Chief Executive Report May 2008

Royal National Orthopaedic Hospital Trust

Commentary on performance

The Trust has made a good start to the year financially with a 59k in month surplus, a significant improvement on our planned position. This position is very significant bearing in mind the major shifts in funding that we are seeing this year. We have lost the £5.5m tariff transitional funding that we have received in previous years and replaced this with income for procedures that are now excluded from the tariff. This good start to the year suggests that our negotiations with primary care trusts to get a fair price of these excluded procedures, has been successful.

The key performance target that we have to monitor very closely is our progress towards the 18 week target for December 2008. Our particular challenge is to ensure that by this date at least 90% of our patients admitted are on an 18 week pathway. We achieved 69% in April which is close to the average for the other specialist orthopaedic hospitals, but does demonstrate that we have a major challenge ahead of us between now and December.

Our challenge is to clear the backlog of patients waiting so that we can get down to the 18 week pathway and the entire executive team is focused on achieving this. This topic dominates the discussion at the weekly executive team meetings and we are working through plans to clear the backlog on a unit by unit basis. This includes sending cases to the private sector. The area that presents us with the biggest challenge is spinal surgery and we are actively working on solutions to this problem.

Discussion with Department of Health about 18 week target

I chaired a meeting of the Specialist Orthopaedic Alliance in early May where the main topic of discussion was our progress in achieving the 18 week target. On 16 May Sheila Puckett and I attended a seminar with other representatives of the specialist orthopaedic hospitals meeting with the Department of Health to discuss the 18 week target. Nick Chapman who is directly accountable to David Flory for the delivery of the 18 week programme and his team were present at the meeting.

The performance of the specialist orthopaedic hospitals in achieving the March milestone of at least 85% admitted patients on an 18 week RTT was mixed. The average performance was 70% and as such RNOH with 69% was very close to the average. During the meeting with the Department of Health I had an opportunity to make a presentation on behalf of the Alliance highlighting issues that needed to be addressed to help us hit the target in December. I highlighted three points:

Insufficient capacity in certain areas e.g. scoliosis surgery.
Delays in receiving tertiary referrals.
Recognition of hospitals that receive a high proportion of tertiary referrals so that they have a higher percentage tolerance on hitting the target e.g. 20%.

I think that we got our message across on the need to be supported in areas where there is a national shortage of capacity and I have been asked to join a meeting with the Department of Health on the 24th June specifically looking at spinal surgery in this respect. With regards to the timing of receipt of tertiary referrals, I proposed that if referrals are not received in a timely manner any breach of the 18 week target should count against the referring hospital rather than the specialist centre that receives the referral. I think that the Department of Health is more likely to adopt a breach sharing arrangement and indeed they have signalled their intent is to do this within the operating framework for the NHS published earlier in the year. I am not hopeful that they will adopt a differential in the tolerance for providers but I do think we need to maintain the pressure on this.

Andrew Dismore, MP the Hendon, who visited the trust in early May had asked to be updated on this situation following the meeting with the Department of Health and I have written to him highlighting the points listed above and asking for his support.

OBC submission and timetable

The OBC for the Stanmore redevelopment was submitted to the SHA as agreed at the last board meeting. We know that the document is now being analysed by different teams within the SHA and I am seeking feedback from Malcolm Stamp as to the overall timetable for getting approval of the OBC. The critical timing issue will be the date of the SHA capital investment committee which will need to agree to sign off the OBC before we get formal approval. Board members may be aware of the recent announcement that George Greener, chair of the SHA, will be standing down and clearly it would be in our best interest to move ahead with the OBC approval prior to Mr Greener moving on.

Updates on strategic issues

Barking and Havering

Sheila Puckett and I met with the Chief Executive and other members of the executive team from the Barking and Havering NHS trust earlier in the month to agree how we reach a conclusion as to whether RNOH is going to work with the trust to help resolve the issue of their orthopaedic service. I am not confident that Barking and Haveringwant RNOH to take on the management of all of the orthopaedic service but are more interested in us resolving the issue of clinical leadership and in particular helping to ensure that the Trust has a group of well motivated consultants who are working together as a team. We will need to decide on what basis we would be willing to help sort out the problem in Barking and put this proposal both to that trust and to NHS London. We have agreed to work with the trust over the next few weeks to look at alternative ways that RNOH could be involved with the aim of reaching a conclusion by the end of June. I will be having further discussions with Tim Briggs on this during the next few days and both Tim and I can give a verbal update at the Trust board meeting.

Nuffield orthopaedic hospital NHS trust

RNOH has agreed to participate in the exercise being undertaken by the SHA to see whether merging the Nuffield orthopaedic hospital with another organisation would resolve their financial problems. PwC have been engaged to undertake this work and Rob Hurd and I are meeting with them this week and will give a verbal update at the trust board. At this stage our approach is to participate in the review and see what benefit could be achieved by joining together with the Nuffield Orthopaedic Centre, but without delaying our own foundation trust application. We will keep the board informed of developments.

Specialist commissioning review

A key priority of the specialist orthopaedic alliance is to ensure that more of the specialist work in each of our hospitals comes under the remitof either the National Specialist Commissioning Group or the 10 regionally-based specialist commissioning groups. There is a very strong link between this priority and the work we are doing with the Department of Health to ensure that the tariff properly reflects the cost of the specialist surgery that we undertake. The Department of Health looks to the specialist commissioning groups to help them decide which hospitals should receive the specialist top-ups within the payment by results regime.

Having met with Adrian Pollit, the director of the National specialist commissioning group, it has been agreed that the Alliance will be formally consulted on the definition sets that will be used by the 10 regional groups to help them choose which services should be commissioned at that level. The definition sets that we will be consulted on are (a) orthopaedics and (b) spinal surgery. At that stage it was suggested that these definition sets would go out for consultation in May, but I have checked with the Department of Health on progress this week, and had been told that this has been postponed until July. In the meantime each of the Trusts within the Alliance will also make contact with their regional specialist commissioning group so that we can emphasise the importance of them putting into place commissioning arrangements for our services.

Key performance measures

The performance and finance committee has discussed and proposed a set of key performance measures to be used by the Trust board to replace the top 10 targets used last year. These measures are listed below and board members are asked to consider and if they agree sign up to these measures. The measures listed below have been used in the performance report for this month showing current performance against each of the measures.

Quality of care and infection control
Zero MRSA
Zero pressure ulcers
National tolerance on C. Difficile (9 cases for the year)
No increase in surgical site infection rates – monitored quarterly

18 week access target
Referral to Treatment trajectory to 90% admitted patients and 95% non-admitted
Maintain data completeness in line with national target (90% - 120%)
No breaches of stages of treatment targets

Activity target

(10,931 inpatient discharges currently agreed with PCTs (2007/08 + 7%) but internal trajectory needs to be agreed)

Foundation Trust status by April 2009

Performance will be measured based on a monthly progress assessment proposed by the Executive Team and reviewed at Finance & Performance Committee.

Redevelopment - OBC approval and commencement of FBC project

Performance will be measured based on a monthly progress assessment proposed by the Executive Team and reviewed at Finance & Performance Committee.

Finance

Financial plan monthly trajectory to £985k surplus by March 2009 and the monthly pay bill trajectory agreed by the Trust Board in the financial plan.

Leadership & Management
Staff appraisal – 80% by October 2008; 90% by March 2009
Sickness – 4% by October 2008; 3.5% by March 2009

Productivity and Service Improvement
All cancelled operations readmitted within 28 days
No increase in cancellations before admission
No increase in cancellations after admission (S22)
No increase in outpatient follow up ratio

Andrew Woodhead

Chief Executive

21 May 2008