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Annual Report and Accounts 2012/13 Annual Report and Accounts 2012/13 Contents 02 Who we are 16 Quality Account 03 Facts about The Royal Marsden 18 Statement on quality from the Chief Executive 04 Chairman and Chief Executive statement 20 Priorities for improvement 06 What we do 55 Statements of assurance from the Board 06 Research 61 Review of quality performance 07 Diagnosis 74 08 Treatment and care 78 Our workforce 10 Education and regulation 82 Statement of approach to staff engagement 11 Our staff 85 Governance and membership 15 Charity 88 Our Board of Directors 91 Sustainability/climate change report The work of the Board 94 The Management Executive 95 Regulatory Ratings Report 96 Directors’ Report 97 Remuneration report 99 Financial Review for the year ended 31 March 2013 102 Annual Accounts for the year ended 31 March 2013 1 The Royal Marsden NHS Foundation Trust Who we are The Royal Marsden NHS Foundation Trust is a world-leading cancer centre specialising in cancer diagnosis, treatment, research and education. Our academic partnership with The Institute of Cancer Research (ICR) makes us the largest comprehensive cancer centre in Europe with a combined staff of 4,300. Through this partnership, we undertake ground-breaking research into new cancer drug therapies and treatments. We have two hospitals: one in Chelsea, London, and another in Sutton, Surrey. Also in Surrey, we have a Chemotherapy Medical Daycare Unit at Kingston Hospital and an academic partnership with the Mount Vernon Cancer Centre. This partnership enhances our research programmes and our contribution to the NHS in finding new and better ways to treat patients diagnosed with cancer. We also provide Sutton and Merton Community Services. Since April 2011 The Royal Marsden has managed a range of community services, and together we are ensuring that treatment and care is of the highest quality and seamless between hospital and home environments. The Royal Marsden was founded in 1851 by William Marsden. His vision was to create a pioneering cancer hospital dedicated to excellence in the study, treatment and care of people with cancer. Today we continue to build on this legacy, constantly raising standards to improve the lives of the 50,000 cancer patients from across the UK and abroad that we see each year. 2 Annual Report and Accounts 2012/13 Facts about The Royal Marsden The Royal Marsden was the first hospital in the world dedicated to cancer when it opened in 1851. Its founder, William Marsden, had a vision to create a pioneering cancer hospital dedicated to the treatment and care of people with cancer and research into the underlying causes of cancer. 1. This year, we celebrated nine years as an NHS Foundation Trust. We were one of the first hospitals to be awarded this status in April 2004. 2. The Royal Marsden has been rated as one of the top performing trusts in the country in the 2012 Picker Inpatient and Outpatient Surveys. For the fifth year in a row The Royal Marsden has been rated as excellent by the Patient Environment Action Team (PEAT) following an inspection. The PEAT scored the Trust as “excellent” for overall hospital environment, levels of privacy and dignity given to patients, and quality of food. The Trust’s levels of cleanliness and infection prevention and control rates were also rated as “excellent”. 3. We have a Medical Day Unit at Kingston Hospital. The William Rous Unit was created in partnership with Kingston Hospital and Macmillan Cancer Support, and aims to provide the very best in cancer treatment to patients closer to their homes. 4. We have academic partnerships with The Institute of Cancer Research (ICR) and Mount Vernon Cancer Centre. These relationships strengthen our ‘bench-to-bedside’ approach, enabling the research and development of new cancer drugs and new imaging and radiotherapy techniques. They also allow us to combine our expert teams of scientists and clinicians to give the best care to our patients. 6. Our Drug Development Unit, rated “outstanding” by Cancer Research UK, has had major breakthroughs in the treatment of advanced melanoma and prostate cancer. Thirty phase 1 drug trials have taken place in the hospital this year. The Royal Marsden also has the largest paediatric inpatient drug development programme in the UK. 7. We are a technology and research hub for part of the Cancer Research UK Stratified Medicine Programme. This is a ground-breaking national project which aims to establish a world-class NHS genetic testing service in the UK. This means that as and when new targeted treatments become available, doctors will have access to the tests they need to help them decide which drugs are best for their patients. 8. We opened our new £18.2 million Centre for Molecular Pathology (CMP) in Sutton in November 2012. The CMP is a state-ofthe-art facility dedicated to the research of personalised cancer treatment, bringing together clinicians, geneticists, pathologists and scientists from The Royal Marsden and the ICR under one roof for the first time and accelerating our work to improve treatment and a cure for patients with cancer. 9. In the past year, The Royal Marsden School has educated over 700 nurses and allied health professionals across the UK. 10. The Royal Marsden, along with 16 other NHS Trusts across west and south London, and the ICR, is part of the London Cancer Alliance (LCA). The LCA aims to develop more integrated pathways of care for patients, set the direction for improvements in patient experience and outcomes and develop common data sets to assess our performance. 5. The Royal Marsden took over responsibility for providing Sutton and Merton Community Services in April 2011. These services include health visiting, specialist community nursing, outpatient physiotherapy, podiatry, a falls service and children’s physiotherapy, all in the Sutton and Merton area. 3 The Royal Marsden NHS Foundation Trust Chairman and Chief Executive joint statement The Royal Marsden has a vital role in championing change and improvement in cancer care through research and innovation, education and leading-edge practice. Together with The Institute of Cancer Research (ICR), we form the largest comprehensive cancer centre in Europe, offering expert treatment supported by highquality research. Since 2011, The Royal Marsden has also been responsible for providing community services in Sutton and Merton. This has helped us to find better ways of providing care between hospital and home to ensure patients receive the highest standards of treatment and the best possible patient experience. During the year, we continued our work on precision medicine, tailoring treatment plans to individual needs. This is a core focus of our benchto-bedside principle, ensuring that our patients receive the treatment and care which is most appropriate to them and maximising the clinical translation of our research. An example of this is the opening of the Centre for Molecular Pathology on our Sutton site to accelerate our work in finding better ways of diagnosing and treating cancer. The centre was opened by Professor Dame Sally Davies, Chief Medical Officer for England, in November 2012 and brings clinicians, pathologists and scientists together under one roof for the first time to advance cancer research and treatment. Working side by side, experts will be able to better understand each patient’s individual tumour type and develop personalised and effective treatment plans, making our vision of personalised medicine a reality and speeding up the research and treatment development process. We will be opening a new clinical research facility in 2013, the West Wing, which will provide a dedicated space and a central facility for the treatment of patients in clinical trials, increasing the opportunities for translating early phase studies conducted in our Drug Development Unit into later phase research. It will enable the transition of early research findings into large scale trials, which is integral to our work for the National Institute for Health Research (NIHR) as a Biomedical Research Centre. Following the installation of CyberKnife technology in 2012, The Royal Marsden is leading a new study on the benefits of CyberKnife treatment for patients and for the NHS. The Prostate Advances in Comparative Evidence study, an international, multicentre, randomised study, will compare CyberKnife stereotactic body radiotherapy with manual laparoscopic/robotic surgery and conventionally fractionated intensitymodulated radiation therapy for the treatment of localised prostate cancer. This will enable clinicians and patients to make informed decisions about their treatment based on the highest level of clinical evidence. 4 Annual Report and Accounts 2012/13 We have continued to form new partnerships and continue with existing ones in order to benefit patient care and maximise efficiency across the cancer pathway. In summer 2012 The Royal Marsden signed up to the London Cancer Alliance (LCA), along with 16 other NHS Trusts across west and south London. The LCA aims to develop more integrated pathways of care for patients, set the direction for improvements in patient experience and outcomes and develop common data sets to assess our performance. We aim to deliver cancer treatment and care in a new way, improving access to screening and diagnostics and increasing the number of patients enrolled in clinical trials. This will ensure we can irradiate variation and improve the standard of care all patients receive cross a population of five million in west and south London. Over the last year we have renovated four of the wards on our Chelsea site to ensure we provide the highest level of comfort alongside the latest in clinical facilities. In October, we were delighted to welcome the Secretary of State for Health, Jeremy Hunt, to one of those wards – Ellis Ward – that re-opened in summer 2012 as a state-of-the-art facility following an extensive refurbishment and modernisation programme. Our Palliative Care ward, Horder, was officially opened by HRH Princess Alexandra in September 2012 after a £3 million renovation. Wiltshaw and Burdett Coutts wards also re-opened in January 2013 after a period of renovation. Both the Ellis Ward and Horder Ward renovations were funded by The Royal Marsden Cancer Charity. We would like to thank the charity and all our supporters for the difference they make to the life and work of The Royal Marsden, and to the quality of service and environment we are able to provide. Finally, we would like to thank the staff at The Royal Marsden for their exceptional commitment and professionalism, which is commented on by so many of our patients. It is the pursuit of excellence, which permeates the organisation and allows us to provide out patients with the best cancer care available anywhere in the world. R. Ian Molson Chairman Cally Palmer CBE Chief Executive 5 The Royal Marsden NHS Foundation Trust What we do Research The Royal Marsden and The Institute of Cancer Research (ICR) form the largest comprehensive cancer centre in Europe and, together, are at the forefront of moving cancer research and treatment from bench to bedside. A new age in the treatment of advanced melanoma Two drugs trialled at The Royal Marsden were approved by the National Institute for Health and Clinical Excellence (NICE) late last year as recommended treatment options for metastatic melanoma, the most aggressive form of skin cancer. Zelboraf (vemurafenib) and Yervoy (ipilimumab) work very differently. Vemurafenib blocks the effects of a cancer-causing mutated gene, BRAF. Fifty percent of patients with metastatic melanoma will have this mutation in their cancer, which drives the cancer’s development. The other drug recommended for treatment, ipilimumab, works by harnessing the power of the body’s own immune system to fight cancer. The results of these two trials represent the biggest ever breakthrough in the treatment of advanced melanoma for more than 30 years. Landmark research into tumour variation Patients with advanced kidney cancer at The Royal Marsden have taken part in a breakthrough study, published in the New England Journal of Medicine, which suggests that taking a sample from just one part of a tumour may not give a full picture of its ‘genetic landscape’. In the first-ever genome-wide analysis of the genetic variation between regions of the same kidney tumour, scientists from Cancer Research UK led by Professor Charles Swanton, analysed samples from patients of Dr James Larkin at The Royal Marsden. They found that about two thirds of gene faults were not shared across other biopsies from the same tumour. The research, which was the second most highly cited scientific paper of 2012, revealed that there were more differences than similarities between biopsies from the same tumour at the genetic level. $10 million boost for prostate research Professor Johann de Bono, Head of the Drug Development Unit, is collaborating with other leading prostate cancer researchers in a $10m global effort to drive the development of 6 personalised treatment for this disease. In April 2012, Stand Up to Cancer, the Prostate Cancer Foundation and the American Association for Cancer Research announced the formation of a ‘Dream Team’, drawn from five leading prostate cancer clinical research centres in London and the USA. The team also includes Dr Gerhardt Attard from The Royal Marsden and the ICR. Over three years, the team will drive the development of personalised treatment by scanning the genomes of patients with advanced metastatic cancer. They will look for gene alterations that are more common in patients who respond to therapies, as well as alterations in patients who develop resistance to the drugs. The aim is to identify a panel of biological markers that doctors can use to deliver precise treatments to their prostate cancer patients. Translational Genetics Laboratory The Translational Genetics Laboratory is a key component of a groundbreaking initiative, called the Mainstreaming Cancer Genetics programme, led by Professor Nazneen Rahman that will provide testing to investigate how the genetic make-up of an individual affects why they develop cancer and what treatment will be most appropriate for them. The Royal Marsden Cancer Charity is providing £1.16 million to set-up the cutting-edge clinical sequencing infrastructure of the Translational Genetics Laboratory and to pilot the new test in patients at The Royal Marsden. By 2014, Professor Rahman, Head of the Cancer Genetics Clinical Unit at The Royal Marsden and Head of the Division of Genetics and Epidemiology at the ICR, hopes to offer genetic testing to ovarian and breast cancer patients at The Royal Marsden. Once established, the lab will also provide genetic testing to many other patients at The Royal Marsden and at other hospitals. The ultimate aim of the Mainstreaming Cancer Genetics programme is for genetic testing to be available for any cancer patient as a matter of course. The Royal Marsden leads international CyberKnife trial The Royal Marsden is leading a new study on the benefits of CyberKnife treatment. The Prostate Advances in Comparative Evidence (PACE) study, an international, multicentre, randomised study, will compare CyberKnife stereotactic body radiotherapy (SBRT) with manual laparoscopic/ robotic surgery and conventionally fractionated intensity-modulated radiation therapy (IMRT) for the treatment of localised prostate cancer. Annual Report and Accounts 2012/13 The current accepted standards of treatment are surgery and radiotherapy; the PACE study aims to establish if CyberKnife is equivalent to, or better than, this in the treatment of prostate cancer and the impact on the patient’s quality of life. This will enable clinicians and patients to make informed decisions about their treatment based on the highest level of clinical evidence. Diagnosis New anticancer drug for prostate cancer goes through successful clinical development CMP – groundbreaking facility now open Professor Johann de Bono has led an international Phase III clinical trial that has led to another novel oral treatment for advanced prostate cancer called enzalutamide. This novel agent is an androgen receptor signalling inhibitor with superior antitumour activity to previously available antiandrogens. The trial resulted in a significant improvement in overall survival and quality of life in patients with advanced prostate cancer and led to the approval of this agent by the US Food and Drug Administration. A new research facility for the Sutton site A new clinical research facility has been approved for The Royal Marsden at Sutton, funded by The Royal Marsden Cancer Charity. The £2.6 million project will provide a dedicated space and a central facility for the treatment of patients in clinical trials, in particular increasing the opportunities for translating early phase studies conducted within the Drug Development Unit into later phase research. The new unit will enable the transition of early research findings into large scales trials, which is integral to the National Institute for Health Research (NIHR) Biomedical Research Centre’s strategy. The facility will increase the amount of research at The Royal Marsden and improve efficiency. The unit, to be located in the West Wing of the hospital, will be open by the end of 2013. Early diagnosis is vital in achieving better outcomes for cancer patients. We have a specialist team and expert diagnostic services at our Rapid Diagnostic and Assessment Centres and comprehensive scanning facilities in both Chelsea and Sutton. The Centre for Molecular Pathology (CMP), a world-class research facility that will revolutionise how we diagnose and treat cancer, was officially opened by Professor Dame Sally Davies, Chief Medical Officer for England, in November 2012. It brings together clinicians, geneticists, pathologists and scientists under one roof for the first time to advance cancer research and treatment. This will dramatically speed up the research and treatment development process. Working side by side, experts will be able to better understand each patient’s individual tumour type and develop personalised treatment plans faster than ever before, making our vision of personalised medicine a reality. The centre was born out of the unique relationship between The Royal Marsden and the ICR. Together, they form the only Biomedical Research Centre (BRC) specialising in cancer in the UK. BRC status was awarded by the NIHR in 2006 and renewed in 2011. Professor Mitch Dowsett, Professor of Biomedical Endocrinology at The Royal Marsden, has been appointed Head of the CMP. Consultants honoured with professorships The research of Chris Nutting, Consultant Clinical Oncologist in the Head and Neck Unit at The Royal Marsden, has been honoured by The Institute of Cancer Research Credentials Committee, which conferred the title of Professor after considerable deliberation and extensive soundings from international experts. The committee also honoured the work of the ICR’s Kevin Harrington, an Honorary Consultant at The Royal Marsden, also awarding him the title of Professor. 7 The Royal Marsden NHS Foundation Trust Treatment and care Partnership, leadership and influence We pride ourselves on our excellent standards of care for all our patients. By working together and using joint expertise, we and our partners can ensure patients receive the best personalised care. The Royal Marsden signs up to the London Cancer Alliance Last summer The Royal Marsden signed up to the London Cancer Alliance (LCA), along with 16 other NHS Trusts across west and south London, and the ICR. The LCA aims to develop more integrated pathways of care for patients, set the direction for improvements in patient experience and outcomes and develop common data sets to assess our performance. It aims to deliver cancer treatment and care in a new way, improve access to screening and diagnostics and increase the number of patients enrolled in clinical trials to improve cancer care across London and our local health communities. After leading the LCA through the design and formation of its management structure and service plan, Cally Palmer, Chief Executive of The Royal Marsden stepped down from her role as Chief Executive Project Lead for the LCA, and handed over to two Independent Chairs, Dr Neil Goodwin CBE and Dame Gill Morgan. Dr Shelley Dolan, Chief Nurse at The Royal Marsden was appointed as Associate Clinical Director, supporting Professor Arnie Purushotham, Director of King’s Health Partners Integrated Cancer Centre, as Clinical Director, in addition to her principal role as Chief Nurse at The Royal Marsden. Secretary of State visits The Royal Marsden Staff and patients met the Secretary of State for Health, Jeremy Hunt, when he visited The Royal Marsden’s Chelsea site in October 2012. Together with senior colleagues from the Department of Health, including Professor Sir Mike Richards, National Clinical Director for Cancer, Mr Hunt took part in two round-table events, discussing ‘Improving patient care and experience’ and ‘Early diagnosis and improving survival’. Senior consultants and nursing staff took part in the discussions, which were chaired by Dr Shelley Dolan, Chief Nurse, and Professor Martin Gore, 8 Medical Director, respectively. Mr Hunt also toured the newly refurbished Ellis Ward, speaking with patients and staff. He was particularly interested in the food served at The Royal Marsden, which has won several awards and is renowned for its high standard. A welcoming facility for the newly refurbished Ellis Ward Ellis Ward re-opened in summer 2012 at our Chelsea site following an extensive refurbishment and modernisation programme. The ward now contains 14 beds, with two single rooms and three four-bedded bay areas. The refurbishment of the unit includes modernised bathroom facilities next to the bedded bays, and en-suites for the single rooms. Each bedside has also had a new patient entertainment system installed. The refurbishment of the ward, for women with breast, gynaecological, gastrointestinal or genitourinary cancers, was made possible due to a generous donation from Jimmy Thomas, whose late wife, Alma, was treated at the hospital. The redesign has been based on Alma’s wishes, who wanted every patient staying on the ward to enjoy the ‘highest levels of comfort’. Royal opening for refurbished Horder Ward The refurbished Horder Ward was officially opened by HRH Princess Alexandra in September 2012 after a £3 million renovation. The refurbishment, which was funded by The Royal Marsden Cancer Charity, turned the ward into a modern palliative care environment with enhanced en-suite single rooms, consultation rooms and a day room for patients and their visitors, all set in light, airy surroundings. Renovated wards open Wiltshaw and Burdett Coutts wards re-opened in January 2013 after a period of renovation. As part of the considerable development and renovation of the Chelsea site over the past few years, the opening of Wiltshaw Ward in particular was a significant milestone in the final stages of whole site redevelopment. Wiltshaw Ward will be predominantly used for Private Care alongside the Granard House development which was completed in 2011. Annual Report and Accounts 2012/13 Palliative care team receives European recognition The Palliative Care service at The Royal Marsden received Europe-wide accreditation for its groundbreaking work. The European Society for Medical Oncology (ESMO) Designated Centers of Integrated Oncology and Palliative Care accreditation programme recognises cancer centres that achieve a high standard of integration between medical oncology and palliative care. This is the second time that The Royal Marsden has been awarded this accreditation, which is valid for three years. Anna-Marie Stevens, Macmillan Nurse Consultant in Palliative Care at The Royal Marsden, said: “We are incredibly proud of our palliative care service and the support and care we give to patients and their families. This reaccreditation recognises the comprehensive and multidisciplinary approach to the care we provide.” New PET CT facility opens at Sutton We have enhanced our scanning capability on the Sutton site, with two new PET CT scanners installed in a new facility. There are now three MRI, two CT and three PET/CT machines on the Sutton site. This is part of a wider project increasing scanning capacity across the whole Trust. Work is currently underway on a redeveloped scanning unit on the Chelsea site, expected to be completed in 2014. Royal Marsden nurses present study at symposium Two Clinical Nurse Specialists (CNSs) from The Royal Marsden presented their research work at the 2012 San Antonio Breast Cancer Symposium in the USA – a first for the Trust. Melissa Warren and Diane Mackie, CNSs in secondary (metastatic) breast cancer, presented their study – entitled ‘The complexity of non faceto-face work with patients affected by metastatic breast cancer and their carers, the “hidden consultations” of the clinical nurse specialist’ – at the prestigious annual symposium, held in San Antonio, Texas, in December. The needs of women with metastatic breast cancer can be complex and the role of the CNS is important in their care. Having contact with someone who has specialist knowledge and understanding of a patient’s treatment and care can help reduce a patient’s anxieties and help them to cope with the complications of having metastatic breast cancer. The study looked at the complexity of patient interaction via telephone, which is not a formally recognised part of a CNS’s role, compared with face-to-face contact. It has highlighted the importance of telephone contact between CNSs, patients and their carers, and that this work needs to be formally identified. Health Services Research – beyond the bedside Considerable work has been carried out this year in the area of Health Services Research, which aims to develop service innovation and research programmes that improve patient-centred care in relation to Living with and Beyond Cancer. Natalie Doyle, Dr Isabel White and Dr Theresa Wiseman are members of the Department of Health/Macmillan Consequences of Cancer and Treatment Collaborative (CCAT) and as a Trust we have also been successful in being part of the Prostate Cancer UK A Survivorship Action Partnership (ASAP) network to offer expertise for improving prostate cancer survivorship care and support. The Trust has implemented the Holistic Needs Assessment (HNA) for patients in all cancer services and has been awarded funding for pilot site status to test and redesign care pathways to support transition and care in the community. Dr Natalie Pattison has also been leading trust-wide research into how we can identify at-risk patients and map this flexibly against staffing, exploring cost-savings, patient-focused outcomes, mortality/ morbidity and patient acuity. The Royal Marsden to join partners in Academic Health Science Networks Academic Health Science Networks (AHSNs) were introduced by the Department of Health in 2011 to spread innovation in healthcare, and bring together local NHS providers, higher education institutions and industry to improve the adoption and spread of innovation. It is important that The Royal Marsden is part of the AHSN initiative to help accelerate the roll out of innovation in cancer care to a wider population. Research and education funding may only be available in the future through the AHSNs and the development of networks and a more integrated approach to the development of care will be essential in improving efficiency longer term. The Royal Marsden is delighted to be a member of both the Imperial College Health Partners AHSN and South London AHSN. 9 The Royal Marsden NHS Foundation Trust Education and regulation Another ‘excellent’ year For the fifth year in a row The Royal Marsden was rated as excellent by PEAT (Patient Environment Assessment Team), a national organisation, following an annual inspection. The NHS Health and Social Care Information Centre announced that the Trust scored an “excellent” rating for the overall hospital environment. This included the levels of privacy and dignity given to patients, and the quality of food. The centre also commented that the Trust’s levels of cleanliness and infection prevention and control procedures and rates were also “excellent”. GP education programme success continues Now in its fourth year, The Royal Marsden’s GP Education series of quarterly one-day seminars and online learning opportunities continues to be a success, contributing directly to GPs’ professional knowledge on cancer diagnosis and treatment. To ensure our Education Days remain relevant and engaging for GPs, we have developed more interactive, case-led sessions to help us further understand the problems faced in primary care and allow us to offer expert secondary care advice. The Royal Marsden has held 15 GP Education Days since September 2009, covering most tumour types, with almost 100 GPs attending each session. Speakers focus on screening, diagnosis and treatment. In line with government objectives, we are helping to build relationships between primary and secondary care by educating GPs on the value of prevention and early diagnosis – recognising cancer signs and symptoms and referring patients at the right time. We also produce video highlights of each GP Education Day, which are made available to all GPs via www.doctors.net.uk, while a quarterly e-bulletin informs GPs of the latest news and general information on specific cancers. 10 The Royal Marsden joins with local hospitals to identify best value The Royal Marsden joined together with Chelsea and Westminster and Royal Brompton & Harefield hospitals and the Institute of Cancer Research as the Fulham Road Collaborative (FCC) to establish a joint contract for its Soft Facilities Management services including catering, portering and cleaning. This was awarded to ISS Mediclean following a competitive tendering process to identify best value for money and best quality of service. The project is a great example of how healthcare organisations can work together to make the best use of resources while maintaining excellent standards of care for patients. The FCC were highly commended at the National Government Opportunities (GO) Excellence in Public Procurement Awards for their work on project. The Friends and Family Test The Royal Marsden is proud to provide worldleading cancer care to our patients but we also want to know what we can do to make the experiences of patients even better. This is why it’s so pleasing to see the positive start made on the Friends and Family Test. The Friends and Family Test is designed to enable comparison between hospitals throughout the NHS quickly and easily. The Royal Marsden has made a successful start to this new government initiative which gives patients the opportunity to rate their care. Since February, all inpatients have been asked to fill in a short questionnaire when they are discharged including the question “How likely are you to recommend our ward to friends and family if they needed similar care or treatment?” Every month the results will be reported online and made available for patients, so they can compare hospitals and identify the trusts which provide the highest quality of care. We can also compare wards within the hospital, as well as the Trust as a whole. In the first two months, The Royal Marsden scored 4.9 out of 5 overall, with seven wards achieving a score of 5/5 mark consistently. Annual Report and Accounts 2012/13 Our staff Thanks to the commitment and expertise of our staff, we have built an international reputation for delivering the highest quality cancer care. Staff were rewarded for their hard work and dedication at the annual Staff Awards Ceremony, held at the Tower of London in November 2012. The winners of the 2012 Staff Achievement Awards were: Pursuing Excellence Dawn Smith, Nursery Manager Ensuring Quality Individual: Paulina Markovic, Quality Manager Team: Pathology Quality Leads Driving Efficiency Individual: Claudine Sustarich (nee Cleaver), Service Improvement Manager Team: Physiotherapy – outpatients, Sutton and Merton Community Services Breaking Boundaries Individual: Emilda Thompson, Senior Research Nurse Team: Professor Mitch Dowsett and team, Academic Biochemistry Developing Potential Dr Khin Thway, Consultant Histopathologist Anything’s Possible Individual: Tina Shaughnessy, Senior Staff Nurse, IV Team Team: PATCH team – specialist palliative care, Oak Centre for Children and Young People Working Together Individual: Lisa Ogden, Specialist Speech and Language Therapist Team: Dr Julia Chisholm, Consultant Paediatric Oncologist, and Amber Conley, Matron, Oak Centre for Children and Young People Outstanding Contribution Individual: Bernadette Knight, Staff Support Facilitator, Psychological Support Team: Lung unit research team, research nurses and clinical trial co-ordinators Unsung Hero/Heroine Patricia Stanley, Welfare Rights Advisor Outstanding Leadership Caroline Blackburn, Specialist Nurse, Dietetics 11 The Royal Marsden NHS Foundation Trust Other notable individual achievements Many Royal Marsden staff are members of national and international research committees and academic groups. Several have been recognised for their contribution to cancer research and treatment. Key achievements are listed below: Mr Bill Allum was elected President of the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS) and Chair of the National Cancer Intelligence Network Upper GI Clinical Reference Group. Dr Liz Bancroft was awarded a PhD in Nursing from the University of Nottingham. Her thesis concerned the factors affecting interest and uptake of genetic testing for prostate cancer susceptibility. Dr Craig Carr was awarded an MBA with Distinction by the University of Oxford and commended by the Dean of the Said Business School for outstanding academic achievement within his class. He is now collaborating with academics from the University of Oxford and the London Business School to assess the interactions of health policy, professional culture and management on operational efficiency and health economics of care provision. Professor David Cunningham was awarded grants from The Peter Stebbings Memorial Charity, The Robert McAlpine Foundation, The Friends of the Royal Marsden and The Leukaemia and Lymphoma Research, as well as from Celgene Corporation, AstraZeneca and Glaxo SmithKline to support ongoing novel research in the fields of gastrointestinal cancer and lymphoma. The Richard Steevens Scholarship (Irish Health Service Executive) also awarded funding towards a clinical research fellow post within Professor Cunningham’s unit. Presented results from Professor Cunningham’s research unit have been awarded the Bradley Stuart Beller Merit Award at the ASCO annual meeting (Chicago, June 2012) and a merit award at the ASCO GI symposium (San Francisco, January 2013). Professor David Dearnaley received a five year grant from Cancer Research UK for the PROMPTS trial (A Prospective Randomised phase III study of Observation versus screening MRI and Preemptive Treatment in castrate resistant prostate cancer patients with Spinal metastasis) and published preliminary safety results from the CHHiP randomised controlled trial in The Lancet. He was also re-elected as a National Institute for Health Research Senior Investigator. 12 Professor Johann de Bono published two phase III studies in the New England Journal of Medicine, both involving new drugs in prostate cancer, enzalutamide and abiraterone. He was also appointed the overall scientific programme chair of ESMO (European Society of Medical Oncology) 2014. His Experimental Cancer Medicine Centre five year grant renewal program was awarded a double outstanding grade from Cancer Research UK and the Department of Health. Professors Nandita deSouza and Martin Leach and Dr Dow-Mu Koh were awarded a Cancer Research UK Cancer Imaging Centre grant, joining only three other centres in the UK (UCL/KCL, Cambridge/Manchester, Oxford) in this area. Professor Ros Eeles was elected to a Fellowship of The Academy of Medical Sciences. Her research has found genetic variants in breast cancer predisposition genes which are also associated with prostate cancer which has led to an international screening study in over 60 centres. Professor Eeles was also invited to give a prestigious lecture at The INSERM agency in Lyon, France. Dr Louise Fearfield was an invited plenary speaker at the British Association of Dermatologist annual meeting on the cutaneous toxicities associated with the newer targeted therapies in cancer. She has subsequently published an article in the British Journal of Dermatology on the management of Vemurafenib associated toxicities in patients with metastatic malignant melanoma. Professor Martin Gore was the invited guest lecturer at the annual meeting of the British Association of Dermatologists. He spoke about new drugs in melanoma treatment. Mr Gerald Gui delivered the Inaugural Tony Gabriel Memorial Lecture at the Annual Sessions of the College of Surgeons of Sri Lanka and was awarded an Honorary Fellowship for his contribution to education and breast cancer services to the people of Sri Lanka. Dr Robert Huddart had a paper on chemoradiotherapy for patients with bladder cancer published in the New England Journal of Medicine and was awarded a grant from Cancer Research UK for a trial of adaptive radiotherapy in bladder cancer and salvage chemotherapy in testicular cancer. Annual Report and Accounts 2012/13 Professor Stan Kaye was part of the team to win the American Association for Cancer Research Team Service Award, awarded to the Institute of Cancer Research/The Royal Marsden Cancer Therapeutics Unit and Drug Development Unit – the first time a non-American team has won the award – for achievements in drug discovery/ development. The award was presented to Professor Stan Kaye, Professor Johann de Bono and Dr Udai Banerji from The Royal Marsden and Professor Paul Workman and his team from ICR. Dr Vincent Khoo and his Clinical Research Trials Team were awarded the INC Research Recognition Award as the best performance site for clinical trials from an international field of cancer centres. Dr Khoo also serves on the Scientific Committees for the European Cancer Organisation (ECCO) and European Society for Radiotherapy and Oncology (ESTRO). Dr Dow-Mu Koh received the Outstanding Teacher Award at the International Society for Magnetic Resonance in Medicine Annual Meeting in Australia. He also received the Editor’s Recognition Award for reviewing with Special Distinction in recognition of outstanding service as a reviewer of scientific manuscripts submitted for publication in Radiology, the journal of the Radiological Society of North America, was appointed to the Editorial Board of Radiology as Associate Editor and to the European Society for Magnetic Resonance in Medicine and Biology School of MRI Steering Committee. Dr Donna Lancaster has been elected as a member of the IBFM Experimental Therapies Committee for Childhood Leukaemia as well as the Novel Agents Group for Childhood Cancer and Leukaemia. Dr James Larkin has been appointed Chair of the National Cancer Research Institute Renal Cancer Clinical Studies Group. The group has a remit to develop portfolios of trials for renal cancer or treatment approaches, including overseeing the portfolio of existing studies and considering new research questions. Dr Mary O’Brien was reappointed as chair of the European Organisation for Research and Treatment of Cancer lung group for a second term of three years. Dr Natalie Pattison was awarded a Florence Nightingale Research Scholarship for training in ethnographic research methods. She was also appointed to the editorial board of European Journal of Cancer Care. Professor Andy Pearson was elected President of Advances of Neuroblastoma Research, the international forum for discussion and presentation of clinical and translational biological research in neuroblastoma. Dr Sanjay Popat was elected as Chairman of the British Thoracic Oncology Group (BTOG), Chairman of the Advanced Diseases Sub-Group of the National Cancer Research Institute (NCRI) Lung Cancer Clinical Studies Group, and has been appointed to sit on the International Rare Cancers initiative for Thymoma as European Organization for Research and Treatment of Cancer (EORTC) representative. He has also been a Clinical Expert Advisor to NICE. Professor Nazneen Rahman received funding from Cancer Research UK to pursue the Clinical Translation of the breast cancer predisposition genes that her group have discovered, a Strategic Award from Wellcome Trust to develop the Mainstreaming Cancer Genetics Programme and a prestigious Senior Investigator Award from Wellcome Trust to support continuing research into the genetic factors associated with developing childhood cancer. She has been the lead author on an article in Nature reporting mutations in a gene called PPM1D which is linked to an increased risk of breast and ovarian cancer. She also published in Nature Genetics reporting the findings from the largest genome wide association study of Wilms tumour which identified genetic susceptibility loci for the tumour. Dr Sheela Rao was awarded a Clinical Trials Awards and Advisory Committee grant to conduct an international multi-centre trial in advanced anal cancer for which she is the chief investigator. The study will be coordinated by The Royal Marsden GI trials unit. Dr Rao has also been awarded a grant from Glaxo SmithKline to conduct research in oesophago-gastric cancer and has been appointed to the national NCRN anorectal subgroup. Miss Jennifer Rusby was invited to lecture to audiences in Aarhus, Denmark and Washington DC on nipple-sparing mastectomy. 13 The Royal Marsden NHS Foundation Trust Dr Bhuey Sharma started a novel annual Royal Marsden anatomical-functional imaging course for medical/clinical/surgical oncologists and was invited to submit a paper on 120 years of multimodality multi-parametric imaging for Nature Reviews Clinical Oncology. Dr Isabel White and Dr Theresa Wiseman received funding from Prostate Cancer UK to pilot a new community care pathway for men with prostate cancer. This will compliment existing funding from Macmillan to develop supportive services following treatment. They were also invited, with Amanda Baxter, Ann Muls and Dr Jervoise Andreyev, to become part of Prostate Cancer UK ASAP (A Survivorship Action Partnership). Dr Robin Wilson was elected President of the European Society of Breast Cancer Specialists, acting chair of the Department of Health Advisory Committee on Breast Cancer Screening and appointed as a visiting Professor in the Department of Applied Visual Science at the University of Loughborough. Professor John Yarnold was re-appointed Senior Investigator to the National Institute of Health Research, and appointed Co-Scientific Chair of the European Cancer Congress to be held in Amsterdam in September 2013. He was also invited to deliver a plenary lecture at the San Antonio International Breast Symposium, Texas, in December 2012. Several Royal Marsden staff members have also been involved in the London Cancer Alliance: Dr Julia Chisholm and Louise Soanes Chairs, children and young people pathway Natalie Doyle Joint chair, survivorship pathway Mr Satvinder Mudan Chair, hepatobiliary pathway Miss Nicky Roche Interim chair, breast pathway group (October 2011 – January 2013.) Dr Alex Taylor Chair, gynaecological cancer pathway 14 New roles within The Royal Marsden Dr Liz Bishop Divisional Director, Cancer Services and Research and Development Dr Claire Dearden Head of Haemato-oncology Department Dr James Larkin Chair, Committee for Clinical Research Mr Satvinder Mudan Divisional Medical Director, Private Care Professor Chris Nutting and Professor Kevin Harrington Joint Heads, ICR Division of Radiotherapy and Imaging Dr Mike Potter Divisional Medical Director, Cancer Services Jonathan Spencer Divisional Director, Clinical Services Dr Naureen Starling Associate Director of Clinical Research & Development Annual Report and Accounts 2012/13 The Royal Marsden Cancer Charity The Royal Marsden Cancer Charity raises money to help The Royal Marsden provide world class diagnosis, treatment and care for cancer patients and supports the hospital’s pioneering work in cancer research. By supporting The Royal Marsden in this way we aim to make life better for people with cancer everywhere and strive for a future without it. Ten10 – a decade of innovation CyberKnife, Critical Care Unit, Oak Centre for Children and Young People, Centre for Molecular Pathology, the da Vinci S robot – all funded by The Royal Marsden Cancer Charity over the last 10 years and all critically important to our patients. We have raised £100 million over the last ten years, and in order to carry on with this groundbreaking work over the next ten years, we need to raise another £100 million. To support this, The Royal Marsden Cancer Charity launched a new campaign in January, ten10 – a decade of innovation, to run throughout 2013. Our President, HRH The Duke of Cambridge, helped launch the campaign, by starring in a specially made film. The campaign will celebrate a different project or facility every month and highlight the impact they have had on cancer treatment both at The Royal Marsden and across the country. Visit www.royalmarsden.org/ten10 to find out more. The Marsden March Over 4,000 people took part in the third Marsden March in March 2013, the annual charity walk between our Chelsea and Sutton hospitals. Participants included supporters, patients, staff and celebrities who came together to take on cancer. Centre for Molecular Pathology The Centre for Molecular Pathology (CMP) is a world-class research facility that will revolutionise how we diagnose and treat cancer. It opened in November 2012. The centre brings together clinicians, geneticists, pathologists and scientists from The Royal Marsden and The Institute of Cancer Research (ICR). Working side by side, they will be able to better understand different tumour types and the most effective way to treat them, leading to the development of personalised treatment plans faster than ever before. With the help of supporters, The Royal Marsden Cancer Charity contributed £2.3 million towards building the CMP, which has been developed in partnership with the ICR. Charity funds ward refurbishments Ellis and Horder wards both reopened this year after renovations funded by The Royal Marsden Cancer Charity. Ellis Ward was the beneficiary of a gift from Jimmy Thomas, whose wife Alma was treated at The Royal Marsden before her death in 2008. He said: “My wife’s treatment at The Royal Marsden was excellent and the staff were superb, but we both felt the environment of the ward did not match up to the standard of care. I am thrilled with the look of the new ward.” HRH Princess Alexandra officially opened Horder Ward in September 2012 and met charity supporters and donors including actor Nathanial Parker, donor and charity Trustee Catherine Armitage, donor and member of the Ethics Committee Dr Michael Harding along with donor Annie Gallon and supporter Dr Fui Mee Quek. It was a fantastic event that raised over £1 million. The Royal Marsden Cancer Charity would like to thank everyone that helped to make the 2013 event such a great success. The next Marsden March will take place on Sunday 16 March 2014. 15 The Royal Marsden NHS Foundation Trust Quality Account What is a Quality Account? All NHS hospitals or trusts have to publish their annual financial accounts. Since 2009 as part of the movement across the NHS to be open and transparent about the quality of services provided to the public, all NHS hospitals must publish a Quality Account. The public and patients can also view quality across NHS organisations by viewing the Quality Accounts on the NHS Choices website: www.nhs.uk The dual functions of a Quality Account are to: 1. Summarise performance and improvements against the quality priorities and objectives we set ourselves for 2012/13 2. Outline the quality priorities and objectives we set ourselves going forward for 2013/14. Review of 12/13 Quality Information Look Back 16 Set out priorities Quality Improvement 13/14 Look Forward Annual Report and Accounts 2012/13 Firstly, we have detailed how we performed in 2012/13 against the priorities and objectives we set ourselves under the following categories: Safe care Effective care Patient experience Where we have not met the priorities and objectives that we set ourselves, we have explained why, and outlined the plans we have put in place to ensure improvements are made in the future. Secondly, we have outlined our quality priorities and objectives for 2013/14 under the same categories. We have detailed how we decided upon the priorities and objectives we have set ourselves, and how we will achieve and measure our performance. The regulated Statements of Assurance are also included in this part of the report. The Quality Account is an important document for the Board, which is accountable for the quality of the service provided by the Trust and can be used in the scrutiny and leadership of the Trust. Frontline staff can use the Quality Account compare or benchmark their care with other Trusts or, if comparable information doesn’t exist, with their own performance over time, to help improve their service. For patients, carers and the public the Quality Account should be a document that is easy to read and understand, and highlights key areas of safety and effective care delivered in a caring and empathetic way. It should also show how a Trust is concentrating on continuously improving its care. As the public get used to reading the Quality Account it may also help patients with choice. It is important to remember that some parts of the Quality Account are compulsory and can be difficult to read – they are about important areas such as the time it has taken to get from an appointment with a GP to first receiving treatment – generally they are presented as numbers in a table at the end of this Quality Account. If there are any areas of the Quality Account that are difficult to read or understand or you would like any help with the content, please contact us via our Patient Advice and Liaison Service (PALS) on 0800 783 7176 or online at www.royalmarsden.nhs.uk The Quality Account is divided into four sections: Part 1 A statement on quality from the Chief Executive (CE) Part 2 Performance against priorities for quality improvement 2012/13 and statements of assurance Part 3 Outline of quality priorities 2013/14 and an explanation of who the Trust has involved in determining the priorities including statements from key stakeholders such as Healthwatch (replacing Local Involvement Networks), Health and Wellbeing Boards and the Commissioners of Services. It is important to note that with the new architecture of the NHS The Royal Marsden will work more closely in 2013/14 with the two Clinical Commissioning Groups in Sutton and Merton to ensure that going forward the Quality Account reflects their needs Part 4 Review of quality performance 17 The Royal Marsden NHS Foundation Trust Part one Introduction to The Royal Marsden NHS Foundation Trust and a statement on quality by the Chief Executive The quality of patient and family care is at the centre of everything we do at The Royal Marsden. The Royal Marsden NHS Foundation Trust is the largest comprehensive cancer centre in Europe and together with its academic partner the Institute of Cancer Research (ICR) is responsible for the largest research programme in cancer in the UK. This year has been another excellent year for the Trust as we have continued to achieve high ratings from our two major regulators, Monitor and the Care Quality Commission (CQC). This commitment to meet the challenges of delivering quality whilst delivering efficiency cost savings of around seven per cent a year underpins our corporate objectives for 2012/13: 1. Improve patient safety and clinical effectiveness 2. Improve patient experience 3. Deliver excellence in teaching and research 4. Ensure financial and environmental sustainability. Our commitment to quality improvement is evidenced by the following achievements in April 2012 – March 2013: National Patient Safety Agency Annual Patient Environment Action Team (PEAT) Assessment The PEAT inspection rated the Trust as “excellent” overall. The inspection, which was performed at both sites and included external inspectors and patients, looked at the following areas: cleanliness of the patient environment (wards, rooms, waiting and reception areas), infection prevention and control, safety and security, hospital food, and the privacy and dignity afforded to patients. The annual staff survey A growing body of evidence has shown a clear correlation between a satisfied workforce and high quality patient care. The national staff survey identifies the extent to which staff feel motivated and engaged with their work and willingness of staff to recommend the Trust as a place of work/and for patients to receive treatment. How members of staff rate the care that their employer organisation provides can be a meaningful indicator of the quality of care and a helpful measure of improvement over time. The Trust has traditionally performed very well with this measure. The 2012/13 staff survey results showed that 87% (421/488) of our staff who responded to the NHS survey agreed or strongly agreed that if a friend or relative needed treatment, they would be happy with the standard of care provided by the Trust. This is an increase on 2011/12, when survey results were 84% (408/485). The national average for this measure is 63%. Customer Service Excellence Standard The Customer Service Excellence (CSE) standard replaced the Charter Mark in 2008 and is a standard achieved by public services that are “efficient, effective, excellent, equitable and empowering – with the citizen always and everywhere at the heart of public services provision” (CSE 2008). The CSE tests, in-depth, those areas that research has indicated are a priority for customers, with particular focus on delivery, timeliness, information, professionalism and staff attitude. Emphasis is also placed on developing customer insight, understanding the user’s experience and robust (reliable) measures of service satisfaction. 18 Annual Report and Accounts 2012/13 The Royal Marsden was the first hospital to be awarded the Customer Service Excellence standard, in 2008. To maintain the award the Trust needs to be assessed regularly and received its last assessment on 14 December 2012. The Trust was found to be compliant and therefore retained the award. Same-sex accommodation Since April 2011 we have been able to declare compliance and have met all the standards set by the Government to provide accommodation for patients that is not shared with the opposite sex. A modern healthcare environment Finally, 2012 has seen the completion of several phases of a substantial capital building programme which is ensuring that patients and their families experience care in the most appropriate, modern and technically sophisticated environment. In autumn 2012 the Centre for Molecular Pathology opened at Sutton. This is the first centre for molecular biology dedicated to cancer in the NHS. This is a very exciting development as it will bring together scientists and doctors in the same environment, working together to develop new medicines and treatments that will be targeted to the unique genetic codes of each individual. These new targeted medicines and treatments will ensure that cancer patients all over the world benefit more rapidly from accurate cancer treatments. This is the fourth year that we have published a Quality Account and we are very grateful for the feedback we received on last year’s Quality Account from patients, carers, the public through Healthwatch (from 1 April 2013 Healthwatch replaced the Local Involvement Networks), Health and Wellbeing Boards and our commissioners and governors. As you will see from this Quality Account, 2012/13 has been another busy year for The Royal Marsden NHS Foundation Trust. The Trust has continued to improve its services for patients and families, achieving key targets despite the economic challenges to the NHS. We are also committed to doing everything we can to improve the environment and care further in 2013/14. I would like to thank all patients, carers, staff, LINks, HWB, governors and commissioners who have contributed to this Quality Account for 2012/13. I can confirm on behalf of the Board of The Royal Marsden NHS Foundation Trust that to the best of my knowledge, the information presented in this Quality Account is accurate and fairly represents the range of services we provide. Cally Palmer CBE Chief Executive 19 June 2013 Integrated Care During 2012/13 the Trust has been very involved in the leadership and shaping of one of the two new integrated cancer systems across London: The London Cancer Alliance (LCA). The aim of the LCA is to improve cancer outcomes, safety of care and the experience of care across two thirds of London (4.8 million people). The Royal Marsden has led and hosted the LCA this year. This is also the second year of our integration with Sutton and Merton Community Services. Work continues on improving patient pathways, ensuring that people with long term conditions have improvements in their care and an improved patient experience. We have also focused on ensuring that our partnerships with the multiagency safeguarding hubs in both Sutton and Merton are robust and effective in ensuring that children are afforded the best joined up care between health, social care and many other agencies. 19 The Royal Marsden NHS Foundation Trust Part two Performance against priorities for quality improvement 2012/13 and statements for assurance Introduction The table below summarises the specific priorities and targets we set ourselves for Safe care, Effective care and Patient experience for 2012/13 in the hospital. Safe care Priority 1 Priority 2 Priority 3 *Reduction in Healthcare Associated Infections (MRSA bacteraemia and Clostridium difficile infections) *Rate of patient safety incidents and percentage resulting in severe harm or death (in 2011/12 the number of deaths from serious incidents per 100 admissions was 0.013; the number of severe harms from incidents per 100 admissions was 0.021) *Percentage of admitted patients risk assessed for Venous thromboembolism Less than one MRSA bacteraemia Reduction in the rate of patient safety incidents per 100 admissions and the proportion that have resulted in severe harm or death 95% of patients to have a completed VTE risk assessment Less than 16 C. difficile infections (Report in Quality Account the number of C. difficile infections per 100,000 bed days) Effective care Priority 4 Priority 5 Priority 6 Priority 7 Reduction in community acquired grade 3 and 4 pressure ulcers Increase the number of patients that die in their preferred place of death (The National Primary Care Snapshot Audit in End of Life Care (2009) found that the number of patients achieving their preferred place of death is 42%) Increase the numbers of patients who have been offered an Holistic Needs Assessment *Avoidance of emergency re-admissions to hospital within 28 days of discharge Reduce the incidence of severe community acquired pressure ulcers (grade 3 and 4) Achieve more than 42% of patients dying in their preferred place of death Increase in the proportion of designated patients who will be offered a Holistic Needs Assessment by the end of 2012/13 Reduction in the number of avoidable re-admissions to hospital within 28 days of discharge 20 Annual Report and Accounts 2012/13 Patient experience Priority 8 Priority 9 Priority 10 Reduction in chemotherapy waiting times and improvement in patient experience related to waiting times *Ensure that we are responding to in-patients’ personal needs *Percentage of staff who would recommend The Royal Marsden to friends or family needing care Reduction in chemotherapy waiting times at Sutton and Chelsea and improvement in the patient experience related to waiting times Improvement in responses to five questions (from the CQC national survey) as monitored through the Inpatient Frequent Feedback Surveys To maintain or increase the staff survey result to this specific question in the survey Safe care for children Priority 11 Percentage of babies who receive the new birth visit up to day 14 90% to be achieved * mandatory priority 21 The Royal Marsden NHS Foundation Trust Priority 1 Reduce the incidence of Healthcare Associated Infections (HCAIs) Target To reduce the number of Clostridium difficile Infections (CDI) to 16 in 2012/13 or less and maintain a very low incidence of Meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia. Patients with cancer are more vulnerable to infection and if an infection is sustained, they are more likely to develop serious complications from it. We therefore see reducing the incidence of HCAIs as an essential safety and quality priority. This priority was selected in 2009/10 and remained an important priority in 2012/13. What did we do in 2012/13? –– We have maintained a high proportion of single rooms, making it easier to isolate infected patients earlier. Almost half the patient accommodation on each site is in single rooms –– Weekly audits against the criteria of the Care Quality Commission Hygiene Code continue across almost all clinical areas of the Trust, including diagnostic and outpatient areas. These are carried out by Sisters/Charge Nurses, Clinical Nurse Specialists, senior Allied Health Professionals and Matrons. These visits serve multiple purposes, allowing senior professionals to view good practice that they can take back to their own areas as well as providing an independent check on cleanliness, practice and staff knowledge –– Synbiotix (live web-based database) is available for all staff to view via the Trust intranet, showing the results of Hygiene Code visits, hand hygiene and other audits, and daily checks and clinical indicators. Performance is closely monitored and highlighted by regular emails from the Infection Prevention and Control Team. Synbiotix also shows the results of equivalent audits of community services –– Hydrogen peroxide vapour (HPV) decontamination of patient rooms where the occupant has had an infection that may pose a risk to the next person to use the room is available across both hospitals. Priority is given to rooms that have been occupied by patients with symptomatic Clostridium difficile infection because this is the most effective way to destroy Clostridium difficile spores and minimise the risk to other patients –– Infection prevention and control is included in the induction programme and there is update training, which is mandatory for all new and existing staff –– Each ward and unit has clinical link nurses for infection prevention and control acting as clinical champions and the Infection Prevention and Control Team hold monthly meetings for all ‘link’ staff. These meetings include an educational session and allow staff to discuss infection prevention and control issues –– The Royal Marsden Infection Prevention and Control Team hosted a national study day in July 2012 on combating HCAIs, including sessions on antimicrobial resistance, water safety and the importance of the environment in infection prevention. Almost 100 delegates from across the South East attended and feedback on the event was very positive –– All Trust Infection Prevention and Control policies are reviewed annually –– Mattress audit and evaluation has been undertaken and any faulty mattresses replaced to assist in the prevention of infection –– Disinfectant and sporicidal wipes have been standardised across the Trust for cleaning equipment, especially commodes –– Advance weekly notification is provided to all wards before admission of patients previously identified as infected or colonised with MRSA or another organism of concern, and of patients with no recorded MRSA screen within the previous month. Outpatient departments and medical day units are notified of patients with appointments who have previously been identified with MRSA, Clostridium difficile or respiratory infections and provided with recommendations for management 22 Annual Report and Accounts 2012/13 –– Air testing and review of water test results where required during commissioning of new builds –– Filtration of the air supply and careful monitoring (and filtration where necessary) of the water supply to the wards where severely immuno-compromised bone marrow transplant patients are cared for. How did we perform in 2012/13? Table 1 below shows the numbers of two important health care associated infections (HCAIs): meticillin resistant Staphylococcus aureus bacteraemia (MRSAb) and Clostridium difficile (CDI) over recent years. These infections are monitored nationally through the Health Protection Agency (HPA) with all hospitals submitting their information to the HPA website monthly. On 1 April 2013 HPA became Public Health England. Table 1: Number of cases of infections that are attributable to The Royal Marsden Infection Number attributable 2009/10 Number attributable 2010/11 Number attributable 2011/12 Number attributable 2012/13 Royal Marsden annual objective 2012/13 MRSA bacteraemia 1 2 1 0 ≤1 C. difficile 39 34 18 15 ≤16 The graph below shows the number of Clostridium difficile infections from April 2012 to March 2013. Trust objective Trust cumulative total Sutton cumulative total Trust month total Chelsea cumulative total 18 16 14 12 10 8 6 4 3 2 0 April 2012 May 2012 June 2012 July 2012 Aug 2012 Sept 2012 Oct 2012 Nov 2012 Dec 2012 Jan 2013 Feb 2013 March 2013 23 The Royal Marsden NHS Foundation Trust We have worked exceptionally hard to achieve the set objective of less than 16 cases of Clostridium difficile infection in 2012/13, and had no cases of MRSA bacteraemia throughout the year; the target for MRSA bacteraemia was less than or equal to one case, which was a very challenging target to achieve. The Trust continues to commit to reducing the incidence of HCAIs still further in 2013/14. What actions are we planning to improve our performance? For Clostridium difficile we aim to reduce our target from 16 to 11 for 2013/14 and reduce the number of infections by antibiotic resistant organisms, including MRSA but particularly multi-resistant gram negative organisms. We will aim to achieve the following: 1. Ensure that infection prevention is taken into account in all refurbishments, new builds, service developments and other capital projects across the Trust 2. Consolidate and expand the programme of inspections and audits, including Hygiene Code inspections; hand hygiene, Saving Lives and Essential Steps audits; local daily checks and clinical indicators across the Trust, including Sutton and Merton Community Services 3. Facilitate access to the Synbiotix system and database for all staff across the Trust, including Sutton and Merton Community Services, for the recording and transparent display of all the above performance indicators 4. Review the arrangements for the deployment and operation of the hydrogen peroxide vapour (HPV) environmental decontamination equipment to ensure that it is used as effectively as possible and that priority is given to those areas where it will be most beneficial, particularly rooms that have been occupied by symptomatic patients with Clostridium difficile infection 5. Review teaching for all clinical staff (doctors, nurses and rehabilitation therapists) on the importance of optimal infection prevention and control practices to ensure that it is fit for purpose, provides staff with the information, knowledge and skills necessary to minimise the risk of infection and meets the requirements of the Hygiene Code 6. Host a third study day in 2013 at The Royal Marsden on combating HCAIs, with the particular emphasis on the growing threat of multi-drug resistant gram negative organisms 7. Provide a proactive and responsive infection prevention service to all areas of the Trust, with particular emphasis on increasing awareness of the service in community staff 8. Review the costs and benefits of pre-surgical decolonisation for all patients to reduce the risk of post operative wound infection with a view to introducing universal preoperative decolonisation 9. Undertake a detailed retrospective analysis of the antibiotic profiles on those patients who acquired Clostridium difficile in hospital to see if there are ways in which we need to revise our antibiotic usage. How will improvement be measured and monitored? Improvements will be monitored by the monthly Infection Prevention and Control Team meeting. This is a multidisciplinary meeting chaired by the Chief Nurse, who is the Director of Infection Prevention and Control for the Trust. Bacteraemia caused by both meticillin-resistant and meticillin-sensitive Staphylococcus aureus (MRSA and MSSA), vancomycin-resistant enterococci (VRE) and Escherichia coli will be reported externally to the new Public Health England, as will all confirmed Clostridium difficile infections. Numbers of selected infections will be monitored internally to the Board in the Trust Board Scorecard and published in the quarterly Integrated Governance Reports. Reduction in HCAIs remains a priority for 2013/14 to prevent further harm to patients. 24 Annual Report and Accounts 2012/13 Priority 2 To reduce the rate of patient safety incidents that have resulted in severe harm or death Target Reduction in the rate of patient safety incidents per 100 admissions and the proportion that have resulted in severe harm or death. In 2011/12 the number of deaths from serious incidents per 100 admissions was 0.013; the number of severe harms from incidents was 0.021. What did we do in 2012/13? –– We strengthened the use of the World Health Organisation (WHO) Surgical Safety Checklist to promote the safety of patients in the pre, peri and post operative period –– We invested in new digital assisted defibrillators throughout the Trust to be used in the event of cardiac arrest –– We strengthened the use of the national venous thromboembolism prevention and treatment algorithims across the Trust –– We continued to work on preventing medication errors and falls. How did we perform in 2012/13? Patient safety incidents resulting in severe harm or death This year is the first time that this indicator has been required to be included within the Quality Report alongside comparative data provided, where possible, from the Health and Social Care Information Centre. The National Reporting and Learning Service (NRLS) was established in 2003. The system enables patient safety incident reports to be submitted to a national database on a voluntary basis designed to promote learning. It is mandatory for NHS trusts in England to report all serious patient safety incidents to the Care Quality Commission as part of the Care Quality Commission registration process. The Trust reports all patient safety incidents reported on Datix to the NRLS. Prior to NRLS producing their six monthly reports, the Trust re-submits all patient safety incidents which captures changes made as a result of investigations. The NRLS does not update its previously reported figures so these changes may not be reported by the NRLS and the data held by the Trust may not be the same as that reported by the NRLS. Rate of reported patient safety incidents (Severe harm or Death), per 100 admissions – 0.008 Number of patient safety incidents (Severe harm or Death) – 4 Total patient safety incidents – 2978 Patient safety incidents (Severe harm or Death) as % of all patient safety incidents – 0.13% What actions are we planning to improve our performance? –– To increase the use of the Team Simulation for Emergency situations to other clinical teams –– Introduce the use of the new National Early Warning System which will be audited throughout 2013/14 –– Investigate the use of VitalPac systems to ensure clinical teams intervene early when patients deteriorate. How will improvements be measured and monitored? –– Through the specialist Morbidity and Mortality meetings –– Clinical Audit –– National mandatory audits –– Utstein cardiac arrest audit. 25 The Royal Marsden NHS Foundation Trust Priority 3 Reduction in venous thromboembolism (VTE) events/clot formation Target All appropriate patients will have venous thromboembolism (VTE) assessment within 24 hours of admission and receive prophylaxis; to undertake a root cause analysis on all confirmed VTE. VTE is a collective term for deep venous thrombosis and pulmonary embolism. A deep vein thrombosis is a blood clot that forms in a deep vein (usually in the leg) and sometimes a clot breaks off and travels to the arteries of the lung where it will cause a pulmonary embolism. VTE can be avoided by giving preventative treatment (prophylaxis) to patients at risk. Patients with cancer are at greater risk of developing VTE therefore this continues to be a safety priority for us. What did we do in 2012/13? The multidisciplinary VTE Steering Board is now well established and VTE risk assessment for all appropriate patients is embedded into clinical practice in the hospital. All elective inpatients are sent information leaflets in advance of their admission to inform them of what they can do to help prevent clot formation. Furthermore, posters and patient information leaflets are available in the clinical areas or from Patient Advice and Liaison Service (PALS). More specifically the steering group has directed the following actions: –– Ensure that every confirmed diagnosis of a VTE undergoes a root cause analysis to determine the underlying cause of the VTE and if any other preventative action could be taken. The consultant in charge of the patient is contacted if there are any concerns about care –– Performance manage the compliance with risk assessment; detailed performance reports are sent out to appropriate staff daily. Appropriate prophylaxis prescriptions are monitored monthly –– Implementation of the new prescription drug chart which incorporates VTE risk assessment and 24 hour reassessment. The drug chart also contains information on prescribing for the junior doctors –– The day units are developing alert cards for patients and providing stockings for patients who may have a reduction in energy levels. The alert cards instruct patients to apply the stockings if their activity levels reduce when on their chemotherapy –– Updating of the VTE Patient Information booklet in line with NICE guidance published in June 2012. 26 Annual Report and Accounts 2012/13 How did we perform in 2012/13? We have achieved the NHS Commissioning for Quality and Innovation (CQUIN) target of 95% compliance for ensuring all of our patients are appropriately assessed for risk of VTE in 2012/13. Furthermore we have reached the 95% level of appropriate prophylaxis being prescribed to prevent VTE. VTE Q1 Q2 Q3 Q4 Quarter target 95% 95% 95% 95% Prophylaxis prescribed 96% 96% 96% 96% The graph below demonstrates the percentage of patients who had a risk assessment completed. VTE risk assessment compliance April 2011 to March 2013 Level of assessment achieved Trust target 95 90 85 March 2013 Feb 2013 Jan 2013 Dec 2012 Nov 2012 Oct 2012 Sept 2012 Aug 2012 July 2012 June 2012 May 2012 April 2012 March 2012 Feb 2012 Jan 2012 Dec 2011 Nov 2011 Oct 2011 Sept 2011 Aug 2011 July 2011 June 2011 May 2011 80 April 2011 Percentage of patients assessed 100 27 The Royal Marsden NHS Foundation Trust What actions are we planning to improve our performance? –– Regular audit of a new prescription drug chart, checking documentation of patient weights and feeding back to Ward Sisters, Matrons and Pharmacy –– Daily score cards will be sent to VTE leads to check on progress –– Monthly compliance checking of appropriate mechanical prophylaxis –– Weekly compliance checking VTE reassessment within 24 hours –– All hospital acquired thrombosis will be reviewed by consultants who will check for recurring themes –– Emphasis will be placed on weight appropriate prescribing to ensure we are compliant with the CQUIN targets –– Two random cases of hospital acquired thrombosis will be audited monthly, checking for appropriate treatment dose –– Monthly VTE Steering Group meetings have been scheduled –– VTE reporting will take place regularly to the Junior Doctors Forum –– VTE presentation at each Junior Doctors Induction –– Ongoing audit of patient information and support received in the Outpatient departments –– Developing alert cards and anti-thrombolic stockings for patients in day care. How will improvement be measured and monitored? VTE incidents and performance with assessment and prevention procedures will be monitored by the VTE Steering Board. Performance will also be monitored at the Key Performance/CQUIN Steering Board and through the monthly Board scorecard. The Trust has achieved its targets, however this will continue to be included as a priority for 2013/14 because “Quality Accounts: reporting arrangements for 2012/13” (DoH, January 2013) and the “NHS Outcomes Framework 2012/13” suggest this remains an important indicator of improvement in protecting patients from avoidable harm. In 2013/14 the actions described above will be ongoing and embedded into practice. This will be demonstrated by ongoing monitoring and audit of compliance. 28 Annual Report and Accounts 2012/13 Priority 4 Reduction of pressure ulcers Target To reduce the incidence of severe community acquired category 3 and 4 avoidable pressure ulcers. Pressure ulcers are a good indicator of quality of care; their prevention requires assessment and good skin care and adequate hydration and nutrition. Some patients with long term conditions are at high risk of developing pressure ulcers because they have fragile skin, can have reduced nutrition and some medications can increase the risk. A rising incidence of pressure ulcers across many patients can be an early indication of deteriorating standards and therefore must be monitored closely. During 2012/13 guidance was made available from NHS London on pressure ulcers in relation to being avoidable or unavoidable and all factors must be taken into account when deciphering the cause of the pressure ulcer. What did we do in 2012/13? Since 2011 all serious pressure ulcers (category 3 and 4) have been reported as serious incidents nationally. All pressure ulcers in the hospital and the community are reported on Datix our online incident reporting system and all serious pressure ulcers are investigated using root cause analysis. Monthly category 3 and 4 pressure ulcer incident panel meetings are chaired by the Assistant Chief Nurse (Operations). These are multidisciplinary team meetings with representation from both community and hospital teams. These meetings have created great learning opportunities and a venue for sharing best practice. There is also a pressure ulcer working group, chaired by the Clinical Nurse Director for Adult Community Services which is tasked to take forward the recommendations of the incident panel meetings and this is overseen by the Pressure Ulcer Strategy Group chaired by the Assistant Chief Nurse (Operations). More specifically the pressure ulcer group has directed the following actions: –– Updating the pressure ulcer risk assessment and prevention policy to include hospital and community settings –– Mapped the pressure ulcer pathway –– Introducing systems to ensure holistic assessment of patients occurs at the outset of care and that good practice is shared amongst all –– Developed patient and carer information leaflets on pressure ulcer prevention and care –– Completed a knowledge and skills gap analysis and developed appropriate learning and development days –– Ensuring that pressure ulcer prevention and management is part of mandatory training –– Ensuring that all staff are familiar with appropriate documentation for assessing and monitoring pressure areas as well as treating pressure ulcers. From October 2010, all category 3 and 4 pressure ulcers have been classified as a Serious Incident (SI) and have been reported to the Clinical Quality and Review Group and the Integrated Governance and Risk Management committee. This process has been hugely beneficial within community services so that we can easily establish the root cause to why a pressure ulcer developed and determine whether the pressure ulcer was avoidable or unavoidable. Investigation panels attended by representatives from the relevant district nurse teams have been held for each of these incidents to give clinical oversight and to ensure that sufficient organisational learning takes place. 29 The Royal Marsden NHS Foundation Trust How did we perform in 2012/13? There are a larger number of pressure ulcers in the community. Pressure damage in the community is more challenging to prevent because the environment is much harder to control: many people are looked after in the community by formal and informal carers that the Trust has no responsibility for, many patients are frail/elderly and the home environment is less easy to control. The Trust is however committed to reducing pressure ulcers in the community setting. The table below shows the number of community acquired category 3 and 4 pressure ulcers. 2012/13 Number of community acquired pressure ulcers Category 3 39 Category 4 7 The chart below outlines the number of pressure ulcers (category 3-4) that were acquired within the community setting during the period April 2011 to March 2013. Community acquired category 3 and 4 pressure ulcers April 2011 to March 2013 Category 3 Category 4 8 7 Number of pressure ulcers 6 5 4 3 2 1 30 March 2013 Feb 2013 Jan 2013 Dec 2012 Nov 2012 Oct 2012 Sept 2012 Aug 2012 July 2012 June 2012 May 2012 April 2012 March 2012 Feb 2012 Jan 2012 Dec 2011 Nov 2011 Oct 2011 Sept 2011 Aug 2011 July 2011 June 2011 May 2011 April 2011 0 Annual Report and Accounts 2012/13 What actions are we planning to improve our performance? A large programme of work has been commenced by community services to address pressure ulcer prevention strategies. All category 3 and 4 incidents are investigated and presented at a panel to identify root causes and to learn from incidents to improve care for patients. From this the following pieces of work have started: –– Training programmes for internal staff are now mandatory on pressure ulcer prevention and management. A skills gap workshop for registered nurses has been undertaken to identify areas where we need to invest more training –– Training and education for local authority staff (formal carers) has been set up and delivered –– A programme has been delivered to care homes as part of a CQUIN target for staff on pressure ulcer prevention, nutrition, continence, falls and diabetes. The training was well evaluated –– Re-design and re-launch of leaflets for patients and both paid and unpaid carers on skin care and prevention strategies. These are routinely given to patients on admission to the service –– Work commenced on joint care planning with local authority staff that provide care to patients known to the District Nursing teams –– Investment in workforce to assist Tissue Viability Nurses to support District Nursing teams in pressure ulcer prevention and management strategies including the development of registers of patients at risk of pressure ulcer development –– A CQUIN this year has also focussed on pressure ulcer prevention and management with investment for an extra Tissue Viability Nurse to support the project –– Developing care plans and pathways –– Equipment update training days have taken place and continue –– The Pressure Ulcer Prevention and Management policy has been reviewed and updated to reflect any changes in documentation and processes –– Audits of pressure ulcer returns to enforce prevention strategies –– Developing and rolling out checklist to ensure all assessments completed in a timely manner –– To review wound photography guidelines to ensure they are fit for purpose –– Adults at risk policy revised to incorporate pressure ulcer management –– Shared learning for teams –– The pressure ulcer panel continues monthly and clarity gained on whether the pressure ulcer was avoidable or unavoidable. How will improvement be measured and monitored? Pressure ulcers will continue to be monitored by the Pressure Ulcer Working Group which is chaired by the Clinical Nurse Director for Adult Community Services, with serious pressure ulcers being reported in the monthly Quality Account presented to the Board. All category 3 and 4 pressure ulcers will be overseen by the Trust Integrated Governance and Risk Management Committee. Reducing pressure ulcers in the community setting will remain a quality priority for 2013/14; hospital acquired pressure ulcers will continue to be tracked as described but will not form part of the 2013/14 quality account. The actions described above will continue through 2013/14 to ensure we reduce the number of avoidable community acquired pressure ulcers. 31 The Royal Marsden NHS Foundation Trust Priority 5 To increase the proportion of patients that die in their preferred place of death. Target To achieve more than 42% of patients dying in their preferred place of death. To increase the numbers of patients dying in their preferred place of death where previously indicated and recorded on Coordinate my Care (CMC) to over 42% as reported in The National Primary Care Snapshot Audit in End of Life Care (2009). Coordinate my Care is a communication clinical service that coordinates of end of life care for patients who receive multiple services and care from multiple providers, allowing patients to have choice and improved quality of end of life care. There is a central database in London that is hosted by The Royal Marsden. What did we do in 2012/13? –– 17/26 (65.4%) patients known to The Royal Marsden who were entered onto Coordinate my Care by staff of The Royal Marsden NHS Foundation Trust achieved their preferred place of death –– 20/26 (76.9%) patients known to The Royal Marsden who were entered onto Coordinate my Care by staff of The Royal Marsden achieved their preferred place of death or died at home. How did we perform in 2012/13? –– Of the nine patients who didn’t achieve their documented preferred place of death: –– three died at home –– three died in a hospice –– two died in hospital, one due to no bed being available in the hospice –– one had stated ‘other’ as ‘preferred place of death’ with no further documentation to identify where that might be. 32 Annual Report and Accounts 2012/13 What actions are we planning to improve our performance? –– Education –– Palliative care teaching on biannual Royal Marsden hosted south west/north west Core Medical Training regional teaching to include emphasis on end of life care planning –– Palliative care in-house study days to include advance care planning –– Nursing education on identifying progression of the dying phase –– Close working between palliative care and oncology teams –– Involvement of Hospital2Home team when patients are being officially discharged from hospital with no further follow up appointments scheduled –– Use of the weekly Palliative Care multidisciplinary team meeting to ensure that preferred place of care and death is being addressed for patients known to the Palliative Care Team –– Roll out of Coordinate my Care across London with associated education programme which will: –– Highlight the importance of addressing preferences for end of life care –– Improve documentation between different healthcare providers to ensure smooth transfer of accurate, up to date information on end of life care preferences. How will improvement be measured and monitored? –– Weekly review of outcomes for preferred place of care and death for patients referred to the Hospital2Home service –– Weekly reporting on ‘preferred place of death’ from the Coordinate my Care team. This information is then disseminated to lead clinician and lead end of life commissioner within each Clinical Commissioning Group. 33 The Royal Marsden NHS Foundation Trust Priority 6 To increase the number of patients who are offered an Holistic Needs Assessment Target To achieve an increase in the number of designated patients who will undergo Holistic Needs Assessment by the end of 2012/13. A holistic needs assessment (HNA) is a process of gathering information from the patient and/or carer in order to inform discussion and develop a deeper understanding of what the person living with and beyond cancer knows, understands and needs. A Holistic Needs Assessment is not a one-off exercise, but is the basis of assessment and care planning from diagnosis onwards. What did we do in 2012/13? –– The Nurse Consultant for Living With and Beyond Cancer undertook a service evaluation to identify the number of Clinical Nurse Specialists offering Holistic Needs Assessments to patients, and to identify a consistent framework for Holistic Needs Assessment –– In July 2012 the London Cancer Alliance Interim Clinical Board agreed that a Holistic Needs Assessment must be offered within two weeks of a cancer diagnosis and offered again when primary treatment has been completed, whether the treatment is surgery, radiotherapy or chemotherapy –– The Trust has been accepted as a Macmillan e-HNA pilot site and work is underway for this bringing the Holistic Needs Assessment to patients via electronic tablets –– A policy around the purpose and usage of Holistic Needs Assessment is in development. How did we perform in 2012/13? –– By the end of the first quarter Clinical Nurse Specialists offered 249 patients the Holistic Needs Assessment form to complete and 112 (45%) were returned –– Within the second quarter Clinical Nurse Specialists offered 275 patients the Holistic Needs Assessment form to complete and 103 (38%) were returned –– Within the third quarter Clinical Nurse Specialists offered 231 patients the Holistic Needs Assessment form to complete and 30 (13%) were returned –– Within the fourth quarter Clinical Nurse Specialists offered 280 patients the Holistic Needs Assessment form to complete and 113 (40%) were returned –– Throughout the year 1035 holistic assessment needs forms were offered to patients and 358 (35%) were returned. 34 Annual Report and Accounts 2012/13 The table below shows which units and how many patients were offered a Holistic Needs Assessment to complete and how many chose to return the form. Unit HNA offered HNA returned Breast 322 86 Gastrointestinal 69 58 Gynaecology 26 13 Head and Neck 50 11 Lymphoma 28 3 Late Effects 407 174 Lung 86 3 Melanoma 21 1 Palliative Care 14* 3 Urology 9 6 Total 2012/13 1035 358 (35%) * it was agreed that palliative care would not give out anymore forms as patients should be offered a Holistic Needs Assessment at the time of diagnosis and at the end of primary treatment. What actions are we planning to improve our performance? –– Continue to encourage the use of the Holistic Needs Assessment across all clinical teams –– Agreeing Holistic Needs Assessment (HNA) service plans with clinical teams and supporting their implementation –– Encouraging the use of approved HNA and care planning templates using the intranet –– Providing training and support for staff in implementing HNAs –– Present Trust wide HNA results to all MDTs –– Improve the response rate for completion of HNA forms. How will improvement be measured and monitored? –– Assisting with gathering data to meet the London Cancer Alliance metric –– Within The Royal Marsden each clinical team or service will be asked to collect their own data, either by individual Clinical Nurse Specialist or by team. To be agreed by Divisional Clinical Nurse Directors with input from the Nurse Consultant for Living With and Beyond Cancer –– The numbers of completed Holistic Needs Assessments per clinical team will be monitored by the performance team monthly –– Overall completion rates will be presented by clinical speciality in the Quality Account quarterly. 35 The Royal Marsden NHS Foundation Trust Priority 7 Avoidance of emergency readmissions to hospital within 28 days of discharge Target To achieve a reduction in the number of avoidable readmissions to hospital within 28 days of discharge. What did we do in 2012/13? Together with the South West London Acute Commissioning Unit we undertook an external audit of all readmissions over a 12 month period. The results were presented at the Clinical Quality Review Group (CQRG) How did we perform in 2012/13? The chart below shows the percentage of patients that were readmitted within 28 days from April 2012 to March 2013. Reported percentage of emergency readmissions Percentage of eligible admissions resulting in an eligible readmission 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 April 2012 36 May 2012 June 2012 July 2012 Aug 2012 Sept 2012 Oct 2012 Nov 2012 Dec 2012 Jan 2013 Feb 2013 March 2013 Annual Report and Accounts 2012/13 The table below shows the number of patients that were readmitted within 28 days from April 2012 to March 2013. Month Number of patients readmitted within 28 days April 2012 11 May 2012 10 June 2012 14 July 2012 22 August 2012 14 September 2012 13 October 2012 13 November 2012 11 December 2012 8 January 2013 9 February 2013 11 March 2013 9 What actions are we planning to improve our performance? –– Continuous review and evaluation of clinical care especially using the Enhanced Recovery Programme (ERP) –– Monthly prospective audit to monitor rates. 37 The Royal Marsden NHS Foundation Trust Priority 8 Reduction in chemotherapy waiting times and improvement in patient experience related to waiting times Target Reduction in chemotherapy waiting times at Sutton and Chelsea and improvement in the patient experience related to waiting times. What did we do in 2012/13? Reduction of chemotherapy waiting times The management of chemotherapy waiting times is a particular challenge for the organisation because of the complexity of checking it is safe to proceed to chemotherapy. Chemotherapy needs to be prepared in an aseptic unit (where staff are gowned and gloved to prepare chemotherapy). Furthermore several checking procedures have to be undertaken. In addition, the data below also include patients who are on clinical trials. Some chemotherapy research studies need up to four hours preparation time once goahead for treatment has been confirmed. The Trust is working hard at reducing the chemotherapy waiting times and improving the patient experience by the following: –– Introduction of a new appointment system at Chelsea site to improve treatment appointments and reduce waiting times –– Planned introduction of scheduling system at Sutton from March 2013 –– Improvements in pre-prescribing of chemotherapy to give pharmacy time to prepare chemotherapy in advance of the visit –– Production of a new patient information leaflet to inform patients about the process of chemotherapy production –– Improved communication between the staff and patients to keep them informed about their wait. 38 Annual Report and Accounts 2012/13 How did we perform in 2012/13? Patients are asked to give their feedback in real time. As they leave the outpatients department volunteers ask patients to give their responses on hand held devices to a variety of questions about their appointment. During 2012/13 between 30 and 90 patients have responded each month. In response to the question How do you feel about how long, from your stated appointment time you had to wait for your treatment to start? The chart below show that across the Trust during 2012/13 on average 64% of patients waited about the right length of time for their treatment to start. Waiting time to start of treatment Could have been a lot sooner Could have been sooner About right 100 90 80 70 50 40 30 20 10 March 2013 Feb 2013 Jan 2013 Dec 2012 Nov 2012 Oct 2012 Sept 2012 Aug 2012 July 2012 June 2012 May 2012 April 2012 March 2012 Feb 2012 Jan 2012 Dec 2011 Nov 2011 0 Oct 2011 Percentage 60 39 The Royal Marsden NHS Foundation Trust In response to the question Were you told how long you would have to wait? the chart below shows that on average 18% (140) of patients did not have to wait, 30% (241) were not told how long they would have to wait and 44% (336) were told and the wait was shorter or about as long as they had been told. Eight per cent (66) found that the wait was longer than they were told. Were you told how long you would wait? Don’t know Not told Yes and wait was longer Yes and wait was shorter Yes and wait was as long as told No did not have to wait 100 90 80 70 Percentage 60 50 40 30 20 10 40 March 2013 Feb 2013 Jan 2013 Dec 2012 Nov 2012 Oct 2012 Sept 2012 Aug 2012 July 2012 June 2012 May 2012 April 2012 March 2012 Feb 2012 Jan 2012 Dec 2011 Nov 2011 Oct 2011 0 Annual Report and Accounts 2012/13 In response to the question Were you told why you would have to wait? the chart below shows that on average 56% (371) of patients were told why they would have to wait and 29% (191) were not told but did not mind. Were you told why you would have to wait? No, would have liked reason Yes No and didn’t mind 100 90 80 70 Percentage 60 50 40 30 20 10 March 2013 Feb 2013 Jan 2013 Dec 2012 Nov 2012 Oct 2012 Sept 2012 Aug 2012 July 2012 June 2012 May 2012 April 2012 March 2012 Feb 2012 Jan 2012 Dec 2011 Nov 2011 Oct 2011 0 What actions are we planning to improve our performance? –– New information leaflets explaining the visit for treatment have been produced –– Waiting time information for display on the Medical Day Unit has been implemented –– Announcements being made every 30 minutes in the outpatients department –– Staff are speaking with individual patients when delays to appointments occur. 41 The Royal Marsden NHS Foundation Trust Priority 9 Ensure that we are responding to inpatients’ personal needs Target To improve in the responses to five questions related to “Improving responsiveness to personal needs of patients”. These five questions are taken from the national inpatient survey which is reported by the Care Quality Commission. Delivery of personalised medicine is one of the Trust’s strategic priorities. It is therefore important that we understand the patient experience when they attend outpatient departments, day units and inpatient areas. In May 2009 we started using frequent feedback hand-held devices in our day units and outpatient areas and the matrons are responsible for developing action plans in response to recurrent concerns. In 2012 these started being used in the inpatient areas. What did we do in 2012/13? The Patient Experience Feedback Group chaired by the Chief Nurse has overseen the following actions: –– Development of the real time feedback to the inpatient areas; the questionnaire has been developed and agreed with the Patient Feedback Steering Group and the volunteers have been trained to deliver the questionnaire –– Development of the real time feedback plan for the Oak Centre for Children and Young People including Focus Groups for selected age groups –– Commencement of new scheduling system unit to formalise the scheduling of day unit appointments in an effort to reduce waiting times for chemotherapy. 42 Annual Report and Accounts 2012/13 How did we perform in 2012/13? Inpatient Survey 2012 CQUIN data The NHS Commissioning for Quality and Innovation (CQUIN) groups together five questions from the annual national inpatient survey that indicate how trusts perform in “Improving responsiveness to personal needs of patients”. The following five questions are below and the table shows how the scores have improved over the last three years. Q32 Were you involved as much as you wanted to be in decisions about your care and treatment? Q34 Did you find someone on the hospital staff to talk to about your worries and fears? Q36 Were you given enough privacy when discussing your condition or treatment? Q56 Did a member of staff tell you about medication side effects to watch for when you went home? Q62 Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital? The Patient Experience CQUIN results for The Royal Marsden are as follows: Year Q32 Q34 Q36 Q56 Q62 Overall CQUIN score 2012 86.8 76 92.2 73 93 84.2 2011 83.4 75.7 91.6 70.4 92.8 82.8 2010 82.3 74.6 90 68.4 94.5 82 What actions are we planning to improve our performance? The Trust will continue to develop the nurse handover structure to ensure that discharge planning is discussed and agreed with the patient. Furthermore, it is proposed that patients are provided with a copy of their discharge summary when they leave the hospital. How will improvement be measured and monitored? The inpatient experience will be measured by the frequent feedback survey that has commenced in the inpatient areas and by the annual national inpatient survey. This will continue to remain important for the Trust and will continue to be part of the Quality Account for 2012/13; the NHS Operating Framework for 2012/13 includes an organisation’s responsiveness to patients needs as key indication of the quality of the patient experience. 43 The Royal Marsden NHS Foundation Trust Priority 10 Monitoring of the percentage of staff who would recommend The Royal Marsden to friends and family Target To maintain or increase the staff survey result to this specific question in the annual national staff survey. The national staff survey is conducted annually. In 2011/12 the Trust survey showed that when asked to consider the following statement If a friend of relative needed treatment, I would be happy with the standard of care provided by this Trust 84% (408/485) of staff would recommend The Royal Marsden to friends and family. What did we do in 2012/13? We continued to work with staff to improve services for patients through the year and have held focus groups with staff to discuss ways in which services could be provided better. We shared outcomes of patient surveys and our monitoring reports with staff. The Trust took part in the national early implementer scheme to introduce the Prime Minister’s question to all inpatients. The ‘friends and family’ test was in place from January 2013 in all inpatient areas. All patients when they are discharged are asked to answer the ‘friends and family’ question and place their response in a confidential box. The first results show that across 18 wards during the month of February 2013 of patients that were discharged 106 responded with a score of 4.9/5.0. How did we perform in 2012/13? Staff in this year’s survey have been asked to consider the following statement: If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation 87% (421/488) of staff would recommend The Royal Marsden to friends and family. This is an increase of three per cent from last year’s result. Table 1: Numbers of staff responding to question in national staff survey Agreed or strongly agreed Neither agree nor disagree Disagreed or strongly disagreed 2012 421 (87%) 51 (10%) 13 (3%) 2011 408 (84%) 55 (11%) 19 (4%) What actions are we planning to improve our performance? –– Encourage staff feedback on how our patient services could be improved –– Continue to promote quality monitoring reports and other information on our performance to staff –– Continue to feedback on the ‘friends and family’ test responses to staff. How will improvement be measured and monitored? –– Through the annual staff survey responses. 44 Annual Report and Accounts 2012/13 Priority 11 Safe care for children Target New Baby Review: The percentage of babies who receive the new birth visit up to day 14 after birth. 90% to be achieved. The New Birth Visit is part of the Healthy Child Programme – the universal clinical and public health programme for children and families from pregnancy to 19 years of age. The Healthy Child Programme, led by health visitors and their teams, offers every child a schedule of health and development reviews, screening tests, immunisations, health promotion guidance and support for parents tailored to their needs, with additional support when needed and at key times. There is strong evidence supporting delivery of all aspects of the Healthy Child Programme, which is based on Health for All Children, the recommendations of the National Screening Committee, guidance from the National Institute of Health and Clinical Excellence and a review of health-led parenting programmes by the University of Warwick. This universal service visit from health visitors provides the Healthy Child Programme to ensure a healthy start for children and family and support for parents and access to a range of community services/resources. This child health surveillance, health promotion and parenting support elements of the Healthy Child Programme for pregnancy and the first five years of life. The New Baby Review is a face-to-face review by 14 days with mother and father and includes advice and support on: –– Infant feeding –– Promoting sensitive parenting –– Promoting development –– Assessing maternal mental health –– Sudden Infant Death support –– Keeping safe – accident prevention advice. If parents wish or there are professional concerns: –– An assessment of baby’s growth –– On-going review and monitoring of the baby’s health –– Safeguarding. Health Visitors regard this review as a priority together with safeguarding and we are continually reviewing how we address those families not visited within the timescale. Reasons for this include mother and baby staying with relatives outside the area for an initial period of time and babies being born in the area who are resident in other areas. However, there are still a number that we can aim to visit within the timescale. 45 The Royal Marsden NHS Foundation Trust Table 1: Percentage of visits undertaken within 14 days after birth (those who live in the borough of Sutton): Target 90% monthly. Sutton borough Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Number (percentage) of children receiving new-birth visit by 14 days of age 163 (92.6%) 193 (91.9%) 221 (94%) 213 (94.2%) 184 (94.4%) 166 (93.3%) 200 (90.5%) 202 (94.8%) 186 (92.1%) 172 (93.0%) 178 (95.2%) 159 (95.8%) Number of children reaching 14 days of age in period 176 210 235 226 195 178 221 213 202 185 187 166 Table 2: Percentage of visits undertaken within 14 days after birth (those who live in the borough of Merton): Target 90% monthly. Merton borough Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Number (percentage) of children receiving new-birth visit by 14 days of age 217 (90.4%) 208 (92.4%) 212 (92.6%) 236 (92.2%) 236 (90.4%) 209 (92.5%) 249 (90.2%) 228 (91.9%) 214 (90.3%) 208 (94.5%) 211 (92.1%) 195 (91.5%) Number of children reaching 14 days of age in period 240 225 229 256 261 226 276 248 217 220 229 213 46 Annual Report and Accounts 2012/13 Table 3: Percentage of visits undertaken within 14 days after birth (those who are registered with a GP in Sutton and Merton): Target 90% monthly. Sutton and Merton PCT Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Number (percentage) of children receiving new-birth visit by 14 days of age 403 (91.4%) 414 (91.6%) 454 (92.7%) 470 (93.4%) 437 (91.8%) 464 (93.1%) 452 (90.1%) 417 (93.2%) 396 (91.2%) 396 (94.1%) 403 (93.5%) 372 (92.5%) Number of children reaching 14 days of age in period 441 452 490 503 476 423 515 485 457 421 431 402 47 The Royal Marsden NHS Foundation Trust Part three Outline of Quality Improvements in 2013/14 The Department of Health and Monitor issued ‘Quality Accounts: reporting requirements for 2011/12 and planned changes for 2012/13’ in February 2012. The proposed changes followed consideration by the National Quality Board as to how Quality Accounts should be strengthened through the introduction of mandatory reporting against a small, core set of quality indicators. Monitor will consult on these requirements as part of its consultation on the Annual Reporting Manual for NHS Foundation Trusts 2012/13. From 2011/12, all acute Trusts will be required to have limited assurance work performed on their Quality Accounts. Given the likely changes, we chose to include the proposed core set of quality indicators proposed for requirements from 2012/13. Some of the indicators are not very relevant to us e.g. ambulance response times, therefore these have been excluded However, we also felt it was important to consult with our members and governors to incorporate their views about “quality” into the Quality Account. The process for agreeing the priorities for quality improvement were as follows: October 2012 –– Key milestones and timetable outlined at the Patient Experience Feedback group were agreed. Members of the Patient experience feedback group were: Sutton LINks, Sutton Health and Wellbeing Board, Patients and Carers, Governors, Matrons from acute Trust and Community. November 2012 –– Review of first draft of the annual quality account 2012/13 priorities and progress to date –– Member’s event to discuss progress with developing and selection of quality priorities. December 2012 –– Agreed on process for selecting quality priorities. January 2013 – Review of progress –– Review second draft of annual quality account 2012/13. February 2013 – Engagement –– Final draft of annual Quality Account 2012/13 –– Senior Nurse and Therapies committee reviewed priorities –– Member’s event to discuss progress with developing and selection of quality priorities –– Council of Governor’s meeting assisted in the selection of priorities 48 Annual Report and Accounts 2012/13 –– Patient Experience Feedback group selected final quality improvement priorities –– Chief Nurse to discuss and agree measurable targets alongside relevant Trust staff –– Engagement and refinement – final draft to Patient and Carer Advisory Group, Council of Governors, Local Involvement Networks, Commissioner and the Health and Wellbeing Board; to comment and provide a statement about the annual Quality Account. March 2013 – Engagement –– Patient Experience Feedback group finalised quality improvement priorities and targets for 2013/14 –– Chief Nurse informed Board of progress to date and obtained approval of quality improvement priorities and targets for 2013/14 –– Draft to external stakeholders for comments and statements –– Draft to Trust staff for comments. April and May 2013 – Engagement and refinement –– Progress against 2012/13 targets to be added to final draft of annual quality account –– Copy to Marketing and Communications Department –– To external auditors for review –– Final copy to designer via marketing and communications team. May and June 2013 – Submission and publication –– Reviewed at Trust’s Audit committee –– Trust’s Annual Report submitted to Monitor by 31 May 2013 –– Trust publishes annual Quality Account on NHS Choices website and own website and submitted copy to Department of Health by 30 June 2013. 49 The Royal Marsden NHS Foundation Trust The quality priorities for 2013/14 The quality priorities and targets for 2013/14 are displayed in the table below. The priorities marked with * were mandatory quality indicators in 2012/13 and are expected to remain mandatory for 2013/14. There are three new (^) quality priorities for 2013/14. Table 1: Quality priorities and targets for 2013/14 Safe care Priority 1 Priority 2 Priority 3 *Reduction in Healthcare Associated Infections (MRSA bacteraemia and Clostridium difficile infections) Applies to Acute beds at The Royal Marsden and patients of Sutton and Merton Community Services (SMCS) *Rate of patient safety incidents and percentage resulting in severe harm or death (in 2012/13 the number of deaths from serious incidents per 100 admissions was 0; the number of severe harms from incidents per 100 admissions was 0.012) Applies to acute beds and SMCS *Percentage of admitted patients risk assessed for Venous thromboembolism Less than one MRSA bacteraemia Reduction in the rate of patient safety incidents per 100 admissions and the proportion that have resulted in severe harm or death Maintain above 95% the number of patients who have a completed VTE risk assessment Less than 11 C. Difficile infections (Report in Quality Account the number of C. difficile infections per 100,000 bed days) Effective care Priority 4 Priority 5 Priority 6 Priority 7 Reduction in community acquired grade 3 and 4 pressure ulcers: applies to SMCS Increase the number of patients that die in their preferred place of death (The National Primary Care Snapshot Audit in End of Life Care (2009) found that the number of patients achieving their preferred place of death is 42%) Applies to acute and SMCS Increase the numbers of patients who have an Holistic Needs Assessment *Avoidance of emergency re-admissions to hospital within 28 days of discharge. Reduce the incidence of severe community acquired pressure ulcers (grade 3 and 4) Achieve more than 42% of patients dying in their preferred place of death. Increase the proportion of designated patients who will be offered a Holistic Needs Assessment by the end of 2013/14 Reduction in the number of avoidable re-admissions to hospital within 28 days of discharge 50 Annual Report and Accounts 2012/13 Patient experience Priority 8 Priority 9 Priority 10 Reduction in chemotherapy waiting times and improvement in patient experience related to waiting times *Ensure that we are responding to in-patients’ personal needs *Percentage of staff who would recommend The Royal Marsden to friends or family needing care* Reduction in chemotherapy waiting times at Sutton and Chelsea and improvement in the patient experience related to waiting times Improvement in responses to five questions (in the CQC national survey described above) as monitored through the Inpatient Frequent Feedback Surveys Introduce a Patient Experience survey for SMCS To maintain or increase the staff survey result to this specific question in the survey. To achieve a baseline measurement and if possible benchmark with other community services Patient experience Priority 11 Priority 12 ^Improve communication, particularly when patients arrive for first appointments ^Reduce the length of time a patient waits for medicines or equipment at the point of discharge Increase or maintain the high percentage of positive comments in dedicated patient feedback Increase or maintain the high percentage of positive comments in dedicated patient feedback Childrens services Priority 13 ^The uptake of immunisation working in partnership with primary care Increase the percentage of children receiving pre-school immunisations in partnership with GPs (*) mandatory priority (^) new quality priorities 51 The Royal Marsden NHS Foundation Trust The table below summarises the quality objectives and priorities of the Trust for the last four years. Community services are detailed from 2011/12 onwards. Safety 2009/10 2010/11 2011/12 2012/13 Incidence of healthcare associated infections Reduction of healthcare associated infections Reduction of healthcare associated infections *Reduction in Healthcare Associated Infections Reduction in medication errors Reduction in medication incidents Reduction in medication incidents *Rate of patient safety incidents and percentage resulting in severe harm or death Incidence of falls Reduction in falls Reduction in falls. (hospital services) A 15% increase in number of falls screens compared to 2010/11 (SMCS) Assessment, monitoring and treatment of venous thromboembolism Reduction in venous thromboembolism (blood clots) Compliance with national health visiting targets: new birth visits (SMCS) Safeguarding children priorities – compliance with national guidance and training (SMCS) 52 *Percentage of admitted patients risk assessed for venous thromboembolism Annual Report and Accounts 2012/13 Effective care 2009/10 2010/11 2011/12 2012/13 Mortality rate, hospital standardised mortality ratio (HSMR) Reduction in the hospital standardised mortality ratio (HSMR) Reduction in the hospital standardised mortality ratio (HSMR) Reduction in the hospital standardised mortality ratio (HSMR) Incidence of hospital acquired pressure ulcers Reduction in the incidence of hospital acquired pressure ulcers Reduction in the incidence of hospital acquired pressure ulcers (hospital services) Reduction in community acquired grade 3 and 4 pressure ulcers Reduction in pressure ulcers especially grades 3 and 4 (SMCS) Achieve more than 42% of patients dying in their preferred place of death Effective length of stay Reduced length of stay Reduced length of stay Increase the numbers of patients who have been offered an Holistic Needs Assessment *Reducing the number of emergency re-admissions to hospital within 28 days of discharge 53 The Royal Marsden NHS Foundation Trust Patient experience 2009/10 2010/11 2011/12 2012/13 Patients in pain To be in top 20% of trusts for key areas on the national inpatient survey To be in top 20% of trusts for key areas of national inpatient survey *Improve or maintain a high score in relation to responding to inpatients’ personal needs in the national survey Patients treated with dignity and respect To be in top 20% of trusts for key areas on the national outpatient survey To be in top 20% of trusts for key areas of national outpatient survey Patients given enough information on discharge Roll out of the real time patient feedback throughout the Trust Roll out of the real time patient feedback throughout the Trust New initiatives to improve the patient experience in 2011/12. 1) To reduce chemotherapy waiting times, Reduction in chemotherapy waiting times and improvement in patient experience related to waiting times 2) To improve the patient experience of hospital transport, 3) To improve communication at every part of the patient journey *Percentage of staff who would recommend The Royal Marsden to friends or family needing care 54 Annual Report and Accounts 2012/13 Statements of assurance from the Board Review of services During 2012/13 The Royal Marsden NHS Foundation Trust provided and/or sub-contracted comprehensive cancer services. The Royal Marsden NHS Foundation Trust has reviewed all the data available to them on the quality of care in 100% of these services. The income generated by the NHS services reviewed in 2012/13 represents all of the total income generated from the provision of NHS services by The Royal Marsden NHS Foundation Trust for 2012/13. The data reviewed in part three of this Quality Account covers the three dimensions of quality: patient safety, clinical effectiveness and patient experience. In all areas the data has been available to review the service. Participation in clinical audits National clinical audits and national confidential enquiries are tools that NHS organisations use to assess the quality of services provided, against the best available evidence based guidance and standards. At The Royal Marsden we undertake many clinical audits. We participate in all the national cancer audits which are applicable to the organisation. This allows us to benchmark against other hospitals in England and sometimes across the world. We also have a comprehensive programme of local clinical audits which clinical staff including consultants, junior doctors, nurses and allied health professionals conduct regularly to improve local areas of care. During 2012/13 11 national clinical audits and three national confidential enquiries covered NHS services that The Royal Marsden provides. National confidential enquiries These are “inspections” that are carried out nationally to investigate areas of care where there may have been problems nationally or where the patients may be particularly vulnerable. All hospitals are asked to take part in them so that all care across England can be monitored. During 2012/13 The Royal Marsden participated in all 11 of the national clinical audits and three national confidential enquiries in which it was eligible to participate (Table 1). Many of the national audits undertaken by other hospitals cannot be undertaken at The Royal Marsden because we only have patients with cancer. The national clinical audits and national confidential enquiries that The Royal Marsden participated in, and for which data collection was completed for the period 2012/13, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry (Table 1 and 3). 55 The Royal Marsden NHS Foundation Trust Table 1: National clinical audits The Royal Marsden participated in 2012/13 No National Clinical Audits Participated Cases submitted (%) 1 National Comparative Audit of Blood Transfusion: Blood sampling and labelling Yes 100% 2 National Oesophago-Gastric cancer audit (NOGCA) Yes 100% input of those diagnosed at the Trust 3 The National Bowel Cancer Audit (NBOCAP) Yes 100% input of those diagnosed at the Trust 4 Lung Cancer (National Lung Cancer Audit) Yes Note: Tertiary Trust Standards do not apply as most patients are not “first seen” at tertiary trusts 5 Head and Neck Cancer (DAHNO) Yes 100% 6 Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme (CMP) Yes 100% Other National Audits 7 The Association of Breast Surgery (ABS) & NHS Breast Screening Programme Yes 100% 8 Breast Cancer Clinical Yes 100% Outcome Measures (BCCOM) Project 9 National Health Service Cancer Screening Programme (NHSCSP) Audit of Invasive Cervical Cancer Yes Ongoing data-collection for quarterly submission. 100% input of those treated at the Trust 10 Royal College of Radiologists (RCR) National Re-audit of Radiotherapy in the Treatment of Malignant Spinal Cord Compression Yes 100% 11 The British Association of Urological Surgeons (BAUS) Nephrectomy audit Yes 100% 56 Annual Report and Accounts 2012/13 The reports of 13 national clinical audits were reviewed by The Royal Marsden in period 2012/13. The Royal Marsden will take the following actions to improve the quality of healthcare provided. Table 2: National clinical audits published reports and actions taken in 2012/13 No National Clinical Audit reports published in 2012/13 Description of actions 1 National Lung cancer Audit Report 2011 None. Treatment practice exceeds national standards. (Diagnosis is not undertaken at The Royal Marsden) 2 National Head & Neck Cancer Audit 2011: 7th Annual Report Recommendations reviewed 3 National Oesophago-Gastric Cancer Audit Report 2012 Recommendations reviewed 4 National Bowel Cancer Audit Report 2012 Recommendations reviewed 5 2011 Audit of the medical use of red cells Report reviewed 6 2012 Audit of blood sampling and labelling Report reviewed 7 NHSCSP Audit of invasive cervical cancer National report 2007-2011 Report disseminated NHS Breast Screening Programme & ABS An audit of screen detected breast cancers for the year of screening April 2010 to March 2011 Report disseminated 8 NCIN (National Cancer Intelligence Network) Recurrent and Metastatic Breast Cancer Data Collection Project, Pilot report, March 2012 Recommendations reviewed 9 Findings of the UK national audit evaluating image-guided or image assisted liver biopsy. Part I. Procedural aspects, diagnostic adequacy, and accuracy Report disseminated 10 Findings of the UK national audit evaluating image-guided or image assisted liver biopsy. Part II. Minor and major complications and procedure-related mortality 2009/10 Report disseminated 11 RCR Summary Report of the Results of the Royal College of Radiologists’ National Breast Radiotherapy Audit Reviewed by members 12 RCR National Oesophago-Gastric Cancer Audit – 2012 Annual Report Report disseminated 13 BAUS section of oncology Report disseminated Analyses of Nephrectomy dataset 1 January – 31 December 2011, June 2012 57 The Royal Marsden NHS Foundation Trust Table 3: National confidential enquiries The Royal Marsden eligible to participate in No National Confidential Enquiry into Patient Outcome and Death (NCEPOD) studies Participated % cases submitted 1 Alcohol related liver disease Yes 100% 2 Subarachnoid haemorrhage Yes 100% 3 Tracheostomy care (pilot) Yes 100% The reports of two national confidential enquiries report were reviewed by The Royal Marsden in 2012/13. The Royal Marsden intends to take the following actions to continue to improve the quality of healthcare provided. Table 4: National Confidential Enquiries reports published in 2012/13 and actions No National Confidential Enquiry into Patient Outcome and Death (NCEPOD) studies Description of actions (local) 1 Bariatric Surgery: Too Lean a Service? (2012) Not applicable. Bariatric surgery for weight loss 2 Cardiac Arrest Procedures: Time to Intervene? (2012) Recommendations reviewed The reports of 88 local clinical audits and local action plans to improve the quality and outcomes of patient care were reviewed by The Royal Marsden in 2012/13. Participation in clinical research The Royal Marsden, The Institute of Cancer Research and Mount Vernon Cancer Centre form the largest centre for cancer research in Europe. This is important because it means that our patients and our staff are always aware of the latest research in treatments, medicines and therapies that make such a major difference to outcomes and the experience of care. If you would like to find out more about our research work please go on to our website on www.royalmarsden.nhs.uk The number of patients receiving NHS services provided or subcontracted by The Royal Marsden in 2012/13 that were recruited during that period to participate in research approved by a research ethics committee was 7,274 patients into 307 different trials. Revalidation of doctors Revalidation began in December 2012. The Trust has been preparing for this for some time and reported good progress on the Organisational Readiness Self-Assessment (ORSA) as at March 2012, with a delivery plan to ensure the four outstanding items are in place by the end of 2012. Of these four key tasks two have been fully implemented, with the others updated to reflect recent changes. The process to ensure doctors provide information from their work at other organisations in their appraisal portfolio has been revised based on further guidance and is being implemented in a consistent manner with neighbouring trusts. The policy for the reskilling, rehabilitation and remediation of doctors has been updated based on recent guidance and is progressing through the implementation stage. An electronic system to support revalidation has been procured and is now being rolled out. The appraisal system has been enhanced and is tightly monitored with the rates of completed appraisals improving. The Trust’s Responsible Officer has been revalidated and other doctors will begin to be revalidated from May 2013. The Trust’s progress to a ‘revalidation ready’ state is managed through clear governance arrangements and has been reported and discussed at all levels and relevant forums including the Trust Board. 58 Annual Report and Accounts 2012/13 Use of the CQUIN payment framework The Commissioning Quality and Innovation (CQUIN) payment framework is a method that the NHS introduced in 2009/10 to reward hospitals and other NHS services for taking quality and innovative patient care initiatives seriously. If hospitals did not achieve their CQUIN targets then, in 2010/11, 1.5% of a hospital’s income was removed and, in 2011/12, 2.5%. In challenging financial times for the NHS it is important that quality initiatives are linked to a financial lever to ensure that the front line staff and the Board are able to prioritise quality care. For a list of the CQUIN targets for 2012/13 and then 2013/14 please go on to the CQUIN page on our website via www.royalmarsden.nhs.uk or contact us via the Head of Quality Assurance on 020 7808 2702 and we can post details out to you. A proportion of The Royal Marsden NHS Foundation Trust’s income in 2012/13 was conditional on achieving quality improvement and innovation goals agreed between The Royal Marsden NHS Foundation Trust and any person or commissioning PCT they entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework. In 2012/13 The Royal Marsden achieved 100% of its CQUIN target which is £3 million. In 2011/12 The Royal Marsden achieved 93% of its CQUIN target which is £1.7 million. In 2012/13 Sutton and Merton Community Services achieved 86.7% of its CQUIN target which is £712,474. In 2011/12 Sutton and Merton Community Services achieved 90% of its CQUIN target which is £418,000. Further details of agreed goals for 2012/13 and for the following 12 month period are available online at: http://www.monitor-nhsft.gov.uk/sites/all/modules/fckeditor/plugins/ktbrowser/_openTKFile.php?id+3275 Or at The Royal Marsden website: www.royalmarsden.nhs.uk What others say about the provider Statements from the Care Quality Commission (CQC) The Royal Marsden NHS Foundation Trust is required to register with the Care Quality Commission and its current registration status is “registered with no conditions”. The Care Quality Commission has not taken enforcement action against The Royal Marsden NHS Foundation Trust during 2012/13. The Royal Marsden NHS Foundation Trust has not participated in any special reviews or investigations by the CQC during the reporting period, 2012/13. Data quality Good quality information is very important in underpinning the effective delivery of the best patient care. The Royal Marsden NHS Foundation Trust submitted records during 2012/13 to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data, which included the patient’s valid NHS number, was 98.7% for admitted patient care, 98.8% for outpatient care, and none for accident and emergency care (specialist cancer trust without an accident and emergency). The percentage of records that included the patient’s valid General Practitioner Registration Code was 98.9% for admitted patient care, 98.9% for outpatient care and none for accident and emergency. 59 The Royal Marsden NHS Foundation Trust Data quality – England and Wales % completeness NHS number GP practice 2010/11 2011/12 2012/13 2010/11 2011/12 2012/13 Inpatient & Day cases 98.6 98.6 98.7 99.0 99.0 98.9 Outpatients 98.6 98.8 98.8 98.9 99.1 98.9 Although Data Quality at The Royal Marsden is very good the Trust strives for continual improvement. The Royal Marsden NHS Foundation Trust implements the following actions to improve data quality: 1. A dedicated data quality team are responsible for running routine validation checks and reports to identify errors and inconsistencies in data entry 2. In 2013 Trust wide monthly communications started promoting the importance of accurate information and data collection centrally for all Trust staff 3. Trust wide audits of data quality involving key information points are conducted annually. Information Governance Toolkit attainment levels The Royal Marsden score for 2012/13 for Information Quality and Records Management assessed using the Information Governance Toolkit was 88%. This marks an improvement on the interim submission score in October 2012 of 86%. Furthermore, the Trust scored a minimum of Level 2 on all 45 requirements. Our final position is: satisfactory (Green). The Information Governance Toolkit is available on the Connecting for Health website (www.igt.connectingforhealth.nhs.uk). Clinical coding error rate The Royal Marsden NHS Foundation Trust was not to subject the Payment by Results clinical coding audit during the reporting period by the Audit Commission. Clinical coding Coding Errors Primary Diagnosis Errors Primary Procedure Code Errors Secondary Diagnosis Errors Second Procedure Code Errors 2009/10 2010/11* 2011/12** 2012/13** 5.0% 2.5% 3.5% 8.0% 35.7% 2.1% 12.4% 4.7% 7.2% 1.9% 2.9% 5.1% 12.8% 8.4% 26.4% 8.8% * The Trust was not eligible for an Audit Commission Clinical Coding Audit in 2010/11; these figures are therefore based on an audit commissioned by The Royal Marsden in November 2010. ** These figures are draft pending the final report from the Audit Commission for the 2012/13 audit. 60 Annual Report and Accounts 2012/13 Part four Review of quality performance (previous year’s performance) National targets National target 2012/13 2012/13 performance Q1 2012/13 performance Q2 2012/13 performance Q3 2012/13 performance Q4 2012/13 performance Cancer waiting times targets All urgent GP referrals seen within 14 days 93% 95.3% 98.0% 99.0% 97.6% 97.5% All referrals for breast symptoms seen within 14 days 93% 93.0% 89.2% 96.3% 97.1% 94.7% Treatment within 31 days of decision to treat for first treatment 96% 98.8% 99.5% 99.2% 99.3% 99.2% Subsequent surgical treatment started within 31 days of decision to treat 94% 96.2% 96.1% 96.8% 98.2% 96.8% Subsequent drug treatment started within 31 days of decision to treat 98% 99.5% 99.8% 100% 100% 99.8% Subsequent radiotherapy treatment started within 31 days of decision to treat 94% 95.6% 96.4% 98.8% 99.3% 97.6% Treatment started within 62 days of urgent GP referrals* 85% 86.6% 86.1% 87.3% 83.3% 85.9% Treatment started within 62 days of recall date for urgent screening centre referrals 90% 94.4% 90.6%* 95.7% 92.5% 93.2% * Figures include agreed reallocations between Trusts 61 The Royal Marsden NHS Foundation Trust NHS 18 week targets Target/ Priority National target 2012/13 2010/11 % achieved 2011/12 % achieved 2012/13 % achieved National target 2013/14 Patients requiring admission who waited <18 weeks from referral to treatment (not national targets since 2010) 90% 94.90% 94.8% 96.0% 90% Patients not requiring admission who waited <18 weeks from referral to treatment (not national targets since 2010) 95% 98.40% 98.8% 98.6% 95% Access targets National target 2010/11 % achieved 2011/12 % achieved 2012/13 % achieved Q1 2012/13 % achieved Q2 2012/13 % achieved Q3 2012/13 % achieved Q4 National target 2013/14 Target/ Priority Operations cancelled by the Trust at the last minute Less than 5% 0.3% 0.3% 0.16% 0.15% 0.36% 0.22% Less than 5% Last minute cancelled operations not subsequently performed within one month 0% 0% 0% 0% 0% 0% 0% 0% The Royal Marsden NHS Foundation Trust met all key performance waiting times and access targets in 2011/12 and 2012/13. 62 Annual Report and Accounts 2012/13 Appendix 1 Quality Indicators where national data is available from the Health and Social Care Information Centre (HSCIC) The Trust considers this data is as described as taken from the Health and Social Care Information Centre. The Trust has taken actions to improve the percentage and so the quality of its services (see priorities for each indicator in Part 2 for further information). The tables below shows how the trust compares against other trusts and shows the highest and lowest national scores. Quality Indicators A. The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information centre with regard to the rate per 100,000 bed days of cases of C. difficile infection reported within the trust amongst patients (Trust Priority 1). Period The Royal Marsden National highest (all acute and specialist trusts) National lowest (all acute and specialist trusts) Average acute trusts England national April 2011 – March 2012 30 51.6 *0 - 21.8 April 2010 – March 2011 56.6 71.8 *0 29.6 * The Trust is advised that the zero recorded here may be due to missing data reported to the centre. B. The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre Incidents reported within the trust during the reporting period and the number and percentage of such patient safety incidents that resulted in severe harm or death (Trust Priority 2). Percentage Period The Royal Marsden National highest (all specialist trusts) National lowest (all specialist trusts) Average specialist trusts October 2011 – March 2012 0.1 2.9 0 0.6 April 2011 – September 2011 0.3 4.6 0 0.3 63 The Royal Marsden NHS Foundation Trust Number Period The Royal Marsden National highest by % (all specialist trusts) National lowest by % (all specialist trusts) Average specialist trusts October 2011 – March 2012 2 6 *0 4.4 April 2011 – September 2011 5 11 *0 2.1 * The Trust is advised that the zero recorded here may be due to missing data reported to the centre. C. The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of patients who were admitted to hospital and who were risk assessed for venous thromboembolism during the reporting period (Trust Priority 3). Period The Royal Marsden National highest (all acute and specialist trusts) National lowest (all acute and specialist trusts) Average acute trusts England national Q3 2012/13 97 100 84.6 -* 94.1 Q2 2012/13 97 100 80.9 -* 93.8 * The Trust is advised that the zero recorded here may be due to missing data reported to the centre. 64 Annual Report and Accounts 2012/13 D. The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of patients aged – i) 0-14; and ii) 15 or over, readmitted to a hospital which forms part of the Trust within 28 days of being discharged from a hospital which forms part of the Trust during the reporting period (Trust Priority 7). Period The Royal Marsden National highest (all trusts) National lowest (all trusts) Average specialist trusts England national 2010/11 standardised to persons 2006/07 7.94 17.33 *0 9.52 11.42 2009/10 standardised to persons 2006/07 6.7 22.09 *0 9.45 11.16 * The Trust is advised that the zero recorded here may be due to missing data reported to the centre. E. The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regards to the trust’s responsiveness to the personal needs of its patients during the reporting period (Trust Priority 9). Period The Royal Marsden National highest (all trusts) National lowest (all trusts) Average specialist trusts England national 2011/12 82.8 85 56.5 *- 67.4 2010/11 82 82.6 56.7 *- 67.3 * The Trust is advised that the zero recorded here may be due to missing data reported to the centre. F. The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of staff employed by, or under contract to, the trust during the reporting period who would recommend the trust as a provider of care to their family or friends (Trust Priority 10). Period The Royal Marsden National highest (all specialist trusts) National lowest (all specialist trusts) Average acute trusts England national 2012 87 94 62 65 63 2011 85 96 66 65 60 65 The Royal Marsden NHS Foundation Trust Appendix 2 Statements from key stakeholders Statement from Patient and Carer Advisory Committee on the Quality Account Robert Francis QC, in his letter to the Secretary of State submitting his final report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, described a Trust that did not listen sufficiently to its patients and staff. The report made several recommendations surrounding openness and transparency. Robert Francis also wrote about the need to develop and share ever improving means of measuring and understanding of performance of hospitals. The Royal Marsden’s Quality Account for the period 2012/13 is the fourth report published by the Trust. This Quality Account demonstrates that the Trust remains focussed on listening to its patient, carer and staff community. It continues to strive to improve the quality of care and its services within the framework of its regulators. The document also makes clear The Royal Marsden’s commitment to be an organisation that does measure and understand its performance, meeting we believe, a vital recommendation of the Francis Public Inquiry. Importantly, the Quality Account sets out detailed quality priorities and targets for the period 2013/14. The Patient and Carer Advisory Committee commend this Quality Account. Charles McGregor Chairman of Patient and Carer Advisory Group Statement from the Council of Governors on the Quality Account 2012/13 The Council of Governors routinely reviews information prepared for inclusion in the Quality Account and has discussed the chosen priority quality issues at each of the Council of Governors meetings. A sub-group of the Council of Governors, the Patient Experience and Quality Account Group, has also reviewed feedback from patients, including from the frequent feedback surveys, and has influenced the questions used in these surveys, to reflect patients’ interests. Governors agreed the process for developing and selecting priorities for quality improvement and have met with patient, carer and public members at two Members’ Events, in July and November 2012. At these meetings, round table discussions were held to obtain members’ views on current and future areas relating to patient safety, clinical effectiveness and patient experience. The results were then formulated into priority topics for inclusion in the forthcoming Quality Account and submitted to the full Council of Governors for approval. Dr Carol Joseph, Public Governor for Kensington and Chelsea served as the representative from the Patient Experience and Quality Account Group, which was responsible for monitoring the development of the Quality Account throughout the year. The Royal Marsden strives to improve the presentation of data each year to make the Quality Account, now in its fourth year of publication, more succinct, interesting, and readable by the general public as well as by healthcare professionals. This year the Group of Governors have seen a considerable improvement in the layout of the information, making it easier to read and digest. Based on their involvement and the feedback they have received from members and other patients and carers, Governors endorse the key priorities for improvement as set out in the Quality Account. Dr Carol Joseph Public Governor for Kensington and Chelsea 66 Annual Report and Accounts 2012/13 Statement from NHS South West London on the Quality Account The Quality Account shows and reflects the huge amount of effort and commitment from all in the organisation to improve the quality of services in an already highly performing trust. It should give great assurance to all who use The Royal Marsden. Dr Tony Brzezicki Chair of The Royal Marsden Clinical Quality Review Group Healthwatch Central West London response to The Royal Marsden NHS Foundation Trust Quality Account 2012/13 Healthwatch Central West London (CWL) welcomes the opportunity to comment on The Royal Marsden NHS Foundation Trust’s Quality Account (QA) 2012/13. Prior to the commencement of Healthwatch (April 2013), K&C LINk Cancer sub group had ongoing correspondence with The Royal Marsden throughout 2012/13 with RMFT represented on the cancer sub-group. We would like to commend the Trust for their work on VTE risk assessment; however we would also like the Trust to further outline whether or not they intend on implementing thrombosis alert cards for outpatient and day patients. Healthwatch CWL would like clarity about how the Trust intends on monitoring the use of Holistic Needs assessment (HNA) as there is a seemingly low compliance rate of 38%. There does not seem to be a plan outlined to clarify what the trust will be implementing to review the leaflet, its ease of use, accessibility nor whether it addresses low and no literacy issues. Whilst we commend the trust for consistently low readmission figures, the figure for July 2012 (22) shows a significant increase upon previous months, we would like the trust to explain further what remedial process was put into place to alleviate this from recurring. Healthwatch CWL would like to suggest that the new patient experience leaflets outlined in priority 8 for patient experience are co-produced between the Trust and patients. Healthwatch CWL very much looks forward to continuing our strong working relationship with The Royal Marsden NHS Foundation Trust in 2013/14, particularly engaging with patients and members to take part in the new PLACE assessments. Note: For further information on this statement please contact Melanie Christodoulou, Interim coordinator, Healthwatch CWL on email: [email protected] or call 020 8968 7049 67 The Royal Marsden NHS Foundation Trust Statement from Sutton Health and Wellbeing Board on the Quality Account Page number* Comment(s) 24 second bullet point “across almost all”: can you clarify use of “almost” (or express as a percentage) explaining why those areas which are not audited are not part of the scheme. 34 Is the target sufficiently stretching when performance has substantially achieved it? 36/37 With the low response rates for some conditions have you undertaken any work to try to understand why? Is it that the process could be more sensitive to patient needs / is the form too off-putting or complicated? Are staff at some locations using better techniques to get better responses? Are some conditions ‘naturally’ more likely to generate a response? The quarterly response rate figures deteriorate quite significantly in quarter 3 of 2012/13 (and were below target). Some explanation or comment on this would be helpful. It would be helpful for the narrative to make some comment on these figures. Particularly in light of the comments above the actions planned are expressed in too general a fashion. 38 This section would benefit from more narrative explanation particularly of the high and low months of July and December and some comment on what might be done to rectify. 42 The fact that a full third of patients were not told how long they would have to wait is concerning. As well as the other planned actions could you also consider offering indicative waiting times so that people would at least have some guide. 44/45 The fact that just under and just over a quarter of patients could not find someone to talk to about worries and fears (Q34) and were told about side effects (Q56) is concerning. Further narrative explaining what is being done to improve these areas would be helpful. 52 Targets for some priorities need to be expressed more robustly e.g. Priority 5 should set a new target value (see also point above re p.34) as a percent not simply to improve on the value set last year. See also Priorities 6 and 7. 62 Is it possible to provide some explanation and comments on improvement actions in relation to the significant increase in errors between 2010/11 and 2011/12 for ‘primary procedure code errors’ and ‘second procedure code errors’. Councillor Mary Burstow Chair Sutton Health and Wellbeing Board *Sutton Health and Wellbeing Board commented on a draft of the Quality Accounts dated 25 March 2013. The page numbers have been adjusted to correlate with this final version. 68 Annual Report and Accounts 2012/13 Response from Merton Clinical Commissioning Group to The Royal Marsden NHS Foundation Trust Quality Account Merton Clinical Commissioning Group reviewed the Quality Account from The Royal Marsden NHS Foundation Trust at its Clinical Quality Meeting on 12 April 2013. Merton CCG is the host commissioner for the Sutton and Merton Community Services and commissions this community contract on behalf of Sutton CCG and the London Boroughs of Sutton and Merton and Public Health & the NHS England. Merton CCG recognises that the quality account covers both the acute hospital and community services, however we will comment solely on the community services aspect of the report. We recognise that much of the content of the quality account is mandated by the Department of Health and we regret that this makes some of the document rather technical and therefore less accessible to the lay reader. In terms of clinical care, the CCG was pleased to see the focus both on the very young and the elderly, with schemes relating to preventing pressure ulcers, choice of place of death and improving support to mothers after birth. We also welcome the focus on improved immunisation and vaccination take up rates for 2013/14. Within the CCG, our GPs are very keen for the local district nursing teams and other allied health professionals to work with them in a closer and more responsive and integrated way than has been the case over the last two years. To this end, we have asked The Royal Marsden to present their development plans for the community service to the CCG for discussion. We will be monitoring progress in achieving the targets set out in this quality account – as well as more general improvement goals – closely over the forthcoming year. Jenny Kay Director of Quality Eleanor Brown Chief Officer 69 The Royal Marsden NHS Foundation Trust Appendix 3 Statement of Director’s responsibilities in respect of the Quality Account The Directors are required under the Health Act 2009 and the NHS (Quality Accounts) Regulations 2010 to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS Foundation Trust Boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that Foundation Trust Boards should put in place to support the data quality for the preparation of the Quality Account. In preparing this Quality Report directors have taken steps to satisfy themselves that the content of the Quality Report meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2012/13. The quality of the Quality Report is consistent with internal and external sources of information including: –– Board minutes and papers for the period April 2012 to May 2013 –– Papers relating to quality reported to the Board over the period April 2012 to May 2013 –– Feedback from the commissioners dated 25 April 2013 –– Feedback from the Governors through the Council of Governors throughout the year dated 15 April 2013 –– Feedback from Healthwatch Central West London (during 2012/13 known was Kensington and Chelsea Local Involvement Network) dated 15 April 2013 –– The Trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Regulations 2009, dated 24 April 2013 –– The 2012 national in-patient survey results –– The 2012 national staff survey –– The Head of Internal Audit’s annual opinion over the Trust’s control environment dated 29 May 2013 70 –– CQC quality and risk profiles throughout April 2012 to March 2013 –– The Quality Report presents a balanced picture of The Royal Marsden NHS Foundations Trust’s performance over the period covered –– The performance information reported in the Quality Report is reliable and accurate –– There are proper internal controls over the collection and reporting of the measures of performance included in the Quality Report, and these controls are subject to review to confirm that they are working effectively in practice –– The data underpinning the measures of performance reported in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed definitions is subject to appropriate scrutiny and review; and the Quality Report has been prepared in accordance with Monitor’s annual reporting guidance (which incorporates the Quality Accounts regulations) published at www.monitor-nhsft.gov.uk/annual reporting manual as well as the standards to support data quality for the preparation of the Quality Report (available at www.monitor-nhsft.gov.uk/ annualreporting manual). The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Report. By order of the Board Mr R. Ian Molson Chairman 19 June 2013 Cally Palmer CBE Chief Executive 19 June 2013 Annual Report and Accounts 2012/13 Appendix 4 Independent Assurance Report Independent Auditor’s Report to the Council of Governors of The Royal Marsden NHS Foundation Trust on the Quality Report We have been engaged by the Council of Governors of The Royal Marsden NHS Foundation Trust to perform an independent assurance engagement in respect of The Royal Marsden NHS Foundation Trust’s Quality Report for the year ended 31 March 2013 (the “Quality Report”) and certain performance indicators contained therein. This report, including the conclusion, has been prepared solely for the Council of Governors of The Royal Marsden NHS Foundation Trust as a body, to assist the Council of Governors in reporting The Royal Marsden 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 2013, 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 The Royal Marsden NHS Foundation Trust for our work or this report save where terms are expressly agreed and with our prior consent in writing. Scope and subject matter The indicators for the year ended 31 March 2013 subject to limited assurance consist of the national priority indicators as mandated by Monitor: –– Clostridium difficile; –– Maximum 62 day waiting time from urgent GP referral to treatment for all cancers. We refer to these national priority indicators collectively as the “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 criteria set out in the NHS Foundation Trust Annual Reporting Manual issued by Monitor. 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 is not prepared in all material respects in line with the criteria set out in the NHS Foundation Trust Annual Reporting Manual; –– the Quality Report is not consistent in all material respects with the sources specified in the guidance; and 71 The Royal Marsden NHS Foundation Trust –– the indicators in the Quality Report identified as having been the subject of limited assurance in the Quality Report are not reasonably stated in all material respects in accordance with the NHS Foundation Trust Annual Reporting Manual and the six dimensions of data quality set out in the Detailed Guidance for External Assurance on Quality Reports. We read the Quality Report and consider whether it addresses the content requirements of the NHS Foundation Trust Annual Reporting Manual, and consider the implications for our report if we become aware of any material omissions. We read the other information contained in the Quality Report and consider whether it is materially inconsistent with the documents specified within the detailed guidance. 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. 72 Assurance work performed We conducted this limited assurance engagement in accordance with International Standard on Assurance Engagements 3000 (Revised) – “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 –– Testing key management controls –– Limited testing, on a selective basis, of the data used to calculate the indicator back to supporting documentation –– Comparing the content requirements of the NHS Foundation Trust Annual Reporting Manual to the categories reported in the Quality Report –– Reading the documents. A limited assurance engagement is smaller 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. Annual Report and Accounts 2012/13 Limitations Conclusion 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. Based on the results of our procedures, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2013: 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 criteria set out in the NHS Foundation Trust Annual Reporting Manual. The scope of our assurance work has not included governance over quality or non-mandated indicators which have been determined locally by The Royal Marsden NHS Foundation Trust. –– the Quality Report is not prepared in all material respects in line with the criteria set out in the NHS Foundation Trust Annual Reporting Manual; –– the Quality Report is not consistent in all material respects with the sources specified in the guidance; and –– the indicators in the Quality Report subject to limited assurance have not been reasonably stated in all material respects in accordance with the NHS Foundation Trust Annual Reporting Manual. Deloitte LLP Chartered Accountants St Albans 20 June 2013 73 The Royal Marsden NHS Foundation Trust Sustainability/climate change report Sustainability is an integral part of delivering high quality healthcare efficiently and The Royal Marsden continues to be committed to conducting all aspects of its activities with due consideration to the wider financial, social and environment impacts. Adaptation to climate change will pose a challenge to both service delivery and infrastructure in the future. It is therefore appropriate that the Trust considers it when planning how we will best serve patients in the future. Carbon and energy management The Trust’s Carbon Management Plan continues to provide the framework for our environmental agenda for the last and coming years up to 2015/16 with its goal of achieving 26% carbon savings on a 2010/11 baseline year of 13,350 tonnes of CO2. The chart below shows the Trust’s carbon reduction progress against its target Carbon Management Plan and shows that we are on programme due to better energy monitoring and control, fine tuning of our BMS system and optimisation of plant room pumps which has also resulted in savings. Carbon progress against target BAU Target emissions Carbon plan emisssions Actual emmissions 18 16 Per 1,000 tonnes CO 2 14 12 10 8 6 4 2 0 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 Further Carbon Management Plan projects that are in progress at the moment that will result in further carbon emission saving in the financial year 2013/14 are: –– The Combined Heat and Power Plant at our Sutton site which is due to go on line by the end of April 2013 which will save in the region of 4,168 tonnes of carbon emissions –– Upgrade of interior and external lighting at the Sutton site which completed at the end of March 2013 with an estimated saving of 400 tonnes of carbon emissions. Both these schemes will also produce a substantial monetary saving on energy costs which will be reinvested in patient care through better environmental facilities. 74 Annual Report and Accounts 2012/13 Good Corporate Citizen The Trust registered with the Good Corporate Citizen (GCC) assessment model during 2012/13 which allows organisations to score themselves against a range of questions to assess progress on sustainable development. The assessment was divided into six sections with the Trust’s score against each section shown in the table below. This gave the Trust an average score of 50% however as demonstrated by the table the Trust is ahead of time in most sections. Travel 46% Procurement 7% Facilities management 48% Workforce 70% Community engagement 57% Buildings 70% 2012 2015 2020 Governance The Trust has a Sustainable Development Management Plan which we continue to implement and update through the Carbon Management Programme Board to ensure that we fulfil our commitment to conducting all aspects of our activities with due consideration to sustainability whilst providing an excellent quality of patient care. Travel and transport The Trust continues to promote healthy travel to work for its staff through walking and cycling and is at present going for Stage 3 of the London NHS Cycling Scheme. It also promotes a car sharing scheme for staff which helps to reduce carbon emissions on staff travelling to work. The Trust also continues to encourage the use of its extensive video conferencing equipment in an effort to reduce its need to travel between hospital sites. The Trust has also just taken delivery of its first electrically powered vehicle for use in the Estates Department. 75 The Royal Marsden NHS Foundation Trust Sustainability Performance Summary The figures in the table 1 below are based upon the Trust’s Carbon Footprint data and shows comparison between data for the years 2011/12 and 2012/13 as determined under the Trust’s Carbon Management Plan using the Green house Gas Protocol. Table 2 shows performance against key growth metrics. Table 1: Summary of performance (water, gas, electricity and waste) April 2012/13 Area Data 2011/12 Data 2012/13 Cost (£) 2011/12 Cost (£) 2012/13 tonnes tonnes £ £ 1210 1078 353,760 319,733 High temperature disposal waste weight 173 166 152,590 149,645 Non burn treaement (alternative treatment plant) disposal waste weight 155 171 60,970 66,938 Landfill disposal waste weight 290 15 33,030 5,000 7 5 3,360 1,150 585 720 103,810 97,000 22,486,095 kWh 25,803,221 kWh £592,421 £838,304 17.257,791 kWh 18,766,643 kWh £1,717,892 £1,812,100 77,771 m3 94,858m3 £126,830 £2,650,404 13,573tCO2 14,582tCO2 Waste Minimisation & Management Total waste weight Waste electrical & electronic equipment (WEEE) weight Waste recovery/ recycling volume Finite resources Gas Electricity Water Green House Gas Emissions Electricity & Gas Scope 1 & 2 CO2 Emissions 76 Annual Report and Accounts 2012/13 Table 2: Performance against key growth metrics 2010/11 2011/12 2012/13 12,886 13,573 14,582 7.4% 5.3% 7.4% £257,887,000 £311,587,000 £320,203,000 4.40% 20.80% 2.8% 4.997 4.356 4.55 57,939 57,955 61,840 % increase in Area 5.4% 0.0% 6.7% Tonnes of CO2 Emissions per m2 Building Area 0.222 0.234 0.238 334,984 349,845 367,585 0.038 0.039 0.040 Tonnes of CO2 Emissions % increase in emissions over previous year Trusts Yearly Revenue (£) % increase in Revenue Tonnes of CO2 Emissions per £100k of revenue Trusts Building Area m2 Patient Attendances Tonnes of CO2 Emissions per patient attendance. Whilst the Trust and its partners are committed to sustainability, it is not just about achieving carbon reduction targets – it goes beyond just measuring carbon. A sustainable health and care system is achieved by delivering high quality care and improved public health without exhausting natural resources or causing severe ecological damage. This can more easily be achieved by ‘engaging’ with all concerned parties which the Trust will seek to enhance. The Trust, in line with business as usual, has increased its carbon emissions, however the area of the Trust, due mainly to the construction of a new Centre for Molecular Pathology has increased by 6.7%, with revenue increasing by 2.8% and patient attendances by 5.1%. Waste recycling continues to increase with waste to landfill reducing to our target of zero to landfill. Future direction The coming financial year will provide us with an excellent opportunity to further embed sustainability into the Trust as we hope to embark on a further large capital development at the Sutton hospital site which will allow the possibility of low or zero carbon technologies to be included at the very beginning of the project. We anticipate seeing good environmental and financial returns from a number of initiatives which are being planned at present which include; –– The installation of a Combined Heat & Power Engine at our Chelsea site which will supply electricity and heat at a reduced cost, reduce our carbon emissions and allow the removal of very old inefficient steam boilers –– Replacement of inefficient interior lighting with energy saving LED lamps through an LED Lighting Project at the Chelsea site which will give an estimated saving of 125 tonnes of carbon emissions. † All figures shown in this report are accurate at time of writing. 77 The Royal Marsden NHS Foundation Trust Our workforce The Trust employed 3,783 staff as at 31 March 2013. The breakdown by staff group is detailed below. Clinical Assistants 8% Physicists, Biomedical Scientist 4% Pharmacists & Technicians 4% Nursing 33% The HR function provides a comprehensive service across the full range of specialist areas. All departments have key performance indicators and performance is monitored to ensure the best fir and contribution to the business. Considerable work has continued over the last year to further modernise and improve the quality of several key services within the HR function. AHP 12% Ancillary 6% Medical 10% Our people are our most important resource. The Trust has monitored performance against plan for key human resources (HR) performance indicators on a monthly basis. Key indicators have included turnover, vacancy levels, sickness and agency spend. A comprehensive balance scorecard is in place which measures additional indicators such as total remuneration costs, human capital ROI, skill mix, e.g. ratio of nursing and clinical staff as a percentage of total staff, productivity and staff engagement. There continues to be good performance against all indicators. Admin & Clerical 23% Recruitment As part of the Resourcing Strategy, the number of assessment centres has increased through a planned programme. This approach strengthens the selection process and supports the hiring of high calibre staff through more robust assessment methods. Some routine elements of the recruitment process have been outsourced which has allowed the recruitment team to provide more focus on elements relating to patient safety such as pre-employment checks. The new online recruitment management system has been well received by managers and applicants and further benefits of the system will be realised over the next year. Employee relations The department has supported an increased number of organisational change programmes this year resulting from new ways of working and the introduction of new technologies. People management policies have been shortened and made simpler where possible, recognising we need responsive processes that support service needs. 78 Annual Report and Accounts 2012/13 Staff benefits The Annual Staff Survey The Trust recognises the need to value and reward its people appropriately and continues to offer a range of staff benefits. Online reward statements are available where staff can see the breakdown of all benefits in addition to pay. These include an on-site nursery, childcare vouchers, emergency childcare cover and holiday play schemes. The national staff survey identifies the extent to which staff feel motivated and engaged with their work as well as areas that the Trust can focus on to improve staff experience. Workforce information A number of new initiatives have been introduced this year. These include electronic HR forms which will support a reduction in overpayments and a new managers integrated workforce report which will give managers the information they need to help manage their staff in one report. Our new Human Resources and Organisational Development Service (HROD) The 2012 survey showed that the overall engagement of Trust staff is better then average, scoring 3.95 out of 5. In addition 83% of staff feel satisfied with the care they deliver, an increase from 77% last year. How members of staff rate the care that the organisation provides can be a meaningful indicator of the quality of care and a helpful measure of improvement over time. The 2012/13 staff survey results showed that the Trust staff scored 4.1 out of 5 that they would recommend the Trust as a place of treatment. While we have improved our services over recent years we believe that a different type of service is now necessary so that we can more proactively support and respond to business needs. We asked our stakeholders what they need from an HROD service and worked with them during 2012/13 to develop our new HROD service model. Our new model was launched in April 2013. Key to the new HROD Service is an HR Business Unit with HR Business Partners. The HR Business Unit works closely with senior leaders in the divisions. They act as strategic partners, creating and delivering value added workforce interventions that support patient care, business objectives and workforce productivity. The HR Business Unit works with a team of specialist HR practitioners and the HR services manager who oversees all transactional services. The HR Services Team delivers services for recruitment, temporary staffing, workforce information and training administration. A team of HR Services Advisers answer all new enquiries into the service, acting as a single reference point for managers. 79 The Royal Marsden NHS Foundation Trust Summary of performance NHS Staff Survey Overall performance in many aspects of the staff survey continues to be positive. The staff survey format has changed slightly this year with fewer key findings measured. The majority of scores (24/28) are either average or better than average in comparison to acute specialist Trusts, with 10 out of the 28 findings being better then average at The Royal Marsden. The overall score for staff engagement was 3.95 (out of five). Table 1 – Response rate 2011/12 Response rate 2012/13 Trust National average Trust National average 57 54 58 52 Table 2 – Top 5 ranking scores 2011/12 2012/13 Trust National average Acute specialist average Trust National average Acute specialist average Key finding 6 Percentage of staff receiving job relevant training, learning or development in the last 12 months 83 78 77 85 81 81 Key finding 15 Fairness and effectiveness of incident reporting procedures 3.7 3.45 3.53 3.68 3.5 3.60 Key finding 14 Percentage of staff reporting errors, near misses or incidents witnessed in the last month 98 96 96 96 90 92 Key finding 4 Effective team working 3.86 3.72 3.73 3.87 4 3.77 Key finding 9 Support from immediate managers 3.84 3.84 3.64 3.78 3.85 3.69 The top five ranking scores show that the staff feel supported by their line managers and that they are an integral part of an effective team. The Trust staff continue to put patient care at the centre and report incidences to ensure they can be managed and care improved. Staff development needs have continued to be met and relevant learning accessed consistently. 80 Annual Report and Accounts 2012/13 Table 3 – Bottom 5 ranking scores 2011/12 2012/13 Trust National average Acute specialist average Trust National average Acute specialist average Key finding 5 Percentage of staff working extra hours 72 65 67 78 70 72 Key finding 19 Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months 11 15 14 24 23 23 Key finding 7 Percentage of staff appraised in the last 12 months 81 80 81 74 83 83 8 13 10 10 12 8 83 79 83 75 72 76 Key finding 28 Percentage of staff experiencing discrimination at work in the last 12 months. Key finding 10 Percentage of staff receiving health and safety training in the last 12 months For key findings 5, 7 and 10 the change is statistically significant in comparison to last years results. The 24% percent of staff experiencing harassment, bullying or abuse from staff in last 12 months is a concern and does not reflect the number of complaints received that are investigated. Work will continue to promote the Trust mechanisms to support people feeling bullied and harassed including the promotion of the workplace adviser service, occupational health and the staff support facilitators. It is also disappointing that staff are still working additional hours despite recent promotion of work life balance initiatives including flexible working options. However, the majority of staff are working no more then five additional hours per week. The staff receiving equality and diversity training over past 12 months has increased by almost 20% in comparison to 2011. This increase could have influenced the perception of experiencing discrimination. 81 The Royal Marsden NHS Foundation Trust Statement of approach to staff engagement The Royal Marsden recognises the importance and value of having an engaged workforce and uses a number of mechanisms to ensure staff engagement and involvement. Staff are represented on the Trust’s Council of Governors by Staff Governors, representing doctors, nurses, other clinical staff and non-clinical staff. Following a review of the membership of the Council of Governors in 2012, it is intended to increase the number of Staff Governors on the Council in 2013 to ensure appropriate representation and reflect the size of the workforce. The Trust’s Consultative Committee meets on a bi-monthly basis to discuss and receive updates on the work and performance of the Trust and issues of concern to union members. Staff side and other staff representatives sit on the Equality and Diversity Committee. Staff representatives continue to meet through the quarterly Employment Partnership groups. These groups are the custodians of the Trust’s Employment Partnership principles, which represent the local values for the Trust and reflect the principles of the NHS Constitution and the NHS Staff Pledges. Staff side and other representatives have been involved in focus groups and action planning in response to the staff survey findings. Occupational Health The Occupational Health Department (OHD) has continued its commitment to providing a service that contributes towards a safe environment and promotes health and well-being at work. This commitment is supported by operating procedures which comply with legislation, policy and good practice. The OHD has been working towards accreditation by the Quality Strategy Standards as part of the Black Review to establish standards for all providers of occupational health services which are designed to improve the quality of OH services. The occupational health departments works in closely with other teams within the hospital including staff support services, infection control and health and safety. Activity –– 24,701 appointments were undertaken by the OHD of which 9,534 were undertaken for staff working on The Royal Marsden NHS Foundation Trust contract –– The seasonal influenza vaccination programme is offered to all staff to protect patients staff and their families –– Monthly health promotion topics are displayed on notice boards and on the intranet to encourage staff to take steps to improve their health –– Formal counselling and support services continue to be available to all staff on request, via the OHD –– The Cognitive Behavioural Therapy (CBT) workshops have continued with an increase in the number of sessions following the success of the initial pilot. The workshops are designed to support self management of normal stressors and develop resilience but also to enable a more positive approach towards those employees with mental health problems requiring additional support at work –– Attendance management referrals are a core OHD activity. Case conferences have increased to help managers to deal effectively with complex sickness absence issues 82 Annual Report and Accounts 2012/13 –– Self referral for sickness absence is available for staff who are concerned about their attendance and want to seek advice on how they might improve their attendance –– Fast track physiotherapy is provided for staff to facilitate appropriate effective intervention for musculo-skeletal conditions –– Free travel vaccines are provided for all staff travelling abroad –– Travel vaccines are offered to the wider community at competitive rates. The OHD continues to take an active role in promoting the health and well being of all the staff employed by The Royal Marsden NHS Foundation Trust. New services are developed where a need is identified to provide the proactive support to reduce sickness absence and maintain attendance. Equality reporting The Royal Marsden NHS Foundation Trust believes in providing equality in our services, in treating people fairly with respect and dignity and in valuing diversity both as a provider of cancer health services and as an employer. Our equality and diversity aims are to: –– Provide the best healthcare services we can that are accessible and are delivered in a way that respects the differing needs of the individual –– Employ staff who are motivated because they feel valued for the contributions they make and the diversity they bring to the Trust, who are well trained and who reflect at all levels the diversity of the population the Trust serves –– Embed our equality and diversity values into our policies and procedures and our everyday practice –– Regularly monitor and report on our Equality Objectives, on patient and staff information and on Equality Impact Assessments to evaluate how we are doing and set goals and actions in response –– Ensure that all services procured for the Trust either directly or indirectly and all staff working on behalf of the Trust, understand and support the Trust’s commitment to promoting equality and diversity in everything we do. The Equality and Diversity Committee approved the 2013 Equality Information which is available on our website. This information is part of our public commitment to meeting the equality duties placed on us by legislation and is updated annually. The information includes a Workforce Equality Profile report, a Patient Equality Profile report and an equality profile of our staff survey findings. We use this information to inform our decision making and action planning for equality, diversity and inclusion. Our Equality Objectives were developed in the light of the findings from our Equality Information and were published in April for the four year period, April 2012 – March 2016. A critical part of our Equality Objectives is ensuring that we continue to undertake equality analysis for our services and policies and for any organisational change in order to highlight potential inequality or discrimination within the functions of our organisation. Summaries of our Equality Impact Assessments are published on our website. We held an equality week in June and through this we launched the national Personal Fair and Diverse Champions campaign and ran round table sessions with our lesbian, gay, bisexual and transsexual staff. We also employed the EW Group to help us explore issues raised through our staff survey for staff from black and minority ethnic backgrounds and staff with disabilities and to raise awareness of these with managers within the Trust. This year, as a Stonewall Diversity Champion, we made a first submission to their Workplace Equality Index where we were commended for the progress made to supporting lesbian, gay and bisexual staff in the workplace. The Trust is committed to the Disability Two Ticks symbol and operates a guaranteed interview scheme to make sure that full and fair consideration is given to applications from candidates with disabilities. Our Managing Absence Policies ensure that where staff become disabled in the course if employment, we take active steps and make reasonable adjustments to enable staff to remain employed. All of our people management policies apply equally to staff with and without disabilities. 83 The Royal Marsden NHS Foundation Trust We have reviewed the Equality and Diversity Committee and Operational Group, to look at their purpose, responsibilities, membership and achievements. As a result of this review, two new Groups will be established – a Diversity and Inclusion Steering Group and a Stakeholder Reference Group. The Steering Group will be responsible for providing the strategic leadership for driving the equality, diversity and inclusion agenda across the Trust for patient care and service development and employment opportunity. The Stakeholder Reference Group will provide feedback to the Steering Group from patients and other service users, staff, trade unions, other stakeholders and groups that represent people who share a protected equality characteristic, in order to inform our priorities and action plans. Education The Trust continues with its strong commitment to the education, training and development of its staff. We ensure that staff are able to keep upto-date professionally, in order to perform their roles safely and further develop their knowledge and skills. The professional development of clinical staff is supported with a significant investment for all staff groups to access external conferences, workshops and courses as well as internal programmes. A full range of Continuing Professional Development (CPD) activities have continued over the year. These include workshops, journal clubs, study sessions, use of competency workbooks, and participation and presentation of papers and posters in multiple national and international conferences. We give support in undertaking some form of post-graduate education for clinical professional continues, including a post-graduate Certificate, Diploma module, Masters course or dissertation for a PhD. The Trust also continues to play a key role as a lead provider of education and training in cancer and nursing. The Royal Marsden School was one of a very few education providers in London this year to gain 100% in NHS London CPD Contract Performance Monitoring for provision of CPD. 84 Some key activities during the year have included: –– Dementia education has been a priority during the year in line with national policy. The Trust engaged with an NHS London Dementia Train the Trainer programme equipping eight members of staff to deliver this training which is now being rolled out to all clinical staff –– The Sage and Thyme model of communication training which enables staff to communicate effectively with patients, families and carers who are concerned or distressed is being rolled out across the organisation. This is intended to enable staff to recognise psychological distress, avoid causing psychological harm, communicate honestly and compassionately and know when they have reached the boundary of their competence –– In response to the pan-London results of the Cancer Patient Experience Survey in which patients had rated the way information was given to them as ‘poor’ or less than ‘excellent’ The Royal Marsden School ran a study day for Clinical Nurse Specialists and Senior Allied Health Professionals (AHPs) on ‘information giving’ –– The Trust’s commitment to work-based learning has been strengthened this year by the establishment of three new Practice Educators covering Medicines Management, School Nursing and Heath Visiting –– Physics and Radiotherapy ran an IntensityModulated Radiation Therapy (IMRT) Clinical Practice Teaching Course attended by 120 delegates from all over the country in order to assist achievement of government targets of 24% inverse planned IMRT in the treatment of all radical cancer patients –– The Royal Marsden School has been involved in a pan-London programme, sponsored by Macmillan, to educate staff working in general settings (District General Hospitals and the Community) about cancer –– The Trust has worked with the London Deanery to meet the Department of Health targets to increase the numbers of Health Visitors trained in 2012/13 by doubling the number of clinical placements for Health Visiting Students in the community division of the Trust. Annual Report and Accounts 2012/13 Governance and membership After nine years as an NHS Foundation Trust The Royal Marsden continues to maintain and develop strong governance arrangements through the Council of Governors and Trust Board. The Foundation Trust Led by the Board of Directors, the Trust is accountable to the communities it serves via the Council of Governors who represent the Trust’s members and the wider public. With the support and input from Governors, the Trust is able to meet the needs of its stakeholders and deliver the Trust’s strategy. The Board of Directors is responsible for the day-to-day management and performance of the Trust. Composition of the Council of Governors At 31 March 2013 there were 32 seats on the Council of Governors comprising 21 elected Patient and Carer, Public, and Staff Governors and 11 appointed Nominated Governors as shown in table 1. The table shows details of their terms of office, attendance at meetings of the Council of Governors and the Annual General Meeting in 2012/13. During the year the Governors approved a process to reconfigure the composition of the Council which comes into effect during 2013/14. The role of the Council of Governors As set out in the Trust’s constitution, the main duties of the Council are to: 1. appoint or remove the Chairman and other NonExecutive Directors 2. approve the appointment of the Chief Executive 3. decide the remuneration, allowances and other terms and conditions of office of the Non-Executive Directors 4. appoint or remove the Trust’s financial auditor 5. be consulted on the development of the forward business plans of the Trust and any significant changes to the healthcare provided by the Trust. Executive Directors routinely attend the Council of Governors meetings and Reverend Dame Canon Sarah Mullally, Non-Executive Director, continued her role as designated link with the Council. Through this position, she attended Council meetings and acted as an additional conduit between the Council and the Board. This enabled members of the Board, in particular the NonExecutive Directors, to better understand the views of Governors and members. Governors are invited to attend meetings of the Board which held in public, where they can observe the Non-Executive Directors carrying out their roles. Elections and appointments to the Council of Governors All Governors hold terms of office for a period of three years and are eligible for re-election or reappointment to serve a maximum of nine years. In accordance with the Model Rules for Elections, elections were held in the following subconstituency classes with respective nominees and turnout rates as below: Table 1 Constituency Nominations Election turnout (%) Patient South West London 8 33 Patient East Elmbridge and Mid Surrey 2 43 Membership Who can become members of The Royal Marsden? Anyone aged 16 years old or over and lives in England can become a member of The Royal Marsden. The membership is split into three constituencies: Patient and Carer, Public, and Staff, as defined below: Patient and Carer membership The Patient and Carer constituency is subdivided into the four geographical areas of South West London, Greater London, East Elmbridge and Mid Surrey, and Elsewhere in England. Anyone living in these areas who has been a patient at the Trust within the last five years can become a Member of the relevant Patient constituency. The Carer sub-constituency is open to individuals who 85 The Royal Marsden NHS Foundation Trust class themselves as Carers of patients that have attended the Trust within the last five years and live in England. As part of the Trust’s Membership Strategy, recruitment and engagement activities over the past year included: Anyone who has been a patient within the last five years, aged 16-25 years, can become a member of the Paediatric and Adolescent sub-constituency. –– maintaining links with the Trust’s volunteer service Public membership The Public constituency comprises individuals who live within the three geographical areas of the Royal Borough of Kensington and Chelsea, London Boroughs of Sutton and Merton, and Elsewhere in England. Staff membership The Staff constituency comprises individuals who are employed by the Trust, hold an honorary contract with the Trust or hold a joint contract with the Trust and The Institute of Cancer Research. Staff automatically become members upon joining the Trust unless they choose to opt out. The constituency is divided into four staff groups: Doctor, Nurse, Other Clinical and Other Non-Clinical. Membership overview Over the past year membership numbers have increased from 7,815 to 9,506 and exceeded the target. At 31st March 2013 the Trust had 9,506 members, comprising: Staff 3,364 Public 4,540 –– utilising marketing tools across both sites to promote membership and engagement initiatives across hospital sites –– supporting Governors to have an active presence on the hospital sites to meet patients and the public to discuss membership –– encouraging existing members to recruit members –– maintaining the connection with staff who have left the Trust by transferring their membership to the public constituency –– promoting Membership and the work of the Council to members and the wider public through RM magazine –– Two members’ events were held to engage on the process of the Trust’s Quality Account; provide tours of new facilities; and updates on the Trust’s developments. Contact us The Foundation Trust Office continues to be the central point of contact for all Members and the public who wish to make contact with Governors. Post Foundation Trust Office The Royal Marsden NHS Foundation Trust Fulham Road London SW3 6JJ Email [email protected] Telephone 020 7808 2844 or freephone 0800 587 7673 Patient and carer 1,602 86 The Register of Governors’ interests is held at the Foundation Trust Office and members of the public can gain access to this by contacting the Foundation Trust Office. Annual Report and Accounts 2012/13 Terms of office and attendance by Governors at meetings of the Council of Governors 2012/13 Governor Constituency / Organisation Term of office End of current term Meetings attended total meetings = 5 Miss Stacey Munns Paediatric and Adolescent First June 2014 0 Mrs. Anita Gray South West London Third June 2014 4 Mrs Raelene Salter South West London First June 2012 0 (out of 1) Mr. Edward Crocker South West London Second June 2015 5 Ms Fiona Stewart South West London First June 2014 5 Mrs. Liz Coyne South West London First June 2015 3 (out of 4) Dr. James Laxton East Elmbridge & Mid Surrey Third April 2013 5 Mr. Christopher Pelley East Elmbridge & Mid Surrey Second June 2012 1 (out of 1 ) Mr. Simon Spevack East Elmbridge & Mid Surrey First June 2015 3 (out of 4 ) Mrs. Hilary Bateson Greater London Second April 2013 3 Dr. Geoff Harding* Greater London Second April 2013 3 Ms. Vikki Orvice Elsewhere in England First April 2013 3 Mrs. Sally Mason Elsewhere in England Third April 2013 5 Mrs. Lesley-Ann Gooden Carer First April 2013 3 Mr. John Preston Carer First April 2013 2 Mr. John Howard Carer First July 2013 5 Dr Carol Joseph Kensington and Chelsea First June 2014 5 Mr. Anthony Hazeldine Sutton and Merton Third April 2013 5 Mrs Ann Curtis Elsewhere in England Second January 2015 3 Professor Ian Smith Doctor Third April 2013 3 Ms. Lorraine Hyde Nurse Second April 2013 4 Ms. Nina Kite Other Clinical First April 2013 2 (out of 4) Ms. Kim Andrews Non Clinical First April 2013 3 Mrs Cathy Scivier Institute of Cancer Research First January 2015 4 Dr Chris Elliott Primary Care Referrer Second October 2013 0 Ms. Alison Hill South West London Cancer Network First March 2013 1 (out of 3) Vacant West London Cancer Network n/a n/a n/a Cllr. Robert Freeman London Borough of Kensington & Chelsea First July 2014 4 Dr Martyn Wake Sutton and Merton PCT Third April 2013 0 Vacant Croydon PCT n/a n/a n/a Ms. Mable Wu Kensington and Chelsea PCT First July 2012 0 (out of 3) Vacant Surrey PCT Second October 2013 n/a Vacant University Partner n/a n/a n/a Kate Law Cancer Research UK (Charity) First December 2014 2 Patient Governors Carer Governors Public Governors Staff Governors Nominated Governors * Lead Governor appointed for the Council of Governors Expenses of Governors The Trust’s expenses policy ensures Governors are appropriately reimbursed for reasonable expenses incurred in fulfilling their roles. A total expense incurred by the Council of Governors during the year was £629.90. 87 The Royal Marsden NHS Foundation Trust Governance Our board of Directors The Board of Directors comprises five Executive Directors, including the Chief Executive and seven Non-Executive Directors, including the Chairman. The role of the Board is to provide effective leadership and set the strategic aims and vision for the Trust. It is responsible for ensuring the Trust’s management delivers the strategy whilst complying with its constitution, and statutory and regulatory requirements. The description below of each Director’s background demonstrates the balance, completeness and relevance of the skills, knowledge and expertise that each of the Directors bring to the Trust. The table on page 93 shows details of their attendance at meetings and committees during 2012/13. Key R Member of Remuneration and Terms of Service Committee A Member of Audit and Finance Committee I Member of Investment Committee E Member of Equality and Diversity Committee ICR Member of the Board of Trustees of The Institute of Cancer Research QAR Member of Quality, Assurance and Risk Committee 88 Mr R Ian Molson Chairman R ICR (alternate) QAR I Ian Molson was appointed Chairman in December 2010. From 1999 to 2004, he was Deputy Chairman of the Board and Chairman of the Executive Committee of Molson Inc, a Canadian public corporation founded in 1786. Between 1977 and 1997, he was employed by Credit Suisse First Boston, one of the leading investment banking and securities firms in the world. From 1993 to 1997, he served as co-Head of their Investment Banking Department in Europe, a position which encompassed all corporate finance, corporate advisory, mergers and acquisitions businesses in Europe, Russia, Africa and the Middle East. He graduated from Harvard University (AB Honours) in 1977. Ian is also Chairman of The Royal Marsden Cancer Charity. Executive Directors Miss Cally Palmer CBE Chief Executive ICR QAR I Cally Palmer became Chief Executive of The Royal Marsden in 1998 and a Trustee of The Institute of Cancer Research (ICR). Previously, Cally was Deputy Chief Executive and Director of Services at the Royal Free Hampstead NHS Trust. Cally is an MSc graduate in management from the London Business School, which she gained with distinction in 1995, and a member of the Institute of Health Services Management. Cally was awarded a CBE in 2006 for her contribution to the NHS. Dr Shelley Dolan Chief Nurse A QAR Shelley Dolan was appointed to the role of Chief Nurse at The Royal Marsden NHS Foundation Trust in June 2007. She was promoted to Chief Nurse from her position as the first Nurse Consultant in Critical Care in the UK, a role she took up at The Royal Marsden in 2000. Shelley has worked clinically in the field of intensive care for over 20 years and is a trained Intensive Care and Cancer Nurse who achieved her MSc in Cancer Care in 1996 and Doctorate in 2011. She is also the Vice Chair of the Board of the MHRA Annual Report and Accounts 2012/13 (DH). In December 2012 Shelley was appointed as the Associate Clinical Director of the London Cancer Alliance; and is also on the Membership Council for the South London and North West London Local Education Training Boards. Shelley is a member of the European Oncology Nursing Society and the International Nurses in Cancer Care and lectures extensively nationally and internationally. Her research is in the areas of early detection of sepsis, acute and critical care of the cancer patient, patient involvement and experience of care. Shelley took adoption leave from 1 October 2011 to May 2012. Dr Liz Bishop Interim Chief Nurse A QAR (1 October 2011 – 30 April 2012) Liz Bishop was appointed Interim Chief Nurse with effect from 1 October 2011 to cover Shelley Dolan’s adoption leave. Previously she was Divisional Director and Divisional Nurse Director for Cancer Services at The Royal Marsden between January 2009 and October 2011. She has worked in the NHS since 1982, obtaining a BSc in Nursing, an MSc in Advanced Clinical Practice and completed her Doctorate in Clinical Practice in 2009. She has worked in a variety of clinical settings including surgery, haematology and oncology, as a Nurse Consultant and in a range of clinical and general management roles. From May 2012 she took the role of Divisional Director for Cancer Services/ Research and Development. Mr Alan Goldsman Director of Finance I A QAR Alan Goldsman was appointed in 2002 from Guy’s and St Thomas’ NHS Trust where he was Deputy Director of Finance. Prior to this, Alan’s career included four years in senior finance roles with the health service in New Zealand and a further four years in the construction industry and in commercial banking. Alan is a qualified accountant and has an MSc in Health Management from City University. Professor Martin Gore Medical Director QAR Professor Martin Gore qualified in medicine at St Bartholomew’s Hospital, London in 1974. He trained in General Internal Medicine for five years and then was appointed as a Clinical Scientist at the Ludwig Institute of Cancer Research (1981-1984). In 1984, he joined the training programme at The Royal Marsden and was appointed Consultant Cancer Physician to The Royal Marsden and Senior Lecturer at the ICR in 1988 and Professor of Cancer Medicine at The Institute of Cancer Research in 2002. He is co-Patron of The Rarer Cancers Foundation and a Medical Advisor to the Kidney Cancer Association in the US. His previous appointments included Chair of Department of Health’s Gene Therapy Advisory Committee, President of the UK Melanoma Study Group, Chair of the NCRI Melanoma Clinical Studies Group and he was on the Council of the International Gynecologic Cancer Society and the Program Committee of the American Society of Clinical Oncology. He has served on the editorial boards of several journals, published over 350 articles and edited eight textbooks. Mr David Probert Chief Operating Officer E QAR David Probert joined The Royal Marsden in October 2007 as its first Chief Operating Officer. Having completed his MBA in 1998, David has worked in a mixture of community and acute settings including a period of time spent with the world renowned Institute of Healthcare Improvement in Boston, USA. Following his time in the US, David joined Guy’s and St Thomas’ NHS Trust as a Deputy General Manager, being promoted to General Manager in 2003. He joined The Royal Marsden having held the position of Divisional General Manager/Deputy Divisional Director at Guy’s and St Thomas’ NHS Foundation Trust for almost four years, looking after a mixture of surgical, specialist and chronic services. 89 The Royal Marsden NHS Foundation Trust Non-Executive Directors The Reverend Canon Dame Sarah Mullally* Senior Independent Director A E QAR The Reverend Canon Dame Sarah Mullally was Chief Nursing Officer for England/Director of Patient Experience until September 2004 and Assistant Curate at Battersea Fields Benefice, London until September 2006. Following six years as Rector for the Church of England Team Ministry in Sutton she became Canon of Salisbury Cathedral in September 2012. Dame Sarah is the designated Link Non-Executive Director with the Council of Governors and was Chair of the Equality & Diversity Committee until December 2012. She was appointed Senior Independent Director in November 2008 and was Acting Chairman from 1-30 November 2010. She stood down as a NonExecutive Director from 31 March 2013. Mr Gregory Andrews FCA* A Greg Andrews joined The Royal Marsden as a Non-Executive Director on 1 April 2008. He is Chair of The Royal Marsden’s Audit and Finance Committee. He spent most of his career in financial services and held a number of positions at Merrill Lynch, including that of a Managing Director in the Wealth Management Division. Since leaving the City, he has served as Chief Operating Officer of New Philanthropy Capital from 2002 to 2006 and as a strategic consultant in financial restructuring and change management. Mr Colin Clark* RA Colin Clark joined The Royal Marsden as a Non-Executive Director on 1 May 2005. He has over 30 years experience in the investment management industry. Colin previously worked with Mercury Asset Management and Merrill Lynch Investment Managers. Sir John Craven* R QAR Sir John Craven joined The Royal Marsden as a Non-Executive Director on 1 April 2008. He had a long career in banking culminating in membership of the Board of Managing Directors of the Deutsche Bank in Germany. He served as chief executive and Chairman of Morgan Grenfell from 1989 to 1996 and before that was Vice Chairman of SG Warburg. After his retirement from banking he served as non-executive Chairman of Lonmin plc 90 for several years. At an earlier stage in his career he served as non-executive director of a number of companies, including Reuters (of which he was the Senior Independent Director), Societe Generale de Surveillance and Ducatti SpA. He was also Chairman of Fleming Family and Partners limited, an independent privately owned investment house. He holds both British and Canadian nationality and was knighted for his services to banking and to the City. Professor Alan Ashworth FRS QAR ICR Professor Ashworth joined The Royal Marsden as a Non-Executive Director on 17 January 2011. He is Chief Executive of The Institute of Cancer Research, where he is responsible for a major programme of cancer research which extends from basic laboratory science through translational research to clinical implementation. He is a Professor of Molecular Biology and a Fellow of The Royal Society. Mr Richard Turnor* R QAR A Richard Turnor joined The Royal Marsden as a Non-Executive Director on 1 January 2009. He was a partner with the international law firm Allen & Overy LLP from 1985 to 2009 where he headed the Commercial Trust and Partnership Group. In 2010, he established Maurice Turnor Gardner LLP, an independent firm practising in association with Allen & Overy LLP from which he continues to advise professional firms and fund managers on structuring and constitutional issues including international structure, disputes, mergers, demergers and governance issues. * The Non-Executive Directors which the Board considers to be independent Members of the public can gain access to the Register of Directors’ Interests through the Corporate Affairs Office by emailing [email protected]. Significant commitments of the Trust Chairman R. Ian Molson is a director of the following organisations: Alphatec Spine Inc., Cayzer Continuation PCC Ltd, Central European Petroleum Ltd (Deputy Chairman), Healthpoint Capital LLC and Lennox Investment Management. He is no longer a Director of Maggie’s Oxford Campaign Board. Annual Report and Accounts 2012/13 Governance The work of the Board The Royal Marsden NHS Foundation Trust’s Standing Financial Instructions Policy sets out the powers reserved for the Board of Directors and the Scheme of Delegation sets out its other responsibilities. Decisions taken by the Board include the following: –– regulations and control –– appointment and dismissal of committees –– strategy, business plans and budgets –– policy determination –– appointment of internal auditors –– receipt and approval of the Trust’s Annual Report and Accounts –– monitoring and continuous appraisal of the affairs of the Trust. Decisions delegated to management include policy implementation and operational management. The Trust’s Management Executive (ME) meets every six to eight weeks. ME has two sub-committees, the Performance Review Group, which looks at key performance issues, and the Financial Strategy Group (formerly the Quality and Efficiency Group) monitors the financial position and drives quality initiatives across the Trust through efficient service and working arrangements. Board of Directors’ balance, completeness and appropriateness The Board is satisfied that its current composition and balance between skills, knowledge and experience is complete and appropriate to the requirements of the Trust. Performance evaluation of the Board of Directors, its Committees and its Directors The Chairman is generally appraised annually through a three stage process led by the Senior Independent Director. This takes into account the views of the Board, the Council of Governors and The Royal Marsden Cancer Charity Trustees. The Senior Independent Director formally reports the outcome of these discussions to the Trust Board and Council of Governors. The Chairman completed his second year in office at the end of 2012 and, at the time of writing, the appraisal process is in progress. The Chairman conducts an annual appraisal of Non-Executive Directors. This information is an important part of the consideration when an individual is seeking re-appointment. The Chairman also conducts the Chief Executive’s appraisal, following discussion with the NonExecutive Directors. The Chief Executive evaluates the performance of each Executive Director to ensure continued high standards of performance and effectiveness, which is discussed at the Remuneration Committee. Committees of the Board of Directors The Audit and Finance Committee The Audit and Finance Committee is formally constituted as a sub-committee of the Trust Board and its main purpose is to independently contribute to the Board’s overall process for ensuring that an effective internal control system is maintained. In particular, the Committee has the following key objectives: –– providing confidence in the objectivity and fairness of financial reporting –– providing assurance about the adequacy of internal control –– safeguarding of assets –– reducing the risk of illegal or improper acts –– reinforcing the importance, independence and effectiveness of internal and external audit. 91 The Royal Marsden NHS Foundation Trust The Nominations Committee Remuneration Committee The Council of Governors has responsibility for approving the appointment or re-appointment of the Chairman and other Non-Executive Directors, as recommended by the Nominations Committee. The Remuneration Committee met once during 2012/13. Disclosures of the remuneration paid to members of the Board are provided in the accounts. Please also refer to the remuneration report. Membership of the Nominations Committee comprises: The Equality and Diversity Committee –– Chairman (or Vice Chair/Senior Independent Director) –– three Non-Executive Directors –– one Executive Director –– three Council of Governor representatives to include one Elected Governor, –– one Stakeholder Governor and one Staff Governor. Within the above membership, those attending particular meetings will vary according to the business of the meeting, i.e. a Non-Executive Director would not attend when his/her reappointment is under discussion. Where remuneration is discussed, only Council Governors attend. There was one meeting of the Nominations Committee during 2012/13. Having agreed the process, job description and person specification that ensured the Board maintained its completeness and balance, the committee recommended the appointment of Dame Nancy Hallett as a Non-Executive Director to replace Reverend Dame Canon Sarah Mullally when her term expired at the end of the year. The Council of Governors unanimously approved the appointment. Non-Executive Director appointments are for a term of three years. The removal of a nonexecutive director requires the approval of threequarters of members of the Council of Governors. Details of the criteria for disqualification from holding the office of a director can be found in the Trust’s constitution. The Quality, Assurance and Risk Committee The Quality, Assurance and Risk Committee supports the Trust Board in developing an integrated approach to governance by ensuring robust systems to monitor achievements against objectives. A key focus of the Committee is patient safety, including infection control. 92 Following a review of the governance arrangements for equality and diversity in Autumn 2012. A new Equality, Diversity and Inclusion steering group was formatted under the leadership of the Director of Workforce and Corporate Affairs. This will report to the Integrated Governance and Risk Management Committee and Workforce Strategy Group, driving the equality, diversity and inclusion agenda across the Trust for patient care, service development and employment opportunity. A new Stakeholder Reference Group will provide input and feedback to the Steering Group from patients and service users, staff, trade unions, and other stakeholders and interest groups. NHS Foundation Trust Code of Governance – compliance statement The Royal Marsden has governance policies and procedures which support the main and supporting principles of the NHS Foundation Trust Code of Governance, which was updated in April 2010. The Trust Board considers that it was compliant with the provisions of the Code with the following exception: Balance and independence of the Board of Directors The Royal Marsden does not comply with the provision that requires at least half the Board, excluding the Chairman, comprising NonExecutive Directors determined by the Board to be independent. This is because one of its NonExecutive Directors, Professor Alan Ashworth, is not considered to be independent as he is the Chief Executive of the Trust’s academic partner, The Institute of Cancer Research. Annual Report and Accounts 2012/13 Terms of office and attendance at meetings of the Board Directors, Audit and Finance and Remuneration Committees 2012/13 Name Role Board of Directors Meetings attended Term of office End of current term Total meetings = 7 R Ian Molson Chairman (from 1 December 2010) 7 First 30.11.13 Gregory Andrews Non-Executive Director 7 Second 31.3.14 Liz Bishop Interim Chief Nurse (covering Adoption Leave to May 2012) 1 (out of 1) Colin Clark Non-Executive Director 5 Third 30.4.14 Sir John Craven Non-Executive Director 7 Second 31.3.14 (to be confirmed annually in March from 2012) Reverend Canon Dame Sarah Mullally Senior Independent Director 7 Third 31.3.13 (standing down) Professor Alan Ashworth Non-Executive Director 6 First 16.1.14 Richard Turnor Non-Executive Director 7 Second 31.12.14 Cally Palmer Chief Executive 7 Shelley Dolan Chief Nurse (from May 2012) 6 (out of 6) Alan Goldsman Director of Finance 7 Professor Martin Gore Medical Director 7 David Probert Chief Operating Officer 7 Audit and Finance Committee Total meetings= 4 Gregory Andrews Chairman of Committee / Non-Executive Director 4 Liz Bishop Divisional Director of Cancer Services/Research and Development (from May 2012) and Interim Chief Nurse (until May 2012) 4 Colin Clark Non-Executive Director 2 Shelley Dolan Chief Nurse 4 Alan Goldsman Director of Finance 4 Reverend Dame Canon Sarah Mullally Non-Executive Director 4 Richard Turnor Non-Executive Director 4 Remuneration Committee Total meetings =1 Sir John Craven Chairman of Committee / Non-Executive Director 1 R. Ian Molson Chairman of the Trust 1 Cally Palmer Chief Executive 1 Colin Clark Non-Executive Director 1 Richard Turnor Non-Executive Director 1 93 The Royal Marsden NHS Foundation Trust Governance The Management Executive Cally Palmer Chief Executive Dr. Liz Bishop Divisional Director of Cancer Services/Research and Development (from May 2012) and Interim Chief Nurse (October 2011 – April 2012) Nicky Browne Director of Performance and Strategy Implementation Gary Burkill Head of Facilities Anne Carey Project Director (Strategic Planning) (to August 2012) Mick Carey Assistant Director of Projects (Estates) Professor David Cunningham Director of Clinical Research and Development (from October 2012) Dr. Shelley Dolan Chief Nurse (returned from Adoption Leave, May 2012) 94 Adam Doyle Divisional Director, Sutton and Merton Community Services (to September 2012), Director of Private Care (from September 2012) Alan Goldsman Director of Finance Professor Martin Gore Medical Director Ian Haig Divisional Director of Clinical Services (to January 2013) Kerensa Heffron Director of Business and Private Practice (on maternity leave from September 2012) Professor Stephen Johnston Director of Clinical R&D (to September 2012) David Probert Chief Operating Officer Jon Reed Director of ICT (to June 2012) Rachael Reeve Director of Marketing and Communications Colin Rickard Director of Capital Projects Jonathan Spencer Divisional Director of Clinical Services (from January 2013) Deborah Tarrant Director of Workforce and Corporate Affairs Sunil Vyas Deputy Director of Projects, Director of Project and Estates (from January 2013) Sarah Wright Interim Divisional Director, Sutton and Merton Community Services (from September 2012) Annual Report and Accounts 2012/13 Regulatory Ratings Report Monitor uses a risk-based framework to guide the intensity of its monitoring and indicate any concerns which may cause a breach of the terms of the Trust’s authorisation. This covers three areas: –– Financial Risk Rating –– Governance Risk Rating –– Mandatory Services Financial risk is based on indicators including delivery of plan, operating margin, return on assets and liquidity to provide a weighted metric rated 1 (highest risk) to 5. Governance risk is derived from factors including performance against national targets and indicators, and Care Quality Commission registration and ongoing performance against registration requirements. The metrics are graduated using green (lowest risk), amber-green, amber-red, and red (highest risk) The mandatory services rating assesses the provision of mandatory goods and services set out in the terms of authorisation and is measured on a similar scale to the governance risk rating. The tables below set out the Trust’s quarterly performance in 2011/12 and 2012/13 against its annual plan. Financial Risk Rating Annual Plan 2011/12 Q1 2011/12 Q2 2011/12 Q3 2011/12 Q4 2011/12 3 3 3 3 3 Annual Plan 2012/13 Q1 2012/13 Q2 2012/13 Q3 2012/13 Q4 2012/13 4 4 4 4 4 Governance Risk Rating Mandatory Services Rating Financial Risk Rating Governance Risk Rating Mandatory Services Rating There have been no deviations from the plan in year and no requirements for intervention by Monitor. 95 The Royal Marsden NHS Foundation Trust Directors’ Report The Directors present their report and audited financial statements for the year to 31 March 2013. The names of the individuals who were directors of the NHS Foundation Trust during the year are reported on page 88. Principle activities The Trust’s principle activity is the provision of healthcare services to patients. Disclosure of information to auditors As far as each of the Directors are aware, there is no relevant audit information of which the auditors are unaware. Each Director has taken all the steps a Director ought to have taken to make themselves aware of any relevant audit information and to establish that the auditors are aware of such information. Auditors –– Chairman’s and Chief Executive’s statement on pages 4 to 5 The Trust’s appointed external auditors are Deloitte LLP. The auditors provide audit services comprising carrying out the statutory audit of the Trust’s annual accounts and the use of resources work as mandated by the Healthcare Commission, and a review of the Quality Accounts. The cost of this services in 2012/13 was £82,000 (2011/12 £80,000). –– The Financial Review on pages 99 to 101. Cost allocation and charging requirements In addition to this, other information relevant to the NHS Foundation Trust’s activities are set out in the other sections of this document. The Trust has complied with the cost allocation and charging requirement set out in HM Treasury and office of Public Sector Information Guidance. Post balance sheet events Going Concern There have been no significant events since the balance sheet date that have had a material impact on the NHS Foundation Trust. The Directors have a reasonable expectation that the NHS Foundation Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. Business review The NHS Foundation Trust’s activities are reviewed in: Political and charitable donations The NHS Foundation Trust has not made any political or charitable donations this year or in previous years. Public sector payment policy The Trust aims to pay its non-NHS trade creditors in accordance with the CBI prompt payment code and government accounting rules. The target is to pay non NHS trade creditors within thirty days of receipt of goods or a valid invoices (whichever is the later) unless other payment terms have been agreed with the supplier. The Trust also aims to pay local community suppliers within ten days. 96 Annual Report and Accounts 2012/13 Remuneration report The Royal Marsden NHS Foundation Trust’s Remuneration Report describes how the Trust applies the principles of good corporate governance in relation to Directors’ remuneration as required by the Companies Act 2006, Regulation 11 and Schedule 8 of the Large and Medium-Sized Companies and Groups (Accounts and Reports) Regulations 2008 and elements of the NHS Foundation Trust Code of Governance. The Remuneration report summarises the Trust’s remuneration policy and its application in connection with the Executive Directors and members of the Management Executive. Details of the Executive Directors’ remuneration and pension benefits are set out in the tables within the Account on page 125. This information has been subject to audit. Remuneration Committee The Remuneration Committee is a sub-committee of the Trust Board chaired by Sir John Craven, a Non-Executive Director, with membership comprising the Trust Chairman, R. Ian Molson, Colin Clark and Richard Turnor, Non-Executive Directors. Two meetings were held during this financial year, attendance at which is shown on page 87. The Chief Executive is in attendance to provide information on Directors. The Director of Workforce & Corporate Affairs provides general support and prepares review of general pay and reward intelligence including comparative data on Directors’ salaries and NHS guidance on pay and terms and conditions as requested. Neither these individuals nor any other executive or senior manager participated in any discussion relating to their own remuneration. Remuneration policy The Royal Marsden is committed to the overarching principles of value for money and high performance. The Trust must attract and retain a high calibre senior management team and workforce in order to ensure it maintains its excellent standards of clinical outcomes and patient care, functions efficiently and is well positioned to deliver the business strategy. In making decisions on remuneration, the Committee considers the responsibilities and requirements of the role, time in the role, marketability of the individual, market rates, the external economic environment and the performance of the Trust. The comparative data used to determine market rates includes high-performing NHS foundation trusts in London and elsewhere. Reference is normally made to Incomes Data Services reports. This is the second year of a two-year pay freeze set for NHS staff and has been applied at The Royal Marsden. Performance of Directors is assessed through regular appraisal against predetermined objectives. Non-Executive Directors’ remuneration Proposals for the remuneration of Non-Executive Directors are developed by the Nominations Committee (details of which are set out on page 92) for approval by the Council of Governors. Only Governors attend the Nominations Committee meetings where remuneration is discussed, with support from the Director of Workforce & Corporate Affairs. Remuneration was last reviewed in January 2010 and a position statement presented to the Council of Governors in February 2010. In view of the economic climate, it was not felt appropriate to recommend an increase in the remuneration of Non-Executive Directors, although the Committee wished to record its view that remuneration rates should be increased in due course, in order to recognise the significant responsibilities of directors in NHS foundation trusts and to attract individuals with the necessary experience and ability to make an important contribution to The Royal Marsden’s strategy, business and general corporate affairs. The Nominations Committee and Council of Governors did however agree that the Senior Independent Director should have a higher rate of remuneration because of the substantial additional responsibilities attached to the position and given that this was a relatively new role and one established since the last remuneration review. None of the Non-Executive Directors are employees of the Trust. They receive no benefits or entitlements other than fees and are not entitled to any termination payments. The Trust does not make any contribution to the pensions arrangements of Non-Executive Directors. 97 The Royal Marsden NHS Foundation Trust Off payroll engagements Table 1: For off-payroll engagements at a cost of over £58,200 per annum that were in place as of 31 January 2012 Number in place on 31 January 2012 12 Of which Number that have since come onto the Organisation’s payroll 1 Of which Number that have since been re-negotiated/re-engaged to include to include contractual clauses allowing the (department) to seek assurance as to their tax obligations 1 Number that have not been successfully re-negotiated, and therefore continue without contractual clauses allowing the (department) to seek assurance as to their tax obligations 3 No. that have come to an end 7 Total 12 Table 2: For all new off-payroll engagements between 23 August 2012 and 31 March 2013, for more than £220 per day and more than 6 months Number of new engagements 9 Of which Number of new engagements which include contractual clauses giving the department the right to request assurance in relation to income tax and National Insurance obligations 0 Of which Number for whom assurance has been accepted and received 0 Number for whom assurance has been accepted and not received 0 Number that have been terminated as a result of assurance not being received 0 Total 9 98 Annual Report and Accounts 2012/13 Financial Review for the year ended 31 March 2013 In its ninth year as an NHS Foundation Trust The Royal Marsden has maintained its excellent track record of financial performance. The Trust has met, and in most cases, exceeded its financial and performance plans for the year. The accounts show that the Trust generated a deficit of £3.8m after accounting for the impact of a technical accounting loss of £14.6m from the valuation of its estate, and donations for capital schemes of £8.5m; which under new accounting rules these are now recorded as income. The ‘underlying’ surplus after excluding these changes for valuations and for depreciation on donated assets is £6.3m; £1.3m more than the planned surplus of £5m. This result is due to a combination of factors including strong income performance, the continued delivery of the Trust’s efficiency programme, and good financial discipline and control. The surplus will be applied to capital development, in particular to schemes that will enhance services to patients on both the Chelsea and Sutton sites. The Trust continues to maintain a strong balance sheet and cash position. At 31 March 2013 the Trust held cash deposits of £14.3m, a reduction of £8.1m from the previous year end. This reduction reflects capital expenditure of £31m and payment of the Department of Health Dividend of £4.2m; funded by increased net cash flow from operations of £18.6m and from charitable donations towards capital projects of £8.5m. Efficiency In a challenging economic environment the Trust has continued to deliver its efficiency targets in 2012/13. This programme of efficiency has delivered improvements in order to meet NHS tariff reductions, to support the local health economy and to provide a surplus of £6.3m for development. The efficiency programme is comprised of initiatives which will increase private income with less, or no, increase in costs and those which reduce costs with less, or no, reduction in income. Financing and Investment The Trust has an authorised Prudential Borrowing Limit of £57.6m, which excludes a working capital facility of £21.6m. Because the Trust has maintained healthy cash flow it has not needed to either borrow or use its working capital facility to date. In 2011/12, the Trust Board approved a five-year capital programme for 2011 – 2016 totalling £121m. This programme will, for the most part, provide new assets that are considered ‘protected’ for the NHS under the Foundation Trust Terms of Authorisation. During the year the Trust spent £27.8m of which £8.5m was financed by charitable donations, with the remainder being funded by operating surpluses and free cash. In light of the capital development in the year, a professional valuation firm completed a valuation of the Chelsea and Sutton sites as at 31 March 2013. As a result fixed asset values were reduced by £14.9m; £0.3m related to land and was charged to the revaluation reserve and the remaining £14.6m was charged to expenditure since there was no balance sheet reserve available. 99 The Royal Marsden NHS Foundation Trust Income and Expenditure Relationships with key stakeholders In 2012/13 our overall income was £321.4m (£311.6m in 2011/12). The increase of £9.8m comprises increases in NHS patient income of £11.2m and Private Patient income of £8.7m, partly offset by a reduction in research and charitable income of £11.8m. However, charitable income will fluctuate year-on-year due to the scale of capital schemes funded. On 1 April 2011 the Trust acquired Sutton and Merton Community Services following a process of selection and due and careful enquiry by Sutton and Merton Primary Care Trust and NHS London, as part of a process called ‘externalisation’. The Trust Board conducted its own due diligence including taking advice from professional advisors. The Foundation Trust receives the majority of its patient care income from Primary Care Trusts. Patient referrals are centred on the Trust’s sites in London, Sutton and Kingston, but extend from this local base to cover all of England and beyond, particularly for referrals for rare cancers. NHS patient income is supplemented by income to provide infrastructure and support for research and development activity and from private patient income. The margin delivered on our private patient income remains a vital source of support for NHS services to patients. The Health and Social Care Act 2012 introduced a new requirement that a Foundation Trust’s income from the provision of goods and services for the purposes of the health service in England must be no greater than its income from the provision of goods and services for any other purpose. The Trust has met this requirement. In reaching this assessment the Trust has considered whether an exchange of goods and services has occurred, and whether income relates to activities required under the Act. The Trust’s overall operating expenditure was £320.7m (£300.1m in 2011/12) an increase of £20.1m. The increase is mostly due to staff costs (£7.4m), drug costs (£5.8m), and £6.9m of other operating expenses. 100 During the year the Trust has continued to develop its relationships with its stakeholders including South West London Acute Commissioning Unit, Sutton and Merton PCT, Kingston Hospital NHS Trust and St Georges Healthcare Trust. Its contracts with Primary Care Trusts are governed by the legally binding contract introduced as part of the Foundation Trust reforms. Over the year the Trust has delivered increased activity for NHS patients. The Trust’s relationship with The Institute for Cancer Research and the Mount Vernon Cancer Centre to develop a new academic and research partnership continue to grow stronger with the aim of increased collaboration and joint working on trials and research. Annual Report and Accounts 2012/13 Managing risks Principle risks and future developments Finance The following are regarded as the principle areas of risk and future development for the Trust: Over the full year the Trust has consistently maintained a financial risk rating of four in line with its plan (where five is the lowest risk and one is the highest). This means that the Trust is considered, by Monitor – the Independent Regulator of NHS Foundation Trusts, to be medium risk in financial terms. This risk rating incorporates the key financial performance indicators for the Trust. Governance The Trust is rated green on its governance arrangements covering compliance with the terms of authorisation and meeting NHS standards and targets for performance. The rating is based on performance throughout the year and on self-certification; where the Trust Board has confirmed that all core national healthcare targets and standard have been met, and that plans are in place to ensure that they will be met going forward. –– The continuation of a deflator for NHS patient income, slower growth in NHS funding and the impact of the new commissioning bodies –– In order to meet its ongoing capital equipping and development plans the Trust is planning to increase its surplus, and to reduce financial risk in order to achieve a financial risk rating of four. This must be delivered at a time of economic challenge –– The Trust has continued to be fully engaged in the Pan London Cancer Services Review and with the Better Value, Better Services review being undertaken in south west London on behalf of NHS London. It is important that the Trust’s development strategies can be delivered within the future direction set out in this policy. Quality Board statement The Trust Board has declared that it is satisfied with its arrangements and will continue to keep in place arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients Mandatory services The Trust is rated on its provision of mandatory services in conjunction with the Healthcare Commission. The Trust has continued to maintain its ‘green’ rating from Monitor. Counter Fraud The Trust has a counter-fraud officer in place that proactively reviews the Trust’s counter-fraud arrangements and follows up on any incidents reported. There is also a whistle-blowing procedure in place and available to all staff; all matters raised are dealt with in confidence. 101 The Royal Marsden NHS Foundation Trust Annual Accounts for the year ended 31 March 2013 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: Foreword to the accounts The Royal Marsden NHS Foundation Trust – observe the Accounts Direction issued by Monitor, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis; These accounts for the year ended 31 March 2013 have been prepared by The Royal Marsden NHS Foundation Trust in accordance with paragraphs 24 and 25 of Schedule 7 to National Health Service Act 2006. Cally Palmer CBE Chief Executive 29 May 2013 Statement of Chief Executive’s responsibilities as Accounting Officer of The Royal Marsden NHS Foundation Trust The National Health Service Act 2006 states that the Chief Executive is the Accounting Officer of the NHS Foundation Trust. The relevant responsibilities of Accounting Officer, including their responsibility for the propriety and regularity of the public finances for which they are answerable, and for the keeping of proper records, are set out in the NHS Foundation Trust Accounting Officer Memorandum issued by the Independent Regulator of NHS Foundation Trusts (“Monitor”). Under the National Health Service Act 2006, Monitor has directed The Royal Marsden 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 The Royal Marsden NHS Foundation Trust and of its income and expenditure, total recognised gains and losses and cash flows for the financial year. 102 – make judgements and estimates on a reasonable basis; – state whether applicable accounting standards as set out in the NHS Foundation Trust Annual Reporting Manual have been followed, and disclose and explain any material departures in the financial statements; and – prepare the financial statements on a going concern basis. The Accounting Officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the NHS Foundation Trust and to enable her to ensure that the accounts comply with requirements outlined in the above mentioned Act. The Accounting Officer is also responsible for safeguarding the assets of the NHS Foundation Trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities. To the best of my knowledge and belief, I have properly discharged the responsibilities set out in Monitor’s NHS Foundation Trust Accounting Officer Memorandum. Cally Palmer CBE Chief Executive 29 May 2013 Annual Report and Accounts 2012/13 Annual Governance Statement 2012/13 The Royal Marsden NHS Foundation Trust 1. Scope of responsibilities As Accounting Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of The Royal Marsden 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 Royal Marsden 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 The Royal Marsden 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 The Royal Marsden NHS Foundation Trust for the year ended 31 March 2013 and up to the date of approval of the annual reports and accounts. A Board Assurance Framework has been established and used within the Trust for the last six years which is designed to meet the requirements of the 2012/13 Annual Governance Statement and provide reasonable assurance that there is an effective system of internal control to manage the principal risks as identified by the NHS Foundation Trust. The controls and assurances noted within the Framework have been in existence for some time and continue to be in place. 3. Capacity to handle risk The NHS Foundation Trust’s Board of Directors provides leadership and commitment for establishing effective risk management systems across the organisation. The Chairman of the Quality, Assurance & Risk Committee is a Non-Executive Director with senior health service experience, and membership includes other Non-Executive and Executive Directors. As a subgroup of the Board, the Committee is responsible for approving the strategic management of risk and monitoring the implementation of risk management arrangements within the NHS Foundation Trust. The Chief Nurse is identified as the Executive Director with responsibility for risk management. Responsibility for implementing risk management is delegated to a range of staff across the organisation. Their roles and responsibilities for risk management are clearly defined and can be found in the overarching Trust risk management policy. Risk management training is provided for every member of staff at induction and is part of the annual mandatory training programme. The Head of Risk Management is responsible for providing advice and expertise to all staff. Specific ongoing training is determined via the appraisal and personal development planning process at an individual level and by training needs analysis against key risk areas at a strategic level. Guidance for staff is provided through training programmes and information is available in the Risk Management Policy. This is supported by the Accident/Incident & Patient Safety Incident Reporting Policy Including Serious Incidents Requiring Investigation, which supports a learning culture within the organisation. Any incident of any severity including near miss is reported on the Trust wide datix system. More serious incidents require a panel and the results of the root cause analysis including best practice recommendations are fed back through all the relevant clinical bodies in the Trust through from the Board Quality Assurance and Risk committee through the Medical Advisory Committee, the Nursing, Rehabilitation and Radiography committee, the Matrons, Sisters and Staff Nurses Forums, Junior doctors forums. All policies relating to risk management are easily accessible and available to staff on the hospital intranet policy section with supporting information available under the risk management department section. This year the Trust undertook the NHSLA Level 3 assessment for the first time and passed. 103 The Royal Marsden NHS Foundation Trust 4. The risk and control framework The Risk Management Policy has been approved by the Board and is reviewed on an annual basis. It defines the process for the systematic identification and control of risks. It clearly defines accountability structures, roles and responsibilities. The policy details the process for risk identification and evaluation using a standardised risk assessment matrix and sets out the levels of authority for the management of identified risk. During 2012/13 there were no Never Events at the Trust. (This refers to Never Events as described in the NHS Never Events Policy Framework published in October 2012). Risk management is firmly embedded into the activity of the organisation and operational responsibility for risk identification and control is delegated to individual Directors and Senior Managers who have functional responsibility within their areas of management. The policy has been disseminated throughout the NHS Foundation Trust and communicated to key stakeholders. The Assurance Framework was originally adopted by the Board for 2003/04 in line with Department of Health guidelines and was revised and further developed in 2007/08 to incorporate, for example, the Healthcare Commission Standards for Better Health Domains. The Assurance Framework maps out the NHS Foundation Trust’s objectives, key risks to achieving the objectives, and the controls and assurance mechanisms in place to mitigate the risks. The NHS Foundation Trust in 2012 again updated the Board Assurance Framework following national guidance and continues to monitor the assurances it receives against those expected within the Framework and review progress on the action plans drawn up to close the gaps in both controls and assurance. The NHS Foundation Trust is fully compliant with the core Standards for Better Health. The NHS Foundation Trust is committed to having an effective structure for patient and public stakeholder involvement at all levels within the organisation and as an NHS Foundation Trust is provided with strategic direction by the Council of Governors. 104 The NHS Foundation Trust has implemented a Patient and Public Involvement Strategy. The Trust Integrated Governance and Risk management Committee has at least two patient / carer representatives on it as core members. The Patient and Carer Advisory Group acts as the focus for all local patient involvement initiatives often working alongside the Governors. The Board reviewed the systems and procedures for securing personal data, including patient data in transit and were satisfied that these have been and remain compliant with relevant information governance guidance and the Data Protection Act 1998. A new programme highlighting the risks surrounding sensitive information has been initiated to reinforce awareness amongst staff. Encryption devices have been supplied to relevant members of staff and internal audit reviews into data and IT systems security have been carried out during the year, the recommendations of which have been, or are in the process of being, implemented. The Royal Marsden NHS Foundation Trust score for 2012/13 for Information Quality and Records Management assessed using the Information Governance Toolkit was 88%. The Trust scored a minimum of Level 2 on all 45 requirements and therefore achieved a satisfactory (Green) score. The Information Governance Toolkit is available on the Connecting for Health website (www.igt. connectingforhealth.nhs.uk). The Foundation Trust is fully compliant with the requirements of registration with the Care Quality Commission (CQC). The Trust has unconditional registration with the CQC. To ensure that the Trust’s Board, Council of Governors, Management Executive and front line staff can regularly review performance against the CQC’s Essential Standards of Quality and Safety (2010) the Trust publishes a portfolio of quality and performance documents: – A nnual Quality Account – Monthly Quality Account – Integrated Governance Monitoring Report. Annual Report and Accounts 2012/13 The Integrated Governance Monitoring Report includes details on compliance with key performance indicators from the Essential Standards of Quality and Safety. The 28 outcomes are grouped into six areas: – Involvement and information – Personalised care, treatment and support – Safeguarding and safety – Suitability of staffing – Quality and management – Suitability of management. 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 that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations. Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with. The 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. The Foundation Trust is involved, through Borough Resilience Forums and Regional Emergency Planning Network Groups, in extensive multi agency risk reduction and planning work. This is in accordance with the Civil Contingencies act and against the National, Regional and Borough Risk Registers. Risk assessments have been carried out against emergency preparedness and civil contingency requirements. The systematic identification, analysis and control of risks are a key organisational responsibility. A culture of ownership and responsibility for risk management/patient safety is fostered throughout the organisation and all managers and clinicians undertake risk management as one of their fundamental duties. The Trust’s procedures for reporting and investigating accidents, non-clinical incidents, near misses and patient safety incidents aim to support active learning and to ensure that the lessons learnt from these events are embedded into the organisation’s culture and practices. Learning from incidents is an essential part of integrated governance and risk management within the Trust and also a requirement of the Trust Risk Management Policy. Risk management and incident reporting processes identify risks of all levels of severity throughout the organisation. These processes feed into the divisional risk registers which are reviewed on an ongoing basis. Risks that score above 12 are included on the Trust risk register which is reviewed quarterly by the Trust Board. Current high-level clinical risks include issues with (1) junior doctor support, and (2) the resilience of clinical IT systems. 1. There are national problems associated with junior doctor recruitment and core trainee availability. Robust processes are in place led by the Medical Director and Chief Operating Officer to ensure there is high quality cover by Consultant or Associate Consultants. The Trust has also invested in the training and development of Advanced Nurse Practitioners who are working within surgical teams. This innovation has been well evaluated by patients/families/medical and nursing teams 2. The Trust has a very high quality clinical IT system that was designed by The Royal Marsden around the requirements of a specialist cancer hospital. Although the product is still excellent the underpinning IT architecture is now dated and unable to be renewed. The IT teams have dedicated support to the system and are releasing more functionality to ensure stability until a new systems wide development can be resourced. The Medical Director/ Chief Nurse and Director of IT are currently investigating alternative international systems used in cancer care particularly in the US. The above risks have associated high-level action plans which are updated quarterly with the risk scores being adjusted as the level of risk is reduced. These risks are reviewed quarterly by the Trust Board. 105 The Royal Marsden NHS Foundation Trust 5. Review of economy, efficiency and effectiveness of the use of resources The NHS Foundation Trust has established arrangements for managing its financial and other resources which demonstrate that value for money is being managed and achieved. The NHS Foundation Trust: – Achieved its financial plan and efficiency targets in 2012/13 and has an ongoing plan to improve organisational efficiency. This is managed by the NHS Foundation Trust’s Board of Directors. The Audit and Finance Committee reviews performance against the efficiency programme on a regular basis. The Performance Review Group chaired by the Chief Operating Officer meets every two months and reviews the financial performance of each division including the delivery of the efficiency programme – Reviewed key processes, such as the levels of pre-ordering of chemotherapy drugs by clinicians, to improve the efficiency of the service – Is working on several initiatives with shared services with other NHS Foundation Trusts across a range of clinical and non-clinical functions – Is developing its benchmarking capability and gathering the evidence to be able to demonstrate differences between services and organisations – Continued to identify potential productivity gains to be obtained from new workforce contract arrangements and internal workforce planning systems – Internal Audit undertake audits each year which include the review of efficiency and use of resources across an range of expenditure types. 6. Annual Quality Report The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual Quality Reports which incorporate the above legal requirements in the NHS Foundation Trust Annual Reporting Manual. The Board of Directors of The Royal Marsden NHS Foundation Trust is assured that the Quality Report presents a balanced view and that there are appropriate controls in place to ensure the accuracy of data. The Quality Report is discussed throughout the year at monthly Trust Board meetings and at the Quality, Assurance and Risk sub committee of the Board. 106 The Quality Account is authored by the Chief Nurse with input from a wide range of stakeholders throughout the year including: – The Foundation Trust Board – The Council of Governors – The Management Executive – The Patient and Carer Advisory Group – Frontline staff – The Trust Consultative Committee – Local Involvement Networks (LINks) – South West London Acute Commissioners Unit. All the improvement priorities since 2009/10 have been identified and endorsed by members of the stakeholder groups (above). Members of the stakeholder groups have also reviewed progress on achievements over the last two years and ensured that the Trust has realistic but stretching improvement targets. In 2012/13 for the first time Merton Clinical Commissioning Group has been invited to review and add its critique and support to targets for the Sutton and Merton Community Services. On 29 November 2012 the Trust held a patient and public involvement event which over 70 people attended to ensure that priorities for 2012/13 were coherent with all stakeholders. The data presented in the Quality Account is generated by either the Information Team or external bodies such as the Health Protection Agency or Dr Foster Limited who are independent of the operational and clinical teams in the Trust. Finally, the Trust’s external auditors undertook sample data testing of Clostridium difficile cases, cancer treatments started within 62 days of urgent GP referral and Serious Incident reporting. 7. Review of effectiveness As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review is informed by the work of internal auditors, clinical auditors 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. Annual Report and Accounts 2012/13 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, Audit and Finance Committee and Quality, Assurance and Risk Committee, and Clinical Governance Committee, and a plan to address weaknesses and ensure continuous improvement of the system is in place. The Assurance Framework provides me with evidence that the effectiveness of controls to manage risks to the organisation achieving its principal objectives have been reviewed. My review is also informed by: – Assessment of financial reports submitted to Monitor, the Independent Regulator of NHS Foundation Trusts – Opinions and reports made by external auditors – Opinions and reports made by internal auditors – Opinions and reports made by clinical auditors – Achievement of the Customer Service Excellence standard – Unannounced CQC Inspections – N HSLA Level 3 attainment – N HS London Annual Emergency Planning Assurance Process The process that has been applied in maintaining and reviewing the effectiveness of the system of internal control has been reviewed by: – The Board; through consideration of key objectives and the management of principal risks to those objectives within the Assurance Framework – The Integrated Governance and Risk Management Committee; by reviewing all policies relating to governance and risk management and monitoring the implementation of arrangements within the Trust – The Audit and Finance Committee; by reviewing and monitoring the opinions and reports provided by both internal and external audit – The Quality, Assurance and Risk Management Committee; by implementing and reviewing clinical governance and risk management arrangements and receiving reports from all operational risk committees – External assessments of services. 8. Conclusion As Accounting Officer and based on the review process detailed above, I am assured that there are no significant internal control issues. – ISO 9001 compliance for Radiotherapy and Chemotherapy – Clinical Pathology Accreditation (CPA) held for designated pathology services – Quarterly Integrated Governance Monitoring Reports Cally Palmer CBE Chief Executive 29 May 2013 – Infection Control Annual Report – Clinical audit reports and action plans – Investigation reports and action plans following serious and significant incidents – Departmental and clinical risk assessments and action plans – National Health Service Litigation Assessment Level 3 attainment – Results of the national patient surveys – Results of the National Staff Survey. 107 The Royal Marsden NHS Foundation Trust Independent Auditor’s Report to the Board of Governors and Board of Directors of The Royal Marsden NHS Foundation Trust We have audited the financial statements of The Royal Marsden NHS Foundation Trust for the year ended 31 March 2013 which comprise the Statement of Comprehensive Income, the Statement of Financial Position, the Statement of Changes in Taxpayers Equity and the Statement of Cash Flows and the related notes 1 to 22. The financial reporting framework that has been applied in their preparation is applicable law and the accounting policies directed by Monitor – Independent Regulator of NHS Foundation Trusts. This report is made solely to the Board of Governors and Board of Directors (“the Boards”) of The Royal Marsden NHS Foundation Trust, as a body, in accordance with paragraph 4 of Schedule 10 of the National Health Service Act 2006. Our audit work has been undertaken so that we might state to the Boards those matters we are required to state to them in an auditor’s report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Trust and the Boards as a body, for our audit work, for this report, or for the opinions we have formed. 108 Respective responsibilities of the accounting officer and auditor As explained more fully in the Accounting Officer’s Responsibilities Statement, the Accounting Officer is responsible for the preparation of the financial statements and for being satisfied that they give a true and fair view. Our responsibility is to audit and express an opinion on the financial statements in accordance with applicable law, the Audit Code of NHS Foundation Trusts and International Standards on Auditing (UK and Ireland). Those standards require us to comply with the Auditing Practices Board’s Ethical Standards for Auditors. The directors are responsible for the maintenance and integrity of the corporate and financial information included on the company’s website. Legislation in the United Kingdom governing the preparation and dissemination of financial information differs from legislation in other jurisdictions. Scope of the audit of the financial statements 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 Trust’s circumstances and have been consistently applied and adequately disclosed; the reasonableness of significant accounting estimates made by the Accounting Officer; and the overall presentation of the financial statements. In addition, we read all the financial and non-financial information in the annual report 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. Annual Report and Accounts 2012/13 Opinion on financial statements Certificate In our opinion the financial statements: We certify that we have completed the audit of the accounts in accordance with the requirements of Chapter 5 of Part 2 of the National Health Service Act 2006 and the Audit Code for NHS Foundation Trusts. – give a true and fair view of the state of the Trust’s affairs as at 31 March 2013 and of its income and expenditure for the year then ended; – have been properly prepared in accordance with the accounting policies directed by Monitor – Independent Regulator of NHS Foundation Trusts; and – have been prepared in accordance with the requirements of the National Health Service Act 2006. Opinion on other matter prescribed by the National Health Service Act 2006 In our opinion: Heather Bygrave FCA, BA (Hons) Senior Statutory Auditor 29 May 2013 For and on behalf of Deloitte LLP Chartered Accountants and Statutory Auditor St. Albans, United Kingdom – 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, 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; – proper practices have not been observed in the compilation of the financial statements; or – the NHS foundation trust has not made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. 109 The Royal Marsden NHS Foundation Trust Statement of comprehensive income for the year ended 31 March 2013 Note 2012/13 2011/12 £000 £000 Income from activities 3 247,026 226,056 Other operating income 3 74,331 85,530 Operating expenses 4 (320,717) (300,617) 640 10,969 35 149 Public Dividend Capital dividends payable (4,516) (4,216) Net finance costs (4,481) (4,067) (Deficit)/surplus for the year (3,841) 6,902 (315) 54 (4,156) 6,956 2012/13 2011/12 £000 £000 (3,841) 6,902 (8,532) (19,362) 4,065 3,611 Operating surplus Finance costs Finance income 7 Other comprehensive (losses)/income Revaluation and impairment gains on land 9 Total comprehensive income and expense for the year Surplus for the year pre impairment and adjustments relating to capital charitable donations (Deficit)/surplus for the year Donated capital income 9 Depreciation on donated assets Impairment 4 14,620 13,374 Loss on disposal 4 19 26 6,331 4,551 Surplus for the year pre impairment 110 Annual Report and Accounts 2012/13 Statement of financial position as at 31 March 2013 Note 31 March 2013 31 March 2012 £000 £000 Non-current assets Intangible assets 8 483 227 Tangible assets 9 218,393 216,463 218,876 216,690 Total non-current assets Current assets Inventories 10 4,895 4,416 Trade and other receivables 11 34,881 32,662 Cash and cash equivalents 14 14,287 22,397 54,063 59,475 Total current assets Current liabilities Trade and other payables 12 (30,592) (35,822) Provisions 12 - (11) Other liabilities 12 (20,706) (14,686) Tax payable 12 (3,924) (3,772) (55,222) (54,291) - (1) - (1) 217,717 221,873 101,350 101,350 12,850 13,165 Income and expenditure reserve 103,517 107,358 Total taxpayers’ equity 217,717 221,873 Total current liabilities Non-current liabilities Provisions 13 Total non-current liabilities Total assets employed Financed by taxpayers’ equity Public Dividend Capital Revaluation reserve Cally Palmer CBE Chief Executive 29 May 2013 Alan Goldsman Director of Finance 29 May 2013 111 The Royal Marsden NHS Foundation Trust Statement of changes to taxpayers’ equity for the year ended 31 March 2013 Total taxpayers’ equity Public Dividend Capital Revaluation reserve Income and expenditure reserve £000 £000 £000 £000 214,917 101,349 13,110 100,458 6,902 - - 6,902 54 - 54 - Public Dividend Capital received - - - - Other transfer between reserves - 1 1 (2) Taxpayers’ equity at 31 March 2012 221,873 101,350 13,165 107,358 Taxpayers’ equity at 1 April 2012 221,873 101,350 13,165 107,358 Taxpayers’ equity at 1 April 2011 Surplus for the year Revaluation losses and impairment losses on property, plant and equipment Deficit for the year Revaluation losses on property, plant and equipment (3,841) (315) Public Dividend Capital received - Other transfer between reserves - Taxpayers’ equity at 31 March 2013 112 (3,841) 217,717 (315) 101,350 12,850 103,517 Annual Report and Accounts 2012/13 Cash flow statement for the year ended 31 March 2013 2012/13 2011/12 £000 £000 27,079 26,259 35 149 (31,024) (41,075) - 2 (30,989) (40,924) - - Public Dividend Capital dividends paid (4,200) (4,091) Net cash generated from financing activities (4,200) (4,091) Decrease in cash and cash equivalents (8,110) (18,756) Cash and cash equivalents at 1 April 22,397 41,153 Cash and cash equivalents at 31 March 14,287 22,397 Note Cash flows from operating activities Net cash generated from operations 14.1 Cash flows used in investing activities Interest received Purchase of property, plant and equipment Proceeds from sale of property, plant and equipment Net cash generated from investing activities Cash flow from financing activities Public Dividend Capital received 113 The Royal Marsden NHS Foundation Trust 1. Accounting Policies Monitor has directed that the financial statements of NHS foundation trusts shall meet the accounting requirements of the Foundation Trust Annual Reporting Manual which shall be agreed with Treasury. Consequently, the following financial statements have been prepared in accordance with the NHS Foundation Trust Annual Reporting Manual 2012/13 issued by Monitor. The accounting policies contained in that manual follow International Financial Reporting Standards (IFRS) and HM Treasury’s Financial Reporting Manual to the extent that they are meaningful and appropriate to NHS foundation trusts. The accounting policies have been applied consistently in dealing with items considered material in relation to the accounts. Accounting convention These accounts have been prepared under the historical cost convention modified to account for the revaluation of property, plant and equipment, intangible assets, inventories and certain financial assets and financial liabilities. An estimate of the value of partially completed patient episodes is included in Accrued Income. This estimate has been derived by assessing the patient episodes that span both sides of the year end, and estimating the unbilled value of these episodes by pro-rating the number of days spent as an inpatient pre and post year-end. 1.2 Expenditure on employee benefits Short term employee benefits Salaries, wages and employment-related payments are recognised in the period in which the service is received from employees. The cost of annual leave entitlement earned but not taken by employees at end of period is recognised in the financial statements to the extent that employees are permitted to carry forward leave into the following period. Long term employee benefits The policy for accounting for pension costs and liabilities is described in section 1.18. Employers pension cost contributions are charged to operating expenses as and when they become due. 1.1 Income recognition 1.3 Expenditure on other goods and services 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 NHS Foundation Trust is contracts with commissioners in respect of healthcare services. Where income is received for a specific activity which is to be delivered in the following financial year, that income is deferred. Income from sale of non-current assets is recognised only when all material conditions of sale have been met, and is measured as the sums due under the sale contract. Expenditure on goods and services is recognised when, and to the extent that they have been received, and is measured at the fair value of those goods and services. Expenditure is not recognised in operating expenses where it results in the creation of non-current assets such as property, plant and equipment. Monitor’s guidance states that there should be no netting off of income and expenditure. There are a number of employees of the NHS Foundation Trust that perform work for other organisations, who in turn reimburse the NHS Foundation Trust for this work. The accounts show the income and expense from these arrangements under the headings ‘Other income’ and ‘Staff costs’ respectively. 114 Monitor’s guidance states that there should be no netting off of income and expenditure. There are a number of employees of the NHS Foundation Trust that perform work for other organisations, who in turn reimburse the NHS Foundation Trust for this work. The accounts show the income and expense from these arrangements under the headings ‘Other income’ and ‘Staff costs’ respectively. Annual Report and Accounts 2012/13 1.4 Property, plant and equipment Recognition Property, plant and equipment is capitalised where: – it is held for use in delivering services or for administrative purposes – it is probable that future economic benefits will flow to, or service potential be provided to, the Trust – it is expected to be used for more than one financial year – the cost of the item can be measured reliably – individually they have a cost of at least £5,000, or – collectively they have a cost of at least £5,000, 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 – they form part of the initial setting-up cost of a new building or refurbishment of a ward or unit, irrespective of their individual or collective cost. Where a large asset, for example a building, includes a number of components with significantly different asset lives e.g. plant and equipment, then these components are treated as separate assets and depreciated over their own useful economic lives. Valuation All property, plant and equipment assets are measured initially at cost, representing the costs directly attributable to acquiring or constructing the assets and bringing it to the location and condition necessary for it to be capable of operating in the manner intended by management. In accordance with NHS Foundation Trust Annual Reporting Manual 2012/13, all land and buildings are revalued every five years with an interim valuation in the third year. A land and buildings valuation was undertaken as at 31 March 2013. This valuation forms the basis of the land and buildings values on the balance sheet as at 31 March 2013. Valuations are carried out by professionally qualified valuers in accordance with the Royal Institute of Chartered Surveyors (RICS) Appraisal and Valuation Manual. Valuations are carried out primarily on the basis of Modern Equivalent asset value (MEV) for specialised operational property and fair value for non-specialised operational property. Assets in the course of construction are valued at cost and are valued by professional valuers as part of the five or three-yearly valuation, on completion. Operational equipment is valued at net current replacement cost. Equipment surplus to requirements is valued at net recoverable amount. Subsequent Expenditure Subsequent expenditure relating to an item of property, plant and equipment is recognised as an increase in the carrying amount of the asset when it is probable that additional future economic benefits or service potential deriving from the cost incurred to replace a component of such item will flow to the enterprise and the cost of the item can be determined reliably. Where a component of an asset is replaced, the cost of the replacement is capitalised if it meets the criteria for recognition above. The carrying amount of the part replaced is de-recognised. Other expenditure that does not generate future economic benefits or service potential, such as repairs and maintenance, is charged to the Statement of Comprehensive Income in the period in which it is incurred. 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. Freehold land is considered to have an infinite life and is not depreciated. Assets in the course of construction are not depreciated until the asset is brought into use. Buildings and dwellings are depreciated on their current value over the estimated remaining life of the asset as advised by the NHS Foundation Trust’s professional valuer (576 years). Leaseholds are depreciated over the primary lease term. 115 The Royal Marsden NHS Foundation Trust Equipment is depreciated on cost, including historic indexation, evenly over the estimated remaining life of the asset. These are estimated as follows: Plant and machinery 5-15 years Transport equipment 7 years Information technology 5-8 years Furniture and fittings 10 years Revaluation gains and losses Revaluation gains are recognised in the revaluation reserve, except where, and to the extent that, they reverse a revaluation decrease that has previously been recognised in operating expenses, in which case they are recognised in operating income. Revaluation losses 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’. Impairments In accordance with the NHS Foundation Trust Annual Reporting Manual 2012/13, 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. 116 An impairment arising from a loss of economic benefit or service potential is reversed when, and to the extent that, the circumstances that gave rise to the loss is reversed. Reversals are recognised in operating income to the extent that the asset is restored to the carrying amount it would have had if the impairment had never been recognised. Any remaining reversal is recognised in the revaluation reserve. Where, at the time of the original impairment, a transfer was made from the revaluation reserve to the income and expenditure reserve, an amount is transferred back to the revaluation reserve when the impairment reversal is recognised. Other impairments are treated as revaluation losses. Reversals of ‘other impairments’ are treated as revaluation gains. Donated assets Donated fixed assets are capitalised at their fair value on receipt. The donation is credited to income at the same time, unless a donor has imposed a condition that the future economic benefits embodied in the grant are to be consumed in a manner specified by the donor, in which case, the donation is deferred within liabilities and is carried forward to future financial years to the extent that the condition has not been met. The donated assets are subsequently accounted for in the same manner as other items of property, plant and equipment. 1.5 Intangible fixed assets Recognition Intangible assets are non-monetary assets without physical substance which are capable of being sold separately from the rest of the NHS Foundation Trust’s business or which arise from the contractual or other legal rights. They are recognised only where it is probable that future economic benefits will flow to, or service potential be provided to, the NHS Foundation Trust and where the cost of the asset can be measured reliably. Where internally generated assets are held for service potential, this involves a direct contribution to the delivery of service to the public. Annual Report and Accounts 2012/13 Software Recognition 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. Financial assets and financial liabilities which arise from contracts for the purchase or sale of non-financial items (such as goods or services), which are entered into in accordance with the NHS Foundation 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. Measurement Intangible assets are recognised initially at cost, comprising all directly attributable costs needed to create, produce and prepare the asset to the point that it is capable of operating in the manner intended by management. Subsequently intangible assets are measured at fair value. Revaluation gains and losses and impairments are treated in the same manner as for property, plant and equipment. Amortisation Intangible assets are amortised over their expected useful life in a manner consistent with the consumption of economic or service delivery benefits. 1.6 Inventories Inventories are valued at the lower of cost and net realisable value. 1.7 Financial Instruments and Financial Liabilities Financial instruments are defined as contracts that give rise to a financial asset of one entity and a financial liability or equity instrument of another entity. The NHS Foundation Trust will commonly have the following financial assets and liabilities: trade debtors (but not prepayments), current asset investments, cash at bank and in hand, trade creditors (but not deferred income), finance lease obligations, loans, provisions. Financial assets or financial liabilities in respect of assets acquired or disposed of through finance leases are recognised and measured in accordance with the accounting policy for leases described below. Regular way purchases or sales are recognised and de-recognised, as applicable, using the trade date. All other financial assets and financial liabilities are recognised when the NHS Foundation Trust becomes a party to the contractual provisions of the instrument. De-recognition All financial assets are de-recognised when the rights to receive cash flows from the assets have expired or the NHS Foundation Trust has transferred substantially all of the risk and rewards of ownership. Financial liabilities are de-recognised when the obligation is discharged, cancelled or expires. Classification and measurement Financial assets are classified into the following specified categories: – financial assets ‘at fair value through income and expenditure’ or – ‘loans and receivables’. Financial liabilities are classified as either: – financial liabilities ‘at fair value through income and expenditure’ or – ‘other financial liabilities’. 117 The Royal Marsden NHS Foundation Trust Loans and receivables Determination of fair value Loans and receivables are non-derivative financial assets with fixed or determinable payments with are not quoted in an active market. They are included in current assets. For financial assets and financial liabilities carried at fair value, the carrying amounts are determined from quoted market prices/independent appraisals/ discounted cash flow analysis. The NHS Foundation Trust’s loans and receivables comprise: cash at bank and in hand, NHS debtors, accrued income and ‘other debtors’. Impairment of financial assets 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. 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 balance sheet date, which are classified as longterm liabilities. Interest on financial liabilities carried at amortised cost is calculated using the effective interest method and charged to Finance Costs. Interest in financial liabilities taken out to finance property, plant and equipment or intangible assets is not capitalised as part of the costs of those assets. 118 At the balance sheet date, the NHS Foundation Trust assesses whether any financial assets, other than those held at ‘fair value through income and expenditure’ 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 Statement of Comprehensive Income and the carrying amount of the asset is reduced through the use of an allowance account/bad debt provision. Provision for impairment of receivables The NHS Foundation Trust provides for the impairment of its receivables based on the age and type of each debt. The percentages applied reflect an assessment of the recoverability of each class of debt. During 2012/13 the method was reviewed and the percentages amended based on historical recovery and write off levels. Provisions are charged to operating expenditure. 1.8 Cash, bank and overdrafts Cash, bank and overdraft balances are recorded at the current values of these balances in the NHS Foundation Trust’s cash book. Overdrafts are disclosed within creditors. Interest earned on bank accounts and interest charged on overdrafts is recorded as, respectively, ‘finance income’ and ‘finance expenses’ in the periods to which they relate. Bank charges are recorded as operating expenditure in the periods to which they relate. Annual Report and Accounts 2012/13 1.9 Leases Non-clinical risk pooling Finance leases The NHS Foundation Trust participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the NHS Foundation Trust pays an annual contribution to the NHS Litigation Authority and in return receives assistance with the costs of claims arising. The annual membership contributions, and any excesses payable in respect of particular claims are charged to operating expenses when the liability arises. Where substantially all risks and rewards of ownership of a leased asset are borne by the NHS Foundation Trust, the asset is recorded as a 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. Operating leases Other leases are regarded as operating leases and the rentals are charged to operating expenses on a straight-line basis over the term of the lease. Operating lease incentives received are added to the lease rentals and charged to operating expenses over the life of the lease, even if payments are not made on such a basis. 1.10 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 2.9% in real terms. Clinical negligence costs The NHS Litigation Authority (NHSLA) operates a risk pooling scheme under which the NHS Foundation Trust pays an annual contribution to the NHSLA which in return settles all clinical negligence claims. Although the NHSLA is administratively responsible for all clinical negligence cases the legal liability remains with the NHS Foundation Trust. The total value of clinical negligence provisions carried by the NHSLA on behalf of the NHS Foundation Trust is disclosed at note 13 but is not recognised in the NHS Foundation Trust’s accounts. Other insurance The NHS Foundation Trust holds commercial insurance for a range of risks in excess of those covered by the Non-clinical risk pooling scheme. This includes cover for property damage, business interruption and increased costs of working. 1.11 Contingencies Contingent assets are assets arising from past events whose existence will only be confirmed by one or more future events not wholly within the entity’s control. These are not recognised as assets, but are disclosed in note 16 where an inflow of economic benefits is probable. Contingent liabilities are not recognised, but are disclosed in note 16, unless the probability of a transfer of economic benefits is remote. Contingent liabilities are defined as: – possible obligations arising from past events whose existence will be confirmed only by the occurrence of one or more uncertain future events not wholly within the entity’s control or – present obligations arising from past events but for which it is not probable that a transfer of economic benefits will arise or for which the amount of the obligation cannot be measured with sufficient reliability. 1.12 Public dividend capital 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 IAS32. 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. 119 The Royal Marsden NHS Foundation Trust 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 the audit of the annual accounts. 1.13 Value added tax Most of the activities of the NHS 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. 1.14 Corporation Tax Health service bodies, including Foundation Trusts are exempt from tax on their principal health care income. The NHS Foundation Trust has determined that there is no corporation tax liability due for 2012/13. 1.15 Foreign exchange The functional and presentational currencies of the trust are sterling. 1.16 Third party assets Assets belonging to third parties (such as money held on behalf of patients) are not recognised in the accounts since the NHS Foundation Trust has no beneficial interest in them. However, they are disclosed in a separate note to accounts in accordance with the requirement of HM Treasury’s Financial Reporting Manual. 1.17 Pension costs Past and present employees are covered by the provisions of the NHS Pensions Scheme. The scheme is an unfunded, defined benefit scheme that covers NHS employers, General Practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The scheme is not designed to be run in a way that would enable NHS bodies to identify their share 120 of the underlying scheme assets and liabilities. Therefore, the scheme is accounted for as if it were a defined contribution scheme. Employers’ pension cost contributions are charged to operating expenses as and when they become due. Additional pension liabilities arising from early retirements are not funded by the scheme, except where the retirement is due to ill-health. The full amount of the liability for the additional costs is charged to operating expenses at the time the Trust commits itself to the retirement, regardless of the method of payment. 1.18 Key areas of estimation and judgement The key areas of estimation and judgement used in the preparation of the accounts have been disclosed within other sections of the accounting policy notes. These include provisions for impairment of receivables, estimates of partially complete patient episodes, valuation of land and buildings, and depreciation rates applied to property, plant and equipment. 1.19 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. 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). The losses and special payments note, note 17.2, is compiled directly from the losses and compensations register which reports on an accrual basis with the exception of provisions for future losses. Annual Report and Accounts 2012/13 2. Segmental analysis Income Surplus before interest and dividends Assets 2012/13 2011/12 £000 £000 321,357 311,586 640 10,969 217,717 221,873 The Trust has only one segment of business which is the provision of healthcare. The segment has been identified with reference to how the Trust is organised and the way in which the chief operating decision maker (determined to be the Board of Directors) runs the Trust. The geographical and regulatory environment and the nature of services provided are consistent across the organisation and are therefore presented in one segment. The necessary information to develop detailed income and expenditure for each product and service provided by the Trust is currently not discretely available and the cost to develop this information would be excessive. Significant amounts of income are received from transactions with the Department of Health and other NHS bodies, but none of these amounts to over 10% of total income. Disclosure of all material transactions with related parties is included in note 18 to these financial statements. There are no other parties that account for more than 10% of total income. 3. Operating income 3.1 Income from activities by source 2012/13 2011/12 £000 £000 601 878 181,184 168,516 696 38 Other NHS 3,450 4,105 Local Authority 1,280 1,375 59,815 51,144 247,026 226,056 Mandatory healthcare Strategic Health Authority Primary Care Trusts Department of Health Non-mandatory healthcare Private care The above analysis classifies income from activities arising into mandatory and non-mandatory services as set out in the Trust’s Terms of Authorisation. 121 The Royal Marsden NHS Foundation Trust 3.2 Analysis of income from activities by type Elective income Non-elective income Outpatient income Other types of activity income Private patient income 2012/13 2011/12 £000 £000 36,292 35,773 8,233 8,135 20,971 20,623 121,715 110,381 59,815 51,144 247,026 226,056 The Health and Social Care Act 2012 repealed the statutory limitation on private patient income; therefore the private patient cap is no longer disclosed. 3.3 Other operating income 2012/13 2011/12 £000 £000 25,000 30,083 6,456 6,117 25,049 31,790 Non-patient care services to other bodies 3,979 2,894 Services provided to associated charities 1,706 1,634 3,325 3,441 544 552 Catering 1,150 1,104 Other 7,122 7,915 74,331 85,530 Research and development Education and training Charitable and other contributions to expenditure Other income includes: Salaries and wages recharged to other organisations Car parking 122 Annual Report and Accounts 2012/13 4. Operating expenses 4.1 Analysis of operating expenses 2012/13 2011/12 £000 £000 180,118 172,744 Executive Directors’ costs 827 982 Non-Executive Directors’ costs 128 129 Drug costs 46,870 41,045 Supplies and services – clinical 27,677 31,293 Supplies and services – general 5,278 4,876 Establishment 3,069 2,590 Transport 2,756 2,488 Premises 11,420 8,173 (345) (373) Depreciation and amortisation 11,002 10,179 Property, plant and equipment impairment 14,620 13,374 Audit services – statutory audit 81 77 Audit services – other external - 3 1,037 975 Loss on disposal of fixed assets 19 26 Other services from NHS Foundation Trusts 29 - 9 3 5,793 3,538 10,329 8,495 320,717 300,617 Staff costs Bad debts Clinical negligence Other services from NHS Trusts Other services from other NHS bodies Other operating expenses The Trusts property assets have been impaired by £14,620,000. This is necessary for two reasons: Firstly, the assets are valued under the Modern Equivalent Asset Value method in accordance with the accounting policy set out in note 1.4. This basis of valuation incorporates the latest building cost indices and seeks to establish what assets would cost should they be replaced with assets in an equivalent state of repair at an alternative location. Since standard building cost indices are applied, and across London these have decreased over the last year, an impairment is required. Secondly, the Trust has a significant capital expenditure programme taking place on its established estate in Sutton and Chelsea. This capital programme is based on the requirement to continue to provide high quality care in the existing locations. Because the capital programme exceeds the values implied by the Modern Equivalent Asset Valuation an impairment is recognised in the accounts. This is a technical accounting adjustment and does not require any payment of cash. 123 The Royal Marsden NHS Foundation Trust 4.2 Operating leases Operating lease rentals include: Minimum lease payments 2012/13 2011/12 £000 £000 Plant and machinery 208 635 Buildings 692 593 900 1,228 2012/13 2011/12 £000 £000 - 452 19 85 1,190 1,474 387 56 1,491 1,207 - - 3,087 3,274 Operating lease commitments include: Minimum lease payments Total commitments on leases expiring Not later than one year Building Other Between one and five years Building Other After more than five years Building Other 124 Annual Report and Accounts 2012/13 4.3 Salary and pension entitlements of senior managers Short term benefits Name Title Other long term benefits Salary Other remuneration Real increase in pension at age 60 (bands of £5,000) (bands of £5,000) (bands of £2,500) £000 £000 40-45 Total accrued pension at age 60 at 31 March (bands of £5,000) Cash equivalent transfer value at 31 March Real increase in cash equivalent transfer value £000 £000 £000 £000 - - - - - 2012/13 Mr R.I. Molson Chairman Mr C Clark Non Executive Director 10-15 - - - - - Rev Dame S. Mullally Non Executive Director 15-20 - - - - - Sir J. Craven Non Executive Director 10-15 - - - - - Mr R. Turnor Non Executive Director 10-15 - - - - - Mr G. Andrews Non Executive Director 10-15 - - - - - Prof A. Ashworth Non Executive Director 10-15 - - - - - Miss C. Palmer CBE Chief Executive 220-225 - n/a n/a n/a n/a Mr A. Goldsman Director of Finance 145-150 - 2.5-5 30-35 617 88 Prof M. Gore Medical Director 10-15 155-160 0-2.5 70-75 n/a n/a Dr S. Dolan Chief Nurse 115-120 - 0-2.5 35-40 783 41 Dr E. Bishop Acting Chief Nurse Appointed 01/10/11 Acting Chief Nurse 5-10 - 0-2.5 25-30 462 38 Mr D. Probert Chief Operating Officer 120-125 - 0-2.5 20-25 277 27 40-45 - - - - - 2011/12 Mr R.I. Molson Chairman Mr C Clark Non Executive Director 10-15 - - - - - Rev Dame S. Mullally Non Executive Director 15-20 - - - - - Sir J. Craven Non Executive Director 10-15 - - - - - Mr R. Turnor Non Executive Director 10-15 - - - - - Mr G. Andrews Non Executive Director 10-15 - - - - - Prof A. Ashworth Non Executive Director 10-15 - - - - - Miss C. Palmer CBE Chief Executive 220-225 - 2.5-5 85-90 1,764 161 Mr A. Goldsman Director of Finance 135-140 - 2.5-5 25-30 530 99 Prof M. Gore Medical Director 10-15 155-160 2.5-5 70-75 n/a n/a Dr S. Dolan Chief Nurse 95-100 - 2.5-5 35-40 743 128 Dr E. Bishop Acting Chief Nurse Appointed 01/10/11 Acting Chief Nurse 65-70 0 2.5-5 n/a 424 n/a Mr D. Probert Chief Operating Officer 120-125 - 2.5-5 20-25 251 84 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 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. 125 The Royal Marsden NHS Foundation Trust 5. Employee expenses and numbers 5.1 Employee expenses 2012/13 2011/12 £000 £000 144,007 138,753 Social security costs 12,411 11,757 Employer contributions to NHS Pensions Agency 16,304 15,653 8,223 7,563 180,945 173,726 Salaries and wages Agency Staff 5.2 Average number of persons employed (full time equivalent) Permanently employed number Temporary and contract staff number 2012/13 total number 2011/12 total number Medical and dental 346 346 347 Administration and estates 841 841 803 Healthcare assistants and other support staff 272 272 256 1,115 1,115 1,100 784 784 782 413 413 432 413 3,771 3,720 Nursing, midwifery and health visiting staff Scientific, therapeutic and technical staff Bank and agency staff 3,358 126 Annual Report and Accounts 2012/13 5.3 Median Pay The Trust is required to disclose the relationship between the remuneration of the highest-paid director in the Trust and the median remuneration of the Trust’s workforce. The mid-point of the banded remuneration of the highest-paid director in the Trust in the financial year 2012/13 was £222,500 (2011/12 £222,500). This was 6.7 (2011/12 6.7) times the median remuneration of the workforce, which was £33,452 (2011/12 £33,150). The median has been calculated to include London-weighting, as the highest paid director is London-based. Total remuneration includes salary, non-consolidated performance-related pay, benefits-in-kind as well as severance payments. It does not include employer pension contributions and the cash equivalent transfer value of pensions. 5.4 Retirement due to ill-health During 2012/13 there was one early retirement from the Trust agreed on the grounds of ill-health (2011/12 two). The estimated additional pension liability of this ill-health retirement will be £9,183 (2011/12 £259,589). The cost of ill-health retirements is borne by the NHS Pensions Agency. 5.5 Staff exit packages Exit package cost < £10,000 £10,000 – £25,000 £25,001 – £50,000 Number of compulsory redundancies Number of other departures agreed Total number of exit packages by cost band 7 22 29 (15) (15) 8 11 (8) (8) 4 10 (1) (1) 3 6 £50,001 – £100,000 3 1 4 £100,001 – £150,000 - 1 1 19 36 55 454 539 993 Total number of exit packages by type Total resource cost (£000) Of the 55 departures agreed, 31 were under a Mutually Agreed Redundancy Scheme. Prior year comparatives are provided in brackets. 127 The Royal Marsden NHS Foundation Trust 6. Profit/(loss) on disposal of plant, property and equipment 2012/13 2011/12 £000 £000 Profit on disposal of buildings Loss on disposal of plant and equipment (19) (25) Loss on disposal of transport equipment (1) Profit on disposal of fixtures and fittings (19) (26) 2012/13 2011/12 £000 £000 35 149 35 149 7. Financing income Interest receivable 128 Annual Report and Accounts 2012/13 8. Intangible assets Software licences £000 Cost at 1 April 2012 309 Additions purchased 298 Disposals - Cost at 31 March 2013 607 Accumulated depreciation at 1 April 2012 (82) Provided during the year (42) Disposals Depreciation at 31 March 2013 (124) Net book value at 31 March 2013 Purchased Donated 483 483 Cost at 1 April 2011 133 Additions purchased 176 Disposals - Cost at 31 March 2012 309 Accumulated depreciation at 1 April 2011 (59) Provided during the year (23) Disposals Depreciation at 31 March 2012 (82) Net book value at 31 March 2012 Purchased Donated 227 227 129 The Royal Marsden NHS Foundation Trust 9. Property, plant and equipment 9.1 Property, plant and equipment at the balance sheet date comprise the following elements: Cost at 1 April 2012 Land Buildings excluding dwellings Assets under construction Plant and machinery Transport equipment Information technology Furniture and fittings Total £000 £000 £000 £000 £000 £000 £000 £000 24,535 121,882 28,139 61,332 58 15,546 2,025 253,517 Additions purchased Additions donated Reclassifications Revaluation 32,051 (315) 19,310 19,310 8,532 8,532 (42,854) 24,220 Depreciation at 1 April 2012 Provided during the year Revaluation 4,815 367 0 (19,119) (5,311) (38) (3,174) (283) (8,806) 61,642 20 17,187 2,109 253,434 (184) (28,570) (47) (7,594) (659) (37,054) (4,254) (4,613) (3) (1,914) (176) (10,960) 135,129 13,127 4,185 4,185 Disposals Depreciation at 31 March 2013 0 (18,804) Disposals Cost at 31 March 2013 5,621 5,293 38 3,174 283 8,788 - (253) - (27,890) (12) (6,334) (552) (35,041) Net book value at 31 March 2013 24,220 134,876 13,127 33,752 8 10,853 1,557 218,393 Cost at 1 April 2011 24,481 105,339 31,311 52,681 137 13,419 1,517 228,885 Additions purchased - - 22,592 - - - - 22,592 Additions donated - - 19,361 - - - - 19,361 Reclassifications - 33,697 (45,125) 8,785 - 2,135 508 - 54 (17,154) - - - - - (17,100) - - - (134) (79) (8) - (221) 24,535 121,882 28,139 61,332 58 15,546 2,025 253,517 Depreciation at 1 April 2011 - (72) - (24,378) (91) (5,814) (514) (30,869) Provided during the year - (3,892) - (4,323) (8) (1,788) (145) (10,156) Revaluation - 3,780 - - - - - 3,780 Disposals - - - 131 52 8 - 191 Depreciation at 31 March 2012 - (184) - (28,570) (47) (7,594) (659) (37,054) 24,535 121,698 28,139 32,762 11 7,952 1,366 216,463 Revaluation Disposals Cost at 31 March 2012 Net book value at 31 March 2012 None of the land or buildings were held under finance leases or hire purchase contracts at 31 March 2013 or 31 March 2012. 130 Annual Report and Accounts 2012/13 9.2 Property, plant and equipment by funding source Purchased Land Buildings excluding dwellings Assets under construction Plant and machinery Transport equipment Information technology Furniture and fittings Total £000 £000 £000 £000 £000 £000 £000 £000 24,220 83,511 5,584 22,131 8 9,029 659 145,142 51,365 7,543 11,621 1,824 898 73,251 Donated Net book value at 31 March 2013 24,220 134,876 13,127 33,752 8 10,853 1,557 218,393 Purchased 24,535 75,043 16,609 20,012 10 6,177 513 142,899 - 46,655 11,530 12,750 1 1,775 853 73,564 24,535 121,698 28,139 32,762 11 7,952 1,366 216,463 Land Buildings excluding dwellings Assets under construction Plant and machinery Transport equipment Information technology Furniture and fittings Total £000 £000 £000 £000 £000 £000 £000 £000 24,220 131,051 Donated Net book value at 31 March 2012 9.3 Property, plant and equipment by status Protected Unprotected 155,271 3,825 13,127 33,752 8 10,853 1,557 63,122 Net book value at 31 March 2013 24,220 134,876 13,127 33,752 8 10,853 1,557 218,393 Protected 24,535 116,507 - - - - - 141,042 - 5,191 34,460 31,398 11 7,398 1,232 79,690 24,535 121,698 34,460 31,398 11 7,398 1,232 220,732 Unprotected Net book value at 31 March 2012 9.4 The net book value of land, buildings and dwellings comprises: Freehold 31 March 2013 31 March 2012 £000 £000 159,096 146,233 159,096 146,233 131 The Royal Marsden NHS Foundation Trust 10. Inventories 2012/13 2011/12 £000 £000 4,895 4,416 4,895 4,416 2012/13 2011/12 £000 £000 7,642 9,720 (3,402) (3,865) Prepayments 2,029 1,874 Accrued income 9,881 8,321 18,731 16,612 34,881 32,662 2012/13 2011/12 £000 £000 At 1 April 3,865 4,302 (Decrease)/increase in provision (345) (373) Amount utilised (118) (64) At 31 March 3,402 3,865 Raw materials and consumables 11. Trade receivables and other receivables 11.1 Current NHS trade receivables Provision for impaired receivables Other receivables 11.2 Provision for impairment of receivables 132 Annual Report and Accounts 2012/13 11.3 Analysis of impaired trade and other receivables 2012/13 2011/12 £000 £000 Up to three months 305 537 In three to six months 427 804 2,670 2,524 3,402 3,865 17,617 16,578 In three to six months 1,193 1,171 Over six months 1,720 627 20,530 18,376 Ageing of impaired receivables Over six months Ageing of non-impaired receivables past their due date Up to three months 133 The Royal Marsden NHS Foundation Trust 12. Current liabilities 2012/13 2011/12 £000 £000 Trade and other payables 17,015 19,695 Accruals 13,577 16,127 - 11 3,924 3,772 20,706 14,686 55,222 54,291 Provisions Tax payables Other liabilities 13. Provisions for liabilities and charges Pensions relating to other staff Other Total £000 £000 £000 23 - 23 (11) - (11) Released to operating expenses during the year - - - Provided in year - - - At 31 March 2012 12 - 12 At 1 April 2012 12 12 (12) (12) At 1 April 2011 Utilised during the year Utilised during the year Released to operating expenses during the year - Provided in year At 31 March 2013 - - - - - - Expected timing of cash flows Less than one year Between one and five years 134 Annual Report and Accounts 2012/13 Clinical negligence £2,511,033 is included in the provisions of the NHS Litigation Authority at 31 March 2013 in respect of clinical negligence liabilities of the Trust (31 March 2012 £2,863,116). Pensions Provision for the pre-1995 pension related costs on early retirements have been accounted for by the Trust. 14. Notes to the cash flow statement 14.1 Reconciliation of operating surplus to net cash flow from operating activities 2012/13 2011/12 £000 £000 640 10,969 Depreciation and amortisation 11,002 10,179 Impairment 14,620 13,374 Increase in inventories (479) (198) Increase in receivables (2,534) (11,418) (Decrease)/increase in trade and other payables (2,195) 4,996 6,018 (1,658) (12) (11) 19 26 27,079 26,259 2012/13 2011/12 £000 £000 Decrease in cash in the period (8,110) (18,756) Net funds at 1 April 22,397 41,153 Net funds at 31 March 14,287 22,397 Total operating surplus Non-cash income and expense Increase/(decrease) in other liabilities Decrease in provisions Other non-cash movements Net cash inflow from activities 14.2 Reconciliation of net cash flow to movement in net funds 135 The Royal Marsden NHS Foundation Trust 14.3 Analysis of changes in net funds/(debt) At 31 March 2013 Changes in cash in year At 1 April 2012 £000 £000 £000 14,001 (7,448) 21,449 286 (662) 948 14,287 (8,110) 22,397 Government Banking Service cash at bank Commercial cash at bank and in hand Cash and cash equivalents 15. Capital commitments Commitments under capital expenditure contracts at the balance sheet date were £1,775,104 (2011/12 £4,454,908). A further £482,921 (2011/12 £3,587,680) capital expenditure is committed to be funded by The Royal Marsden Cancer Charity. 16. Contingencies There are no contingent liabilities at the balance sheet date. 17. Financial performance targets 17.1 Public dividend capital The Trust is required to pay an annual dividend of 3.5% of its forecast average relevant net assets. The actual dividend rate is the dividend paid figure in the cash flow statement, £4,200,000 (2011/12 £4,091,000), divided by the average of relevant opening and closing net assets, £128,042,309 (2011/12 £120,462,000), expressed as a percentage. This gives an actual dividend rate for 2012/13 of 3.3% (2011/12 3.5%). 17.2 Losses and special payments There were 1,612 cases of losses and special payments (2011/12 299) totalling £120,986 (2011/12 £69,354). These payments are the cash payments made in the year and are not calculated on an accruals basis. There were no clinical negligence, fraud, personal injury, compensation under legal obligation or fruitless payment cases where the net payment exceeded £100,000 (2011/12 nil). 136 Annual Report and Accounts 2012/13 17.3 Prudential borrowing limit The Trust is required to comply and remain within the prudential borrowing limit set by Monitor. This is made up of two elements. – the maximum cumulative amount of long-term borrowing. This is set by reference to the five ratio tests set out in Monitor’s Prudential Borrowing Code. The financial risk rating set under Monitor’s Compliance Framework determines one of the ratios and therefore can impact on the long-term borrowing limit – the amount of any working capital facility approved by Monitor. 2012/13 2011/12 £000 £000 Maximum cumulative long term borrowing 57,600 57,600 Working capital facility 21,600 21,600 Prudential borrowing limit set by Monitor 79,200 79,200 - - Actual borrowing in year The Trust’s dividend cover ratio for the year was 3.9 compared to a minimum dividend cover ratio required of 1 (3.6 for the year ended 31 March 2012). 18. Related party transactions The Royal Marsden NHS Foundation Trust is a public benefit corporation and has been authorised pursuant to Section 6 of the Health and Social Care (Community Health and Standards) Act 2003. During the year none of the Board Members or members of the senior management team or parties related to them has undertaken any material transactions with the Trust. During the year the Trust has had a significant number of material transactions with the following NHS bodies: – N HS Primary Care Trusts – N HS Foundation Trusts – N HS Strategic Health Authorities – N HS Trusts – N HS Pension Scheme – N HS Blood and Transplant. 137 The Royal Marsden NHS Foundation Trust The Trust has entered into the following material transactions with related parties: Income 2012/13 £000 Sutton and Merton PCT 62,171 Croydon PCT 29,398 Surrey PCT 23,236 Department of Health 17,778 West Sussex PCT 8,241 Kingston PCT 7,344 Hampshire PCT 6,520 London Strategic Health Authority 6,103 Wandsworth PCT 5,911 East of England Specialised Commissioning Group 5,168 Richmond and Twickenham PCT 5,034 Kensington and Chelsea PCT 3,821 South West Specialist Commissioning Group 3,558 Epsom and St Hellier NHS Trust 3,319 Guy’s and St. Thomas’ NHS Foundation Trust 3,074 Eastern and Coastal Kent PCT 2,725 Westminster PCT 2,515 Hounslow PCT 2,438 198,354 Expenditure 2012/13 £000 NHS Pension Scheme 16,312 HM Revenue and Customs 12,411 Sutton and Merton PCT 5,961 NHS Blood and Transplant 3,606 38,290 138 Annual Report and Accounts 2012/13 Payables 31 March 2013 £000 HM Revenue and Customs 3,924 NHS Pension Scheme 2,238 6,162 The Trust has had a number of transactions with Government departments and other central and local Government bodies. These include transactions with the Royal Borough of Kensington and Chelsea and the London Borough of Sutton relating to business rates. 19. Financial instruments IFRS 7 requires disclosure of the role that financial instruments have had during the period in creating or changing the risks an entity faces in undertaking its activities. The Trust does not have any complex financial instruments and does not hold or issue financial instruments for speculative trading purposes. Because of the continuing service provider relationship the Trust has with Primary Care Trusts and the way those Primary Care Trusts are financed, the 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 the listed companies to which IFRS 7 mainly applies. The 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 Trust in undertaking its activities. The Trust’s financial instruments comprise loans, finance lease obligations, provisions, cash at bank and in hand and various items, such as trade debtors and trade creditors, that arise directly from its operations. The main purpose of these financial instruments is to raise finance for the Trust’s operations. 19.1 Categories of financial instruments 2012/13 2011/12 £000 £000 54,063 53,185 55,222 35,822 Financial assets Loans and receivables (including cash) Financial liabilities Other financial liabilities (amortised cost) 139 The Royal Marsden NHS Foundation Trust 19.2 Fair values 31 March 2013 Book value 31 March 2013 Fair value 31 March 2012 Book value 31 March 2012 Fair value £000 £000 £000 £000 - - 12 12 Financial liabilities Provision under contract As allowed by IFRS 7, short term trade debtors and creditors measured at amortised cost may be excluded from the above disclosure as their book values reasonably approximate their fair values. 19.3 Liquidity and interest risk tables Less than 1 year Total £000 £000 32,851 32,851 14,287 14,287 Gross financial assets at 31 March 2013 47,138 47,138 Non-interest bearing 30,788 30,788 22,397 22,397 53,185 53,185 Weighted av. interest rate % Financial assets Non-interest bearing Variable interest rate instrument Variable interest rate instrument Gross financial assets at 31 March 2012 0.25% 0.25% 20. Third party assets The NHS Foundation Trust held nil cash at bank and negligible cash in hand at 31 March 2013 (31 March 2012 – nil) which relates to monies held by the NHS Foundation Trust on behalf of patients. 21. Events after the reporting period There have been no material events after the reporting period. 140 Annual Report and Accounts 2012/13 22. Adoption of new and revised standards At the date of authorisation of these financial statements, the following standards and interpretations which have not been applied in these financial statements were in issue but not yet effective (and in some cases had not yet been adopted by the EU): IAS 12 (December 2010) Income taxes IFRS 7 (December 2011) Offsetting financial assets and liabilities (disclosure) IFRS 9 (October 2010) Financial liabilities IFRS 9 (November 2009) Financial assets IFRS 10 (May 2011) Consolidated financial statements IFRS 11 (May 2011) Joint arrangements IFRS 12 (May 2011) Disclosure of interests in other entities IFRS 13 (May 2011) Fair value measurement IAS 1 (June 2011) Presentation of financial statements IAS 27 (May 2011) Separate financial statements IAS 28 (May 2011) Associates and joint ventures IAS 19 (June 2011) Employee benefits IAS 32 (December 2011) Offsetting financial assets and liabilities (presentation) The Trust does not expect that the adoption of these standards and interpretations in future periods will have a material impact on the financial statements of the Trust. 141 The Royal Marsden NHS Foundation Trust Life demands excellence. At The Royal Marsden, we deal with cancer every day so we understand how valuable life is. And when people entrust their lives to us, they have the right to demand the very best. That’s why the pursuit of excellence lies at the heart of everything we do. No matter what we achieve, we’re always striving to do more. No matter how much we exceed expectations, we believe we can exceed them still further. We will never stop looking for ways to improve the lives of people affected by cancer. This attitude defines us all, and is an inseparable part of the way we work. It’s The Royal Marsden way. You can visit, write to or call The Royal Marsden using the following details: Chelsea, London The Royal Marsden Fulham Road London SW3 6JJ Tel 020 7352 8171 Sutton, Surrey The Royal Marsden Downs Road, Sutton Surrey SM2 5PT Tel 020 8642 6011 www.royalmarsden.nhs.uk 142 Spine The Royal Marsden NHS Foundation Trust Please adjust width according to bulk of bound document. Text centres on the vertical. Annual Report and Accounts 2012/13