North Middlesex University Hospital NHS Trust. Annual Audit Letter 2005/06. Report to the Directors of the Board

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1 North Middlesex University Hospital NHS Trust Annual Audit Letter 2005/06 Report to the Directors of the Board

2 1 Introduction The Purpose of this Letter 1.1 The purpose of this Annual Audit Letter (letter) is to summarise the key issues arising from the work that we have carried out during the year. Although this letter is addressed to the directors of the Trust, it is also intended to communicate the significant issues we have identified, in an accessible style, to key external stakeholders, including members of the public. The letter will be published on the Audit Commission s website at and also on the Trust s website. 1.2 This letter has been prepared in the context of the Statement of Responsibilities of Auditors and Audited Bodies issued by the Audit Commission. This is available from Responsibilities of the auditor and the Trust 1.3 We have been appointed as the Trust s independent external auditors by the Audit Commission, the body responsible for appointing auditors to local public bodies in England, including NHS trusts. 1.4 As the Trust s external auditors, we have a broad remit covering financial and governance matters. We target our work on areas which involve significant amounts of public money and on the basis of our assessment of the key risks to the Trust achieving its objectives. It is the responsibility of the Trust to ensure that proper arrangements are in place for the conduct of its business and that public money is safeguarded and properly accounted for. We have considered how the Trust is fulfilling these responsibilities. The scope of our work 1.5 Our main responsibility as the appointed auditor is to plan and carry out an audit that meets the requirements of the Audit Commission s Code of Audit Practice (the Code). Under the Code, we are required to review and report on: the Trust s accounts whether the Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. 1.6 This letter summarises the significant issues arising from both these areas of work and highlights the key recommendations that we consider should be addressed by the Trust. A list of all reports issued to the Trust in relation to the 2005/06 audit is provided in the Appendix. Introduction 1

3 2 Activities and services of the Trust 2.1 North Middlesex University Hospital NHS Trust is a busy district general hospital serving a diverse population of approximately half a million people living in the London Boroughs of Enfield and Haringey. The Trust employs nearly 2,000 staff. As well as providing general acute services the Trust also provides a range of specialist services, such as HIV, diabetes and radiotherapy. 2.2 In 2005 the Trust entered into a partnership with Great Ormond Street Hospital whereby children s services at the hospital are now run by Great Ormond Street Hospital, an organisation which has an international reputation for its work with children. 2.3 By the end of March 2006, the Trust had no patients waiting more than 6 months for an inpatient admission or more than 13 weeks for outpatient appointments. The target for A&E patients was achieved, with 98% of patients being seen, treated, admitted or discharged within four hours. 2.4 The Trust continues to advance its plans for a 100 million redevelopment of the hospital under a Private Finance Initiative (PFI) scheme with its preferred bidder and is awaiting feedback from the Department of Health following its review of the scheme. 2.5 The Trust has achieved a level two assessment against the Clinical Negligence Scheme for Trusts for its arrangements for clinical risk management and received accreditation for Improving Working Lives Practice Plus, demonstrating its commitment to staff. 2.6 The Healthcare Commission, the regulator for health care and public health, awarded the Trust a zero star rating in 2005, the lowest rating for patient care and management. This rating was the result of the Trust failing to achieve financial breakeven, the 17 week outpatient waiting time target and the 98% target for 4 hour waits in A&E in 2004/ The Trust has assessed itself as fully compliant with 20 of the 24 core national Standards for Better Health for the 2006 Annual Health Check as further work is required to monitor equal opportunities amongst staff, ensure that all staff members attend all necessary mandatory training, monitor staff personal development and complete the Trust s Data Protection audit. The Healthcare Commission will announce its 2006 assessment of the Trust in October Activities and services of the Trust 2

4 3 Key findings 3.1 The Trust has faced a particularly challenging year as a result of continued financial pressures, demanding NHS Plan targets and the full implementation of national initiatives such as Agenda for Change. 3.2 Whilst much has been achieved in the year, the Trust has incurred a significant deficit of 8,166,000 for the year. Following a review by the Department of Health, the Trust has formed a Turnaround Team and embarked on a challenging programme of change to reach financial balance and recover its cumulative deficit over the next few years. 3.3 Demonstrating an ability to operate within its available financial resources will be key to the Trust reaching financial close on its PFI Scheme for the new hospital build. Accounts 3.4 We were able to issue an unqualified opinion on the Trust s accounts on 10 July, by the deadline set by the Department of Health. Our opinion confirms that the accounts give a true and fair view of the Trust s financial affairs and of the income and expenditure recorded by the Trust during the year. Accounts preparation processes 3.5 As part of the accounts closedown process, NHS organisations are required to agree income and expenditure and year end balances and to resolve any disputes with other NHS organisations. Should local negotiations fail to resolve any disputes, these should be referred for arbitration to the local Strategic Health Authority. 3.6 The Trust was in dispute with a number of other NHS organisations regarding amounts receivable and payable, mainly as a result of over-performance on contract activity, which had not been referred to the Strategic Health Authority for arbitration and agreement. As a result, disputed amounts totalling 579,000 and 558,000 were included in NHS debtors and creditors respectively and these disputes were not resolved with the counter parties before certification of the accounts. We are informed that the largest of these disputes has since been escalated to the Strategic Health Authority for arbitration. 3.7 In future years the Trust should seek to resolve disputes in a timely manner and, where possible, to refer unresolved disputes to the Strategic Health Authority for arbitration prior to the Department of Health submission deadline for audited accounts. Key findings 3

5 Stock count procedures 3.8 The Trust had counted stock to the value of 2,188,000 at year end, which consisted mainly of medical consumables and pharmaceutical stock. Stock quantities were confirmed by a stock count by Trust staff at year end. We noted, however, that there was scope to improve the overall management and control of the stock count so as to ensure that stock delivered or utilised on the day of the count is appropriately included or excluded from stock and that consignment stock not owned by the Trust is excluded from the stock balance. We have recommended that the Trust better manage and control its stock count procedures going forward. Use of resources 3.9 We are required to issue a conclusion on whether we are satisfied that the Trust has put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources. This is known as the value for money conclusion We are also required to assess how well NHS organisations manage and use their financial resources by providing scored judgements on the Trust s arrangements in five specific areas. This is known as the Auditor s Local Evaluation. Financial position 3.11 For the third successive year the Trust has failed to achieve financial breakeven although it has managed to achieve its other key statutory financial duties for the year: Breakeven on income and expenditure Performance The Trust has incurred a deficit of 8,166,000 in the year Target met No Keep within the Capital Resource Limit (CRL) Keep within the External Financing Limit (EFL) Cumulative breakeven deficit to 31 March 2006 of 13,526,000 The Trust under-spent by 2,086,000 against the CRL of 3,879,000 The Trust undershot by 1,500,000 against the EFL of 3,433,000 Yes Yes Key findings 4

6 3.12 The Trust s financial plan for 2005/06 set out its strategy for delivering in-year breakeven. However, this plan did not represent a robust savings plan as many of the cost savings had not been allocated to specific services, budgets or projects and it required non-recurrent financial support that was not received in full. The Trust did manage to achieve some 2.5 million of cost savings in this plan by reducing certain patterns of spending, including a recruitment freeze on certain posts, closure of 52 beds, and a thorough review of all significant procurement. However, these cost savings were largely offset by significant additional staff costs under Agenda for Change and other cost pressures As a result of the 2005/06 deficit, the Trust was identified by the Department of Health as one of the organisations to be subject to a nationally co-ordinated Turnaround process. An external review was commissioned in December 2005, which resulted in the Strategic Health Authority appointing external Turnaround support to the Trust and a Turnaround plan has subsequently been produced by the Trust. This plan aims to achieve in-year breakeven in 2006/07 and repayment of cumulative deficits of 12 million from 2007/08 to 2009/10. Auditor s Local Evaluation (ALE) 3.14 We have assessed the Trust s overall arrangements for securing economy, efficiency and effectiveness in each of the five areas reviewed below: Area Score Financial reporting 3 Financial management 1 Financial standing 1 Internal control 2 Value for money The assessments are scored from level 1 (inadequate performance) through to level 4 (performing strongly), and the Trust is required to score at least at level 2 to achieve minimum expected requirements (adequate performance) A score of 1, inadequate performance, was achieved on financial standing, due to the 8.2m deficit incurred in the year, and on financial management as the Trust s budget for 2005/06 was not based on realistic assumptions and the Trust failed to develop adequate savings and cost improvement plans to respond to significant budgetary variances. In addition, within the value for money assessment, the Trust scored poorly in one out of the four key lines of enquiry, namely its arrangements for managing and achieving value for money, due to the absence of comprehensive efficiency plans during 2005/06. Key findings 5

7 3.17 In other areas we concluded that the Trust is generally performing adequately and meeting minimum requirements. The Trust has performed well in producing annual accounts that are supported by comprehensive working papers. Acute Hospital Portfolio 3.18 The Acute Hospitals Portfolio is a review of services carried out by the Audit Commission and its audit suppliers on behalf of the Healthcare Commission. The work is mandatory in all acute trusts The aim is to inform the Trust about its performance compared to other trusts. The following three topics were covered this year: Admissions management 3.20 The achievement of the four-hour access target in A&E is a constant challenge for the Trust as the department sees a significant number of patients each year. Despite this, the Trust achieved the 98% target waiting time for 2005/06 as it is continually targeting ways in which waiting times can be bought down. Improvements have been made in Decision to Admit procedures and the Trust s 6-hour Minor Assessment Unit and short stay facility, that target patients that are likely to only require an assessment, has helped to keep the level of admissions from A&E down. The Trust is continuing to investigate inappropriate A&E attendances. The Trust is also working to reduce its long lengths of stay in the hospital and high cancellation and suspension rates in order to better control patients access to the hospital s services. Diagnostic services (pathology, imaging and endoscopy) 3.21 The Trust has long waits for endoscopy and MRI imaging procedures that could impact on patient care and discharge decisions. Steps have been taken to address endoscopy service improvements although there is still significant scope for greater availability of information and digital technology in the endoscopy unit. Improvements in MRI services and capacity have been restricted due to the outsourcing of this service, however the Trust has recently secured additional resources to procure a MRI scanner. Turnaround times for all imaging procedures are long and the level of examinations reported was found to be low in comparison to other trusts, although recent improvements have been made to the reporting rota. Turnaround times for pathology reports are very good in comparison to other trusts. Key findings 6

8 Medicines Management 3.22 A shortage of staff in the pharmacy, resulting from delays in recruitment, have resulted in long waits in the outpatient pharmacy and limitations to pharmacists abilities to contribute more to patient care on the wards. There is scope to better utilise pharmacy staff and improve patient access to medication through the use of higher automation in the pharmacy, self medication for patients on wards and the development of new prescribing techniques, such as nurse and pharmacist prescribing As trusts move towards shorter waiting times and reduced lengths of stay, medicines management is instrumental in further driving down these indicators. Whilst there are good risk assessment and control procedures in place, there is scope for improvement in the Trust s formulary process so as to support more effective prescribing and in the provision of information and advice available to patients on their medication. Specific risk-based work 3.24 We also carried out a number of specific pieces of work based on our assessment of the key risks facing the Trust, including a review of e-booking and following up on previous recommendations raised in respect of the Trust s use of resources. E-booking 3.25 All of the Trust s inpatients, day cases and outpatients are now fully or partially booked and bookings can be made electronically through the Choose and Book system. The Trust was one of the first hospitals in the country to launch the Choose and Book system, which allows patients to choose the place, date and time for their first outpatient appointment. Whilst there was some slippage in rolling out the system to all services, the Trust has resolved the system difficulties initially experienced, booking staff have been trained and there are help desk facilities in place However, utilisation of Choose and Book by general practitioners has to date been low and there is a need for the PCTs to work with general practitioners to encourage higher utilisation. Audit recommendations 3.27 Our follow up of previous audit recommendations found that the Trust has made progress in many areas, particularly in respect of Data Quality, waiting list management, and the three areas of the Acute Hospital Portfolio covered in the previous year, namely Accident and Emergency, day surgery and ward staffing However, more needs to be done in some areas to fully address all recommendations and the Audit Committee should take a more proactive role in monitoring the status of outstanding recommendations. Key findings 7

9 Value for money conclusion 3.29 As the Trust s overall arrangements for securing economy, efficiency and effectiveness had not met the Audit Commission s expected minimum requirements for financial management and financial standing, we have issued an adverse value for money conclusion for the 2005/06 financial year. Specifically, the Trust s arrangements for the following criteria are below minimum levels: putting in place a medium-term financial strategy, budgets and a capital programme that are soundly based and designed to deliver its strategic priorities managing performance against budgets ensuring that its spending matches its available resources managing and improving value for money. Key findings 8

10 4 Key recommendations 4.1 During the year we made a number of recommendations to the Trust. We have highlighted below the key recommendations required to drive improvements at the Trust and responses from management: Recommendation As part of the accounts preparation, the Trust should seek Strategic Health Authority arbitration for disputed NHS balances to ensure early resolution in advance of the submission deadline for audited accounts. The Trust Board should closely monitor the Trust s financial position and its progress in implementing its Turnaround Plan. The Trust s medium term financial plan should be more explicitly linked to corporate objectives and service plans to ensure that that it clearly drives internal resource allocations. The Trust Board should agree a plan for improving organisational efficiency, including consideration of shared service arrangements, national procurement contracts, benchmarking data and clarification of the Trust s reference cost position. Management response Agreed. The Trust does seek arbitration from the SHA to assist in the resolution of disputes, however it is not always possible to raise and resolve issues within the submission deadline for the annual accounts. Where this is the case the Trust ensures its accounts reflect the potential impact of any outstanding issues. Agreed. In 2006/07 the Trust Board is undertaking rigorous and detailed reviews of the Trust s financial position and Turnaround Plan. This has been supported by a Finance Committee chaired by a non-executive, revised operational management structures, the Turnaround Team and changes to the structure of the Finance Department. A Director of Turnaround has been appointed to lead the Turnaround Plan. Agreed. The Trust has sought to improve financial planning for 2006/07 and going forward. This will remain a key area of focus. Agreed. The Director of Turnaround is leading this process, supported by the Director of Finance. Improvements in efficiency represent a major element of the current and future Turnaround Plans. Acknowledgement 4.2 We would like to take this opportunity to express our appreciation for the assistance and cooperation provided during the course of the audit. Our aim is to deliver a high standard of audit which makes a positive and practical contribution that supports the Trust s own agenda. We recognise the value of your co-operation and support. Key recommendations 9

11 Reports issued in relation to the 2005/06 audit Report Date Issued Audit Plan May 2005 E-booking Red Risk Review May 2006 Report on the audit of the financial systems and use of resources ( Interim Audit Memorandum ) Report on the audit of the financial statements and use of resources ( Final Audit Memorandum ) June 2006 June 2006 Acute Hospitals Portfolio Phase 6 Admissions Management July 2006 Acute Hospitals Portfolio Phase 6 Medicines Management July 2006 Acute Hospitals Portfolio Phase 6 Diagnostic Services July 2006 Annual Audit Letter Appendix

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