The Royal National Orthopaedic Hospital Trust

Minutes of the Trust Board Meeting

Held onWednesday, 31st October2007

Present:Trust Board Members

Mr D HoodlessChairman

Mrs S LaddieVice-Chairman

Mr A WoodheadChief Executive

Mrs S PuckettDirector of Operations & Service Improvement

Mr R HurdDirector of Finance

Mrs K CorderActing Director of Nursing

Ms H FarrowNon-Executive Director

Mr J RajputNon-Executive Director

Mr M CreegerNon-Executive Director

Mr T BriggsJoint Medical Director

Dr N MitchellJoint Medical Director

Associate Directors

Mr M VaughanDirector of Human Resources

Mr M MastersDirector of Projects, Estates & Facilities

Dr S PatelDirector of IM&T

Apologies:Prof D MarshInstitute of Orthopaedics

Ms M Habibzay Patient & Public Involvement Forum

In attendance:Ms E CockshootMinute-Taker

Ms S McCabeGeneral Manager

Miss S TennantConsultant Orthopaedic Surgeon

Ms S Lalor-McTaguePaediatric Matron

Ms S ScottSpeech & Language Therapist

Dr B JacobsPaediatrician

Dr C McKennaConsultant Child & Adolescent Psychiatrist

Ms M KopershoekClinical Psychologist

PART ONE (Open)

  1. Apologies for Absence

All Apologies noted.

  1. Minutes of the meeting held on Thursday, 27th September 2007

The minutes of part one of the meeting held on Thursday, 27th September2007 were agreed as a correct and accurate record of the meeting.

  • Proposed 2008 Trust Board Meeting Dates

The Board agreed the 2008 Trust Board meeting dates.

  1. Matters Arising

None.

  1. Chairman’s Report

Mr Hoodless advised the Board of the recent Chair and Chief Executives meeting he had attended with the London Strategic Health Authority (SHA). The main focus of discussion related to workforce, finance and commissioning. It is expected that the London SHA is heading for a substantial surplus at year end.

  • Non-Executive Director Appointments

Mr Hoodless advised that the Appointments Commission had appointed Mr Guy Billington and Mr Anthony Watson as the Trust’s new Non-Executive Directors. Mr Watson and Mr Billington will have their induction during November and have been invited to attend the November Trust Board meeting.

In response to Mr Vaughan’s query, Mr Hoodless advised that UCL had nominated a candidate to replace Professor Delpy. The interview with the candidate will take place shortly.

Mr Hoodless said a leaving party had been arranged prior to the next Trust Board meeting for Mrs Laddie, Mr Creeger and Mr Rajput.

5.Chief Executive’s Report

Mr Woodhead gave his report.

  • Healthcare Commission Ratings

The Trust received a weak rating for the use of resources and a fair rating for quality of services.

The resource rating was expected because the Trust ended the financial year 2006/07 with a deficit even though the deficit was less than 0.5% (£350k) of the Trust’s turnover. The Auditor’s local evaluation scored the Trust at 2 out of 4.

The quality of services rating is disappointing and as a specialist Trust the RNOH should be achieving a good rating. It is unlikely the RNOH could achieve an excellent rating for this standard until it replaces old and inappropriate buildings.

He went on to brief the Board on the other standards. Key points included:

  • The Trust was fully compliant in patient safety, clinical and cost effectiveness, governance, accessible and responsive care, public health
  • The Trust did not meet the care environment and amenities standard because 67% of the site is not suitable for modern healthcare
  • The Trust could not give sufficient assurance on patient focus because there were concerns about arrangements for obtaining patient consent for procedures and issuing patient information
  • Access Targets – the Trust achieved the standard for 13 week outpatient, delayed transfer minimised, cancer waiting times, appointment booking arrangements, urgent referrals within 2 weeks
  • Access Targets – the Trust did not achieve the 26 week inpatient target due to a small number of breaches and also failed on the target to readmit cancelled patients within 28 days. The Trust also had a number of breaches of the MRI wait target.
  • The Trust achieved the MRSA target and the improved patient experience target
  • The Trust failed on data quality of ethnic group monitoring and underachieved on the 18 week wait and a smoking reduction target

Mr Woodhead said the Executive Team was developing an action plan to address the shortcomings so the Trust can achieve a good rating next year. Mr Hoodless said the Board expected the Trust to work towards an improvement in the standards in which the Trust failed or appeared as weak.

Mr Woodhead went on to advise the Board that Mrs Corder would be submitting a paper at the next meeting which will highlight the lessons learned following an outbreak of C Difficile and the subsequent patient deaths at the Maidstone and Tunbridge Wells Trust. The paper will also outline the actions the RNOH needs to undertake in response to the recommendations in the national report. He said he believed this incident demonstrates the importance of good hygiene on the wards and low infection rates. He said the report points out the risks of following hard targets at the expense of patient safety.

  • Royal Free Review

Mr Woodhead reminded the Board that the SHA independent review panel, chaired by Malcolm Stamp, met on the 9th October to review the Royal Free proposal and compare it with the Stanmore solution. He advised that there was no decision from the SHA at this meeting. The panel reconvened on 26th October to score the options against the criteria set by the RNOH. Following this meeting a recommendation will be given to the SHA’s Capital Investment Committee (CIC) and it is this Committee that will make the decision. The CIC is chaired by George Greener and Ruth Carnell, the SHA Chief Executive, is also a member of this Committee with other members of the SHA executive team.

Mr Woodhead said the RNOH had provided a copy of the RNOH review panel conclusions and the advisor’s report. He said he had highlighted the benefits and deliverability of the Stanmore solution and the undeliverability of the Royal Free proposal in terms of their proposal not meeting the RNOH criteria in that it disperses the RNOH services around the Royal Free site. The Royal Free proposal does not provide sufficient floor space for the RNOH services and there are concerns as to whether planning permission will be granted to the Royal Free. Mr Woodhead said he had also highlighted the Trust’s concerns that the RNOH would not be able to maintain its low infection rates with the arrangements being proposed. There has been an element of lobbying taking place with key officials of the SHA to ensure they all understand the shortcomings of the Royal Free proposal.

Mr Woodhead said that following the SHA independent review panel meeting on 26th October, the SHA had concluded that the Royal Free proposal had scored slightly ahead of the Stanmore solution. Mr Woodhead assured those present that despite this conclusion no formal decision or recommendation has been made by the SHA panel. Mr Woodhead said he had been advised that at the start of the panel meeting those representatives present were able to declare their positions in terms of the outcome they wanted. The representatives on the panel included Malcolm Stamp, Chief Executive (SHA), Damien Reid, Head of Provider Reform (SHA), Ralph Murray, Estates Lead (SHA), Charles Hollwey, Chief Executive (Barnet PCT), Professor Ed Byrne (UCL), Mr Martin Bircher (BOA representative), John Kelly, Director (RKW), Dr Jane Collins, Chief Executive (Great Ormond Street). Mr Woodhead said he had also been advised that the majority of those present where in favour of the Royal Free proposal and it appeared that during the panel meeting the weighting of the criteria was changed and more emphasis was placed on theoretical and academic benefits of the RNOH moving to the Royal Free. It is believed that this change may have swayed the result in favour of the Royal Free proposal. A letter has been sent to Mr Malcolm Stamp from Mr Bircher which outlines his concerns in relation to this matter. Mr Briggs circulated a copy of the letter to Board members.

The Board discussed Mr Bircher’s concerns and the lack of support from UCL. The Board also expressed its concern about the impact on the RNOH’s Foundation Trust application because its strategic direction remains unresolved. Mr Woodhead said the RNOH has been advised that it will not proceed in wave 7 of applications but would be part of wave 8, which will put the RNOH timetable back by 3 months.

Mr Hoodless said he was concerned about the role of UCLand their support for the Royal Free proposal which effectively closes the RNOH and disperses the RNOH services on the Royal Free site. He said he was also concerned that the RNOH funds UCL activity through the Institute of Orthopaedics based on the Stanmore site. He said he could not see why the RNOH should continue to fund an organisation that supports the closure of the RNOH.

In response to Ms McCabe’s query, Mr Hoodless said the RNOH was aware of UCL’s position in relation to this matter and were also aware that Professor Byrne had signed a document in support of the Royal Free proposal prior to the panel meeting. He said he believed this also called into question the impartiality of those on the SHA independent review panel.

The Board discussed the suggestion made by Mr Hoodless to rescind RNOH support for the Professorship of the Institute of Orthopaedics. Mr Creeger said he believed the Trust had a legitimate reason for considering the suggestion made by Mr Hoodless because it appeared that those given the authority to decide on the future of the RNOH have a vested interest in closing the hospital. Mr Briggs said he felt the letter from Mr Bircher demonstrated that those making the decisions do not understand the services the RNOH provides and that proper consideration has not been given to what is in the best interests of the patients. He went on to suggest that the RNOH take a more prudent approach in the first instance by withdrawing support for the Epidemiologist. He said he and Dr Mitchell would be exploring academic opportunities and links with other Trusts such as Oxford. He agreed to report back to the Board at the next meeting.

Action: Mr Briggs

Mr Hurd advised the Board of the financial contribution the RNOH makes to the Institute of Orthopaedics, which he said included clinical packages such as Pathology, administrative costs and medical photography. The total contribution is £1.2m (£423k for the Professorship package).

The Board went on to discuss the risks of rescinding financial support. Mr Briggs expressed his view in terms of the perceived effectiveness of the Institute of Orthopaedics and their activities in terms of bidding for funding since the demise of the Cullyer system of sponsoring research. He said he believed the RNOH still had a good case to present because its clinical outcomes and infections rates are good and the Royal Free proposal does not have the support from clinicians. Mrs Laddie said she felt the time was right for the RNOH to use all its influence to lobby the SHA. Mr Briggs agreed and said that he felt the findings of the SHA review panel could not be taken into consideration because of the concerns highlighted by Mr Bircher. He said he believed that if the SHA decide to uphold the findings of the review panel the RNOH would have the morale high ground and could uphold the suggestion made by Mr Hoodless to withdraw all financial support for the Institute of Orthopaedics.

Mr Hoodless said he would write a letter, on behalf of the Trust Board, expressing the Trust’s plans to withdraw funding for the new appointment of an Epidemiologistand that a review of funding options in the future will be undertaken. He agreed that the letter will make it clear that this intention by the RNOH does not reflect on the Trust’s continued support for translational research.

Mr Creeger said the RNOH Special Trustees had expressed their support for the Trust in this matter and would offer their assistance should it be required.

Mr Hoodless said he would be meeting with George Greener to discuss the Trust’s position and Mr Briggs would be invited to attend.

  • Foundation Trust Status

Mr Hoodless said the uncertainty on the future of the RNOH had effected the Trust’s Foundation Trust application. He said the Trust needed to strengthen its performance and should continue to work toward achieving Foundation Trust status. Mr Hurd reiterated that the RNOH would now be part of wave 8 applications.

In response to Mr Creeger’s comment, Mr Hurd said the risks had been discussed with the SHA. The SHA believe that all Trust’s that become Foundation Trusts have similar risks and the issue is how the organisation manages those risks.

For Presentation & Discussion

6.Bi-annual Children’s Services Report

Mrs Puckett said the presentation being given would give the Board an essence of the service the RNOH provides for children and adolescents and the multidisciplinary team involved in the care of patients. The presentation will also mark the contribution made by Mrs Laddie as lead Non-Executive Director of children’s services.

Ms McCabe said the presentation would be given by several of the paediatric multidisciplinary team who will give an overview of the children’s services, the nursing achievements, the role of the speech and language therapists and the work of the paediatricians, psychologists and psychiatrists. She said the multidisciplinary team had worked to improve the quality and safety of the care provided and had improved the quality of the setting and environment in which the children and adolescents are treated. The team had also worked together to make hospital services more child-centred.

Miss Tennant continued with the presentation by summarising the work undertaken by the paediatric orthopaedic surgery team and the recently established outreach clinics developed to meet demand. She went on to brief the Board on the planned pilot scheme to pre-assess every child. She explained the benefits to the patients and how this pilot is expected to improve the management of the service.

Ms Lalor-McTague briefed the Board on the nursing achievements, which she said had led to a fully established ward team, control of the local budget and attendance at national and international conferences to share the Trust’s practices and knowledge within children’s services. She also highlighted the initiatives the service is currently working towards, such as, nurses studying university modules, a review of cleanliness of equipment and providing nursing care for children around the hospital wherever children go.

Ms Scott outlined the role and work of the paediatric speech and language therapy service and how the Trust had developed the Communication Passport Service (Millar 2003) and how this will be rolled out to the wider paediatric special needs population. She also summarised the results of the recent passport service audit carried out within the Trust which indicated that staff feel the service is valuable and could potentially be extended to the adult special needs service.

Dr Jacobs continued with the presentation and outlined the work of the paediatricians in terms of clinical support in areas such as rheumatology, spinal injury, craniosynostosis and metabolic bone disease. He explained their involvement in teaching, child protection and team building and briefed the Board on the future challenges and opportunities which he said included developing a separate children’s HDU, an acute osteomyelitis service and a rehabilitation service for somatisation disorders.

Dr McKenna concluded the presentation by briefing the Board on the work of the Child and Adolescent Psychiatry and Psychology service. She said the aim of this service is to provide integrated medical and psychological care to children, young people and their families within a multidisciplinary framework. She explained why Child and Adolescent Psychiatry and Psychology input is needed and how psychiatric disorders can adversely affect recovery outcomes. She also highlighted the future developments the service plans to undertake.

Mr Hoodless thanked the team for their presentation. He said the Board appreciated the work undertaken by the children’s services team and said that when visitors are given a tour of the hospital they are always hugely impressed by the paediatric wards and the teams working in those areas.

Mr Woodhead said he felt the presentation gave an excellent insight into the work of the service and clearly demonstrates that the Trust’s medical and clinical staff are committed to multidisciplinary working and continues to maintain external links to other NHS services and organisations. The presentation also demonstrates the pride staff have in the service and the keenness to continue to make improvements. Ms McCabe said the children’s service strategy group have collated information relating to the external links to other NHS Trusts in terms of research, academia and clinical practices.