Annual Audit Letter. Basildon and Thurrock University Hospitals NHS Foundation Trust Audit 2009/10 August 2010

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1 Annual Audit Letter Basildon and Thurrock University Hospitals NHS Foundation Trust Audit 2009/10 August 2010

2 Contents Key messages 3 Financial statements and statement on internal control 5 Securing economy, efficiency and effectiveness 6 Additional services 8 Closing remarks 10 Status of our reports The Engagement Letter, issued by the Audit Commission, explains the respective responsibilities of auditors and of the audited body. Reports prepared by engagement leads are addressed to governors, members, non executive directors, directors or officers and are prepared for the sole use of the audited body. Auditors accept no responsibility to: any member, governor, non executive director, director or officer in their individual capacity; or any third party.

3 Key messages Key messages This report summarises the findings from our 2009/10 audit. It includes messages arising from the audit of your financial statements and the results of the work I have undertaken to assess your arrangements to secure economy, efficiency and effectiveness in your use of resources. Audit opinion 1 I issued an unqualified opinion on the Trust s accounts on 4 June, before the deadline set by Monitor of 8 June. In my opinion the accounts give a true and fair view of the Trust s financial affairs at the end of the 2009/10 financial year and of its income and expenditure during that year. 2 Before giving my opinion I reported to those charged with governance, (in this case the Audit Committee) on the issues arising from the 2009/10 audit. I issued this report on 2 June Financial statements 3 The Trust's 2009/10 financial statements are the first prepared under International Financial Reporting Standards (IFRS). The Trust had prepared well for the changes in disclosures, and the additional work required to support these disclosures. My audit work did not identify any material errors in the financial statements. Amendments were agreed by management, to ensure that the disclosures met the requirements of Monitor's Annual Reporting Manual (ARM) and IFRS and to correct a small number of typographical errors. There were no changes to the reported surplus or total assets employed as a result of these amendments. Value for money 4 I am required to conclude whether the Trust put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources. In doing so, I am required to consider: your statement on internal control; reports of regulatory bodies; and any specified pieces of work mandated by the Care Quality Commission. There was no such work specified by the Care Quality Commission for 2009/10. 5 As a result of the section 52 notice issued by Monitor in November 2009 I was not able to satisfy myself that the Trust had made proper arrangements for securing economy, efficiency and effectiveness in its use of resources and I issued a qualified certificate in this regard. 3 Basildon and Thurrock University Hospitals NHS Foundation Trust

4 Key messages Independence 6 I can confirm that the audit has been carried out in accordance with the Audit Commission s policies on integrity, objectivity and independence. Basildon and Thurrock University Hospitals NHS Foundation Trust 4

5 Financial statements and statement on internal control Financial statements and statement on internal control The Trust s financial statements and statement on internal control are an important means by which the Trust accounts for its stewardship of public funds. Significant issues arising from the audit 7 My audit work did not identify any significant issues. 8 My audit planning identified a number of areas of judgement and audit risk in relation to the introduction of International Financial Reporting Standards (IFRS), private patient income, revaluation of property assets and the completeness of provisions. 9 I considered each of these areas specifically as part of the audit and was able to gain sufficient audit assurance against each of the issues in order to conclude my audit and issue an unqualified audit opinion. I concluded that the Trust had prepared well to address the changes in disclosures and additional work required to support them as a result of the introduction of IFRS. My Annual Governance Report sets out these assurances in detail. Material weaknesses in internal control 10 I did not identify any significant weaknesses in your internal control arrangements. Accounting practice and financial reporting 11 I considered the qualitative aspects of your financial reporting and reported on weaknesses I found in the year end stocktake procedures. 12 The Audit Code requires me to review the Trust s Annual Report, to ensure that the financial information disclosed within it is consistent with that within the audited financial statements. My review did not identify any inconsistencies with the financial statements. 5 Basildon and Thurrock University Hospitals NHS Foundation Trust

6 Securing economy, efficiency and effectiveness Securing economy, efficiency and effectiveness I assessed your arrangements for securing economy, efficiency and effectiveness (the 3 Es) in your use of resources. Use of resources 13 In undertaking my assessment I have drawn upon: my audit work on the statement on internal control as part of the audit of the financial statements; the results of the work of regulatory bodies such as the Care Quality Commission; and any specified pieces of work mandated by the Care Quality Commission. There was no such work specified by the Care Quality Commission for 2009/ On 26 November 2009, Monitor issued a notice of exercise of intervention of powers under section 52 of the National Health Service Act 2006 to the Board of Directors and the Board of Governors of the Trust. The notice stated that Monitor was satisfied that the Foundation Trust had contravened and was failing to comply with Condition 2 of its Terms of Authorisation, which requires the Foundation Trust to exercise its functions effectively, efficiently and economically and that Monitor was satisfied that the contravention and failure were significant under section 52(1) of the Act. 15 I considered the scope of Monitor's findings and the reasons for the intervention and judged it appropriate to issue a qualified certificate stating that I am unable to satisfy myself that the Trust has adequate arrangements for securing economy, efficiency and effectiveness. Statement on internal control 16 The Trust is required to establish an assurance framework to manage its risks. This includes the maintenance of effective systems of internal control. The Accounting Officer (Chief Executive) is required, as part of the accounts process, to make a statement on the effectiveness of the controls established. This is known as the statement on internal control (SIC) and includes the review of arrangements for economy, efficiency and effectiveness in the use of resources. Basildon and Thurrock University Hospitals NHS Foundation Trust 6

7 Securing economy, efficiency and effectiveness 17 I have reviewed various documents on which the SIC relies, such as the annual plan, governance reports, corporate risk register and assurance framework, as well as minutes of the Board. I have also reviewed the Head of Internal audit opinion covering the assurance framework, which underpins the system of internal control. 18 I am satisfied that the SIC meets the disclosure requirements and that its content is consistent with my cumulative knowledge gained from work on the accounts and other audit work. 7 Basildon and Thurrock University Hospitals NHS Foundation Trust

8 Additional services Additional services 19 I have been able to support the Trust in the delivery of its strategic objectives by providing additional assurance in key areas. 20 The Audit Code makes a provision for external auditors to provide additional services to foundation trusts, which fall outside of the requirements of the main Code, dependent upon the Trust formulating and adopting a policy for the approval of such work, which the Trust did in 2006/ In this financial year I have commenced or completed work in three key areas as set out below. A review of the impact of changes in accounting arrangements for private patient income 22 The Terms of Authorisation as a foundation trust limit the amount of income which can be derived from private patient income (the private patient income cap). Following a legal challenge to Monitor by Unison in 2009, Monitor has widened the definition of the income to be included as private patient income from 2010/ I was engaged to review the Trust's estimates and assessment of the impact of this change on the private patient income in the future. I have expressed my view in a letter to the Director of Finance and Continuous Improvement. Quality report - data quality 24 Monitor requires that foundation trusts should include within their annual report a report on the quality of care they provide (the quality report). 25 I reviewed the arrangements in place for preparing the quality report for 2009/10 and carried out sample testing on the systems for three performance indicators. In accordance with the scope of our engagement and Monitor s guidance, this work was a 'dry run for giving a published audit opinion in 2010/11 and I did not give any opinion on the arrangements and systems for 2009/10. I issued a report of our findings in July. 26 I concluded that the Trust has in place many of the elements that I would expect to see for data quality. There is a corporate framework for the management and accountability of data quality in relation to quality performance, with a commitment to secure a culture of data quality throughout the organisation. This could be further strengthened by improving systems and controls over data quality and including data quality in the performance appraisal system for all staff. 27 My review of the systems in place for individual indicators found, in common with other foundation trusts, that whilst there are controls in place, these are not always evidenced in a way that makes it possible for them to be audited by a third party. Where I was able to identify evidenced controls my testing suggests that these operated appropriately. Basildon and Thurrock University Hospitals NHS Foundation Trust 8

9 Additional services Payment by Results (PbR) Data Assurance Framework 28 We reviewed the way the Trust records the treatments patients receive. In the NHS, hospitals receive payments under a national tariff system (Payment by Results) from their service commissioners (Primary Care Trusts). The payments are linked to the complexity of the treatment and the length of stay within the hospital. 29 It is therefore critical that the Trust accurately records the type and extent of individual treatments patients receive (clinical coding). Our audit was to assess the accuracy of such patient level data, and compare the Trust s performance against the national average. 30 We issued a report to NHS South West Essex, as the lead service commissioner, in June 2010 on the results of our admitted patient care clinical coding audit at the Trust. 31 The Trust is in line with the performance of other trusts in the overall accuracy of its clinical coding and has made progress in implementing the recommendations made in previous reviews. Looking forward 32 The Government has made clear its priority to tackle the UK's deficit. On 24 May 2010, the Chancellor of the Exchequer and Chief Secretary to the Treasury announced the first step in tackling the deficit, setting out how the Government intends to save over 6 billion from spending in 2010/ The Government has subsequently announced details of how the next Spending Review will be conducted. The Spending Review will focus on reducing the deficit and consider alternative approaches to public service provision with the aim of delivering a step change in the drive for efficiency and value for money in the public sector, including cutting the cost of operational delivery. Due to conclude in the autumn, the Spending Review will set spending limits for every government department for the period 2011/12 to 2014/ The Government has also stated that it will guarantee that health spending will increase in real terms in each year of the Parliament. However, the pressure on activity levels remains, and the Trust will continue to face significant demands upon its services, especially as Commissioners seek to achieve efficiency savings and change care pathways. This will continue to be a significant challenge to the Trust, as it strives to match clinical excellence with financial delivery. 35 The Trust has consistently met its financial target of generating a surplus each year; although the surplus for 2009/10 was lower because of the additional costs of addressing the issues identified by Monitor. The Trust's Programme Management Office has been put in place to oversee improvements in quality and the Trust is working on the integration of that quality agenda with the cost improvement plans in its financial projections. 36 As the Trust's appointed auditor, I will continue to reflect on the Trust's response to these wider issues and work with the Trust where possible to address any specific risk areas that it identifies. 9 Basildon and Thurrock University Hospitals NHS Foundation Trust

10 Closing remarks Closing remarks 37 I have discussed and agreed this letter with the Chief Executive and the Director of Finance and Continuous Improvement. I will present this letter at the Audit Committee on the 8 September 2010 and will provide copies to all Board members. 38 Further detailed findings, conclusions and recommendations in the areas covered by our audit are included in the reports issued to the Trust during the year. Table 1 Reports issued during the year Report Date issued Initial fee letter March 2009 Audit plan October 2009 Interim audit memorandum March 2010 Memorandum on stock take procedures June2010 Annual governance report June 2010 Audit opinion on the financial statements June 2010 Quality Report - data quality July 2010 Annual audit letter September The Trust has taken a positive and constructive approach to the audit. I wish to thank the Trust staff for their support and co-operation during the audit. Debbie Hanson Engagement Lead September 2010 Basildon and Thurrock University Hospitals NHS Foundation Trust 10

11 The Audit Commission The Audit Commission is an independent watchdog, driving economy, efficiency and effectiveness in local public services to deliver better outcomes for everyone. Our work across local government, health, housing, community safety and fire and rescue services means that we have a unique perspective. We promote value for money for taxpayers, auditing the 200 billion spent by 11,000 local public bodies. As a force for improvement, we work in partnership to assess local public services and make practical recommendations for promoting a better quality of life for local people. Copies of this report If you require further copies of this report, or a copy in large print, in Braille, on tape, or in a language other than English, please call Audit Commission 2010 For further information on the work of the Commission please contact: Audit Commission, 1st Floor, Millbank Tower, Millbank, London SW1P 4HQ Tel: Fax: Textphone (minicom):

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