This world renowned heart and lung hospital is a few minutes drive from Ruislip. Its reputation for clinical excellence is second to none, despite its old buildings.
There are plans to rebuild the hospital on its present site, but that lies a long way ahead. It is part of the Royal Brompton and Harefield NHS Foundation Trust and we obtain regular reports on that Trust’s Board Meetings held in public
Research Funding: The Trust in partnership with Imperial College London failed to obtain a combined Cardiovascular / Respiratory Biomedical Research Centre grant, so from 1st April 2017 the Trust will face a research funding loss of approximately £4m per year; funding has been redistributed from the capital to the regions. The impact would not be only financial as the Trust had put more energy and resources into research than it got back; staff morale would suffer. However, the Trust’s Charity was considering bridging the funding gap until new sources of research funding can be identified. The Trust will also be obliged to consider extending its private patient income.
Care Quality Commission’s Report: The inspection took place in June 2016 but the Draft Inspection Report is currently awaited.
Infection control: In 2016/17 to date the Trust has reported 7 cases of clostridium difficile to NHS England, but no cases have been deemed due to lack of care by the Trust so they do not count against the Trust’s target of maximum 12 cases in year. There were no outbreaks of infection in September and no cases of MRSA have been reported this year.
Pressure ulcer incidence: There were 138 cases in 2014/15. The following year this dropped by 38% to 88, of which only three cases were regarded as Serious Incidents. NHS England was impressed with the thoroughness of investigation undertaken by the Trust and has agreed that only repeat incidents need to be reported. In 2015/16 the Trust extended its work to included wider tissue lesions and that work continues.
Cancelled Operations: There were 34 cancelled operations and procedures in September 2016, 11 at Royal Brompton Hospital and 23 at Harefield Hospital. Patients whose operations are cancelled for non-clinical reasons must be offered another binding date within 28 days at the time and hospital of the patient’s choice.
Complaints: A new approach last year to managing complaints ensures that key people get together at the beginning and co-ordinate their efforts. There is currently a project underway to co-ordinate the learning from all forms of feedback. In 2015-16 there were 91 complaints, an 8% decrease from the previous year. There were also 1,416 PALS contacts but 68% of issues raised by that informal route were resolved within 24 hours.
Finance: NHS England activity was £1m below plan in September but CCG and other NHS commissioned activity was on plan leading to a surplus for the month of £11.4m. £3.9m favourable to plan, of which £4.3m was attributable to an additional gain on the sale of 151 Sydney Street – the sale price of £24m was higher than the planned £20m, providing an actual gain of £13.6m, £4.3m higher than plan.
In September the Harefield Heart Division generated a contribution of £0.7m, £0.6m adverse to plan, but year to date this reduces its contribution to £7.6m, in line with plan.
2. Performance against targets: Trajectories for measuring performance have now been agreed with NHS England and NHS Improvement. For the 18 week incomplete pathway target, the trajectory will take the Trust back to compliance with the national target (93%).
For the 18 week referral to treatment time pathway the Trust did not meet the trajectory for Month 4 but was back on track for Month 5. The trajectory is a cumulative measure so the sustainability and transformation funding target has been met for both months, as was the 62 day cancer target.
3. Infections: There have been no reported cases of MRSA in 2016/17, but five cases of clostridium difficile have been attributed to the Trust.
4. Cancelled operations: Patients whose operations are cancelled for non-clinical reasons on or after the day of admission should be offered another binding date within 28 days, to be funded at the time and hospital of the patient’s choice. There were 28 cancelled operations and procedures in the Trust in August 2016, 14 at Royal Brompton and 14 at Harefield Hospital.
5. Finance: The Trust planned a deficit of £2m for August 2016 but achieved a deficit of £1.9m, slightly better than planned. NHS England activity was £0.5m better than expected, but CCG and other NHS commissioned activity was £1.4m worse than planned. Private patient income at £3m was £0.5mless than planned. The Harefield Heart division had year to date raised £6.9m, £0.5m above planned. The Lung division contribution year to date stands at £10.3m, 8% behind plan.
6. Annual appraisals and revalidation of doctors: The Trust is responsible for the revalidation of 377 doctors, internally audited by KPMG in April 2016. In June 2016, NHS England performed a Higher Level Responsible Officer Quality Review Visit, leading to a favourable review but with some suggestions for further improvement, which have been acted upon.
7. Consultant in Respiratory Medicine with Expertise in Severe Asthma: A new appointment, the consultant will join two full-time physicians providing specialist severe asthma management commissioned by NHS England for over 600 new referrals a year. There are also around 3000 outpatient evaluations and 10,000 inpatient / daycase spells per year.
8. 77 Wimpole Street, London: This private patient facility opened on 18th July 2016 and in its first week received 58 patients, which was encouraging.
9. Although selling this property on the open market was considered, its configuration and services are inextricably linked with those of the adjacent 250 Kings Road, a property owned by the Trust’s linked charity. Another area of uncertainty is the possible construction of a Crossrail 2 station under 151 Sydney Street.
A series of negotiations have culminated in a draft Agreement to transfer the property to the Charity for £24m which is supported by market valuations. There is also an option agreement granted to the Charity to purchase an adjacent parcel of land for £2m.
The Trust is under considerable financial pressure following withdrawal in April 2015 of Project Diamond funding for complex clinical procedures. In 2014/15 this represented income of £13.3m. As a result, and linked to downward pressure on NHS tariffs, the Trust has been obliged to budget substantial financial deficits for the first time in 2015/16 and also for 2016/17, which are likely to continue for the foreseeable future. A disposal of 151 Sydney Street - which is held for income generation or capital appreciation and is non-operational, as it is leased to third party and office retail tenants (other than part of one floor which is used by the Trust) - would provide the cash to fund the Trust’s capital expenditure for a further 18 months. The sale would have various financial pros and cons, which have been taken into account.
From the Board Papers
NHS targets: For Quarter 1 of 2016-17 (April - June), the 62 day cancer target and the 18 week incomplete patient pathway target were not met.
New trajectories have now been agreed with NHS England and NHS Improvement. This will take the Trust back to 92% compliance for the incomplete pathway target. For the cancer target the trajectory starts at 50% and rises by 5% each quarter to achieve 65% by Q4.
This allows the Trust to conform with sustainability and transformation funding conditions.
Care Quality Commission Inspection: The inspection took place between 14th and 17th June 2016 plus unannounced out of hours inspection visits for 2 weeks thereafter.
The information team responded to over 200 data requests since the start of the inspection and it is anticipated that data requests will continue to be received during the report writing phase.
The Trust will be sent a draft of the report and will have 10 days to respond on matters of factual accuracy.
Infections: In Month 3, June 2016, there were no cases of MRSA, but there was one case of clostridium difficile.
Cancelled operations: In June 2016 there were 40 cancelled operations at Royal Brompton Hospital and 56 cancellations at Harefield Hospital.
Patients whose operations are cancelled on or after the day of admission for non-clinical reasons must be offered another binding date within 28 days, at a time and hospital of the patient’s choice.
Finances: To end of June 2014 the Trust planned a deficit of £6.8m but achieved a deficit of only £5.4m, £1.4m better than plan. Private Patient income was £10.2m which was £0.1m adverse to plan.
The Trust has a Financial Sustainability Risk Rating of 2, in line with plan.
The Trust’s cash position remains healthy and allows all approved creditors to be paid on time.
Sale of 151 Sydney Street: The planned sale is proceeding; Some historic planning shortcomings have been identified, but these are now being resolved and should not delay the sale which is planned for September, although the planning application could be challenged.
A sale price of £20m is planned but a further £4m is possible subject to contract.
Note: Information on the congenital heart disease review is available on the Trust’s website and on the website of the Community Voice www.communityvoicehealth.org.uk
The Chairman was unwell so the meeting was chaired by Neil Lerner.
CQC inspection June: The Care Quality Commission requires some 300 documents prior to its inspection. This is not just a visit, it will be more of a forensic analysis going back some years.
Budget: The draft plan submitted to Monitor showed an £8.9 million deficit. This received an uncompromising response stating that a new control total of £3.7 million deficit was required, so more work is being done. Meanwhile NHS England is grabbing an estimated £3 million profit that the trust makes from supply of high-end devices. Final plan is required by 11 April, which is not achievable.
Property sale is a necessity to ensure positive cash flow. Block contract with NHS England ceases 31st March and there is no new agreement for the period ahead. A cash sum will be due next month regardless. 151 Sydney Street might be sold to RBHT charity to raise further funds. Currently NHS margins are now wafer thin. Some 80% of staff costs are for clinical staff, with little scope for more cuts.
If the Board cannot come up with a rational solution with Monitor, then RBHT will be subject to an external challenge by NHS Improvement. Bob Bell, the Chief Executive intimated that he would welcome anyone wanting to come in to end this "charade". Monitor appears to understand the basis of the financial figures but comes back with its own inexplicable figures.
Private facilities: Wimpole Street opens in May, with its first patients expected around June. Wigmore Street and Kuwait both represent income risk due to lack of beds. Most profit comes from converting out-patients to in-patients. No finalised contract yet with Kuwait, but the Chief Executive was confident that this will be agreed.
Planning ahead: A new Board brainstorming session is to be held to discuss planning strategy for 2017 onwards. Input suggestions should also come from clinicians and middle managers. Innovations may impact further on cost pressures. Income generation is the priority as they are already running "lean and mean".
Targets: The Trust appears to fail on its 62-day lung treatment target yet is way ahead in successful outcomes for over 60-day and 90-day survival rates.
New infection risk: The Trust is working with Public Health England to work out where and how this infection, candida auris, is arriving in hospitals. There are currently no national protocols in place.
Staff abuse from management: This is a cause for concern, a serious issue, which CQC is expected to address.
Finance: The deficit is less than forecast, but year to date is virtually on plan. The target for the whole year deficit is £10 million.
Bad debt write-offs were approved.
Dr Grocott-Mason has worked at Hillingdon Hospital and Harefield Hospital since 1999, combining clinical work with clinical leadership roles, including clinical director for medicine and then joint medical director and responsible officer for The Hillingdon Hospitals NHS Foundation Trust.
1. Proposed sale of land at Royal Brompton: In the papers it was noted that a key element in the Trust’s ambitions to develop its Royal Brompton site depended on the sale of part of that site for residential use to enhance its value, which was opposed by the Trust’s neighbour, the Royal Marsden Hospital. This ambition, at least in the medium term, has been thwarted by a combination of planning and “political” factors. There was no discussion of this issue during the meeting.
2. Harefield development: Developing increased capacity at Harefield will allow reconfiguration of services between the two sites.
3. Finance: The Trust had a deficit of £3.3m in 2014/15. Project Diamond funding ceased on 1st April 2015. That source of funding was set up to compensate for services with costs in excess of the basic NHS tariff, so its loss is challenging for this Trust which provides many very complex services. To offset that loss, some items of capital expenditure have been deferred and others cancelled, but much of the proposed investment is already committed and essential for the Trust to operate at its expected level. The Trust is therefore seeking £10m of additional funding in 2015-16 to enable its capital programme to proceed as planned.
4. Private patients: Income from private patients exceeded £37m in 2014/15. A new private patient facility is to open in Wimpole Street, London, in early 2016. Refurbishment of the 28 bedded wing at Royal Brompton Hospital provides modern facilities and accommodation. Facilities at Harefield have been extended to provide rapid access and diagnostic facilities, including evenings and weekends.
5. The Trust’s NHS commissioners: Around 85% of the Trust’s NHS services are commissioned by NHS England and most of the rest by Clinical Commissioning Groups.
6. The Trust’s international role: Heart and lung diseases are the world’s biggest killers. This Trust treats patients from across UK and other countries. The size of its patient population allows research and development on a scale attractive to the research and development arms of global enterprises.
7. Research: 2014/15 research income reached £11m. Over 5400 patients participated in research, either by research studies or retention of their tissue in the Trust’s ethically approved Biobanks. Trust consultants have published over 370 research publications.
8. Harefield activity: In 2014/15 25 heart and 49 lung transplants were undertaken and 47 ventricular assist devices were implanted at Harefield. Respiratory activity there continues to grow ahead of plan.
9. Failure to achieve the 62 day cancer waiting time: Patients referred to the Trust from other hospitals often arrive late in the 62 day period, sometimes after the 62 days has expired, making it impossible for the Trust to start treatment within that target time.
10. General facts:
- Patient Numbers: In 2014/15 there were 178,495 patients at outpatient clinics and over 38,619 in-patients.
- Research ranking: The Trust is Europe’s top ranked respiratory research centre and the cardiac, cardiovascular and critical care teams are rated in the top three most highly cited health research teams in Europe.
- Angioplasty: Harefield pioneered primary angioplasty for heart attacks and has one of the fastest arrival to treatment times in the UK.
- Harefield’s cardiac catheterisation laboratories: This is one of the top facilities in Europe
- Cystic fibrosis: The Royal Brompton provides the largest treatment centre in Europe.
- Foetal cardiology: The Trust’s feoetal cardiology service allows babies in the womb to be scanned at just 12 weeks when the heart measures just over a millimetre.
- Adult congenital heart disease: The Trust provides the largest such centre in the country.
- A multi–million pound expansion to services will begin shortly in three phases implemented over five years, the first due for completion during 2015, the centenary year. Beds are expected to increase from 176 to over 200 with many other enhancements including a new endoscopy suite, new MRI and CT scanners, and a reconfigured main entrance.
- The newly agreed “Enhanced Tariff Option” for 2015-16 increases payment for emergency hospital admissions beyond the agreed threshold, from 30% to 70% and the marginal rate for specialised services from 50% to 70%, as well as lowering efficiency requirements by 0.3%.
- Despite this revised tariff, many hospitals will find it difficult to set a balanced budget for 2015/16.
b. Monitor’s review of Foundation Trusts: In the third quarter of 2014-15 the Foundation Trust sector failed to meet Accident & Emergency targets, cancer waiting times and other targets. Patients attending FT A&Es rose by 8% versus last year and bed occupancy rates were up 2%. The aggregate deficit of FTs is £321m, five times higher than planned. Smaller acute FTs remain the most financially challenged - 78% of small and medium acute FTs are in deficit, with overspends on agency staff.
c, Challenging of CQC reports: (Health Service Journal 27 March 2015) There is wide variation in the number of factual accuracy challenges to Care Quality Commission inspection reports, topped by 500 challenges from East Kent Hospital University FT which led to changes to 9 of its CQC ratings. London North West Healthcare NHS FT, which includes Northwick Park Hospital, challenged two ratings with no success.
d. March budget 2015 - more mental health support: (Healthwatch Harrow e-bulletin March 2015) The budget includes, over five years, £15m for perinatal mental health services and £235m for children and young people’s mental health services.
e. Victory in campaign to cancel diabetic fines: The Government has agreed to reimburse diabetics who have been unfairly fined for not having a valid medical exemption certificate. Poor communication led many diabetics without a certificate to claim free prescriptions for years without any problems, but since September 2014 thousands were suddenly fined up to £100!
f. Health Service Journal names the top NHS Chief Executives: (HSJ 27 March 2015) In its second annual list the HSJ judges rated Clair Murdoch, Chief Executive of Central & North West London FT, in the top 15! She was quoted as ” … an incredibly influential system leader who looks beyond her own organisation”. Bob Bell of Royal Brompton & Harefield FT was listed amongst the top fifty CEOs, as was Cally Palmer, CEO of the Royal Marsden FT.