1 Annual Report and Accounts 2009/10
3 About The Royal Marsden 3 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.
4 Annual Report and Accounts 2009/10 4
5 5 Contents About The Royal Marsden 6 Who we are 8 Ten facts about The Royal Marsden 10 Chairman and Chief Executive joint statement 13 What we do 16 Referral 18 Diagnosis 20 Treatment 26 Care 30 Ongoing support 32 Research 39 Our staff 45 Our charity Our performance 49 Quality account 50 Statement on quality from the Chief Executive 52 Priorities for improvement 64 Statements of assurance from the Board 82 Performance against key metrics 85 Valuing people 86 Staff engagement 90 Equality and diversity 95 Sustainability 99 Governance 100 Membership 104 Our Board of Directors 108 The work of our Board 112 The Management Executive 114 Regulatory findings 117 Finance 118 Directors Report 120 Remuneration Report 122 Financial review for year ended 31 March Annual Accounts for the year ended 31 March 2010
6 Annual Report and Accounts 2009/10 6 Who we are The Royal Marsden NHS Foundation Trust is a world leader in cancer research, science and education. We have two hospitals: one in Chelsea, London, and a health and science campus in Sutton, Surrey. We also have a Medical Daycare Unit which we run in partnership with Kingston Hospital. We work closely with The Institute of Cancer Research (ICR) and together we are the only National Institute of Health Research (NIHR) Biomedical Research Centre specialising in cancer in the UK. We work in partnership to undertake groundbreaking research into new cancer drug therapies and treatments. The partnership makes us the largest comprehensive cancer centre in Europe with a combined staff of 3,500. The Royal Marsden and the ICR recently announced a new academic partnership with Mount Vernon Cancer Centre which, through translational research linked to clinical trials, will make a major contribution to improvements in personalised medicine and patient care. This year, the Trust celebrated six years as an NHS foundation trust. We were one of the first hospitals to be awarded this status in April 2004.
7 About The Royal Marsden 7
8 8 Ten facts about The Royal Marsden Annual Report and Accounts 2009/10 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 patients from across the UK and abroad. 1The Royal Marsden is a first wave NHS foundation trust and is ranked as one of the best performing trusts in the country. We are the only foundation trust to be awarded the highest possible score of double excellent for quality of services and quality of financial management in the Care Quality Commission s (CQC) Annual Health Check four years in a row. 2With our academic partners The Institute of Cancer Research (ICR), we are the largest comprehensive cancer centre in Europe. We offer leading-edge treatment in surgery, chemotherapy and radiotherapy, supported by world-class innovation and discovery by our clinical and scientific teams. 6As a specialist hospital, The Royal Marsden works with a range of partners to benefit patients. This includes Kingston Hospital for the local delivery of chemotherapy services and The Royal Brompton and Chelsea and Westminster Hospitals for surgery, respiratory medicine and palliative care. We have just launched an academic partnership with the Mount Vernon Cancer Centre to enhance cancer research across London and Hertfordshire. 7We are the largest NHS provider of molecular diagnostics in the UK, allowing us to identify patients who would benefit from specific anti-cancer therapies and to tailor treatment programmes to the individual.
9 About The Royal Marsden 9 3The Royal Marsden and the ICR work across the boundaries of medicine and science and together our activities span basic science, and translational and clinical research. In the last year, we recruited over 4,000 patients to more than 450 clinical research projects to help us improve treatment and outcomes for patients worldwide. 4The CQC s 2009 National Inpatient and Outpatient Surveys both showed that patients rated us in the top 20% of hospitals in the country for their experience of care. 5The Royal Marsden is due to open some major new facilities shortly including a 16 million new Children s and Young Persons Centre and a 20 million Centre for Molecular Pathology, both of which will provide the most advanced personalised treatment for our patients. 8As a leader and innovator in cancer care, The Royal Marsden is among the first in the NHS to provide the very latest in cancer technology and treatments including the da Vinci S surgical robot, Cyberknife VSI1, PET/CT scanners, image-guided radiotherapy and intensitymodulated radiotherapy. 9The Royal Marsden is consistently one of the highest scoring trusts in the country for staff satisfaction and for staff who would recommend it as a place to work. 10In the past year, The Royal Marsden School of Cancer Nursing and Rehabilitation educated over 400 nurses and allied health professionals. The Royal Marsden Manual of Clinical Nursing Practice is the best-selling nursing textbook in the UK.
10 Chairman and Chief Executive joint statement 10 Annual Report and Accounts 2009/10 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 one of the largest comprehensive cancer centres in Europe, offering expert treatment supported by high quality research. We are designated as a specialist Biomedical Research Centre by the NIHR and operate in partnership with a range of other organisations whenever this will benefit patients. Our aim is to contribute to global improvement in the effective treatment of cancer as well as local treatment and care of the highest quality. During 2009/10, The Royal Marsden achieved a rating of excellent for quality of service and quality of financial management in the CQC s Annual Health Check. The Trust has achieved the highest rating possible for nine consecutive years and has also been given the Customer Service Excellence Award for all its services, including the Chemotherapy Suite run by The Royal Marsden at Kingston Hospital. The Annual Inpatient Survey, undertaken across the NHS, shows that patients rate the quality and experience of care they receive from The Royal Marsden with high scores for the privacy afforded and dignity shown to them. As an NHS foundation trust, The Royal Marsden has a strong risk rating of four from the independent regulator Monitor and has achieved its planned financial surplus at the end of 2009/10 to reinvest in services and facilities in the year ahead. The effective diagnosis and management of patients with cancer remains one of the major challenges in healthcare today, with the rising incidence of cancer worldwide and the speed of technological advance. Our service strategy continues to focus on the comprehensive provision of services across all tumour types and all treatment modalities. We have made a 30 million investment in a new Ambulatory Care Centre, new theatres and a 19 bed Critical Care Unit in Chelsea to ensure patients are treated in the best and most modern and efficient environment for all their needs from day care to specialist surgery. At Sutton, we are due to complete a new 16 million Children s and Young Persons Centre in 2011, built in conjunction with the Teenage Cancer Trust, to respond to a significant increase in demand for this area of our service. This forms part of our strategy to enhance our site at Sutton as a health and science campus, incorporating a full range of services and co-located research facilities including our Drug Development Unit. During 2009/10, The Royal Marsden and the ICR were selected as an academic partner for Mount Vernon Cancer Centre by East and North Hertfordshire NHS Trust. We are delighted to be formally launching the partnership in June 2010, with the aim of integrating research structures and maximising the contribution all partner organisations make to research into better ways of diagnosing and treating cancer. We look forward to building partnerships with other organisations in research, treatment and professional education whenever this will benefit patients. Our plans for the future are ambitious and essential if we are to fulfil our mission to make a difference to cancer research and treatment globally. We are strengthening the interaction with the ICR with the appointment of Professors David Cunningham and Alan Ashworth as Co-Directors of Research Integration. Together, we are building a Centre for Molecular Pathology which will allow us to develop new approaches in personalised medicine and achieve the best results for patients. Increasingly, we are able to personalise the delivery of therapeutics by identifying which tumours respond to specific drugs and other modalities of treatment. The Centre for Molecular Pathology will enhance and extend the work we already undertake in molecular diagnostics and drug development to make a real difference to patients worldwide.
11 About The Royal Marsden 11 Left to right: Miss Cally Palmer CBE, Chief Executive and Mrs Tessa Green CBE, Chairman. Innovation and discovery are challenging in a tough economic climate and all our staff are working hard to ensure treatment and care is given as efficiently as possible so that we can continue to invest in excellent facilities and the best service for patients. This means changing the way we work, delivering care at home when possible and minimising inpatient stays in hospital. Our aim is to ensure that quality remains at the centre of our service and that efficiency is visible to patients only as a positive experience of care. Cally Palmer CBE Chief Executive Tessa Green CBE Chairman This has been a year of immense achievement and progress. We would like to take this opportunity to thank the staff of The Royal Marsden for their exceptional commitment and professionalism which are commented on by so many of our patients.
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13 What we do 13 It is estimated that one in three people will be diagnosed with cancer at some point in their life. Even for those who have not been personally affected, it is likely that someone they know has gone through their own cancer experience. About The Royal Marsden For this reason, treating patients as individuals is at the heart of our patient-centred approach. In the following pages, we present some of the achievements from the last year which will allow us to continue to deliver personalised cancer care along each step of the patient pathway.
14 What we do 14 Annual Report and Accounts 2009/10 Referral General Practitioners (GPs) play a key role in assessing symptoms and referring patients for specialist diagnosis. Developing interactions that build our relationship with GPs is therefore vital to give patients fast access to care. Diagnosis A fast and accurate diagnosis contributes to better outcomes for patients. Our Rapid Diagnostic and Assessment Centre provides patients with immediate access to a specialist team and expert diagnostics, including digital imaging and molecular diagnostics to help sub-classify cancer types. Research As a world-class cancer centre, The Royal Marsden works with The Institute of Cancer Research to accelerate research from bench to bedside. Together, we apply knowledge about the basic science of cancer to clinical research and treatment. Our work has been internationally recognised and has led to a better understanding of the causes of cancer and ways of treating it more effectively.
15 Care Our approach to care is patient-centred. This means we consistently strive to improve the patient experience in hospital and use our expertise to tailor care to meet the needs of individual patients. 15 About The Royal Marsden Treatment We offer a comprehensive range of services, from surgery to radiotherapy and chemotherapy in state-of-the-art facilities. A multidisciplinary team of experts works together to plan each patient s course of therapy in order to achieve the optimum outcome. Ongoing support With increasing emphasis on treating cancer as a chronic disease, we have in place the essential support to help patients feel empowered and educated about their ongoing health.
16 What we do 16 Annual Report and Accounts 2009/10 Referral For many patients, the first and most consistent point of contact in their cancer pathway is their GP. In order to assist GPs in making timely referrals, we have published and distributed a directory of services. Working closely with GPs in this way can increase early diagnosis and achieve better outcomes. Providing faster access has also been a priority over the last year and our Breast Unit has demonstrated success by surpassing the new national standard. Building relationships with GPs GPs play a critical role in the cancer care pathway, from referral and diagnosis to supporting patients through treatment and co-ordinating their follow-up care. That s why The Royal Marsden has launched the GP Education Series, a calendar of quarterly one-day seminars that allow us to contribute to GPs professional knowledge. Each GP Education Day covers several tumour types and examines aspects of cancer diagnosis, treatment and research relevant to GPs the latest in screenings, what symptoms to look for and when to refer. The programme for each seminar is planned and delivered by a multi-disciplinary team of clinical experts and consultants through lectures, case studies and interactive panel discussions. The event is filmed and edited for webcast which means that GPs who cannot attend can still access the learning online. Over 200 GPs have attended the first two GP Education Days which took place in September 2009 and April The positive feedback from participants continues to help shape the programme for the rest of the Series. Demonstrating swifter referral times Our Breast Unit has exceeded the new standard brought in by The Department of Health in early Over 98% of new GP patient referrals are now seen within 14 days of referral and over half are seen within one week. This surpasses the national target which was set at 93% of breast symptomatic patients to be seen within two weeks. Achieving these results has been greatly aided by prompt referrals to our state-of-the-art Rapid Diagnostic and Assessment Centre which offers quick and effective diagnosis with a fast-track through treatment if required. These results go a long way to show our desire to support primary care and we continue to grow our responsive diagnostic practice for common cancers such as breast cancer. Our goal is to reduce waits to just 72 hours while speeding up the turnaround times for biopsy results. Genetic assessment services Genetic assessment has become a vital part of the services we offer to individuals and families referred to us with a concern about a risk of inherited cancer. This involves assessment for breast, ovarian, colorectal and rarer cancers and includes a risk estimation using a family history, screening advice and genetic testing when necessary. We have aimed to make the service more accessible, ensuring that GPs understand when patients should be referred. Our team also works closely with primary care to advise on riskreduction and management so that those who are referred to us can make informed decisions about their health.
17 Referral About The Royal Marsden 17 By running the GP Education Series, the Trust s specialists are giving us an opportunity to improve our awareness of the detection and up-to-date management of specific cancers and, in the process, helping us to aspire to the best possible care for our patients. Dr Shuman Hussein, GP Principal, The Surgery, Stanhope Mews West
18 What we do 18 Annual Report and Accounts 2009/10 Diagnosis Early diagnosis is essential in achieving better outcomes for patients with cancer. We provide patients with immediate access to a specialist team and expert diagnostic services through our Rapid Diagnostic Assessment Centre (RDAC). Our focus is on relieving patient anxiety through quick results and a modern environment. We also continue to develop specialised molecular diagnostics which allow us to individualise treatment for patients. Leading the way in targeted molecular diagnostics The concept of personalised medicine stems from the knowledge that cancer is a heterogeneous disease. This means that patients with the same type of cancer may respond differently to the same treatment. Molecular diagnostics tools can help sub-classify cancer types to identify patients who may see greater benefit from specific therapies, at the same time reducing the potential severe side effects. The final goal of this approach is providing therapies that are tailored to the individual patient s needs as opposed to the traditional one-size-fitsall approach of conventional chemotherapy. In the UK, The Royal Marsden is leading the way in providing our patients with routine molecular diagnostics for biomarkers that are clinically relevant in cancer. We are the largest NHS provider of routine molecular diagnostics in the country. We are at the forefront of introducing molecular diagnostics as standard into clinical practice to benefit patients with various cancer types. In the past year, our joint Royal Marsden and ICR molecular diagnostics lab, in conjunction with our Lung Unit, was the first UK centre to routinely start testing for mutations in the EGFR gene in lung cancers of patients. Genotyping, as it is known, enables us to identify patients with an EGFR mutation who would benefit from targeted therapy over more traditional chemotherapy. These patients often have dramatic improvement in their symptoms sometimes within days of treatment and with no major side effects. The Rapid Diagnostic and Assessment Centre Improving access to better and more rapid cancer diagnosis for our patients is a priority at The Royal Marsden. Our one-stop consultant-led RDAC provides diagnostic services for patients with a range of suspected cancers. Patients referred into RDAC for diagnostic service have immediate access to a multi-disciplinary team of experts including a consultant surgeon, consultant radiologist, consultant pathologist and clinical nurse specialist. Assessments are made using the latest diagnostic techniques such as digital mammography and vacuumassisted biopsy which enable biopsies to be taken and examined quickly, ensuring diagnosis is made without any delay. Within the Breast Unit, this also involves the gold-standard triple assessment process which utilises three diagnostic measures. Perhaps the greatest benefit to patients is that, in most cases, all of these investigations can be conducted during just one clinic visit. Most patients can receive their diagnosis the same day which significantly reduces the waiting time and the consequent distress they may feel. The services on offer at RDAC have been expanded this year to include a new skin diagnostic clinic and an expansion of urological diagnostic services. Plans are in place to expand the RDAC s remit to include head and neck cancers and sarcomas.
19 Diagnosis About The Royal Marsden 19 Diagnosis is crucial as patients need to be given the most appropriate treatment for their cancer type as quickly as possible. Our speed and expertise in molecular diagnostics means that tumours can be sub-classified quickly and the results used to plan a personalised course of treatment. Dr David Gonzalez de Castro, Head of the Molecular Diagnostics Laboratory
20 What we do 20 Annual Report and Accounts 2009/10 Treatment Our research into the biology of cancer is helping us to identify and map the unique characteristics of each patient s tumour. This directly influences the choices our team of experts make in planning an individualised course of therapy when treatment is necessary. We offer patients access to all modalities of therapies and services, from the latest robotic surgery to pioneering chemotherapy and radiotherapy. This year, we have continued to invest in expanding our comprehensive range of services, building new state-of-the-art facilities and offering leading-edge treatments. Comprehensive treatment Comprehensive breast services Patients being treated in our Breast Unit have access to a comprehensive range of services including our one-stop diagnostics clinic, breast surgery, plastic surgery (with a full range of breast reconstruction options), radiotherapy, chemotherapy (including cuttingedge research activity) and our lymphoedema service. Professor Ian Smith, the Head of the Breast Unit, was one of the pioneers of neo-adjuvant chemotherapy which involves chemotherapy being given before surgery. This treatment is now routinely offered when appropriate and works by shrinking tumours prior to surgery, allowing women who would have needed a mastectomy to have breastconserving surgery instead. techniques such as intensity modulated and partial organ radiotherapy (IMPORT High) with the aim of reducing the dose and subsequent harm to normal tissue. A new heart-sparing radiotherapy technique for women with leftsided breast cancer uses a special breathing controller that allows the treatment to be given only as the heart naturally moves away from the chest wall with respiration. Comprehensive prostate services The Urology Unit offers a uniquely comprehensive service with the latest techniques in robotic surgery, intensity-modulated and image-guided radiotherapy (IMRT and IGRT respectively), and access to clinical trials which are changing the standard of treatment worldwide. The comprehensive nature of the services we offer at The Royal Marsden is founded on the principle of a multidisciplinary team (MDT) approach. It means that a range of experts work together to plan each patient s treatment in order to identify the most appropriate course of therapy for that individual. Members of the MDT may include a surgeon, medical oncologist, radiotherapist, pathologist, radiologist and specialist nurse. This approach is common to all of our units, including our Breast and Urology Units. Our Breast Unit continues to develop new ways to improve the patient experience. Their work focuses on maintaining efficiency and minimising toxicity throughout treatment. A new type of surgery is available involving oncoplastic techniques - a less invasive surgery meaning the cosmetic outcome for women is much better. New molecular targets help to identify those patients who will really benefit from chemotherapy and those for whom it would not be the best type of treatment. Improvements to the targeting of radiotherapy are also being examined using innovative Our Urology Unit has pioneered the use of active surveillance which aims to individualise care by selecting only those men with significant prostate cancers for curative treatment. Those on active surveillance are closely monitored using prostate specific antigen (PSA) blood tests and repeat prostate biopsies, avoiding the negative side effect of treatment. The choice between continued observation and curative treatment is based on evidence of disease progression during this monitoring.
21 Treatment About The Royal Marsden 21 Multi-disciplinary team working ensures our patients have immediate access to a comprehensive range of treatments including surgery, radiotherapy and chemotherapy all under one roof. This ultimately sets them on the best personalised treatment course for their particular tumour type and helps to achieve the best outcome for them. Dr Christopher Nutting, Consultant Clinical Oncologist and Clinical Unit Head, Head and Neck Unit
22 What we do: Treatment 22 Annual Report and Accounts 2009/10 For patients requiring surgery, the da Vinci S robotic surgical system continues to improve outcomes. Patients operated on by the da Vinci S robot have been shown to suffer less from incontinence, normally spend as little as hours in hospital and experience less disease recurrence than those undergoing traditional open surgery prostatectomies. The da Vinci S has now been used in more than 800 operations and The Royal Marsden continues to perform the largest number of these surgeries within both the NHS and private sectors in the UK. The Unit has also invested in the latest technology that allows precise tracking of prostate tumours during external beam radiation therapy. We are the first cancer centre in the UK to offer the Calypso System which provides real-time tumour position information. We are also the first to have the ExacTrac system which is another image-guided system that allows more accurate targeting of treatment. The Unit works closely with the Drug Development Unit and the ICR so that prostate cancer patients have access to the latest randomised trials and drugs including abiraterone. Results from the latest Phase II abiraterone study are encouraging for men who have exhausted standard treatment options with about half the patients in the study showing a substantial reduction in levels of PSA in their blood. Leading-edge practice and facilities The Royal Marsden remains at the forefront of cancer treatment and, over the last year, we have invested in building state-of-theart facilities and acquiring the latest technology. Our clinical teams have also contributed to defining leading-edge practice by investigating the benefits of innovative treatment methods which offer patients better outcomes. Offering novel radiotherapy One of the largest international prostate radiotherapy trials, set to change the practice of radiotherapy, is being carried out by Professor David Dearnaley. He has led the development of an IMRT technique which shapes the radiation beam to the exact treatment area. This means that larger doses of radiotherapy can be delivered precisely to the cancer while reducing damage to the surrounding healthy tissue and resulting treatment-related side effects. We are the first hospital in the UK to implement Volumetric Modulated Arc Therapy (VMAT), a treatment machine that is able to deliver radiotherapy in continuous sweeping arcs. This technology allows us to deliver a treatment that is faster and more accurate, potentially involving fewer visits and decreasing a patient s recovery time. The Royal Marsden will be one of the first hospitals in the country to install the very latest in radiotherapy technology the CyberKnife. It will be based at our Chelsea site and will be available for NHS patients with tumours in the head and neck, liver, lung, pancreas, prostate and spinal cord from early CyberKnife delivers hundreds of beams of high dose radiation from a wide variety of angles using a robotic arm. Its pinhead accuracy means that CyberKnife can target tumours in places where surgery would be dangerous and deliver high doses of radiation targeted at the tumour, reducing the dose to normal tissue, often resulting in fewer treatments being needed. Improving the delivery of chemotherapy A new Ambulatory Care Centre is due to open in the centre of the hospital in Chelsea in autumn The new facility will house a new purpose-built Medical Day Unit (MDU) and a new Clinical Assessment Unit (CAU) where patients can be assessed and treated in a streamlined and efficient manner. The MDU includes 30 chairs situated in modern booths for privacy and dignity. Patients
23 About The Royal Marsden 23 As a world-renowned cancer centre, it is vital that we continue to invest in leading-edge radiotherapy technology, including CyberKnife for image guidance, and trial new techniques to ensure precision-targeted radiotherapy that can potentially offer higher doses in fewer sessions and with less side effects. This can only benefit our patients. Dr Vincent Khoo, Consultant Clinical Oncologist and Head of Radiotherapy will have access to chair-side entertainment systems including internet access. The number of consultation rooms has been increased and a satellite pharmacy will be located in the Unit to improve speed and efficiency of drug dispensing and advice. The new CAU will be an area dedicated to making sure that unwell patients can be seen quickly, assessed by specialist nurses and reviewed by the team so that treatment can commence with minimal delay. Increasing our surgical capacity In January 2010, four new operating theatres in the Wolfson Surgical Suite at our Chelsea site became Treatment fully operational following the successful completion of Phase 1 of our extensive rebuilding programme.
24 What we do: Treatment 24 Annual Report and Accounts 2009/10 Two of these modern theatres are purpose-built to provide better facilities for minimally invasive surgery. When this rebuild is fully completed, our theatre complex will also have a new 14 bay recovery area fitted with the latest monitoring equipment which is fully integrated with theatres and the Critical Care Unit (CCU). The new recovery area will be in a central location which will decrease the distance and time patients have to travel from theatres. The critical care service at The Royal Marsden provides life support for patients following major surgery as well as those with complications of either their disease or treatment. We have the only specialised cancer CCU in the UK and audits demonstrate that outcomes for patients are excellent. A new 19 bed CCU is due to open in summer 2010, allowing us to treat more patients who require this specialised support. The focus of the new Unit is on care tailored to the needs of each patient in an excellent environment with natural light and a majority of single-room accommodation. Glass that opacifies at the touch of a button provides privacy. There is access to an outside balcony from each room and an entertainment We are very much looking forward to the opening of the Ambulatory Care Centre. It will be a major step forward in ensuring that the team can deliver the very best of care to those who have put their faith in us. Dr Sanjay Popat, Consultant Medical Oncologist system for patients recovering from surgery or other treatment. For the first time, two rooms will be dedicated to the specialised care of adolescents. These larger rooms will have space for parents to stay and internet and social networking access. A co-located high dependency unit will also provide care either for patients stepping down from intensive care or with a lower acuity. A key feature of the new Unit is the modern monitoring and IT system. Nursing and medical staff will no longer have to scribe patient observations onto daily recording sheets. Instead, this data will be saved to an electronic charting system linked to theatres,