of its Chief Executive and Executive
Directors, requires the Remuneration Committee
to consider the key business objectives as set out
in the Trust’s Corporate Strategy and business
objectives allocated to each person through the
appraisal process, and receiving a report of the
individuals progress against those objectives.
Performance is closely monitored and discussed
through both an annual and on-going appraisal
process. All senior managers’ remuneration is
subject to satisfactory performance.
Senior managers’ salaries (as defined above) may
include a non-recurrent performance payment
related to collective performance of the Executive
Team. The Chief Executive takes the lead on the
evaluation of Directors and the Chairman takes
the lead on the Chief Executive’s performance.
On an individual basis targets are set against
the Trust’s strategy and aligned to Directors
by a number of agreed objectives at appraisal
meetings. In October 2008 the Remuneration
Committee approved a bonus scheme that
measured both individual and collective
performance, which would not be greater than
10% of Directors’ salaries.
The scheme incorporated evaluation methods
to measure Directors’ performance against
Monitor’s Compliance Framework that relates
to clinical care, managerial standards, efficiency
and effectiveness of the Trust’s achievement
to targets set by Monitor. Both individual and
collective performance was measured through
appraisal meetings for the period 1 April
2010 to 31 March 2011 and reported to the
Remuneration Committee on 19 May 2011.
All key indicators were achieved which would
have indicated a 10% bonus, however taking
account of the current financial climate and
the outcomes of national NHS pay negotiations
the Remuneration Committee decided to
recognise the commitment and performance
of the Executive team over the last year but not
pay any salary increases or provide for a bonus
payment. The Remuneration Committee always
consider the pay and terms and conditions of
service of all Trust employees when making any
decisions relating to the Executive Directors’ pay
and conditions.
Details of Directors’ remuneration and pension
entitlements for the year ending 31 March
2011 are published in this Remuneration Report
and the Annual Accounts which are in Section
14, page 164. There had been no awards
made to past senior managers. The dates of
commencement of the Executive Directors in
their current posts can be found in section 8,
pages 136-137.
Members of Executive Team are appointed on
permanent contracts with a notice period of
three months for them to serve and a period of
six months for the Trust to serve. The Medical
Director is appointed for a term of office of three
years, and this is subject to review in 2013.
The only non-cash element of senior mangers’
remuneration packages are pension-related
benefits, which accrued under the NHS Pensions
Scheme. Contributions are made by the Trust
and the employee in accordance with the rules
of the national scheme which applies to all NHS
staff in the scheme.
Annual Report and Accounts 2011 – 2012
139
There has been no special contractual compensation provisions attached to the
early termination of a senior manger’s contract of employment and there has been
no payment for compensation for loss of office paid or receivable under the terms
of an approved compensation scheme. Early termination by reason of redundancy
is in accordance with the provision of the NHS redundancy arrangements and
in accordance with the NHS pension scheme. Employees above the minimum
retirement age that request termination by reason of early retirement are subject to
the normal provisions of the NHS pension scheme.
In the event of any matters of concern the Trust’s normal investigation and
disciplinary policies apply to senior managers.
Alan Foster
Chief Executive
140
Annual Report and Accounts 2011 – 2012
The following information is required by part 3 of schedule 8 to the regulations and is subject to audit.
Salary and Pension Entitlements of
Senior Managers
Name and Title
To 31 March 2012
Basic Salary &
Allowances
Other Remuneration
(incl. performance
related bonuses)
Benefits
in Kind
Total
Remuneration
(bands of £5,000)
(bands of £5,000)
£000
Rounded to the
nearest £100
(bands of £5,000)
£000
50 - 55
0
0
50 - 55
Mr Alan Foster, Chief Executive
230 - 235
0
0
235 - 240
Mrs Carole Langrick, Director of Strategic
Development, Deputy Chief Executive
135 - 140
0
0
135 - 140
Mr John Gerarde Maddison,
Director of Finance and Information
65 - 70
0
2.1
65 - 70
Mr Neil Martin Atkinson
Acting Director of Finance
40 - 45
0
0.9
40 - 45
0-5
0
0
0-5
25 - 30
145 - 150
0
175 - 180
Mrs Julie Ann Gillon,
Director of Operations and Performance
115 - 120
0
5.1
120 - 125
Mr Kevin Leslie Oxley, Commercial Director
130 - 135
0
1.6
130 - 135
Mrs Susan Lorraine Smith,
Director of Nursing, Patient Safety and Quality
115 - 120
0
0
115 - 120
Mrs Clare Louise Curran, Director of Human Resource
and Education/Company Secretary
110 - 115
0
7.8
115 - 120
Mr Stephen Hall, Non-Executive
15 - 20
0
0
15 - 20
Mrs Rita Taylor, Non-Executive
15 - 20
0
0
15 - 20
Mr Brian Dinsdale, Non-Executive
15 - 20
0
0
15 - 20
Mr Michael Bretherick, Non-Executive
10 - 15
0
0
10 - 15
Mr Ken Lupton, Non-Executive
10 - 15
0
0
10 - 15
Mr Paul Garvin, Chairman
Ms Lynne Hodgson
Director of Finance, Information and Technology
Mr David Glatton Charles Emerton, Medical Director
£000
NOTES:
1. Benefits in kind relate to cars and are expressed in £000’s. The method of calculating benefits in kind is based upon Inland Revenue guidance
and uses the CO2 emissions rate of the vehicle and the type of fuel used. The figures shown, therefore, reflect the taxable benefit.
2. Remuneration in relation to the Medical Director includes payment for clinical sessions as follows:
Mr David Glatton Charles Emerton = £145k - £150k
3. Mr John Maddison, Director of Finance & Information left the Trust on 7 October 2011
4. Mr Neil Atkinson deputised for the Director of Finance & Information from 10 October 2011 until 25 March 2012
5. Mrs Lynne Hodgson - appointed as Director of Finance & Information and Technology from 26 March 2012
6. The above tables form part of the audited statements.
Chief Executive ………………………….......…………………………
28 May 2012
Date .............................................................................
141
Annual Report and Accounts 2011 – 2012
Salary and Pension Entitlements of
Senior Managers
Name and Title
To 31 March 2011
Basic Salary &
Allowances
Other Remuneration
(incl. performance
related bonuses)
Benefits
in Kind
Total
Remuneration
(bands of £5,000)
(bands of £5,000)
£000
Rounded to the
nearest £100
(bands of £5,000)
£000
50 - 55
0
0
50 - 55
Mr Alan Foster, Chief Executive
215 - 220
10 - 15
10
235 - 240
Mrs Carole Langrick, Director of Strategic
Development, Deputy Chief Executive
135 - 140
0
0
135 - 140
Mr John Gerarde Maddison,
Director of Finance and Information
125 - 130
0
6
130 - 135
15 - 20
150 - 155
0
165 - 170
Mrs Julie Ann Gillon,
Director of Operations and Performance
115 - 120
5 - 10
5
130 - 135
Mr Kevin Leslie Oxley, Commercial Director
125 - 130
5 - 10
7
140 - 145
Mrs Susan Lorraine Smith,
Director of Nursing, Patient Safety and Quality
115 - 120
5 - 10
0
120 - 125
Mrs Clare Louise Curran, Director of Human Resource
and Education/Company Secretary
115 - 120
5 - 10
2
120 - 125
Mr Stephen Hall, Non-Executive
15 - 20
0
0
15 - 20
Mrs Rita Taylor, Non-Executive
15 - 20
0
0
15 - 20
Mr Brian Dinsdale, Non-Executive
15 - 20
0
0
15 - 20
Mr Michael Bretherick, Non-Executive
5 - 10
0
0
5 - 10
Mr Ken Lupton, Non-Executive
5 - 10
0
0
5 - 10
0-5
0
0
0-5
Mr Paul Garvin, Chairman
Mr David Glatton Charles Emerton, Medical Director
Mr Alexander Cunningham, Non-Executive
£000
NOTES:
1. Benefits in kind relate to cars and are expressed in £000’s. The method of calculating benefits in kind is based upon Inland Revenue guidance
and uses the CO2 emissions rate of the vehicle and the type of fuel used. The figures shown, therefore, reflect the taxable benefit.
2. Remuneration in relation to the Medical Director includes payment for clinical sessions as follows:
Mr David Glatton Charles Emerton = £150k - £155k
3. Mr Alexander Cunningham - retired as Non-Executive Director on 28 April 2010
4. Mr Michael Bretherick - appointed as Non-Executive Director on 1 August 2010
5. Mr Ken Lupton - appointed as Non-Executive Director on 1 August 2010
6. The above tables form part of the audited statements.
Chief Executive ………………………….......…………………………
142
Annual Report and Accounts 2011 – 2012
28 May 2012
Date .............................................................................
Salary and Pension Entitlements of Senior Managers - B) Pension Benefits
Name and Title
Real
increase in
pension
and
related
lump sum
at age 60
Total
accrued
pension and
related lump
sum at age
60 at 31
March 2012
Cash
Equivalent
Transfer
Value at 31
March 2012
Cash
Equivalent
Transfer
Value at 31
March 2011
Real
Increase
in Cash
Equivalent
Transfer
Value
Employers
Contribution to
Stakeholder
Pension
(bands of
£2,500)
£000
(bands of
£5,000)
£000
£000
£000
£000
To nearest
£100
0
360 - 365
1,718
1,718
0
0
Mrs Carole Langrick, Director of Strategic
Development Deputy Chief Executive
5 - 7.5
175 - 180
782
668
114
0
Mr John Gerarde Maddison
Director of Finance & Information
2.5 - 5
175 - 180
803
740
63
0
7.5 - 10
55 - 60
196
162
35
0
0 - 2.5
155 - 160
648
558
90
0
(5 - 7.5)
115 - 120
539
517
22
0
10 - 12.5
195 - 200
1,048
940
108
0
Mrs Julie Ann Gillon, Director
of Operations and Performance
5 - 7.5
170 - 175
679
565
113
0
Mrs Susan Lorraine Smith, Director
of Nursing, Patient Safety and Quality
5 - 7.5
120 - 125
542
458
83
0
Mrs Clare Louise Curran Director of Human
Resource and Education/Company Secretary
5 - 7.5
130 - 135
602
523
79
0
Mr Alan Foster, Chief Executive
Mr Neil Martin Atkinson
Acting Director of Finance
Ms Lynne Hodgson
Director of Finance, Information & Technology
Mr Kevin Leslie Oxley
Commercial Director
Mr David Glatton Charles Emerton
Medical Director
As Non-Executive members do not receive pensionable remuneration, there will be no entries in respect of pensions for Non-Executive members.
A Cash Equivalent Transfer Value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular
point in time. The benefits valued are the member’s accrued benefits and any contingent spouse’s pension payable from the scheme.
A CETV is a payment made by a pension scheme, or arrangement to secure pension benefits in another pension scheme or arrangement when the
member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits
that the individual has accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity to
which the disclosure applies. The CETV figures, and from 2004-05 the other pension details, include the value of any pension benefits in another
scheme or arrangement which the individual has transferred to the NHS pension scheme. They also include any additional pension benefit accrued
to the member as a result of their purchasing additional years of pension service in the scheme at their own cost. CETVs are calculated within the
guidelines and framework prescribed by the Institute and Faculty of Actuaries.
Real Increase in CETV - This reflects the increase in CETV effectively funded by the employer. It takes account of the increase in accrued pension due
to inflation, contributions paid by the employee (including the value of any benefits transferred from another pension scheme or arrangement) and
uses common market valuation factors for the start and end of the period.
The above tables form part of the audited statements.
28 May 2012
Chief Executive …………................…………………………..............…………….. Date ……........................……………………….
143
Annual Report and Accounts 2011 – 2012
10. Statement
of the Chief
Executive Officer
144
Chief Executive Alan Foster at the volunteers and retired members thank you event.
Statement of the Chief Executive Officer as the Accounting Officer of North Tees
and Hartlepool 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, as 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
North Tees and Hartlepool 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 North
Tees and Hartlepool 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:
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 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.
Alan Foster
Chief Executive and Accounting Officer 28 May 2012
•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
Reporting Manual have been followed, and
disclose and explain any material departures in
the financial statements;
•Prepare the financial statements on a going
concern basis.
145
Annual Report and Accounts 2011 – 2012
11. Annual
Governance
Statement
146
Clinical lead Paula Swindale speaks at a member event.
1. Scope of Responsibility
As Accounting Officer, 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 North Tees and Hartlepool 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 North Tees
and Hartlepool NHS Foundation Trust for the
year ended 31 March 2012 and up to the date
of approval of the annual report and accounts.
3. Capacity to Handle Risk
The Board of Directors participates in an annual
review of skills and competence to undertake the
challenges of interpreting strategy into delivery
and this is accompanied by regular training,
networking and attendance at nationally led
events. This enables the Board to contribute to
the whole Trust agenda and in particular quality
at a strategic level whilst challenging the delivery
of performance and scrutinising the impact of
risks. A Senior Independent Director at NonExecutive Board level who holds regular meetings
with Governors provides a conduit for Governors
to raise concerns on an informal basis.
The Board of Directors undergoes regular self
assessment to test skills and capabilities at Board
“away days” and seminars. Board members have
attended all mandatory training sessions and
also this year have received training on the core
elements of quality, governance and continuous
improvement.
All staff are trained in information governance
and risk matters and understand the processes
for managing and reporting risks, which are
appropriate to their authority and duties. All
learning from good practices, training is shared
appropriately across the Trust, this is described
further under ‘The Risk and Control Framework’
below.
The Director of Nursing, Patient Safety and
Quality together with the Medical Director are
given delegated responsibility to lead the Trust’s
Risk Management and Governance processes.
All Executive Directors have responsibility for
the delivery of a robust risk management and
governance process in both their functional and
corporate roles. The Senior Information Risk
Owner at Board level is the Medical Director. All
other Executive Directors provide assurance for
matters within their own portfolios. The Trust
Risk Management Strategy is reviewed annually
by the Board of Directors. This provides the
clarity of Executive Directors’ responsibilities and
focus for their deputies who have responsibility
for managing risk and ensuring compliance with
Trust policies.
At the commencement of the annual planning
round the Board of Directors identify risks to
quality and service performance and monitor
the implementation of improvement plans,
managing regular scrutiny and review and
assurance around implementation. This has
enabled delivery of all key service performance
and quality measures and enables mitigation of
further risks during the course of the year.
4. The Risk and Control Framework
The Board is committed to leadership of the risk
management and governance functions in the
Trust. Each Executive Director has within their
portfolio a responsibility for some aspect of
risk management and governance and this also
includes Non-Executive Directors chairing Board
Sub-Committees, i.e. Audit, Finance and Patient
Safety and Quality Standards.
Annual Report and Accounts 2011 – 2012
147
The Corporate Risk Structure consists of the Audit, Finance, and Patient Safety and
Quality Standards Committees, all of which report to the Board. All other groups
and committees related to risk are accountable to the Patient Safety and Quality
Standards Committee or the Audit Committee. This structure provides clarity and
rigour around the established communications framework in place. The risks and
uncertainties are further expanded upon in section 4.2.4 page 35.
To ensure risk management is embedded in all Trust activities care is taken to ensure
that Directorate Business Plans support the organisation’s strategic objectives and
are informed by reference to the Trust’s Risk Register. To maintain and promote the
priority given to risk management a system of mandatory training is in place for all
Trust staff, which is informed by the training needs analysis conducted as part of the
individual’s annual appraisal process.
To promote the dissemination and sharing of good practice the Trust uses an
integrated approach to the identification and management of risk. The Risk Register
provides the key focus for this as it demonstrates the interaction of systems.
The register is reviewed bi-monthly by the Patient Safety and Quality Standards
Committee and quarterly by the Audit Committee. It identifies the individual risks,
personnel responsible for risk management, and the system of control. Risks are
identified through processes that include formal risk assessments, in addition to
reviews performed on untoward incident reports, complaints and litigation claims,
learning lessons, Root Cause Analysis (RCA) investigation and deployment of the
Trust’s “Being Open” policy.
In support of Emergency Preparedness the Trust has invested significant resource in
developing emergency planning arrangements. This is demonstrated by the robust
mechanisms for management of business continuity, which have been developed in
collaboration with local partners, and on which the Board has received significant
assurance from Internal Audit this year.
The Trust’s Assurance Framework is in accordance with Monitor’s guidance,
regulations and Terms of Authorisation. Using a quarterly self assessment process,
a review of strategic, financial and governance risks is performed and forwarded to
the Board in the form of a declaration framework. The Board is also informed by
reports from a variety of assurance bodies, and Executive Directors identified with
specific responsibilities, within the Framework, and of action taken in response to
recommendations.
The Framework covers all the Trust’s main activities and includes the use of the
Essential Standards of Quality and Safety (CQC). The Board receives regular reports
on monitoring compliance with these standards and contributes to the challenge
in enabling the annual declaration and completion of any action plans as required.
In an unannounced CQC visit in November of 2011, the Trust met all essential
standards relating to respecting and involving people, and the care and welfare
of people who use our services, safeguarding, supporting staff and assessing and
monitoring the quality of service provision.
The Trust is committed to ensuring equality and diversity in all its activities and has
effective processes for ensuring equity in all our practices, policies and procedures.
The Trust has adopted an equality impact assessment process that is used for
assessing all Trust policies, procedures and practices, this is embedded across the
Trust.
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The Trust’s Assurance Framework is reviewed by
the Board on a quarterly basis, in addition it is
reviewed by the Audit Committee. This ensures
triangulation and validation of the key risks in
relation to the assurance provided. The Trust
works closely with Audit North to inform the
annual Internal Audit Plan. This is based upon
the Assurance Framework to ensure consistency
and focus to enable the provision of assurance
to the Audit Committee and Board in relation
to this. Based upon this review no material gaps
in controls or assurance have been identified, as
evidenced in the Assurance Framework as at 31
March 2012 which was approved by the Audit
Committee on 26 April 2012.
The Assurance Framework was able to identify
the Annual Governance Statement was in
place to manage the risks, identifying review
and assurance mechanisms to demonstrate
effectiveness of the System of Internal Control.
The Council of Governors receive briefings
throughout the year and have provided a
declaration narrative for the Trust’s Quality
Account confirming this.
The Trust also has an active Patient and Public
Involvement Forum, which is actively engaged
in Trust Risk Management activities. The Risk
Management and Clinical Governance Strategy is
subject to annual review by the Board ensuring
the Trust is held to account for the delivery of
the strategy and through seeking assurance that
systems of control are robust and reliable.
The Risk Management Strategy is discharged
by the Risk Register and Assurance Framework,
which ensures processes are embedded in the
operations and culture of the organisation.
This strategy is systematic and rigorous and is
included within Directorate Business Plans, which
are regularly reviewed by the Board of Directors.
Information Governance and risks to data
security are addressed by a number of robust
policies in place. Dissemination of these is in
accordance with the Trust’s high level Training
Needs Analysis, which is delivered through a
range of training programmes. In addition, data
security is reinforced within all forums and levels
within the Trust, and at every stage of planning
for new developments.
The Trust’s Information Governance Lead and
Registration Authority Manager actively identify,
assess and manage any Information Governance
risks. Identified risks are progressed to the Risk
Register along with critical mitigation plans;
these are subject to review and monitoring by
the Information Governance Committee.
Risk Management is embedded in the activity of
the Trust in the following ways:
•Risk Register – populated and timely reviews
with all new risks reviewed by the lead
Executive Director before population. Each
Executive Director is responsible for reviewing
the risks relating to their own areas of
responsibility and all Directors have a corporate
responsibility for the risks outlined in the Risk
Register;
•Risk management performance is reviewed
through Key Performance Indicators at
quarterly directorate review meetings;
•The Trust is able to demonstrate an open
culture of fairness, learning and support, and
supports a “Being Open” policy with respect to
communicating with patients;
•Lessons are learned from incidents, complaints
and claims through use of nationally accepted
Root Cause Analysis tools, as well as trend
analysis. This information is then shared within
the Trust and with external stakeholders as
appropriate;
•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 a strong Patient and Public
Involvement Strategy. This includes patient/
carer representation on clinical quality and
safety related committees i.e. Audit of Clinical
Effectiveness, and Patient Safety and Quality
Standards. By including reviews of Patient
Experience this ensures that stakeholders are
involved in the management of risks which
may impact upon them. Patient representatives
are also considered to be an integral part of
the Patient Experience and Quality Standards
(PEQS) panel, which provides assurance
around the patients’ experience.
The Trust is fully compliant with the registration
requirements of the Care Quality Commission.
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149
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, employer’s contributions and payments into the Scheme are in accordance
with the Scheme rules, and the 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 did have a challenge in respect of Clostridium Difficile during 2011/12 and
did not achieve its target of 59 cases. The Trust recognised this risk at an early stage
and took key actions to manage this activity, these are described in section 4.2.5
page 37, and section 5 page 79.
The Trust continues to pursue its vision of achieving fully-integrated healthcare, as
described in section 4 pages 15-39. This vision would culminate in the development
of a new single-site hospital, the challenges and risks associated with the transition
developments, in particular the changes to emergency services at Hartlepool, the
wider impact of these and the new hospital proposals are also shared in section 4
pages 15-39.
The Foundation Trust has undertaken risk assessments and Carbon Reduction
Delivery Plans are in place in accordance with emergency preparedness and civil
contingency requirements, as based on UKCIP 2009 weather projects, to ensure that
this organisation’s obligations under the Climate Change Act and the Adaptation
Reporting requirements are complied with.
5. Review of economy, efficiency and effectiveness of the use of resources
The Trust has robust arrangements in place for setting objectives and targets on
a strategic and annual basis. These arrangements include ensuring the financial
strategy is affordable, scrutiny of cost savings plans to ensure achievement,
compliance with terms of authorisation and coordination of individual objectives
with corporate objectives as identified in the Annual Plan.
The following processes and mechanisms in place:
•Agreeing via the Annual Plan a rolling three year annual financial strategy and plan;
•A rigorous process of setting annual budgets with underpinning cost improvement
programme presented and approved by the Board prior to the start of the financial
year;
•Robust performance management arrangements;
•Daily, weekly and monthly cash flow monitoring and a rolling 18 month cash flow
projection in accordance with the approved Treasury Management Policy;
•Annual review of Standing Orders, Standing Financial Instructions and Scheme of
Delegation;
•Development of service line reporting/management and patient level information
and costing to support directorates to better understand and manage their relative
efficiency and profitability, and to make informed business decisions;
•New joint collaborative procurement arrangements put in place to ensure best
value through purchasing contracts;
•Estate rationalisation, work force skill mix review and staffing reviews linked to KPIs.
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The Board delegates responsibility for reviewing
the economy, efficiency and effectiveness of the
use of resources to the Audit Committee and
Finance Committee, this is supported throughout
the year with:
•Detailed monthly financial performance,
financial risk and monitoring the delivery of the
CIP;
•Agreeing and approving the Annual plan;
•Reviewing and agreeing all plans for major
capital investment and disinvestment.
The Board also gains assurance from:
•Internal audit reports, including value for
money audits;
•External audit reports;
•Care Quality Commission Annual Registration;
•Various other external accreditation bodies.
6. Annual Quality Report
The Directors are required under the Health Act
2009 and the National Health Service (Quality
Accounts) Regulations 2010 (as amended) 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 requirement in the NHS Foundation Trust
Annual Reporting Manual.
The following steps have been implemented to
provide assurance to the Board that the Quality
Report presents a balanced view and that there
are appropriate controls in place to ensure the
accuracy of data:
•The draft Quality Report/Account was issued to
key stakeholder groups on 5 March 2012 with
agreed timescales for response;
•A summary document for members of the
public that request a less detailed document
has also been developed;
•Stakeholders were asked to review the
document and comment on whether they felt
it accurately reflected their understanding of
the Trust position in relation to quality;
The Council of Governors were asked to review
the document as a key stakeholder;
•A working group of the Council of Governors
reviewed the Quality Report on 8 March
2012 and produced an agreed Third Party
Declaration (section 5, page 88);
•Third-party narratives have been received
from Hartlepool Health Scrutiny Committee,
the Trust’s Council of Governors and the
Trust invited key stakeholders to provide their
narratives for inclusion in the final document;
•The External Auditors reviewed the Quality
Report/Account in April 2012.
6a The Purpose of the system of Quality
Governance
The system of quality governance is designed
to combine structures and processes at and
below Board level to lead Trust-wide quality
performance including ensuring required
standards are achieved, investigating and
taking action on sub standard performance,
planning and driving continuous improvement,
identifying, sharing and ensuring delivery of
best practice and identifying and managing
risks to the quality of care. The internal control
mechanisms support the management of risk
to a reasonable level rather than to eliminate
all risk of failure to achieve patients safety and
quality; the infrastructure of support therefore
provides 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 the 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 quality governance and internal
control infrastructure has been in place in this
Trust for the year ended 31 March 2012 and up
to the date of approval of the annual report and
accounts.
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6b The Impact of the Board of Directors in promoting a quality focus
culture throughout the Trust
The Board of Directors takes a proactive approach to learning applied lessons
from other Trusts and external reports. All such information is considered, a gap
analysis performed and an action plan prepared. The Board is actively engaged in
the delivery of quality improvement initiatives and ensuring appropriate governance
and accountability arrangements are in place throughout the organisation. Three
Non-Executive Directors are members of the Patient Safety and Quality Standards
Committee, one of whom chairs the meeting. The Board understands and promotes
staff empowerment on quality. This ensures all staff, including front line staff, are
involved and therefore, empowered to implement Trust practices and behaviours and
where appropriate challenge colleagues who have not followed Trust procedures.
Internal communications feature regular quality initiatives and improvements, and
bulletins and on-going training to enable staff to review lessons learnt from risk
management processes.
6c Roles and accountabilities in relation to quality governance
Each Board member understands their accountability for quality within the
organisational accountability structure cascading responsibility from Board to Ward
as described in the Quality Report, section 5. Quality is a core part of all Board
meetings which are held in public, and the monthly Patient Safety and Quality
Standards Committee minutes are received with an update provided by the NonExecutive Director Chairman.
Board members are highly visible and have undertaken patient safety “walk rounds”
and out of hours ward visits to gain assurance with regard to the realism of the quality
culture and to listen to staff and patient feedback in relation to quality standards.
6d Processes for escalating and resolving issues and managing
performance
The Board of Directors is clear about the processes for managing quality
performance issues and the structures and systems for potential escalation are
integrated throughout the organisation. Quality management systems including
directorate and corporate level incident, harm and mortality reviews supports trend
analysis, lessons learnt and appropriate and timely action. The Trust has a number of
robust action plans in place to address quality performance issues and every serious
untoward incident has an action plan which is subject to evaluation. These are also
routinely analysed for any emerging themes. In addition, complaints management is
also subject to the same governance process. All action plans have lead individuals
and identified owners and specific timescales for achievement. We have regular
service performance reviews and devolved responsibility and leadership via SLM
and dashboards at Directorate level to support this activity, and ensuring the Trust
manages performance.
The Trust Board are apprised of any follow ups by exception. Lessons from quality
issues are well documented, shared between all directorates across the Trust on a
regular monthly basis. The internal clinical audit process in relation to governance
has recently reviewed the risk management process, the management of adverse
events and control of infection systems. In addition, each week the Director of
Nursing, Patient Safety and Quality and the Medical Director meet key staff to discuss
any serious untoward incidents, thus enabling escalation, resolution and managing
performance to impact immediately.
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6e The Board actively engages patients,
staff and other key stakeholders on quality
Quality outcomes are made public and accessible
regularly involving the Hospital Users Group
and the Quality Standards Steering Group with
patient representatives and LINk representatives.
Patient feedback is actively solicited using patient
surveys and the Patient Experience and Quality
Standards review panels. However, this has
been further developed this year, with real time
collection of data from patients’ surveys and
Matron ward rounds.
This feedback is reviewed on an ongoing basis
with summary reports and action plans. Reports
of CQC patient surveys are all delivered back
to the Patient Safety and Quality Standards
Committee. Members of the Board carry out
walkabouts both announced and unannounced
and provide feedback. Feedback from the PALS
service and LINks is considered and the PALS
service input into a quarterly report called the
Complaints, Litigation, Incidents and PALS report
(CLIP) which is regularly delivered to the Patient
Safety and Quality Standards Committee and also
provided to the Executive Management Team.
It promotes the success of the organisation,
provides leadership within a framework of
effective controls, sets strategic direction
ensuring management capacity and capability
and monitoring and managing performance,
and safeguarding values.
The Board plays a crucial scrutiny role, but adds
value through the strategic role.
To allow the Board of Directors to achieve this,
and to ensure the future success of the Trust, the
performance improvement framework is used to
manage operational performance.
This framework enables an approach through
the concept of Service Line Management (SLM)
to key business units, integrating ownership of
quality, operational and financial performance.
The Board reviews financial, quality and service
performance targets on a monthly basis with
regular reporting to the Executive Management
Team.
6f Quality information analysed and
challenged
Periodic performance management of
directorates by the Executive Team covering
performance against key objectives occurs and
quarterly reporting to Monitor with regard to
compliance with the Terms of Authorisation is
built into this approach.
There are robust arrangements in place
to monitor quality, service and financial
performance information, trends and historical
data to enable challenge and deep diving
where required. The Patient Safety and Quality
Standards Committee is responsible for the
quality and safety governance, and for the
scrutiny and challenge which pervades into
implementation and delivery of goals. The
members of the Board review the best evidence
and influence the strategic vision, always with
an opportunity to see evidence of change in
practice through service visits and clinician and
manager attendance at seminars.
Capacity and capability are core areas of
challenge and discussion by the Board, which
recognise that achievement of the challenging
agenda as set out in the Corporate Strategy can
only be achieved if the Trust’s managers and
staff have the capacity and capability to deliver.
Assurance is required and has been provided to
the Board on this important matter. A key area in
developing capacity has been achieved through
the development of clinical and management
leads across the Trust, and their immediate
teams, in leadership and management
development. This is further explained in section
6.4 page 112.
6g Review of quality information, efficiency
and effectiveness
The Trust has continued its work on Sustainable
Development issues, having created an
Environment, Sustainability & Carbon
Governance Committee to focus resources on
short and longer term goals and to promote the
ideals of Good Corporate Citizenship within the
community we serve.
The Trust has a Performance Improvement
Framework in place and an operational
efficiencies programme. The Board of Directors
takes primary responsibility for compliance with
Terms of Authorisation.
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As such it has taken forward many of the ideas suggested by the NHS Sustainable
Development Unit for environmental good practices, local procurement initiatives
and carbon saving.
Embarking on a strategy of reducing our environmental impact, has demonstrated
our managed direction to follow guidance and be responsible leaders.
A major element of this strategy has been the successful completion of the Carbon
Trust’s Carbon Management Plan:
We have developed 25 separate schemes with identified Carbon Emissions savings.
Estimates show that successful completion of these schemes would potentially
realise 17-20% savings by 2015 reducing the Carbon Footprint by 2,500 Tonnes
of CO2 and cost avoidance of over £500,000. With suitable investment, we have
completed 10 projects; a further 10 are in progress and the remaining five requiring
some more planning and research.
Energy savings of £200,000 have already been realised, together with a further
£50,000 in reduced revenue costs, so we are well on target.
The Plan also includes:
•Travel Plan, whereby the number of journeys are reduced by at least 5%;
•Waste management, and the reduction of waste to landfill, has been a great
success by working closely with our main contractors;
•A Strategy for site rationalisation has reduced the occupied estates.
These actions have already realised savings and can be demonstrated through
enhanced ERIC returns and improving Display Energy Certificates with ratings being
C for University Hospital of North Tees and D for University Hospital of Hartlepool.
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, clinical audit and
the executive managers and clinical leads 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 patient safety and quality standards committee and plan to
address weaknesses and ensure continuous improvement of the system is in place.
The Assurance Framework is well established and is designed to meet the
requirements of the 2011-2012 Annual Governance Statement and provide
reasonable assurance that there is an effective system of internal control to manage
the principle risks identified by the organisation. A plan to address the weaknesses
and ensure continuous improvement of the system is in place.
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The process that has been applied in maintaining
and reviewing the effectiveness of the system of
internal control is outlined within the Terms of
Reference of the Board Committees which are
reflected in section 8, page 133 and include:
•The Board of Directors – has overall
accountability for delivery of patient care,
statutory functions and Department of Health/
Monitor requirements.
•The Audit Committee – oversees the
maintenance of an effective system of internal
control and assurance for the Board on the
Statement of Internal Control.
•The Finance Committee – ensures that the
Trust’s resources are being managed efficiently
and effectively.
•The Patient Safety and Quality Standards
Committee – ensures the highest possible
standards of clinical practice within the Trust.
To ensure the Trust has in place the systems
and the processes to support individuals,
teams and corporate accountability for the
delivery of safe, patient-centred, high-quality
care. To ensure the Quality Report/Accounts
are discharged and that lessons learned and
disseminated to all professionals within the
Trust and to ensure patient outcomes do no
demonstrate the Trust as an outlier.
Care Quality Commission – ensures the
Trust is compliant with the CQC core and
development standards. The additional duty
includes assessment of HAI Code of Conduct by
the CQC. It should be noted that the Trust did
not achieve full compliance with the information
governance toolkit standards in relation to
pseudonumisation.
Review and assurance mechanisms are in place
but continue to develop and ensure that:
•All managers including the Board regularly
review the risks and controls for which they are
responsible;
•All reviews are monitored, documented and
reported to the next level of management;
•Any changes to priorities or controls are
documented and appropriately referred or
actioned;
•Lessons which can be learned from both
successes and failures are identified and
promulgated to those who can gain
from them, both within and out with the
organisation.
An appropriate level of independent assurance
is provided on the whole process of risk
identification, evaluation and control.
•The Trust Directors Group – has
responsibility for achieving the corporate
objectives identified by the Board.
In conclusion, there are no significant internal
control issues that have been identified that
would prevent me from giving assurance.
Key Review Bodies:
8. Conclusion
Internal Audit – provides an independent and
objective opinion on risk management, control
and governance by measuring and evaluating
the effectiveness by which objectives are
achieved.
The Board have considered the Annual
Governance Statement and I can confirm that
there are no significant internal control issues
within the Trust.
External Audit – provides an independent
opinion on the review of resources and the
financial aspects of corporate governance as set
out in their Code of Audit Practice.
The Trust can confirm that the external auditors
of the Trust did undertake/provide some nonaudit activity, this included:
Alan Foster
Chief Executive
28 May 2012
•PWC LLP undertook the Monitor Stage 2
review in the summer of 2011;
•Deloitte (previous external auditors) undertook
the 2:1 savings report on the new hospital
development in December 2011.
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Annual Report and Accounts 2011 – 2012
12. Internal
Audit Statement
Independent Auditors Opinion
156
Speech and language therapist Melissa Cairney.
12.1 Roles and responsibilities
The whole Board is collectively accountable
for maintaining a sound system of internal
control and is responsible for putting in place
arrangements for gaining assurance about the
effectiveness of that overall system.
The Annual Governance Statement is an annual
statement by the Accounting Officer, on behalf
of the Board, setting out:
•How the individual responsibilities of the
Accounting Officer are discharged with regard
to maintaining a sound system of internal
control that supports the achievement of
policies, aims and objectives;
•The purpose of the system of internal control
as evidenced by a description of the risk
management and review processes, including
the Assurance Framework process;
•The conduct and results of the review of the
effectiveness of the system of internal control
including any disclosures of significant control
failures together with assurances that actions
are or will be taken where appropriate to
address issues arising.
The organisation’s Assurance Framework should
bring together all of the evidence required to
support the Annual Governance Statement
requirements.
In accordance with Government Internal Audit
Standards, the Head of Internal Audit (HoIA) is
required to provide an annual opinion, based
upon and limited to the work performed, on
the overall adequacy and effectiveness of the
organisation’s risk management, control and
governance processes (i.e. the organisation’s
system of internal control). This is achieved
through a risk-based plan of work, agreed
with management and approved by the Audit
Committee, which should provide a reasonable
level of assurance, subject to the inherent
limitations described below.
The opinion does not imply that Internal Audit
have reviewed all risks and assurances relating
to the organisation. The opinion is substantially
derived from the conduct of risk-based plans
generated from a robust and organisationled Assurance Framework. As such, it is one
component that the Board takes into account in
making its Annual Governance Statement.
12.2 The Head of Internal Audit
Opinion
The purpose of our annual HoIA Opinion is
to contribute to the assurances available to
the Accounting Officer and the Board which
underpin the Board’s own assessment of the
effectiveness of the organisation’s system of
internal control. This Opinion will, in turn, assist
the Board in the completion of the Annual
Governance Statement.
Our opinion is set out as follows:
1. Overall opinion;
2. Basis for the opinion;
3. Commentary.
Our overall opinion is that significant
assurance can be given that there is a generally
sound system of internal control, designed to
meet the organisation’s objectives, and that
controls are generally being applied consistently.
However, some weakness in the design and
inconsistent application of controls put the
achievement of particular objectives at risk.
The basis for forming our opinion is as follows:
1.An assessment of the design and operation
of the underpinning Assurance Framework and
supporting processes;
2.An assessment of the range of individual
opinions arising from risk based audit
assignments, contained within internal audit riskbased plans that have been reported throughout
the year. This assessment has taken account
of the relative materiality of these areas and
management’s progress in respect of addressing
control weaknesses;
3. Any reliance that is being placed upon third
party assurances;
In accordance with the internal audit plan we
have not relied on any work by third parties.
The commentary below provides the context
for our opinion and, together with the opinion,
should be read in its entirety.
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The design and operation of the Assurance Framework and associated
processes
The Assurance Framework had been updated throughout the year by Trust Directors
and Senior Officers, and presented to the Audit Committee and the Patient Safety
and Quality Standards Committee on a quarterly basis. It has also been presented
regularly to the Board and updated accordingly.
On this basis, it is my view that the assurance framework is in line with the
Statement of Internal Control requirements; however there are opportunities to
further strengthen and revise the approach in 2012/13.
The range of individual opinions arising from risk-based audit assignments,
contained within risk-based plans that have been reported during the year
During the year 2011/12 we have undertaken our work in accordance with the
Internal Audit annual plan. This plan has been developed with reference to the
Assurance Framework, Risk Register and detailed discussions with the Trust’s
executive directors at the start and throughout the year. It was approved by the
Audit Committee in March 2011, with revisions being approved by them throughout
the year. This process has ensured that the internal plan focuses upon the key risks
facing the Trust and areas of significant concern. The openness of this process is an
important factor in determining the internal plan and has been taken into account in
determining the overall level of assurance.
Throughout the year we have reported our findings to the Chief Executive, the
acting/Director of Finance & Information and Executive colleagues. A summary of
the work undertaken has also been provided to the Audit Committee. The majority
of this work has positive conclusions on the Trust’s systems and processes. It should
also be noted that we have issued no final reports with a ‘no assurance’ opinion for
2011/12.
However, in undertaking our duties we have also identified, or Trust Management
made us aware of, some weaknesses in the design or effectiveness of controls
in certain systems. We have reported these issues during the year to the Audit
Committee and have specifically bought these to the Accounting Officer attention
for potential disclosure within the Annual Governance Statement. In accordance with
best practice the Trust should review all of our findings in order to satisfy itself that
any significant control issues have been recognised and appropriately disclosed in the
Annual Governance Statement.
Reliance on third party assurances
In accordance with the agreed internal audit plan, no reliance has been placed on
the work of third parties.
John Whitehouse
28 May 2012
158
Annual Report and Accounts 2011 – 2012
Governor Tom Sant, talks to specialist healthcare assistant Deborah at a clinic in One Life Hartlepool during a patient experience
and quality standards panel.
159
13. External
Audit Opinion
160
Acting director of finance Neil Atkinson talks to members about the financial climate.
Independent Auditors’ Report to the Board Of Governors of North Tees and
Hartlepool NHS Foundation Trust
We have audited the financial statements of North Tees and Hartlepool NHS
Foundation Trust for the year ended 31 March 2012 which comprise the Statement
of Comprehensive Income, the Statement of Financial Position, the Statement of
Cash Flows, the Statement of Changes in Taxpayers’ Equity and the related notes.
The financial reporting framework that has been applied in their preparation
is the NHS Foundation Trust Annual Reporting Manual 2011/12 issued by the
Independent Regulator of NHS Foundation Trusts (“Monitor”).
Respective responsibilities of directors and
auditors
Scope of the audit of the financial
statements
As explained more fully in the Directors’
Responsibilities Statement the directors are
responsible for the preparation of the financial
statements and for being satisfied that they
give a true and fair view in accordance with the
NHS Foundation Trust Annual Reporting Manual
2011/12. Our responsibility is to audit and
express an opinion on the financial statements
in accordance with the NHS Act 2006, the
Audit Code for NHS Foundation Trusts issued by
Monitor and International Standards on Auditing
(ISAs) (UK and Ireland). Those standards require
us to comply with the Auditing Practices Board’s
Ethical Standards for Auditors.
An audit involves obtaining evidence about
the amounts and disclosures in the financial
statements sufficient to give reasonable
assurance that the financial statements are free
from material misstatement, whether caused by
fraud or error. This includes an assessment of:
whether the accounting policies are appropriate
to the NHS Foundation Trust’s circumstances and
have been consistently applied and adequately
disclosed; the reasonableness of significant
accounting estimates made by the NHS
Foundation Trust; and the overall presentation of
the financial statements. In addition, we read all
the financial and non-financial information in the
Annual Report and Accounts to identify material
inconsistencies with the audited financial
statements. If we become aware of any apparent
material misstatements or inconsistencies we
consider the implications for our report.
This report, including the opinions, has been
prepared for and only for the Board of Governors
of North Tees and Hartlepool NHS Foundation
Trust in accordance with paragraph 24 of
Schedule 7 of the National Health Service Act
2006 and for no other purpose. We do not,
in giving these opinions, accept or assume
responsibility for any other purpose or to any
other person to whom this report is shown
or into whose hands it may come save where
expressly agreed by our prior consent in writing.
161
Annual Report and Accounts 2011 – 2012
Opinion on financial statements
In our opinion the financial statements:
•give a true and fair view, in accordance with the NHS Foundation Trust Annual
Reporting Manual 2011/12, of the state of the NHS Foundation Trust’s affairs as at
31 March 2012 and of its income and expenditure and cash flows for the year then
ended; and
•have been properly prepared in accordance with the NHS Foundation Trust Annual
Reporting Manual 2011/12.
Opinion on other matters prescribed by the Audit Code for
NHS Foundation Trusts
In our opinion
•the part of the Directors’ Remuneration Report to be audited has been properly
prepared in accordance with the NHS Foundation Trust Annual Reporting Manual
2011/12; and
•the information given in the Directors’ Report for the financial year for which the
financial statements are prepared is consistent with the financial statements.
Matters on which we are required to report by exception
We have nothing to report in respect of the following matters where the Audit Code
for NHS Foundation Trusts requires us to report to you if:
•in our opinion the Annual Governance Statement does not meet the disclosure
requirements set out in the NHS Foundation Trust Annual Reporting Manual
2011/12 or is misleading or inconsistent with information of which we are aware
from our audit. We are not required to consider, nor have we considered, whether
the Annual Governance Statement addresses all risks and controls or that risks are
satisfactorily addressed by internal controls;
•we have not been able to satisfy ourselves that the NHS Foundation Trust has made
proper arrangements for securing economy, efficiency and effectiveness in its use
of resources; or
•we have qualified our report on any aspects of the Quality Report.
162
Annual Report and Accounts 2011 – 2012
Certificate
We certify that we have completed the audit of the financial statements in accordance with the
requirements of Chapter 5 of Part 2 to the National Health Service Act 2006 and the Audit Code for
NHS Foundation Trusts issued by Monitor.
Neil Austin (Senior Statutory Auditor)
For and on behalf of PricewaterhouseCoopers LLP
Chartered Accountants and Statutory Auditors
Newcastle upon Tyne
28 May 2012
(a) The maintenance and integrity of the website of North Tees and Hartlepool NHS Foundation
Trust is the responsibility of the directors; the work carried out by the auditors does not involve
consideration of these matters and, accordingly, the auditors accept no responsibility for any
changes that may have occurred to the financial statements since they were initially presented on
the website.
(b) Legislation in the United Kingdom governing the preparation and dissemination of financial
statements may differ from legislation in other jurisdictions.
163
Annual Report and Accounts 2011 – 2012
14. Financial
Performance
2011/12
164
Nursery assistant Kirsty Exton with mum Claire Harker and her son Adam.
14.1 Foreword to the Accounts
These accounts for the year ending 31 March 2012 have been prepared by North
Tees and Hartlepool NHS Foundation Trust in accordance with paragraphs 24 and
25 of schedule 7 to the NHS Act 2006 and have been audited by Price Waterhouse
Coopers (PWC) the Trust’s external auditors.
The accounts have received an unqualified
opinion that they give a true and fair view of the
state of affairs of the Trust as at 31 March 2012
including its income and expenditure for the
period.
This report contains the four primary financial
statements:
•The comprehensive statement of income;
•The statement of financial position;
•Statement of total recognised gains and losses,
and;
•Cash flow statement.
Also included for information are the supporting
notes to the accounts.
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.
Alan Foster
Chief Executive
28 May 2012
14.2 Financial Commentary and Metrics
2011/12 has been a challenging year for the
trust with continuing service pressures on
elective targets, high levels of emergency activity
and the need to continuously improve quality
and patient experience. This is set against the
continuing backdrop of a challenging economic
and financial environment and annual operating
plan settlement that required the Trust to deliver
a £15.851 million cost efficiency target.
In light of the above the board took a conscious
decision to maintain a planned income and
expenditure surplus to £2.017 million to ensure
an appropriate balance between the challenging
financial efficiency agenda and the desire to
continue to improve quality, patient experience
and service performance.
This decision recognised an EBITDA margin
percentage at the lower end of the spectrum for
the acute sector, which is a function in the main
of the impact of having no major leases or PFI’s
and been the first FT to integrate community
provider services.
The twin site nature of the trusts estate and
duplication of medical services and diagnostic
support, delivered within a relatively efficient
reference cost index of 94 signifies that it is
becoming increasingly difficult to achieve the
challenging cost efficiencies required to generate
the planned surplus.
In spite of the above the Trust has delivered
another sound financial performance, with an
operating surplus of £3.059 million. Instrumental
in this was the delivery of the majority of the
cost efficiency target alongside the rigorous
control of pay and non-pay budgets, with
particular emphasis on the control and reduction
of agency nursing staff, even during the periods
of immense pressure on beds. The hard work
and dedication of the Trust’s staff has been
fundamental to another successful year.
For 2011/12 Foundation Trust accounts will be
consolidated into the Department of Health
resource account and all NHS organisations are
mandated to agree balances and transactions
with one another. The overall aim of the process
is for the Government to have a single set of
accounts following consolidation of individual
organisation accounts. Additional guidance was
released by the Department of Heath on the
2 April 2012 with specific reference to income
recognition.
This change to accounting policy has increased
the Trust's surplus to £6.274 million and would
be recognised against the Trust's accumulated
Income and Expenditure reserve for future use.
It should be noted that this adjustment is nonoperational in nature and does not detract from
the Trust's underlying financial performance or
standing.
Annual Report and Accounts 2011 – 2012
165
In accordance with the requirement to annually revalue the Trust asset base the District Valuer carried
out a valuation exercise in March 2012 that resulted in an impairment reported in the 2011/12
accounts.
The estate revaluation generates an impairment equivalent to the asset value reduction of £20.211
million. This would result in a technical deficit for the year of £13.937 million. The impairment is a
non-cash debit to operating expenses on the comprehensive statement of income and is accounted for
via the Income and expenditure reserve on the statement of financial position.
This performance has enabled the Trust to strengthen its balance sheet, cash and underlying liquidity
position for the fifth year in a row since achieving foundation trust status.
14.3 Financial Performance against Plan 2011/12
The table below summarises the actual financial performance against plan:
2011/12 Plan
2011/12 Actual
Variance
£000
£000
£000
238.2
240.3
2.1
30.3
31.0
0.7
268.4
271.3
2.9
-182.6
-185.3
-2.7
-74.8
-74.2
0.6
-257.4
-259.5
-2.1
11.0
11.8
0.8
Finance Costs
-9.0
-8.8
0.2
Operational Surplus
2.0
3.0
1.0
Technical Accounting Adjustment*
-
3.2
3.2
Impairment*
-
-20.2
-20.2
Revised non-operating deficit
-
-14.0
-14.0
Closing Cash Balance
35.0
35.1
0.1
I&E CIP – Recurring and Non Recurring
15.8
15.8
0.0
Income
Income from Activities
Other Operating Income
Total Income
Expenses
Pay Costs
Non Pay Costs
Total Costs
EBITDA
* = the above table includes the non-cash impairment reversal of £20.211m and the technical accounting adjustment of £3.215m
Overall financial risk rating = 3
14.4 Income and Contract Performance
Income in 2011/12 totalled c£274.5 million. The majority of the Trust’s income (£235.4 million, 86%)
was derived from Primary Care Trusts in relation to healthcare services provided to patients during the
year. Other operating income relates to services provided to other Trusts; training and education and
miscellaneous fees and charges.
A summary of total income is provided in table 1 opposite:
166
Annual Report and Accounts 2011 – 2012
Table 1 - Analysis of Sources of Income 1 April 2011 to 31 March 2012
£ms
%
235.41
86%
Other Patient Care Income
4.62
2%
Education, Training and R&D
7.36
3%
22.49
8%
4.63
2%
274.52
100%
Primary Care Trusts
Non-Patient Care Services to Other Bodies
Other
Total Operating Income
Services provided to the patients of Stockton Teaching PCT and Hartlepool PCT accounted for 77% of total
income received from Primary Care Trust.
A summary of income from Primary Care Trusts is provided in table 2 below:
Table 2 - Analysis of Income from Primary Care Trusts 1 April 2011 to 31 March 2012
£m
%
North Tees PCT
112
48%
Hartlepool PCT
72
31%
County Durham PCT
40
17%
Middlesbrough PCT
3
1%
Redcar & Cleveland PCT
2
1%
Darlington PCT
2
1%
Other
4
2%
235
100%
£m
%
182
64%
Drugs Costs
17
6%
Supplies and Services – Clinical
(Excl. Drugs Costs)
26
9%
Supplies and Services – General
4
1%
Services From NHS Organisations
0
0%
56
20%
285
100%
Total PCT Income
Expenditure
An analysis of the Trust’s operating expenditure is presented in table 3 below:
Table 3 - Analysis of Operating Expenditure
Employee Expenses
Other Costs
Total Operating Expenses
167
Annual Report and Accounts 2011 – 2012
Table 4 and 5 below highlights the following:
•Elective contract performance shows a decrease of 559 spells, when compared to 2010/11, however
activity seen within a Day Case setting has risen by 1274 spells.
•Non Elective contract performance shows a reduction of 1898 spells, when compared to 2010/11,
however an additional 3,323 patients have been seen, due to the expanded use of Ambulatory Care.
•First and Follow-up Outpatient attendances have decreased by 4,685 and 10,768 attendances
respectively, compared to 2010/11 activity levels. This planned reduction is a continuation of the
Momentum: Pathways to Healthcare project, which ensures patients are treated closer to home and
only attend a hospital setting when appropriate.
•Following the closure of Hartlepool A&E department and the planned transfer of patients to the
Minor injuries unit in the One Life Centre, a net reduction of 7,981 patient attendances have been
seen between the North Tees A&E and Hartlepool MIU.
Table 4 - Analysis of the financial components of the 2011/12 and 2010/11 contract
80
70
£ million
60
50
2011/12
40
2010/11
30
20
10
0
Day Case Spells
Analysis of Income £
Elective
Inpatient Spells
Non Elective
(Emergency) Spells
2011/12
2010/11
Day Case Spells
£19,835,203
£20,169,499
Elective Inpatient Spells
£20,374,956
£20,039,308
Non Elective (Emergency) Spells
£68,268,721
£70,972,303
168
Annual Report and Accounts 2011 – 2012
Table 5 - Analysis of the 2011/12 and 2010/11 contract activity
18
16
£ million
14
12
10
2011/12
8
2010/11
6
4
2
0
First
Outpatient
Attendances
Follow Up
Outpatient
Attendances
Outpatient
Procedures
Ambulatory
Care
Analysis of Income £
2011/12
2010/11
First Outpatient Attendances
£11,633,509
£12,674,278
Follow Up Outpatient Attendances
£16,125,687
£17,949,130
Outpatient Procedures
£2,408,486
£1,637,676
Ambulatory Care
£2,057,654
£627,454
14.5 Capital Investment
In terms of capital investment the Trust expended £5.449 million in the following areas during
2011/12:
•£1.903 million of replacement Medical Equipment, including the conversion of the Breast Screening
Service to a digital X-ray basis;
•Donated equipment – £0.333 million;
•IMT schemes – £0.338 million;
•Intangible additions (i.e. software licences) – £0.032 million;
•Service developments outlined in previous sections of this report – £1.746 million;
•Estates and backlog maintenance schemes – £1.097 million.
169
Annual Report and Accounts 2011 – 2012
14.6 Financial outlook for 2012/13
The challenging economic and financial environment facing the NHS, resulting in
a shift to an environment of zero or marginal growth, coupled to an increasingly
ageing population and the ever increasing demand for hospital and community
services, means that the local health economy and the Trust are facing a period of real
terms reductions in funding in 2012/13.
The Operating Framework, Payment by Result (PbR) tariff for 2012/13 and the Annual
Operating Plan (AOP) agreement with Primary Care Trusts has resulted in the need for
the Trust to deliver a £15.9 million cost efficiency target. The scale of the efficiency
target is significantly above that embodied in the national tariff (4.0%).
The size of the efficiency target presents an extremely challenging year ahead, as was
the case in 2011/12. The financial agenda needs to be delivered in the context of
maintaining and improving quality of care, patient safety and performance targets.
Following an external review of the Trust’s cost efficiency opportunities and internal
governance arrangements, detailed plans have been agreed with directorates and a
rigorous performance management framework has been put in place to ensure plans
are delivered.
For 2012/13 the Trust plans to deliver an income and expenditure surplus margin of
circa £2.6 million, which recognises the need to reverse the downward trend of recent
years in the EBITDA margin percentage and maintain a financial risk rating of 3.
The Trust's medium term financial strategy, linked to the development of the
new hospital, continues to drive clinical and operational efficiency, utilising Lean
management principles and service line management. The Trust will continue to
deliver on-going estate rationalisation with associated recurrent savings and nonrecurrent savings from land sale proceeds where appropriate. We will pursue savings
from back office shared services efficiencies and management cost reductions;
effective and flexible use of the workforce and transformation of services across the
acute and community services to deliver clinical pathway improvements. The Trust will
strive to deliver the challenging financial agenda and will maintain or improve upon
the quality, patient experience and service performance in the difficult years ahead.
The Trust continues to have a strong cash and liquidity base upon which to face this
difficult period.
14.7 Financial Key Performance Targets
The Trust performance against its main financial targets for the period to 31 March
2012 was as follows:
EBITDA margin
Definition: The net earnings before interest, taxation, depreciation and amortisation
shown as a percentage of total income;
Purpose: This measures the underlying performance of the Trust;
Source of Data: Trust audited annual financial statements;
Target: 4.0% based on the Monitor Plan for 2011/12;
Result: 4.5% producing a Risk Rating of 3.
170
Annual Report and Accounts 2011 – 2012
EBITDA percentage achieved (as a
percentage of plan)
Liquid ratio
Definition: The net earnings before interest,
taxation, depreciation and amortisation shown
as a percentage of total income;
Definition: Cash plus trade debtors plus unused
working capital facility minus trade creditors plus
other creditors, expressed in the number of days’
operating expenses that could be covered;
Purpose: This measures the achievement of plan
by the Trust;
Purpose: To ensure that the Trust maintains a
healthy liquidity position;
Source of data: Trust audited annual financial
statements;
Source of data: Trust audited annual financial
statements;
Target: 105.1% based on the Monitor Plan for
2011/12;
Target: 30.3 Days based on the Monitor Plan for
2011/12;
Result: 108.7% producing a Risk Rating of 5.
Result: 50.5 Days due to the amount of cash at
the year end. This produced a Risk rating of 4.
Return on assets
Definition: The Trust’s Surplus before dividends
as a percentage return on average net assets;
Purpose: A measure of financial efficiency;
Source of data: Trust audited annual financial
statements;
Target: 4.0% based on the Monitor Plan for
2011/12;
Result: 4.3% producing a Risk Rating of 3.
Income and expenditure surplus margin
Definition: Net surplus shown as a percentage
of total income;
Purpose: To ensure that the Trust has generated
a continued surplus;
Source of data: Trust audited annual financial
statements;
Target: 0.6% based on the Monitor Plan for
2011/12;
Result: 2.3% producing a Risk Rating of 4.
Cost Allocation
In compiling its reference costs and service line
accounts the Trust complies with NHS and HM
Treasury guidance.
Prudential borrowing limit
Definition: A limit to the amount of borrowings
that the Trust may take on, set for each NHS
Foundation Trust by the independent regulator
guided by the prudential borrowing code;
Purpose: Used to protect the public interest
and the financial stability of individual NHS
Foundation Trusts;
Source of data: Trust audited annual financial
statements;
Limit: £44.3m;
Actual: £1.43m.
Private Patient cap
Definition: The level of private patient income
is capped at the level (as a percentage of total
patient income) as that in the financial year
2002-2003;
Purpose: To ensure that the Trust continues to
focus on NHS work;
Source of Data: Trust audited annual financial
statements;
Target: < 0.11%;
Actual: 0.06%.
171
Annual Report and Accounts 2011 – 2012
The Better Payment Practice Code - All Payments
Definition: Unless other terms are agreed, the Trust is required to pay all its
creditors within 30 days of the receipt of goods, or a valid invoice, whichever is the
later;
Purpose: To ensure that the Trust complies with the better payment practice code;
Source of Data: Trust audited financial statements;
Target: 95%;
Result by number: 98.01%;
Result by value: 96.06%.
The Trust achieved this target for all invoices
Late payment interest
Legislation is in force which requires Trusts to pay interest to small companies if
payment is not made within 30 days (Late payment of Commercial Debts (Interest)
Act 1998).
The Trust’s performance against this criteria is: none
There have been no payments made under the late Payment of Commercial Debts
(interest) Act 1998 for the year ended 31 March 2011.
14.8 Summary
The Trust’s financial performance continues to deliver to plan and has built on the
foundations laid in the previous years. The task ahead over the next five years as
outlined above will be extremely challenging, but is no different to that facing the
majority of trusts and with sound financial control and management, the Trust is
well placed to continue to deliver incremental improvements in the quality of services
delivered to our patients.
172
Annual Report and Accounts 2011 – 2012
14.9 North Tees and Hartlepool NHS Foundation Trust
Annual Accounts 2011/12 Including Financial Statements and Notes
2011/12
£000
2011/12
£000
Operating
result excluding
Impairment
Reversal of
Impairment
value
Operating
result including
impairment
Operating
result excluding
reversal of
Impairment
Impairment
Value
Operating
result &
Impairment
Note
Statement of comprehensive income for the year ended 31 March 2012
2011/12
£000
Restated
2010/11
£000
Restated
2010/11
£000
Restated
2010/11
£000
274,754
270,249
-
270,249
Operating income from
continuing operations
3
274,754
Operating expenses of
continuing operations
6
(282,525)
(20,211)
(265,314)
(265,614)
3,009
(265,623)
(10,771)
(20,211)
9,440
7,636
3,009
4,627
OPERATING SURPLUS/
(DEFICIT)
Finance costs
Finance income
13
151
-
151
101
-
101
Finance expense –
financial liabilities
14
(173)
-
(173)
(148)
-
(148)
Finance expense –
unwinding of discount on
provisions
28
(39)
-
(39)
(41)
-
(41)
PDC Dividends payable
33
(3,106)
-
(3,106)
(3,344)
-
(3,344)
(3,167)
-
(3,167)
(3,432)
-
1,195
Surplus/(Deficit) from
continuing operations
(13,938)
(20,211)
6,273
4,204
3,009
1,195
SURPLUS/(DEFICIT)
FOR THE YEAR
(13,938)
(20,211)
6,273
4,204
3,009
1,195
Revaluations
-
-
-
14
-
14
Other reserve movements
-
-
-
(14)
0
(14)
(13,938)
(20,211)
6,273
4,204
3,009
1,195
NET FINANCE COSTS
Other comprehensive income
TOTAL COMPREHENSIVE INCOME/
(EXPENSE) FOR THE YEAR
All results are attributable to the Trust.
The notes numbered 1 - 36 form part of these financial statements.
The impact of the impairment in 2011/12 created a reported deficit of £13,937k.
The impact of the impairment reversal in 2010/11 created a reported surplus of £4,204K. The operating surplus in 2010/11 was £1,195K which was in line with budgeted
expectations.
173
Annual Report and Accounts 2011 – 2012
Statement of financial position as at 31 March 2012
Note
31 March 2012
£000
31 March 2011
£000
1 April 2010
Restated £000
Intangible assets
16
358
434
251
Property, plant and equipment
15
99,013
119,398
110,217
Trade and other receivables
19
-
1,003
1,025
99,370
120,835
111,493
Non-current assets
Total non-current assets
Current assets
Inventories
18
7,358
6,040
4,695
Trade and other receivables
19
8,785
7,674
9,528
Cash and cash equivalents
21
35,078
30,315
19,956
51,221
44,029
34,179
Total current assets
Current liabilities
Trade and other payables
22
(16,453)
(18,290)
(17,950)
Borrowings
23
(274)
(165)
(96)
Provisions
28
(2,089)
(883)
(1,106)
Other liabilities
24
(1,685)
(2,712)
(1,752)
Net current liabilities
(20,501)
(22,050)
(20,904)
Total assets less current liabilities
130,090
142,814
124,768
Non-current liabilities
Trade and other payables
22
-
(375)
(413)
Borrowings
23
(1,101)
(1,187)
(1,156)
Provisions
28
(1,202)
(1,556)
(1,954)
Other liabilities
24
(13,177)
(11,148)
(5,000)
Total non-current liabilities
(15,480)
(14,266)
(8,523)
Total assets employed
114,610
128,548
116,245
123,645
123,645
115,545
(9,034)
4,904
700
114,610
128,548
116,245
Financed by taxpayers' equity:
Public Dividend Capital
Income and expenditure reserve
Total Taxpayers' Equity
The notes numbered 1 - 36 form part of these financial statements. The financial statements on pages 1 to 4 and the notes 1 to 36 were approved by the Board on 24th May 2012 and
signed on its behalf by:
Chief Executive …………................…………………………..............……………..
174
Annual Report and Accounts 2011 – 2012
28 May 2012
Date ……........................……………………….
Statement of cash flows
NOTE
2011/12
£000
2010/11
£000
Operating surplus/(deficit) from continuing operations
(10,771)
7,636
Operating (deficit)/surplus from continuing operations
(10,771)
7,636
5,687
5,344
20,211
674
-
(3,009)
Cash flows from operating activities
Non-cash income and expense
Depreciation and amortisation
15
Impairments
Reversal of impairments
(Increase)/Decrease in Trade and Other Receivables
22
(107)
1,492
(Increase)/Decrease in Inventories
18
(1,318)
(1,345)
Increase/(Decrease) in Trade and Other Payables
27
(2,212)
188
Increase/(Decrease) in Other Liabilities
24
1,002
7,108
Increase/(Decrease) in Provisions
28
852
(662)
(331)
(265)
13,014
17,162
Other movements in operating cash flows
Cash flows from investing activities
Interest received
13
151
101
Purchase of intangible assets
16
(32)
(272)
Purchase of Property, Plant and Equipment
15
(5,107)
(11,726)
(4,988)
(11,896)
-
8,100
Net cash generated from/(used in) investing activities
Cash flows from financing activities
Public dividend capital received
Other loans received
23
233
196
Other loans repaid
23
(80)
-
Capital element of Private Finance Initiative Obligations
(110)
(96)
Interest element of Private Finance Initiative obligations
(155)
(148)
PDC Dividend paid
(3,150)
(2,960)
Net cash generated from/(used in) financing activities
(3,262)
5,092
4,764
10,358
Cash and Cash equivalents at 1 April
30,315
19,956
Cash and Cash equivalents at 31 March
35,078
30,315
Increase/(decrease) in cash and cash equivalents
The notes numbered 1 - 36 form part of these financial statements.
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Annual Report and Accounts 2011 – 2012
Statement of changes in taxpayers’ equity
Total
Public
dividend
capital
(PDC)
Revaluation
reserve
Donated
asset
reserve
Income and
expenditure
reserve
£000
£000
£000
£000
£000
128,549
123,645
-
-
4,904
6,273
-
-
-
6,273
Impairments
(20,211)
-
-
-
(20,211)
Taxpayers’ Equity at 31 March 2012
114,611
123,645
-
0
(9,033)
Total
Public
dividend
capital
(PDC)
Revaluation
reserve
Donated
asset
reserve
Income and
expenditure
reserve
£000
£000
£000
£000
£000
116,245
115,545
-
1,606
(906)
-
-
-
(1,606)
1,606
116,245
115,545
-
-
700
-
-
-
-
-
4,204
-
-
-
4,204
(13)
-
(14)
-
1
14
-
14
-
-
8,100
8,100
-
-
-
128,549
123,645
-
-
4,904
Taxpayers’ Equity at 1 April 2011
Total comprehensive income for the year
Taxpayers’ Equity at 1 April 2010 - as previously
stated
Prior period adjustment
Taxpayers’ Equity at 1 April 2010 - restated
At start of period for new FTs
Total comprehensive income for the year
- Transfers between reserves
- Revaluations - property, plant and equipment
Public Dividend Capital received
Taxpayers’ Equity at 31 March 2011
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Notes to the
Accounts
1. Basis of Preparation
Monitor has directed that the financial
statements of NHS foundation trusts shall
meet the accounting requirements of the FT
ARM which shall be agreed with HM Treasury.
Consequently, the following financial statements
have been prepared in accordance with the FT
ARM 2011/12 issued by Monitor. The accounting
policies contained in that manual follow
International Financial Reporting Standards
(IFRS) and HM Treasury’s FReM 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.
The financial statements have been in prepared
in accordance with EU endorsed International
Financial Reporting Standards and the
International Financial Reporting Interpretations
Committee (IFRIC).
1.1 Early Adoption of IFRSs
Where the International Accounting Standards
Board has issued amendments to Standards
the Trust has implemented those changes. In
line with guidance from Monitor, the Trust
has not sought to early adopt any changes in
International Accounting Standards.
1.2 Accounting Policies
The accounting policies have been applied
consistently in dealing with items considered
material in relation to the accounts and are
summarised below.
1.3 Consolidation
Subsidiary entities are those over which the Trust
has the power to exercise control or a dominant
influence so to gain economic or other benefits.
Until 31 March 2013, NHS Charitable Funds are
considered to be subsidiaries but the Trust has
excluded them from consolidation in accordance
with the accounting direction issued by Monitor.
In accordance with the Companies Act 2006 the
following details are disclosed in relation to the
Trust's subsidiary entity:
North Tees and Hartlepool NHS Foundation Trust
Charitable Fund. Registered address:
Hardwick Rd
Stockton-on-Tees.
TS19 8PE
The aggregate amount of it’s reserves and
capital as at 31 March 2012 are £1.607m with a
reported surplus of £169k.
1.4 Estimation Techniques
These are methods adopted by the Trust to arrive
at monetary amounts, corresponding to the
measurement basis selected for assets, liabilities,
gains, losses and charges to the Reserves. Where
the basis of measurement for the amount to
be recognised under Accounting Policies is
uncertain, an estimation technique is applied
In the application of the Trust’s 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 and the estimates and
underlying assumptions are continually reviewed.
Revisions to accounting estimates are recognised
in the period in which the estimate is known.
The estimates and assumptions that have a
significant risk of causing a material adjustment
to the Accounts are highlighted below:
Work in Progress
The Trust prepares an estimate of income
generated for incomplete in-patient spells at the
year end. This estimate is based on an equivalent
month end date and partially coded data as at
the 31st March 2012.
Annual Report and Accounts 2011 – 2012
177
Legal claims
Legal claims are based upon professional assessments, which are uncertain to the
extent that they are an estimate of the likely outcome of individual cases. In the
majority of cases the estimate is based on advice from the NHS Litigation Authority.
Asset Valuation and Indices
The valuation of land and buildings is based on building cost indices provided by
and used by the District valuer in his valuation work. These indices are based on an
indication of trend of accepted tender prices within the construction industry as
applied to the Public Sector.
Asset Impairments
An assessment is made each year as to whether an asset has suffered an
impairment loss.
1.4.1 Critical judgements in applying accounting policies
The following are the critical judgements, apart from those involving estimations
(see above), that management has made in the process of applying the Trust’s
accounting policies.
1.4.2 Going concern
The day to day operations of the Trust are funded from agreed contracts with
Primary Care Trusts. The uncertainty in the current economic climate has been
mitigated by agreeing contracts with the Primary Care Trusts for a further year.
These payments provide a reliable stream of funding minimising the Trust exposure
to liquidity and financing problems. The Trusts budgets and expenditure plans are
based on this level of commissioned service and indicate that the Trust has sufficient
resource to meet ongoing commitments. The Board of Directors have assessed the
criteria of a going concern in accordance with IAS 1 and in their opinion, given the
facts at their disposal it is correct to prepare the accounts on a going concern basis.
The cash flow forecast over the next 12 months indicate that the Trust has a monthly
cash surplus available for investment. The Trust treasury policy governs the risk
exposures of monetary financial assets and limits the value that can be placed with
each approved counterparty to minimise the risk of loss. The counterparties are
limited to the approved financial institutions with high credit ratings. Given the
economic uncertainty, particularly in the banking sector, the Trust has predominantly
invested in the Government's National Loan Fund and has not been exposed to bank
insolvency risks. 1.4.3 Key sources of estimation uncertainty
Trade receivables mainly consist of transactions with Primary Care Trusts under
contractual terms that require settlement of obligation within a time frame
established generally by the Department of Health.
The following are the key assumptions concerning the future, and other key sources
of estimation uncertainty at the end of the reporting period, that have a significant
risk of causing a material adjustment to the carrying amounts of assets and liabilities
within the next financial year.
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Annual Report and Accounts 2011 – 2012
The amounts included within Provisions for
liabilities and charges, note 27, are based upon
advice from relevant external bodies, including
the NHS Litigation Authority, NHS Pensions
Agency and the Trust's external legal advisors.
On the 31st March 2012 Land and Buildings
were revalued using the Modern Equivalent
Valuation methodology by the District Valuer
(who is an appropriately qualified member of the
Royal Institute of Chartered Surveyors).
1.5 Income recognition
Income 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 Trust is contracts with
commissioners in respect of healthcare services
• It is expected to be used for more than one
financial year;
•The cost of the item can be measured reliably;
and
•The item has cost of at least £5,000; or
•Collectively, a number of items 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 income is received for a specific activity
that is to be delivered in the following year, that
income is deferred.
Where a large asset, for example a building,
includes a number of components with
significantly different asset lives, the components
are treated as separate assets.
1.6 Employee Benefits
Valuation
Short-term employee benefits
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.
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 carryforward leave into the following period.
1.7 Other expenses
Other operating expenses are recognised when,
and to the extent that, the goods or services
have been received. They are measured at the
fair value of the consideration payable.
1.8 Property, plant and equipment
Recognition
Property, plant and equipment is capitalised if:
•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 will be
supplied to, the Trust;
All assets are measured subsequently at fair
value.
On the 31st March 2012 Land and Buildings
were revalued using the Modern Equivalent
Valuation methodology by the District Valuer,
who is an appropriately qualified member of the
Royal Institute of Chartered Surveyors (RICS).
Properties in the course of construction for
service or administration purposes are carried
at cost, less any impairment loss. Cost includes
professional fees but not borrowing costs, which
are recognised as expenses immediately, as
allowed by IAS 23 for assets held at fair value.
Assets are revalued and depreciation commences
when they are brought into use.
The revaluation undertaken at that date was
accounted for on 31 March 2012. The next
revaluation will be prior and no later than the
1 April 2013.
Annual Report and Accounts 2011 – 2012
179
Additional alternative open market value figures have only been supplied for
operational assets scheduled for imminent closure and subsequent disposal.
An increase arising on revaluation is taken to the revaluation reserve except when
it reverses an impairment for the same asset previously recognised in expenditure,
in which case it is credited to expenditure to the extent of the decrease previously
charged there.
Subsequent expenditure
Where subsequent expenditure enhances an asset beyond its original specification,
the directly attributable cost is capitalised. Where subsequent expenditure restores
the asset to its original specification, the expenditure is capitalised and any existing
carrying value of the item replaced is written-out and charged to operating expenses.
Depreciation
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 which is normally on a straight line basis. The useful economic lives
and hence depreciation rates for equipment assets are determined by staff within the
Estates and facilities department. Freehold land is considered to have an infinite life
and is not depreciated.
Equipment is depreciated on fair value evenly over the estimated life of the asset.
Asset lives fall into the following periods:
Buildings excluding dwellings - forty to ninety years
Dwellings - eighty years
Assets under Construction - eighty years
Plant & Machinery - seven and fifteen years
Transport Equipment - seven years
Information Technology - seven to eight years
Furniture & Fittings - seven to twelve years
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 Trust, respectively.
Revaluation and impairments
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’.
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Annual Report and Accounts 2011 – 2012
Impairments
1.8.1 Intangible assets
In accordance with the FT ARM, impairments
that are due to a loss of economic benefits or
service potential in the asset are charged to
operating expenses. A compensating transfer is
made from the revaluation reserve to the income
and expenditure reserve of an amount equal
to the lower of (i) the impairment charged to
operating expenses; and (ii) the balance in the
revaluation reserve attributable to that asset
before the impairment. Other impairments are
treated as revaluation losses. Reversals of ‘other
impairments’ are treated as revaluation gains.
Recognition
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’;
--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 derecognised when scrapping or demolition occurs.
Intangible assets are non-monetary assets
without physical substance, which are capable
of sale separately from the rest of the Trust’s
business or which arise from contractual or other
legal rights. They are recognised only when it is
probable that future economic benefits will flow
to, or service potential be provided to, the Trust;
where the cost of the asset can be measured
reliably, and where the cost is at least £5,000.
Internally generated goodwill, brands, mastheads,
publishing titles, customer lists and similar items
are not capitalised as intangible assets.
Expenditure on research is not capitalised.
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.
Revaluations gains and losses and impairments
are treated in the same manner as for Property,
Plant and Equipment.
1.9 Amortisation
Intangible assets are amortised in a straight line
over their expected useful economic lives in a
manner consistent with the consumption of
economic or service delivery, normally seven years.
Donated and grant funded property, plant
and equipment assets are capitalised at their
fair value on receipt. The donation/grant is
credited to income at the same time, unless the
donor has imposes a condition that the future
economic benefits embodied in the grant are
to be consumed in a manner specified by the
donor, in which case, the donation/grant is
deferred within liabilities and is carried forward
to future financial years to the extent that the
condition has not yet been met.
Annual Report and Accounts 2011 – 2012
181
1.10 Non-current assets held for sale
Non-current assets are classified as held for sale if their carrying amount will be
recovered principally through a sale transaction rather than through continuing
use. This condition is regarded as met when the sale is highly probable, the asset is
available for immediate sale in its present condition and management is committed
to the sale, which is expected to qualify for recognition as a completed sale within
one year from the date of classification. Non-current assets held for sale are
measured at the lower of their previous carrying amount and fair value less costs to
sell. Fair value is open market value including alternative uses.
The profit or loss arising on disposal of an asset is the difference between the
sale proceeds and the carrying amount and is recognised in the Statement of
Comprehensive Income. On disposal, the balance for the asset on the revaluation
reserve is transferred to retained earnings. For donated and government-granted
assets, a transfer is made to or from the relevant reserve to the profit/loss on disposal
account so that no profit or loss is recognised in income or expenses. The remaining
surplus or deficit in the donated asset or government grant is then transferred to
retained earnings.
Property, plant and equipment that is to be scrapped or demolished does not
qualify for recognition as held for sale. Instead, it is retained as an operational asset
and its economic life is adjusted. The asset is de-recognised when it is scrapped or
demolished.
1.11 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 and the rentals are charged to the operating expenses on a straight line basis
over the term of the lease.
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.
The Foundation Trust as finance lessee
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 derecognised 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.
Contingent rentals are recognised as an expense in the period in which they
are incurred.
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Annual Report and Accounts 2011 – 2012
The Foundation Trust as lessor
PFI liability
Amounts due from lessees under finance leases
are recorded as receivables at the amount of the
Trust’s net investment in the leases. Finance lease
income is allocated to accounting periods so as
to reflect a constant periodic rate of return on
the Trust’s net investment outstanding in respect
of the leases.
A PFI liability is recognised at the same time
as the PFI assets are recognised. It is measured
initially at the same amount as the fair value of
the PFI assets and is subsequently measured as a
finance lease liability in accordance with IAS 17.
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.
1.12 Private Finance Initiative (PFI)
transactions
PFI transactions which meet the IFRIC 12
definition of a service concession, as interpreted
in HM Treasury's FReM, are accounted for as "onStatement of Financial Position" by the Trust.
The annual unitary payment is separated into the
following component parts, using appropriate
estimation techniques where necessary:
a. Payment for the fair value of services
received;
b. Payment for the PFI asset, including finance
costs; and
c. Payment for the replacement of components
of the asset during the contract ‘lifecycle
replacement’.
Services received
The fair value of services received in the year
is recorded under the relevant expenditure
headings within ‘operating expenses’.
PFI Asset
The PFI assets are recognised as property, plant
and equipment, when they come into use.
The assets are measured initially at fair value
in accordance with the principles of IAS 17.
Subsequently, the assets are measured at fair
value, which is kept up to date in accordance with
the Trust’s approach for each relevant class of
asset in accordance with the principles of IAS 16.
An annual finance cost is calculated by applying
the implicit interest rate in the lease to the
opening lease liability for the period, and is
charged to ‘Finance Costs’ within the Statement
of Comprehensive Income.
The element of the annual unitary payment that
is allocated as a finance lease rental is applied to
meet the annual finance cost and to repay the
lease liability over the contract term.
An element of the annual unitary payment
increase due to cumulative indexation is
allocated to the finance lease. In accordance
with IAS 17, this amount is not included in
the minimum lease payments, but is instead
treated as contingent rent and is expensed as
incurred. In substance, this amount is a finance
cost in respect of the liability and the expense
is presented as a contingent finance cost in the
Statement of Comprehensive Income.
Lifecycle replacement
Components of the asset replaced by the
operator during the contract (‘lifecycle
replacement’) are capitalised where they meet
the Trust’s criteria for capital expenditure. They
are capitalised at the time they are provided by
the operator and are measured initially at their
fair value.
The element of the annual unitary payment
allocated to lifecycle replacement is predetermined for each year of the contract from
the operator’s planned programme of lifecycle
replacement. Where the lifecycle component is
provided earlier or later than expected, a shortterm finance lease liability or prepayment is
recognised respectively.
Where the fair value of the lifecycle component is
less than the amount determined in the contract,
the difference is recognised as an expense when
the replacement is provided. If the fair value
is greater than the amount determined in the
contract, the difference is treated as a ‘free’ asset
and a deferred income balance is recognised.
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The deferred income is released to the operating income over the shorter of the
remaining contract period or the useful economic life of the replacement component.
Assets contributed by the Trust to the operator for use in the scheme
Assets contributed for use in the scheme continue to be recognised as items of
property, plant and equipment in the Trust’s Statement of Financial Position.
Other assets contributed by the Trust to the operator
Assets contributed (e.g. cash payments, surplus property) by the Trust to the operator
before the asset is brought into use, which are intended to defray the operator’s
capital costs, are recognised initially as prepayments during the construction phase
of the contract. Subsequently, when the asset is made available to the Trust, the
prepayment is treated as an initial payment towards the finance lease liability and is
set against the carrying value of the liability.
A PFI liability is recognised at the same time as the PFI assets are recognised. It is
measured at the present value of the minimum lease payments, discounted using
the implicit interest rate. It is subsequently measured as a finance lease liability in
accordance with IAS 17.
1.13 Inventories
Inventories are valued at cost, by reference to supplier information on a first-in firstout basis. This is considered to be a reasonable approximation to fair value due to the
high turnover of inventory. Other than Pharmacy Stocks which are valued at current
cost which is not materially different from the lower of cost or net realisable value.
Provision is made for obsolete and defective stock whenever evidence exists that a
provision is required.
1.14 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 Trust’s
cash management.
1.15 Provisions
The NHS foundation trust recognises a provision where it has a present legal or
constructive obligation of uncertain timing or amount; for which it is probable that
there will be a future outflow of cash or other resources; and a reliable estimate
can be made of the amount. The amount recognised in the Statement of Financial
Position is the best estimate of the resources 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, except
for early retirement provisions and injury benefit provisions which both use the HM
Treasury's pension discount rate of 2.8 % (2010/11: 2.9%) in real terms.
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1.16 Clinical negligence costs
De-recognition
The NHS Litigation Authority (NHSLA) operates a
risk pooling scheme under which the Trust pays
an annual contribution to the NHSLA which in
return settles all clinical negligence claims. The
contribution is charged to expenditure. Although
the NHSLA is administratively responsible for
all clinical negligence cases the legal liability
remains with the Trust. The total value of clinical
negligence provisions carried by the NHSLA on
behalf of the Trust is disclosed at note 27 but
is not recognised in the NHS Foundation Trust's
accounts.
All financial assets are de-recognised when the
rights to receive cash flows from the assets have
expired or the Trust has transferred substantially
all of the risks and rewards of ownership.
1.17 Non-clinical risk pooling
Financial assets and financial liabilities at ‘fair
value through profit and loss’ are financial assets
or financial liabilities held for trading they are
subsequently recognised at amortised cost. A
financial asset or financial liability is classified
in this category if acquired principally for the
purpose of selling in the short-term. Derivatives
are also categorised as held for trading unless
they are designated as hedges. Derivatives
which are embedded in other contracts but
which are not ‘closely-related’ to those contracts
are separated-out from those contracts and
measured in this category. Assets and liabilities in
this category are classified as current assets and
current liabilities.
The Trust participates in the Property Expenses
Scheme and the Liabilities to Third Parties
Scheme. Both are risk pooling schemes under
which the 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 as and
when they become due.
1.18 Carbon reduction commitment
EU Emission Trading Scheme allowances are
accounted for as government grant funded
intangible assets if they are not expected to be
realised within twelve months, and otherwise
as other current assets. They are valued at open
market value. As the NHS body makes emissions,
a provision is recognised and is settled on
surrender of the allowances.
1.19 Financial instruments and financial
liabilities
Financial assets and financial liabilities which arise
from contracts for the purchase or sale of nonfinancial items (such as goods or services), which
are entered into in accordance with the Trust’s
normal purchase, sale or usage requirements,
are recognised when, and to the extent which,
performance occurs i.e. when receipt or delivery
of the goods or services is made.
Financial assets and financial liabilities are
recognised when the Trust becomes a party to
the contractual provisions of the instrument
Financial liabilities are de-recognised when the
obligation is discharged, cancelled or expires.
Classification and measurement
Financial assets are categorised as loans and
receivables. Financial liabilities are classified as
other financial liabilities.
These financial assets and financial liabilities are
recognised initially at fair value, with transaction
costs expensed through the comprehensive
statement of income.
Loans and receivables
Loans and receivables are non-derivative financial
assets with fixed or determinable payments
which are not quoted in an active market. They
are included in current assets.
The Trust’s loans and receivables comprise: cash
at bank and in hand, NHS receivables, accrued
income and ‘other receivables’.
Loans and receivables are recognised initially
at fair value, net of transactions costs, and are
measured subsequently at amortised cost, using
the effective interest method. The effective
interest rate is the rate that discounts exactly
estimated future cash receipts through the
expected life of the financial asset or, when
appropriate, a shorter period, to the net carrying
amount of the financial asset.
Annual Report and Accounts 2011 – 2012
185
Interest on loans and receivables is calculated using the effective interest method
and credited to the Statement of Comprehensive Income, except for short-term
receivables when the recognition of interest would be immaterial.
Other financial liabilities
All 'other' financial liabilities are recognised initially at fair value, net of transaction
costs incurred, and measured subsequently at amortised cost using the effective
interest method. The effective interest rate is the rate that discounts exactly estimated
future cash payments through the expected life of the financial liability or, when
appropriate, a shorter period, to the net carrying amount of the financial liability.
They are included in current liabilities except for amounts payable more than 12
months after the Statement of Financial Position date, which are classified as noncurrent liabilities.
Interest on financial liabilities carried at amortised cost is calculated using the
effective interest method and charged to the Statement of Comprehensive Income.
Impairment of financial assets
At the Statement of Financial Position date, the Trust assesses whether any financial
assets, other than those held at ‘fair value through profit and loss ’ is impaired.
Financial assets are impaired and impairment losses are recognised if, and only 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 and expenditure account and the
carrying amount of the asset is reduced through the use of an allowance account/
bad debt provision.
1.20 Value Added Tax (VAT)
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.
1.21 Corporation Tax
The Trust has reviewed its income generation schemes and no individual scheme
exceeds the threshold for Corporation Tax.
1.22 Foreign currencies
There were no foreign currency transactions.
1.23 Third party assets
Assets belonging to third parties (such as money held on behalf of patients) are not
recognised in the accounts since the Trust has no beneficial interest in them. Details
of third party assets are given in Note 34 to the accounts.
186
Annual Report and Accounts 2011 – 2012
1.24 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 cost of capital utilised
by the NHS Foundation Trust, is payable 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 during the
financial year. Relevant net assets are calculated
as the value of all assets less the value of all
liabilities, except for (i) donated assets, (ii)
net cash balances held with the Government
Banking Services and (iii) any PDC dividend
balance receivable or payable. In accordance
with the requirements laid down by the
Department of Health (as the issuer of PDC), the
dividend for the year is calculated on the actual
average relevant net assets as set out in the
‘pre-audit’ version of the annual accounts. The
dividend thus calculated is not revised should
any adjustment to net assets occur as a result of
the audit of the annual accounts.
1.25 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
that individual cases are handled.
1.26 Changes in Accounting Policy
The Foundation Trust Annual Reporting Manual
for 2011/12 brings a change in accounting
policy for accounting for government grants
and donated assets, as a result of a change in
HM Treasury’s Financial Reporting Manual. The
change in policy is in line with IAS 20.
Treatment of Grants Received
Government Grants are recognised in income
unless the funder imposes a condition on the
grant e.g. that it must be used to fund the
construction or acquisition of an asset. If there
are no conditions, or once all conditions have
been met, the grant is recognised in full within
income. If adopted, the impact is likely to be
an increase in volatility in annual results where
capital grants are received or released once
conditions have been met. When the change is
applied, existing government grants deferred
are likely to be released to the Income and
Expenditure Reserve
Donated Assets - The new approach for
donated assets
This is effectively the same as treatment of grants
received, above. Where donations are received
without conditions or where conditions have
been met, they should be recognised in income.
If brought into effect it would result in most,
or all, donations being reflected in income in
the year of receipt which could lead to greater
volatility in the annual result. The existing
donated asset reserve would be transferred to
the Income and Expenditure Reserve and, where
it includes an element of asset revaluation,to the
revaluation reserve.
The impact on the Trust has been the loss of the
Donated Asset Reserve from the 1st April 2010.
Losses and special payments are charged to the
relevant functional headings in expenditure on
an accruals basis, including losses which would
have been made good through insurance cover
had NHS Trusts not been bearing their own risks
(with insurance premiums then being included
as normal revenue expenditure). However, the
note on losses and special payments is compiled
directly from the losses and compensations
register which reports amounts on an accruals
basis with the exception of provisions for future
losses.
187
Annual Report and Accounts 2011 – 2012
1.27 Pension Costs
Past and present employees are covered by the provisions of the NHS Pensions
Scheme (the 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, general practices
and other bodies, allowed under the direction of Secretary of State, in England and
Wales. It is not possible for the Trust to identify its share of the underlying scheme
liabilities. Therefore, the scheme is accounted for as if it were a defined contribution
scheme: the cost to the Trust of participating in the scheme is taken as equal to the
contributions payable to the scheme for the accounting period.
Employers pension cost contributions are charged to operating expenses as and
when they become due.
188
Annual Report and Accounts 2011 – 2012
2. Operating segments
The Trust has determined that the Chief decision maker for the Trust is the Board of Directors, on that basis all strategic
decisions are made by the Board. No segmental information is presented to the Board of Directors so on that basis it has been
determined that there is only one business segment, that of Healthcare.
There are no differences between the figures reported to the Board in April 2011 and those included within these financial
statements.
The Trust conducts the majority of its business with Health Bodies in England. Transactions with entities in Scotland, Ireland
and Wales are conducted in the same manner as those within England.
3. Operating Income by classification
2011/12
2010/11
Total
Inter NHS
Foundation
Trust
Total
Inter NHS
Foundation
Trust
3.1 Income from activities*
£000
£000
£000
£000
Elective income
40,210
-
40,209
-
Non elective income
68,269
-
70,972
-
Outpatient income
32,225
-
32,889
-
7,899
-
8,881
-
59,152
221
51,982
144
A&E income
Other NHS clinical income
Community Trusts (and any Trusts providing Community Services)
Income from PCTs
28,508
-
31,594
-
1,319
5
1,098
13
140
-
126
-
2,312
-
2,938
-
240,034
226
240,689
158
350
2
398
398
7,014
-
7,729
-
333
-
243
-
-
-
-
-
22,490
3,533
13,415
3,836
4,299
318
4,616
-
46
-
2
-
Profit on disposal of other tangible fixed assets
-
-
2
-
Reversal of impairments of property, plant and
equipment
-
-
3,009
-
188
-
147
-
-
-
-
-
34,720
3,853
29,560
4,234
274,754
4,079
270,249
4,392
Income not from PCTs
All Trusts
Private patient income
Other non-protected clinical income
Total income from activities
Research and development
Education and training
Charitable and other contributions to expenditure
Transfer from
Non-patient care services to other bodies
Other
Profit on disposal of land and buildings
Rental revenue from operating leases
Income in respect of staff costs
Total other operating income
TOTAL OPERATING INCOME
189
Annual Report and Accounts 2011 – 2012
3.2 Revenue from patient care activities
2011/12
2010/11
£000
£000
226
158
-
-
897
314
235,411
237,151
909
1,314
-
-
10
2
140
126
NHS Injury Scheme
1,329
1,432
Non NHS: Other
1,112
191
240,034
240,689
350
398
7,014
7,729
333
243
22,490
13,415
4,299
4,616
46
2
Profit on disposal of other tangible fixed assets
-
2
Reversal of impairments of property, plant and
equipment
-
3,009
188
147
34,720
29,560
274,754
270,249
NHS Foundation trusts
NHS Trusts
Strategic Health Authorities
Primary Care Trusts
Local Authorities
Department of Health - Grants
Department of Health - Other
Non-NHS: Private Patients
Other Operating Revenue
Research and development
Education and training
Charitable and other contributions to expenditure
Non-patient care services to other bodies
Other
Profit on disposal of land and buildings
Rental revenue from operating leases
Total Operating Income
*All revenue from patient care activities is derived from mandatory services.
4. Analysis of other operating income
2011/12
2010/11
£000
£000
1,487
1,460
43
65
Staff accommodation rentals
116
138
Crèche services
665
628
Clinical tests
-
65
Clinical excellence awards
-
-
Catering
748
712
Property rentals
182
233
-
-
1,058
1,315
4,299
4,616
Car parking
Pharmacy sales
Grossing up consortium arrangements
Other
190
Annual Report and Accounts 2011 – 2012
5. Private patient income
2011/12
2010/11
£000
£000
140
126
240,034
240,689
Proportion (as a percentage)
0.06%
0.05%
Terms of authorisation
0.11%
0.11%
Private patient income
Total patient related income
Under the Terms of Authorisation the Trust must ensure that the proportion of private patient income to the total patient
related income should not exceed its proportion whilst the body was an NHS Trust in 2002/03 (the base year).
6. Operating Expenses
Services from NHS Foundation Trusts
Services from NHS Trusts
Services from PCTs
Services from other NHS Bodies
Purchase of healthcare from non NHS bodies
Employee Expenses - Executive directors
Employee Expenses - Non-executive directors
Employee Expenses - Staff
Drug costs
Supplies and services - clinical (excluding drug costs)
Supplies and services - general
Establishment
Research and development
Transport
Premises
Increase / (decrease) in provision for impairment of receivables
Depreciation on property, plant and equipment
Amortisation on intangible assets
Impairments of property, plant and equipment
Audit services- statutory audit
Audit services -regulatory reporting
Other services
Clinical negligence
(Profit)/ Loss on disposal of other property, plant and equipment
Legal fees
Consultancy costs
Training, courses and conferences
Patient Travel
Car parking & Security
Redundancy
Early Retirement
Hospitality
Publishing
Insurance
Losses, ex gratia and special payments
Other
2011/12
2010/11
£000
£000
30
1
427
153
1,233
135
180,155
17,105
25,761
4,198
3,866
22
1,087
10,552
632
5,575
111
20,211
52
31
255
4,808
362
1,757
1,007
1
1,477
3,712
1
1
106
37
663
151
1
338
307
1,225
133
183,756
14,868
25,369
3,972
3,934
997
10,461
175
5,256
88
675
58
28
251
4,366
39
329
2,464
761
1,222
674
2
102
32
580
285,525
262,614
Annual Report and Accounts 2011 – 2012
191
7. Auditors Remuneration
Statutory Audit Remuneration is £52k inclusive of irrecoverable VAT. Regulatory Audit reporting is in relation to the Audit of
the Annual Quality Report £31k. Other Services of £255k relate to the provision of internal audit costs.
The Trust approved the principal terms of engagement with its Auditors PricewaterhouseCoopers LLP. The terms on the
authorisation letter include a limit on their liability to pay for losses arising as a direct result of breach of contract damages or
negligence, of £1m.
8. Operating leases
8.1 As lessee
The Trust leases certain items of equipment where financial assessment has determined that leasing represents better value
than the outright purchase of the equipment. The majority of agreements are in relation to lease vehicles over a three year
lease period. Other agreements include the provision of medical equipment.
Arrangements containing an operating lease
2011/12
2010/11
£000
£000
Minimum lease payments
1,419
1,447
Total
1,419
1,447
2011/12
2010/11
£000
£000
- Not later than one year
1,342
1,391
- Between one and five years
2,813
3,075
259
276
4,414
4,742
Arrangements containing an operating lease
Future minimum payments due:
- After five years
Total
8.2 As lessor
The Trust receives rental income from a number of agreements in relation to the leasing of land and accommodation space.
No contingent rent is payable.
Operating lease income
2011/12
2010/11
£000
£000
Rents recognised as income in the period
188
149
Total rental revenue
188
149
- Not later than one year
186
129
- Between one and five years
252
149
8
11
446
289
Future minimum lease payments due
- After five years
Total
192
Annual Report and Accounts 2011 – 2012
9. Employee costs and numbers
9.1 Employee costs
2011/12
Total
£000
2010/11
Total
£000
Salaries and wages
149,578
151,823
Social Security Costs
10,973
10,967
- Employers contributions to NHS Pensions
16,045
16,576
-
-
Termination benefits
2,101
564
Agency/contract staff
6,404
5,725
185,101
185,655
2011/12
Contracted
Number
2010/11
Contracted
Number
461
458
-
-
Pension Cost - other contributions
Employee benefits expense
9.2 Average number of people employed
Medical and dental
Ambulance staff
Administration and estates
925
974
Healthcare assistants and other support staff
1,044
1,151
Nursing, midwifery and health visiting staff
1,491
1,518
-
-
727
720
4,648
4,821
Nursing, midwifery and health visiting learners
Scientific, therapeutic and technical staff
Total
9.3 Employee benefits
There were no employee benefits paid in the year ended 31 March 2012.
9.4 Senior staff remuneration
Full details of senior staff remuneration can be found in the annual report.
9.5 Staff exit packages
The Trust initiated a management restructure in 2011/12 and also offered employee’s the opportunity for voluntary severance.
The amounts agreed but not yet paid are highlighted below.
Exit Package Cost Band
Number of
compulsory
redundancies
Number
of other
departures
agreed
Total number
of exit
packages by
cost band
0 - 10,000
1
-
1
10,000 - 25,000
8
-
8
25,001 - 50,000
5
-
5
50,001 - 100,000
8
-
8
100,001 - 150,000
5
-
5
150,001 - 200,000
-
-
-
27
-
27
Total number of exit packages by type
Total Resource Cost £000
1,633
1,633
193
Annual Report and Accounts 2011 – 2012
9.6 Senior staff remuneration
For a full analysis of senior staff remuneration please refer to the Trust’s Annual Report.
Basic Salary & Allowances £
Other
Total
Remuneration Remuneration
£
£
148,715
1,110,179
Benefits
in Kind
£
17,513.0
No compensation has been paid to senior manager for the loss of office.
The Trust is required to disclose the median remuneration of the Trust's staff and the ratio between this and the mid-point of
the banded remuneration of the highest paid Director. The calculation is based on full-time equivalent staff of the reporting
entity at the reporting period end date on an annualised basis. The median remuneration of all Trust staff is £22,700 and the
ratio between this and the mid-point of the banded remuneration of the highest paid director is a ratio of 10 to the highest
paid Director £236k.
10. Retirements due to ill-health
During 2011/12 there were seven 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 £459K. The cost of these ill-health retirements
will be borne by the NHS Business Services Authority - Pensions Division.
11. Investment revenue
The Trust received no revenue from investments.
12. Other gains and losses
2011/12
£000
2010/11
£000
46
2
-
2
46
4
2011/12
£000
2010/11
£000
Interest on bank accounts
151
101
Total
151
101
2011/12
£000
2010/11
£000
120
108
53
40
173
148
2011/12
£000
2010/11
£000
Profit on disposal of land and buildings
Profit on disposal of other tangible fixed assets
Total
13. Finance income
14. Finance Costs - interest expense
Finance costs in PFI obligations
Main finance costs
Contingent finance costs
Total
14a. Impairment of assets (PPE & intangibles)
194
Loss or damage from normal operations
-
675
Reversal of impairment
-
(3,009)
Changes in market price
20,211
-
Total impairments
20,211
(2,334)
Annual Report and Accounts 2011 – 2012
15. Property, plant and equipment 2011/12
Total
£000
Transport
Land Buildings Dwellings Plant and
£000 excluding
£000 machinery equipment
£000
£000
dwellings
£000
IT
£000
Furniture
& fittings
£000
Valuation/Gross cost at 1 April
2011 - as previously stated
299,360
14,743
226,816
921
34,907
1,319
16,490
4,164
Valuation/Gross cost at
1 April 2011 - restated
299,360 14,743
226,816
921
34,907
1,319
16,490
4,164
Additions - purchased
5,107
-
1,697
8
2,520
33
734
115
310
-
-
-
305
-
-
5
Additions - government granted
-
-
-
-
-
-
-
-
Impairments
-
-
-
-
-
-
-
-
Reversal of impairments
-
-
-
-
-
-
-
-
(25)
-
(208)
1
25
-
(63)
220
Reclassified as held for sale
-
-
-
-
-
-
-
-
Revaluations
-
-
-
-
-
-
-
-
Transferred to disposal group as
asset held for sale
-
-
-
-
-
-
-
-
(2,122)
-
-
-
(1,297)
(303)
(489)
(33)
Valuation/Gross cost at
31 March 2012
302,630 14,743
228,305
930
36,460
1,049
16,672
4,471
Accumulated depreciation at
1 April 2011 - restated
179,963
4,413
137,584
532
21,552
1,122
12,473
2,287
5,575
-
1,599
6
2,322
66
1,328
254
20,211
(1)
20,210
2
-
-
-
-
-
-
-
-
-
-
-
-
(22)
-
(64)
-
44
-
(65)
63
Reclassified as held for sale
-
-
-
-
-
-
-
-
Revaluation surpluses
-
-
-
-
-
-
-
-
Transferred to disposal group as
asset held for sale
-
-
-
-
-
-
-
-
(2,110)
-
-
-
(1,305)
(298)
(475)
(32)
203,617
4,412
159,329
540
22,613
890
13,261
2,572
96,675
10,324
68,803
390
11,954
159
3,395
1,650
690
-
-
-
690
-
-
-
1,648
7
173
-
1,203
-
16
249
99,014 10,331
68,976
390
13,848
159
3,411
1,899
Additions - donated
Reclassifications
Disposals
Depreciation at start of period for
new FTs
Provided during the year
Impairments*
Reversal of impairments
Reclassifications
Disposals
Depreciation at 31 March 2012
0
Net book value
NBV - Owned at 31 March 2012
NBV - Finance Lease at
31 March 2012
NBV - Donated at 31 March 2012
NBV total at 1 April 2012
* Impairments - During 2011/12, following the revaluation of the Trusts Buildings and Land by the District Valuer an impairment took place which has
been charged to the Statement of Comprehensive Income.
195
Annual Report and Accounts 2011 – 2012
15. Property, plant and equipment 2010/11
Total
£000
Transport
Land Buildings Dwellings Plant and
£000 excluding
£000 machinery equipment
£000
£000
dwellings
£000
IT
£000
Furniture
& fittings
£000
Cost or valuation at 1 April 2010
297,466
9,802
230,758
915
34,284
1,287
16,248
4,172
Valuation/Gross cost at
1 April 2011 - restated
297,466
9,802
230,758
915
34,284
1,287
16,248
4,172
11,900
4,935
2,348
-
3,263
18
1,256
80
243
-
21
-
195
-
15
12
Acquisition through business
combination
-
-
-
-
-
-
-
-
Impairments
-
6
-
-
(6)
-
-
-
Reclassifications
-
-
(46)
-
20
29
22
(25)
Revaluation surpluses
-
-
-
-
-
-
-
-
14
-
8
6
-
-
-
-
-
-
0
-
-
-
-
-
Disposals
(10,263)
-
(6,273)
-
(2,849)
(15)
(1,051)
(75)
Cost or valuation at
31 March 2011
299,360 14,743
226,816
921
34,907
1,319
16,490
4,164
Accumulated depreciation at
1 April 2010
187,249
4,413
145,433
526
21,585
1,071
12,117
2,104
-
-
-
-
-
-
-
-
187,249
4,413
145,433
526
21,585
1,071
12,117
2,104
5,256
-
1,475
6
2,045
65
1,407
258
675
-
(42)
-
717
-
-
-
(3,009)
-
(3,009)
-
(1)
1
-
-
Disposals
(10,208)
-
(6,273)
-
(2,794)
(15)
(1,051)
(75)
Depreciation at 31 March 2011
179,963
4,413
137,584
532
21,552
1,122
12,473
2,287
116,973
10,325
88,812
389
11,482
197
3,990
1,779
-
-
-
-
-
-
-
-
795
-
-
-
795
-
-
-
1,628
5
420
-
1,079
-
27
98
119,397 10,330
89,232
389
13,356
197
4,017
1,877
Additions purchased
Additions donated
Revaluations
Transferred to disposal group as
asset held for sale
Prior period adjustment
Accumulated depreciation at
1 April 2010 - restated
Provided during the year
Impairments charged to Operating
Expenses
Reversal of Impairments
Net book value
NBV - Owned at 31 March 2011
NBV - Finance Lease at
31 March 2011
NBV - PFI at 31 March 2011
NBV - Donated at 31 March 2011
NBV total at 1 April 2011
196
Annual Report and Accounts 2011 – 2012
15.1 Economic life of property, plant and equipment
Min. Life Years
Max. Life Years
infinite
infinite
Buildings excluding dwellings
40
90
Dwellings
80
80
Plant and machinery
7
15
Transport equipment
7
7
Information technology
7
8
Furniture & fittings
7
12
Land
Land and buildings have been valued using the Modern Equivalent valuation methodology as at 31 March 2012 by the District Valuer.
15.2 Analysis of Tangible Fixed Assets
Total
£000
Land
£000
Buildings
excluding
dwellings
£000
Dwellings
£000
Plant and
Transport
Machinery equipment
£000
£000
IT
Furniture
£000 and Fittings
£000
Protected assets
69,594
8,588
61,006
-
-
-
-
-
Unprotected assets
29,420
1,743
7,970
390
13,848
159
3,411
1,899
Total
99,013
10,331
68,976
390
13,848
159
3,411
1,899
Protected assets are those which are required for the provision of mandatory goods and services, as set out in the Trusts Terms of
Authorisation. Assets which are protected cannot be disposed of without the approval of Monitor.
15.3 Economic life of property, plant and equipment
Donated additions of £331k relate to the purchase of the medical equipment through the Trust's Charitable Funds. There are no conditions or
restrictions attached to the assets.
16. Intangible assets
2011/12
Software licences
(purchased) £000
2010/11
Software licences
(purchased) £000
1,215
944
Reclassifications*
25
-
Additions purchased
32
271
-
-
Gross cost or valuation at 1 April
Additions donated
Transferred to disposal group as asset held for sale
-
-
(114)
(1)
Gross cost at 31 March
1,158
1,215
Amortisation at 1 April
781
693
Provided during the year
111
88
22
-
(114)
-
800
781
NBV - Purchased at 31 March
-
434
NBV - Finance leases at 31 March 2012
-
-
358
-
358
434
Disposals
Reclassifications
Disposals
Amortisation at 31 March
Net book value
NBV - Donated at 31 March
NBV total at 31 March
* = the reclassification relates to IT assets
16.1 Economic life of intangible assets
Min. Life Years
Intangible assets - purchased
Software
7
Annual Report and Accounts 2011 – 2012
197
17. Capital commitments
Contracted capital commitments at 31 March not otherwise included in these financial statements:
Property, plant and equipment
Intangible assets
Total
2011/12
£000
2010/11
£000
800
680
-
-
800
680
18. Inventories
Drugs
31 March
2012
31 March
2011
31 March
2010
£000
£000
£000
1,245
1,132
1,023
Work in progress
-
-
-
6,113
4,908
3,672
Energy
-
-
-
Inventories carried at fair value less costs to sell
-
-
-
Other
-
-
-
Total
7,358
6,040
4,695
Consumables
There is no material difference between the Statement of Financial Position value of stocks and their replacement cost. Inventories recognised as an
expense £47,064k in 2011/12 and £44,029 in 2010/11.
19. Trade and other receivables
19.1 Trade and other receivables
NHS Receivables - Revenue
NHS Receivables - Capital
Other receivables with related parties - Revenue
Other receivables with related parties - Capital
Provision for impaired receivables
Deposits and Advances
Current
Non-current
31 March
2012
31 March
2011
31 March
2010
31 March
2012
31 March
2011
31 March
2010
£000
£000
£000
£000
£000
£000
2,168
1,600
4,344
-
-
-
-
-
-
-
-
-
2,512
1,528
1,275
-
1,003
1,025
-
-
-
-
-
-
(892)
(362)
(205)
-
-
-
-
-
-
-
-
-
2,558
2,405
1,203
-
-
-
PFI Prepayments
-
-
-
-
-
-
Prepayments - Capital contributions
-
-
-
-
-
-
Prepayments - Lifecycle replacements
-
-
-
-
-
-
1,066
1,779
1,261
-
-
-
Interest Receivable
-
-
-
-
-
-
Corporation tax receivable
-
-
-
-
-
-
Finance Lease Receivables
-
-
-
-
-
-
Operating lease receivables
-
-
155
-
-
-
PDC receivable
259
215
599
-
-
-
VAT receivable
238
79
239
-
-
-
Other receivable
876
430
657
-
-
8,785
7,674
9,528
-
1,003
Prepayments (Non-PFI)
Accrued income
Total
The great majority 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.
198
Annual Report and Accounts 2011 – 2012
1,025
19.2 Analysis of impaired receivables
31 March
2012
31 March
2011
1 April 2010
Restated
£000
£000
£000
0 - 30 days
451
100
-
30 - 60 Days
40
22
-
60 - 90 days
34
12
18
90 - 180 days
181
18
-
180 - 360 days
186
210
187
Total
892
362
205
0 - 30 days
1,301
1,074
2,162
30 - 60 Days
1,309
269
323
60 - 90 days
84
22
156
90 - 180 days
33
254
519
180 - 360 days
252
310
1,429
2,979
1,929
4,589
31 March
2012
31 March
2011
31 March
2010
£000
£000
£000
At 1 April
362
205
285
Increase in provision
632
187
24
(102)
(18)
(104)
-
(12)
-
892
362
205
Ageing of impaired receivables
Ageing of non-impaired receivables past their due date
Total
20. Provision for impairment of receivables
Amounts utilised
Unused amounts reversed
Balance at 31 March
Included in the above is an amount of £263k in 2011/12 relating to the Injury Cost Recovery Scheme which is classified as a non-financial asset.
21. Cash and cash equivalents
31 March
2012
31 March
2011
31 March
2010
£000
£000
£000
Balance at 1 April
30,315
19,956
19,439
Net change in year
4,763
10,359
517
35,078
30,315
19,956
Cash at commercial banks and cash in hand
149
1,565
2,069
Cash with the Government Banking Service
34,929
28,750
17,887
Cash and cash equivalents as in statement of financial position
35,078
30,315
19,956
Cash and cash equivalents as in statement of financial position
and statement of cash flows
35,078
30,315
19,956
Balance at 31 March
Made up of
199
Annual Report and Accounts 2011 – 2012
22. Trade and other payables
Current
Non-current
31 March
2012
31 March
2011
31 March
2010
31 March
2012
31 March
2011
31 March
2010
£000
£000
£000
£000
£000
£000
Receipts in advance
-
-
-
-
-
-
NHS payables - capital
-
-
-
-
-
-
460
2,299
2,531
-
-
-
1,916
2,090
2,078
-
-
-
407
937
823
-
-
-
2,472
2,765
2,216
-
-
-
-
-
-
-
-
-
Other payables
3,818
3,683
3,637
-
375
413
Accruals
7,330
6,516
6,665
-
-
-
16,453
18,290
17,950
-
375
413
NHS payables - revenue
Amounts due to other related parties - revenue
Other trade payables - capital
Other trade payables - revenue
Other taxes payable
Total
23. Borrowings
Current
31 March 31 March
2012
2011
Non-current
1 April 31 March 31 March
2010
2012
2011
Restated
1 April
2010
Restated
£000
£000
£000
£000
£000
£000
Other Loans
152
56
-
197
139
-
Obligations under Private Finance Initiative
contracts
122
109
96
904
1,048
1,156
274
165
96
1,101
1,187
1,156
24. Other liabilities
Current
Non-current
31 March
2012
31 March
2011
31 March
2010
31 March
2012
31 March
2011
31 March
2010
£000
£000
£000
£000
£000
£000
-
-
-
11,148
11,148
5,000
Deferred income
1,685
2,712
1,752
2,029
-
-
Total other liabilities
1,685
2,712
1,752
13,177
11,148
5,000
Deferred Government Grant
25. Finance lease obligations
The Trust did not enter into any contracts to lease any asset that falls within the definition of a Finance Lease during the year to 31 March 2012.
26. Prudential Borrowing Limit
The Trust had a maximum amount of long term borrowing of £44.3m. The following borrowings score against the Trusts limit, a PFI energy plant
that came on the Statement of Financial Position as part of the IFRS transition in 2008/09 and an interest free loan in this financial year for the
purchase of energy lighting for £180K (£223k 2010/11). The Trust has a £14m (£16m 2010/11) working capital facility. The Trust had drawn down
none of its working capital facility at 31st March 2012.
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Annual Report and Accounts 2011 – 2012
27. Private Finance Initiative contracts
27.1 PFI schemes off-Statement of Financial Position
The Trust has not entered into any PFI schemes that are classed as off Statement of Financial Position.
27.2 PFI schemes on-Statement of Financial Position
The scheme was for the redevelopment of the Energy Plant at the University Hospital of Hartlepool. The plant was commissioned in November
2002 and expires in November 2017. The agreement is with Dalkia Utilities and the service they provide is that of energy. At the end of the 15 year
agreement, the asset reverts to the Trust.
Under IFRIC 12, the plant is treated as an asset of the Trust.
Total obligations for on-statement of financial position PFI contracts due:
31 March
2012
31 March
2011
1 April
2010
£000
£000
£000
1,352
1,554
1,758
Not later than one year
203
203
203
Later than one year, not later than five years
811
812
812
Later than five years
338
539
743
(326)
(398)
(506)
1,026
1,157
1,252
85
105
104
Later than one year, not later than five years
621
567
532
Later than five years
320
485
624
1,026
1,157
1,260
Gross PFI liabilities
Of which liabilities are due
Finance charges allocated to future periods
Net PFI liabilities
Not later than one year
Total
The Trust is committed to make the following payments for on-SoFP PFI obligations during the next year in which the commitment expires.
Within one year
288
244
240
2nd to 5th years
1,152
1,004
958
6th to 10th years
475
648
858
201
Annual Report and Accounts 2011 – 2012
28. Provisions for liabilities and charges
Total
Pensions relating to former directors
Pensions relating to other staff
Current
Non-current
31 March
2012
31 March
2012
31 March
2011
31 March
2012
31 March
2011
£000
£000
£000
£000
£000
-
-
-
-
-
-
-
-
-
-
Other legal claims
817
84
82
733
731
Agenda for Change
746
277
317
469
356
Restructurings
-
-
-
-
-
Continuing care
-
-
-
-
-
Equal pay
-
-
-
-
-
1,633
1,633
447
-
-
Other
95
95
36
-
470
Total
3,291
2,089
882
1,202
1,556
Total
Pensions other staff
Other legal Redundancy
claims
Other
£000
£000
£000
£000
£000
2,439
813
673
446
507
0
-
-
-
-
Redundancy
At 1 April 2011
Change in the discount rate
Arising during the year
2,003
65
285
1,633
20
Utilised during the year
(657)
(82)
(223)
(316)
(36)
Reversed unused
(533)
-
(399)
(132)
(2)
39
23
-
-
16
3,291
819
336
1,631
505
2,086
84
277
1,631
95
- later than one year and not later than five years
806
336
-
-
470
- later than five years
399
399
59
-
(60)
3,291
819
336
1,631
505
Unwinding of discount
At 31 March 2012
Expected timing of cash flows:
- not later than one year
Total
The amounts and timings of cashflows are based upon advice from the NHS Litigation Authority and the NHS Pensions Agency.
Included in the ‘other’ category and arising during the period are provisions for injury benefits of £503k of which £53k are current and £450k are
non current; redundancy of £1,633k all included within current.
Legal Claims - based upon professional assessments, which are uncertain to the extent that they are an estimate of the likely outcome of individual
cases. Due dates of settlement of claims are based upon estimates supplied by the NHS Litigation Authority and/or Legal Advisers.
Redundancy - during 2011/12 the Trust initiated a management structure review and this resulted in a reduction of established posts in the
organisation. As at 31st March a provision has been included of £1,631k to reflect redundancy payments outstanding.
The Trust has an insurance arrangement through the NHS Litigation Authority in respect of clinical negligence, with liabilities covered by an annual
insurance premium payment. Excluded from this note therefore is a sum of £33.3m (2010/11 £29.9m) which is included within the provisions of the
NHS Litigation Authority in respect of clinical negligence liabilities of the Trust.
29 Contingencies
29.1 Contingent liabilities
Legal Claims
Equal pay cases
Total
2011/12
2010/11
£000
£000
133
124
0
361
133
485
The Trust, like many NHS organisations, received notification from a number of employees (117) for equal pay claims. During 2011/12 the cases have
been withdrawn. The amount recorded for Legal claims is based on data from the NHS Litigation Authority.
202
Annual Report and Accounts 2011 – 2012
30. Financial instruments
30.1 Financial assets by category
Assets as per SoFP
Loans and receivables
£000
2011/12
Embedded derivatives
-
NHS Trade and other receivables excluding non financial assets
2,479
Non-NHS Trade and other receivables excluding non financial assets
4,380
Other Investments
Cash and cash equivalents at bank and in hand
35,078
Total at 31 March 2012
41,937
2010/11
Embedded derivatives
-
NHS Trade and other receivables excluding non financial assets
1,600
Non-NHS Trade and other receivables excluding non financial assets
4,457
Cash and cash equivalents (at bank and in hand)
30,315
Total at 31 March 2011
36,372
30.2 Financial liabilities
2011/12
Borrowings excluding Finance lease and PFI liabilities
Obligations under finance leases
NHS Trade and other payables excluding non financial assets
Other financial liabilities
£000
349
1,026
460
Non-NHS Trade and other payables excluding non financial assets
15,993
Total at 31 March 2012
17,828
2010/11
Embedded derivatives
Borrowings excluding Finance lease and PFI liabilities
Obligations under finance leases
195
-
Obligations under Private Finance Initiative contracts
1,157
NHS Trade and other payables excluding non financial assets
2,299
Non-NHS Trade and other payables excluding non financial assets
Other financial liabilities
Provisions under contract
Total at 31 March 2011
16,366
2,439
22,456
There is no material difference between the book and market value of each financial asset or liability.
203
Annual Report and Accounts 2011 – 2012
31. 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 Foundation 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.
Credit risk
Because the majority of the Trust’s income comes from contracts with other public
sector bodies, the trust has low exposure to credit risk. The maximum exposures as
at 31 March 2012 are in receivables from customers, as disclosed in the Trade and
other receivables note.
Liquidity risk
The Trust’s operating costs are incurred under contracts with primary care trusts,
which are financed from resources voted annually by Parliament. The trust funds its
capital expenditure from funds obtained within its prudential borrowing limit. The
trust is not, therefore, exposed to significant liquidity risks..
32. Events after the reporting period
There were no post Statement of Financial Position events having a material effect on
the financial statements.
204
Annual Report and Accounts 2011 – 2012
33. Calculation of dividend paid on Public
Dividend capital
From 2010/11 the dividend payable on public
dividend capital is based on the actual (rather
than forecast) average relevant net assets and
therefore the actual capital cost absorption rate
is automatically 3.5%.
34. Related party transactions
During the year some of the Trust board
members or members of the key management
staff, or parties related to any of them, has
undertaken any material transactions with North
Tees and Hartlepool NHS Foundation Trust.
Details of related party transactions with
individuals are as follows:
Payments
to Related
Party
Receipts
from
Related
Party
Amounts
owed to
Related
Party
Amounts
due from
Related
Party
£
£
£
£
1,028,841
372,703
-
11,139
-
-
-
189
Mrs Rita Taylor
Consultant for Hartlepool Youth Offender Service
(Hosted by Hartlepool Borough Council )*
634,953
206,964
-
46,266
Mr Paul Garvin
Family member employed by Ward Hadaway
(Trust’s legal advisors)
220,727
-
-
-
Mr Alan Foster
Family member employed by Beechcroft LLP
(Trust’s legal advisors)
92,854
-
-
-
648,319
-
-
-
Mr Kenneth Lupton
Councillor Leader for Stockton-on-Tees Borough Council
Mr Michael Bretherick
Principal of Hartlepool College of Further Education
Mr Kevin Oxley
Family member employed by Turner and Townsend
(Trust’s Momentum advisors)
* The expenditure relates to the totality of expenditure with Hartlepool Borough Council.
The Department of Health is regarded as a related party. During the year North Tees and Hartlepool
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:
North East Strategic Health Authority
Stockton on Tees Teaching PCT
Hartlepool PCT
County Durham PCT
The NHS Litigation Authority
NHS Buying Solutions - Health
Other Health Authorities and NHS Trusts
The amounts and timings of cashflows are based upon advice from the NHS Litigation Authority and
the NHS Pensions Agency.
The Trust has also received revenue and capital payments from a number of charitable funds, certain of
the trustees for which are also members of the NHS Foundation Trust Board.
The audited accounts/the summary financial statements of the Funds Held on Trust are included in this
annual report and accounts.
Annual Report and Accounts 2011 – 2012
205
35. Third Party Assets
The Trust held £7,265 cash and cash equivalents at 31 March 2012. 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 beneficial interest in them.
36. Losses and Special Payments
NHS Foundation Trusts are required to report to the Department of Health any losses
or special payments, as the Department still retains responsibility for reporting these
to Parliament.
By their very nature such payments should not arise, and they are therefore subject
to special control procedures compared to payments made in the normal course of
business.
There were 140 cases in the year to 31 March 2012 at a value of £37k.
37. 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 2012/13. The expected impact on
the Trust’s financial statements has not yet been considered.
Change published
IFRS 7 Financial
Instruments:
Disclosures - amendment
Transfers of financial assets
IFRS 9 Financial Instruments
Financial Assets:
Financial Liabilities:
IAS 12 Income Taxes
amendment
206
Annual Report and Accounts 2011 – 2012
Published
by IASB
Financial year for which the
change first applies
October 2010
Effective date of 2012/13 but not yet adopted
by the EU.
November 2009
October 2010
Uncertain. Not likely to be adopted by the
EU until the IASB has finished the rest of its
financial instruments project.
December 2010
Effective date of 2012/13 but not yet adopted
by the EU.
14.10 Going Concern
14.11 External Auditors
The Trust’s business activities, together with the
factors likely to affect its future development,
performance and position are set out in the
operational review on pages 30-39.
Price Waterhouse Coopers were appointed
as the Trust’s auditors in accordance with
their appointment approved by the Council
of Governors on 16 September 2010 and
subsequently ratified by the Board of Directors
on 30 September 2010.
The financial position of the Trust, its cash
flows, liquidity position and borrowing facilities
are covered in the Finance Director’s Review
on pages 14-29. In addition, the notes to the
financial statements provide further information
regarding the Trust’s accounting policies and
processes.
The Trust has used robust forecast information
for inflation and has demonstrated in setting its
plans for 2012/13 that there is sufficient financial
resources supported by a three year rolling
contracts with its commissioners that cover over
89% of the Trust’s activities. As a consequence
of the above and after making due 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 annual financial statements.
As far as the Directors are aware there is no
relevant information of which the auditors are
unaware.
The Directors have taken all the required steps
to make themselves aware of any relevant audit
information, and to establish that the auditors
are aware of it.
The Auditors are part of a strategic partnership
with the Durham and Tees Audit Consortia. The
Audit Committee have processes in place to
ensure there are no conflicts of interest arising
from this relationship and can confirm that the
auditors performed no work for the trust outside
of the core areas of the audit code.
A full set of accounts are available to view on the
Trust website: www.nth.nhs.uk or copies can be
obtained by contacting:
Lynne Hodsgon
Director of Finance, Information and Technology
North Tees and Hartlepool NHS Foundation Trust
University Hospital of North Tees
Hardwick
Stockton
TS19 8PE
email: membership@nth.nhs.uk
207
Annual Report and Accounts 2011 – 2012
15. Contact
Information
208
Specialist nurse for cardiac services Deborah De Garis.
Chief Executive
Alan Foster, Chief Executive
Tel: 01642 617617
Email: communications@nth.nhs.uk
Patient Advice and Liaison Services (PALS) University Hospital of North Tees
If you would like information, support or advice about the Trust’s services at the University Hospital of
North Tees, contact:
PALS
Tel: 01642 624719 or 0800 0920084
Email: PALS.NT@nth.nhs.uk
Patient Advice and Liaison Services (PALS) University Hospital of Hartlepool
If you would like information, support or advice about the Trust’s services at the University Hospital of
Hartlepool, contact:
PALS
Tel:01429 522874 or 0800 0920322
Email: PALS.HP@nth.nhs.uk
Membership
If you would like to become a member of our NHS Foundation Trust, contact:
Tel:01642 383765
Email: membership@nth.nhs.uk
Recruitment
If you are interested in becoming a member of staff at North Tees and Hartlepool NHS Foundation
Trust, contact:
Tel: 01642 624023
Email: Trust.recruitment@nth.nhs.co.uk
Further Information
If you have a media enquiry or require further information, contact:
Tel: 01642 624339
Email: communications@nth.nhs.uk
www.nth.nhs.uk
209
Annual Report and Accounts 2011 – 2012
North Tees and Hartlepool
NHS Foundation Trust
Annual Report and Accounts 2011 – 2012
www.nth.nhs.uk