Summary Annual Report 2009/10

Summary Annual Report 2009/10

Summary Annual Report 2009/10 2 Aim of the Trust To be the specialist orthopaedic hospital of choice by providing outstanding patient care, research and education. Our values Patients first Achieving positive outcomes for our patients Providing a clinically safe environment Rigorous monitoring of standards Treating all our patients with honesty, openness and respect Protecting patients rights to courtesy and dignity Treating patients as individuals Responding to patients needs and expectations Honesty Explaining decisions that have been made Sharing key messages, whether good or bad Admitting when we don t know and asking for help Respect Challenging inappropriate behaviour from patients or colleagues Being constructive rather than blaming Listening more than telling Understanding difference Excellence Learning from experience, evidence, education and research Working across departments and professional boundaries to achieve Trust-wide goals and targets Rewarding and celebrating good performance Maximising the benefit of partnerships Paying attention to detail Trust Speaking well of each other Maintaining confidentiality for patients and colleagues Empowering staff to achieve their potential Equality Celebrating the diversity of our staff Valuing the diversity of ideas, roles and backgrounds Ensuring fair and consistent employment practice Recognising achievement at all levels of the Trust Challenging prejudice and discrimination

Statement from our Chairman and Chief Executive Welcome to our review of 2009/10. In the past year, the Trust has reached significant milestones, not least the opening of a state-of-the-art Outpatient Assessment Centre in central London and approval from the Secretary of State for Health to embark on the redevelopment of the Stanmore site. This has come after many years of uncertainty and the Trust can now plan effectively for the future of this hospital with the full support of its Primary Care Trusts, NHS London, Department of Health and the Treasury. Redevelopment approval represents a major step forward in helping to maintain our world-wide reputation for providing excellent specialist orthopaedic care and supports our ambition to become an NHS Foundation Trust over the next 18 months. The first phase of the agreed redevelopment will include a brand new hospital on the Stanmore site providing state-of-the-art wards and imaging, with builders scheduled to be on site in 2012 and completion of this phase in 2014. The level of investment is expected to be in the region of 81 million and will, in the main, be funded through the Private Finance Initiative (PFI). To support the redevelopment, the Trust also plans to undertake several enabling projects such as the refurbishment of the Outpatients Department. This project is currently in its planning stages and will be funded from a combination of our own resources as well as a significant contribution from the RNOH Charity. The refurbishment of outpatients will finish before we start the main new build and provide patients with a significantly enhanced environment and service. Once again, we had record levels of demand for our specialist services and, by the end of the financial year, achieved the 18 week referral to treatment target in all but one area. We maintained a healthy financial performance in 2009/10, building on our fair rating for quality of services and use of resources in 2008/09. The main factors which prevented our quality score from being higher were the condition of the Trust s Stanmore buildings (becoming compliant with the required standards depends on the Stanmore site redevelopment going ahead) and the pace at which we delivered the 18 week access standard. We are pleased that we have been able to start the refurbishment of key areas and expand our theatre capacity, prior to phase one of the Stanmore redevelopment. However this will need to be delivered in a difficult economic climate and the Trust, along with the rest of the NHS, faces significant financial challenges. The Trust will need to not only continue to operate as a financially viable organisation in a very difficult environment, but also deliver the savings and transformation plans necessary to afford its redevelopment plans. In preparing for these challenges, the Trust has put in place financial and operational plans to ensure it achieves the targets it has set itself and successfully delivers its redevelopment project. We have appreciated the hard work of our staff over the past year, their commitment and belief in the Trust and their contribution to the success of the organisation. Their continued support will be vital in what we recognise will be a very challenging year ahead. Signed... Rob Hurd Chief Executive Signed... Donald Hoodless Chairman Summary Annual Report 2009/10 3

Who we are and what we do Annual Report 2009/10 4 The Royal National Orthopaedic Hospital (RNOH) is the largest specialist orthopaedic centre in the UK with a turnover of 94m and is world-renowned for the diagnosis and treatment of neuromusculoskeletal conditions. These range from the most acute spinal injuries, bone tumours and complex joint reconstruction to orthopaedic medicine and specialist rehabilitation for those with chronic back pain. Drawing on a combination of clinical excellence, case complexity and academic excellence achieved through its partnership with UCL, the Trust s portfolio of services is unique within the NHS and attracts scientists and clinicians from all over the UK and beyond. The RNOH treats a high proportion of the sub-specialist work carried out in the UK, for example a third of UK spinal scoliosis surgery and two thirds of specialist peripheral nerve injury work takes place at the Trust. The RNOH is one of five designated bone tumour and one of eight spinal cord injury centres in the UK. The Trust is a national provider; 48% of the Trust s patients live in London, a further 20% in the remainder of the South East and 30% come to the hospital from further afield in the UK. The Trust is a member of the Specialist Orthopaedic Alliance partnership of the UK s specialist orthopaedic hospitals which includes: Nuffield Orthopaedic Hospital NHS Trust, Oxford Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham Robert Jones and Agnes Hunt NHS Trust, Oswestry The Wrightington Hospital, part of Wrightington, Wigan & Leigh NHS Foundation Trust

Our Trust Board in 2009/10 Mr Donald Hoodless OBE Chairman Mr Rob Hurd Chief Executive Officer Mrs Helen Farrow Non-executive Director (Vice Chairman) Mr Anthony Watson Non-executive Director Mr Guy Billington Non-executive Director Professor Simon Shorvon Non-executive Director Mr Laurence Milsted Non-executive Director Professor Tim Briggs Joint Medical Director Dr Rhiannon Mitchell Joint Medical Director (to 31 October 2009) Professor Adrienne Flanagan Joint Medical Director (from 1 November 2009) Mr Ahmet Koray Director of Finance Mr Charlie Sheldon Chief Nurse Mr Mark Vaughan Director of Human Resources and Corporate Affairs Mrs Sheila Puckett Director of Operations and Service Improvement (to 2 March 2010) and then Director of Service Transformation (from 3 March 2010) Jon Scott Interim Director of Operations (from 3 March 2010) Professor David Marsh Director of Research and Development Dr Benjamin Jacobs Director of Children s Services (from 1 December 2009) Mr Mark Masters Director of Projects, Estates and Facilities Dr Saroj Patel Director of Information Management and Technology Annual Report 2009/10 5

Operational and quality review Summary Annual Report 2009/10 6 Keeping patients safe and providing exemplar care remains at the heart of our organisation. Minimising hospital acquired infections and pressure sores remains a top priority at the RNOH and following a Care Quality Commission Hygiene Code inspection in 2009, we received a positive report into the cleanliness of the hospital. In 2009/10 we reported: Zero serious medication errors A reduction in clostridium difficile infections (from five cases in 2008/9 to two cases in 2009/10) Continued low incidence of MRSA Bacteraemia (one case in 2009/10) A reduction in pressure sores Continued low rates of wound infection following hip replacement, knee replacement and spinal surgery In 2009/10 we implemented: Patient safety walk rounds A patient experience improvement committee Matrons inspections Patient experience reports to the Trust Board and clinical directorates Real-time patient feedback The productive ward initiative in six wards A Trust nutrition group The Trust maintained its excellent track record in delivering high quality treatment and care for patients needing complex orthopaedic surgery. Our infection rates were low with one MRSA and and two clostridium difficile cases for the year, out of a total 11,068 inpatient discharges. Our performance target for MRSA was zero cases and a maximum of eight for clostridium difficile. Activity Activity levels continued to grow with a 3% increase in 2009/10 NHS activity recorded against the previous year. This has helped in making significant progress towards delivering the 18 week access target. In March 2010, with a breach-sharing adjustment applied to the performance target, 93% (2008/09-88%) of nonadmitted patients compared to a target of 95% and 88% (2008/09 83%) of admitted patients compared to a target of 90% were treated within 18 weeks. Whilst disappointing that the Trust has not met these performance targets, the Trust is confident of delivering its 18 week recovery plan by the end of 2010/11. This will be achieved in part by the additional investment the Trust has committed to increase capacity across its services to meet on-going demand and clear the backlog of cases. For example, the new theatre is now in place and operational, with the two non-compliant theatres the Trust had currently undergoing refurbishment. Additional clinical and support staff are in the process of being recruited to coincide with the additional theatre capacity coming on stream in the summer of 2010. This will allow the Trust to take immediate advantage of the capacity increase and give it the opportunity to meet the 18 week performance target as well as the financial and business plans it has set itself. In the meantime, to support the capacity pressures facing the organisation, the Trust has continued to access services provided by the independent sector for uncomplicated procedures that can be carried out by our consultants on their premises.

Achievements against our priorities for 2009/10 The Trust Board focused on the following priorities in 2009/10: Financial performance and planning long term financial stability The Trust has continued to make progress in clearing its historical deficits and delivered a surplus of 0.15 million for the year, achieving a risk rating score of 2. This score was restricted to a 2 as a result of the liquidity of the Trust. This is now the third year running that the Trust has delivered a surplus and reflects the strong financial 2004/05 ( m) 2005/06 ( m) management that has developed across the organisation and the commitment from all staff groups to deliver challenging cost improvement schemes. The programme for the year was set at 2.937 million, without which the Trust would not have achieved its surplus. The savings programme, combined with robust income and expenditure procedures, ensured the Trust met its financial targets and allows it to continue to build on its long-term financial stability. The improved financial performance of the Trust is illustrated in the table below: 2006/07 ( m) 2007/08 ( m) 2008/09 ( m) 2009/10 ( m) Summary Annual Report 2009/10 7 Net Surplus/(Deficit) before impairments (3.793) (0.462) (0.315) 1.109 0.483 1.026 Looking forward, commissioners have been guaranteed real revenue uplifts up to 2010/11, which has resulted in funded activity increases for the Trust of 3% in 2009/10 and a commitment to fund an additional 4% in 2010/11. This funding commitment reflects the Trust s historical activity increases and the future levels required to deliver and sustain 18 week performance targets and patient choice demands. The Trust has planned to deliver this additional activity through investments it has made in the year in an additional theatre, consultant surgeon appointments and supporting staff recruitment. Thereafter, commissioners have stated that no activity growth should be assumed. The Trust aims to deliver the following in 2010/11: a. A financially robust plan to deliver surpluses in 2010/11 and 2011/12 b. Clearing previous operational deficits and achieving the cumulative breakeven duty by the end of 2010/11 c. Delivering the capital infrastructure investment required to achieve the activity levels in order to sustain the 18 week performance targets d. Beginning the cash and resource build-up to allow the Trust to afford its future redevelopment proposals e. Allowing the transformation agenda to be successfully set up and delivered effectively from the beginning of 2010/11 f. Ensuring that the Trust s cost improvement and transformation proposals do not affect the excellence of services and the current levels of clinical quality In developing these plans, the Trust has taken account of certain risks and uncertainties. These include: The potential reconfiguration of services and PCTs across London Continued development of the Trust s information systems, costs and prices to support Trust contracts Delivery of the Trust transformation and cost saving programme Pay and other contract settlements against levels of inflation Delivery of capital investment schemes to time and budget and meeting the enabling costs of the Stanmore redevelopment A reduction in demand from private patients These risks are monitored by the Board through our governance structures, and plans are in place to address them.

Operational and quality review Summary Annual Report 2009/10 8 Becoming a Foundation Trust The approval for the Trust s redevelopment of the Stanmore site in March 2010 has meant that the Trust may now progress its plans for becoming an NHS Foundation Trust over the next 18 months. In the past year, the Trust has maintained good contact with its Foundation Trust members through newsletters and events and continues to encourage membership from patients, their carers and the general public. The Trust Board have continued to collaborate on the Trust s business plans, ensuring that cohesive, ambitious but achievable aspirations exist for the Trust s future as a Foundation Trust. Maintaining high quality of patient care Good clinical outcomes remain an important feature of patients experience at the Trust. This includes continued low rates of infection. Effective multi-disciplinary working is a cornerstone of the Trust s clinical services, which translates into a positive experience for patients. Redeveloping both sites to enhance the patient experience and continue to provide and develop services, which other hospitals cannot provide The new central London Outpatient Assessment Centre opened in December 2009 and offers modern healthcare facilities for patients. In addition to the new purpose built facility, the staff have implemented several changes to service delivery to improve the patient experience. This has included attempts to minimise queuing by implementing a larger team of clinical support workers who greet patients on arrival, introducing extended working days to minimise waiting times and creating more capacity by investing in the latest imaging equipment, which is faster and safer. These are just some of the improvements introduced and further information can be found on the Trust s website www.rnoh.nhs.uk. On 31 March 2010, the Secretary of State for Health, Andy Burnham, visited Stanmore to confirm approval of the Trust's case to redevelop the Stanmore hospital, thus giving us the go-ahead to build phase one of our redevelopment project. The decision has subsequently been reaffirmed by the new government Minister of State for Health. The London Borough of Harrow also granted outline planning permission for the redevelopment on 10 March 2010. Developing robust relationships with our strategic partners to enhance research and development in our specialist field The Trust is pursuing a Joint Academic Plan with the Institute of Orthopaedic and Musculoskeletal Science as well as forging links with other academic centres to ensure that the Trust remains at the forefront of translational research and education in orthopaedics and musculoskeletal science.

Priorities and objectives for 2010/11 Building on the achievement of the 2009/10 priorities, the Trust Board has agreed the clinical and academic vision for the RNOH. The Trust Board reviewed and agreed iterations of its integrated business plan and incorporated these plans into the redevelopment business case. The integrated business plan, redevelopment business case and 2010/11 business plan are all supported by a long term financial model reflecting the planning assumptions of NHS London and our main commissioning agency. The Board has agreed an appropriate range of key performance indicators (KPIs) that will be used to measure performance against objectives during the year. The agreed indicators measure a range of quality, activity, financial and productivity measures. Where objectives can be monitored through specific key performance indicators we have agreed that the achievement of objectives relating to redevelopment and supporting service transformation will be measured by regular Board monitoring of progress against agreed milestones. The objectives and priorities for 2010/11 can be summarised as: a. Maintaining clinical excellence To be the pre-eminent, effective, efficient and safe provider of orthopaedic and musculoskeletal services, providing the highest standards of care. b. Re-development and capital investment To redevelop the RNOH Stanmore campus to provide a modern healthcare building and facilities and to use capital investment effectively to improve the working environment and health and safety. To improve and sustain business activity and to deliver agreed milestones during the year that are required to achieve approval of a full business case for redevelopment. c. Finance To achieve financial targets, maintain liquidity and increase turnover. d. Leadership and workforce To ensure that the workforce is fit for purpose and supports the Trust s service and financial plans. e. Governance To implement, embed and monitor effective arrangements that reflect current Trust business. f. Achievement of access/activity targets To achieve access targets and to deliver the activity targets. g. Information Management & Technology (IM&T) To develop and implement a cohesive and integrated IM&T strategy. h. Foundation Trust To achieve Foundation Trust status. i. Service Transformation Programme To ensure that Trust services are clinically and financially sustainable in the new hospital build through delivery of the service transformation programme. Summary Annual Report 2009/10 9

Partnership working Summary Annual Report 2009/10 10 Research and development The Trust, together with UCL s Institute of Orthopaedics and Musculoskeletal Science, has obtained two large research grants over the past year. These will support studies at the Trust and contribute to the development of new treatments. This accomplishment brings closer the Trust s aim to become a centre of excellence for research in the field of orthopaedics and musculoskeletal science, in partnership with UCL. The Trust aims to increase its research portfolio over the coming years, and continue its collaboration with IOMS, as well as other academic centres. Specialist Orthopaedic Alliance The Trust continues to play a key role in the Specialist Orthopaedic Alliance, which exists to enable the Trust, along with other orthopaedic hospitals, to share best practice and address the challenges that specialist orthopaedic hospitals face to secure the future of patient services as well as research and development. During the year, the Specialist Orthopaedic Alliance, in collaboration with the Trust, was involved in discussions with the Department of Health on revised NHS pricing proposals and made a significant contribution to the Road Test and Sense Check work it was requested to undertake as part of the process. The outcome of this was that a number of specialist orthopaedic procedures now have national prices, which more accurately reflect the complexity of work undertaken by the Trust and members of the Specialist Orthopaedic Alliance. Our operating resources Our staff As at 31 March 2010, the Trust employed 1030 staff, 15 more than the previous year. This figure may be broken down as follows: Education and Training Over 20% of all UK orthopaedic surgeons receive training at the RNOH and the Trust hosts a variety of specialist courses which are available to both RNOH staff and delegates from across the UK and beyond. The Trust prides itself on offering its staff excellent opportunities for development, both through internal training programmes and access to external sources as required. The Trust has maintained strong links with universities and provided clinical staff with a wide range of courses to support the specialist nature of our work. Our estate Bolsover Street redevelopment The Trust s Outpatient Assessment Centre in central London opened to patients on 14 December 2009, on time and on budget. The new centre means that patients are seen in an appropriate and modern clinical setting with much enhancement of the environment, including a significant investment in artwork. Staff implemented eight service improvement projects for the new facility, including new roles, which aim to improve the patient experience. Stanmore redevelopment In planning phase one, the approach taken by the Trust has been to ensure the facility is a stand-alone development that is sustainable in the long term, should approval for subsequent phases not be granted at a later date. The Trust acknowledges that in order to deliver the scheme effectively, it is important to ensure effective communication arrangements with both internal and external stakeholders are established and maintained throughout the project. In this respect, the Trust plans to provide opportunities for the general public and specialist interest groups to obtain further information throughout the course of the planning and building stages of the scheme. Once complete, the redevelopment will enhance and support the efficient, effective and safe delivery of treatment and care for patients of the RNOH, augmenting the existing collaborations with the Trust s partners including University College London (UCL) and the Association for Spinal Injury Research, Rehabilitation and Reintegration (Aspire).

Partnership working Patients Patient and public involvement The Trust aims to deliver its services by taking account of every aspect of our patients experience. The Trust has strengthened its links with the RNOH Patients Group who are ex-patient forum members. They evaluate our services from a lay perspective through regular visits to wards and their visit reports are discussed at Trust Board. The RNOH patients group supports the Trust s patient information process by reviewing patient information leaflets before they are published. Members of the RNOH patients group sit on various Trust groups and committees such as the Infection Control Committee, Patients Experience Improvement Committee, Clinical Governance Committee, Diversity Group, Improving the Safeguarding Adults Project Group, and the Productive Ward (Releasing Time to Care) Group. Patient Advisory and Liaison Service (PALS) The Trust s PALS service is well established and located within the Stanmore Outpatients Department for ease of access for our patients, relatives and carers. We aim to provide information about services as well as a prompt resolution to concerns, without the need for a formal complaint. Managing risk and maintaining patient safety The Trust is committed to the management of risk and ensuring patient safety is paramount. The Trust has NHSLA Assessment Level 2 and is confident that, at reassessment in December 2010, will maintain this. The Trust continues to work closely with the National Patient Safety Agency and has, over the past year, continued to undertake a mix of training for all levels of staff to ensure the safety and care of both patients and staff. In 2009/10 the Trust implemented a new risk structure integrating clinical and non clinical risk management as well as implementing a patient experience committee and patient experience reports at local and Trust level. Additionally, in 2009, we appointed a clinical director for clinical governance to work closely with the chief nurse on all aspects of clinical governance and patient safety. Through developing the risk register at directorate level, monitoring and ownership of key risks have been enhanced. The Trust signed up to the Patient Safety First Campaign in 2008 and in 2009 implemented patient safety walk rounds by executive directors. Patient information The Trust provides a wide range of information leaflets for patients, making them available in clinic and on the Trust s website. In addition, professionals in other Trusts seek such information from our staff, given the specialist nature of our work. Preventing and controlling infection Prevention and control of Healthcare Associated Infections (HCAIs) is a key priority for all staff working at the RNOH. The Trust has seen a marked increase in patient throughput during 2009/10, however, infection rates remain low. The Trust started screening all elective surgical patients in March 2009. It has been Trust policy for many years to screen for MRSA all patients who are admitted as emergencies or transferred from other organisations. The senior sisters have taken responsibility for carrying out hand hygiene audits and saving lives audits each month. Large numbers of staff, at Stanmore and Bolsover Street, continue to receive their mandatory infection control training throughout the year at induction and annual update. The Trust has a robust system for mandatory surveillance for all patients undergoing total hip replacements (THR), total knee replacements (TKR) and spinal surgery where prosthesis is inserted or removed. Serious untoward incidents involving data loss or confidentiality breaches During 2009/10, the Trust experienced no serious untoward incidents involving data loss or breaches of confidentiality. The introduction of information governance training, as well as utilising a range of internal communication media, has contributed to greater awareness and understanding of the importance of data confidentiality across the Trust. Annual Report and Accounts for 2009/10 The full annual report and accounts is available from our Communications Department 0208 909 5750, enquiries@rnoh.nhs.uk and on our website www.rnoh.nhs.uk. Summary Annual Report 2009/10 11

Summary Annual Report 2009/10 12 Royal National Orthopaedic Hospital NHS Trust Brockley Hill Stanmore Middlesex HA7 4LP Tel: 020 8954 2300 www.rnoh.nhs.uk