Annual Report & Accounts 2010/11 - James Paget University Hospitals

James Paget University Hospitals 

NHS Foundation Trust 

Annual Report & 

Accounts 2010/11 

Where you come first 

www.jpaget.nhs.uk James Paget University Hospitals NHS Foundation Trust Annual Report 2010/11 Page 1



Annual Report and Accounts 2010/11 

Presented to Parliament pursuant to Schedule 7, 

paragraph 25(4) of the National Health Service Act 2006 


Page 4 James Paget University Hospitals NHS Foundation Trust Annual Report 2010/11 www.jpaget.nhs.uk

Contents 

Welcome 6 

About the Trust 9 

Taking care of our patients 11 

Listening and responding to our patients 20 

Operating and Financial Review 27 

• Our vision and objectives 

27 

• Our performance 

32 

• Stakeholders and commissioners 

36 

• Financial performance 

38 

• Sustainability 

45 

• Equality 

46 

• The Future 

47 

A year in our life 48 

Service developments 49 

Our staff 56 

Our volunteers/fundraising 63 

Governance 65 

Our directors 66 

Audit Committee 71 

Our governors 72 

Our members 76 

Remuneration report 79 

Senior managers’ salaries and benefits 83 

Senior managers’ pension entitlements 84 

Independent Assurance - Quality Report 85 

Abbreviations 87 

Useful contacts and how to get here 89 

Quality Report 

Financial Statements 


Welcome 

From our Chairman, John Hemming 

Welcome to the Trust’s Annual Report for 2010/11. It has been a year of 

significant challenges but also a number of achievements and I am proud of 

what has been achieved against a backdrop of ever increasing demand for 

healthcare. 

The Trust has experienced severe pressure with increased emergency admissions, 

6% higher than forecast and heavy use of the Accident & Emergency service. 

We are continuing to work with NHS Great Yarmouth and Waveney and other 

partners to ensure the services available in the area are sufficient for our 

patients’ needs. 

Despite those pressures, our staff have risen to the challenge and maintained 

their hard work, commitment and excellence in providing quality care to 

patients. They have been supported by our dedicated volunteers, local charities 

and other partners who work with us. 

In October, the Trust recorded zero infection rates for MRSA bacteraemias 

(bloodstream) and Clostridium difficile. This reflects our continuous 

improvement in the management of infections and is a tribute to the staff that 

have maintained our robust infection prevention and control measures to ensure 

patient safety is the number one priority. 

There have been major achievements over the last year in respect of human 

resources and employment issues. The work around Apprentices has been 

recognised nationally and the Project Search scheme has also been very 

successful. 

There has been close working with staff side and the Local Negotiating 

Committee on the range of change and transformation schemes that are being 

developed, both locally and nationally. 

The Trust has supported and utilised the development programmes offered by 

Suffolk Partnership and provided several in house development courses for ward 

managers. This is in addition to the range of training offered for staff within 

speciality and mandatory fields. 

Our Governors have grown in confidence and expertise and have enhanced 

the work of our hospitals. They feed the views of our members into the Trust’s 

planning and decision making and are involved in many areas of work. The 

performance of the Trust is keenly monitored by the Governors who take the 

task of holding the Board to account very seriously. This is reflected in the two 

extra meetings held with the Governors this year when they had concerns about 

the appointment of an additional Executive Director and standards of care. 

We have said goodbye to Nick Coveney, Director of Nursing, who left the 

Trust in April. Nick has many achievements at the Trust that have made real 

improvements to patient care and to the nursing and clinical professions. His 

contribution will be greatly missed in every area of the organisation. We will 


welcome his successor in July. In the meantime we are grateful to Andrew Fox 

for taking the role in addition to his responsibilities managing the Emergency 

Division. 

Annette Standard, Non Executive Director, left the Trust in July. Annette was 

focused on services for our younger patients and was the lead for Safeguarding 

Children. We are sorry to have lost Annette’s legal knowledge and the 

perspective she brought to the Board as a working mother. 

In November we welcomed Peter Franzen OBE as a Non Executive Director. He 

is perhaps best known as the former Editor of the EDP, a role he held for 16 

years before retiring in 2009. He joins the Trust at a challenging time and Peter’s 

experience and skills are already being put to good use on the Board. 

Investment to improve our facilities and services has continued despite the 

financial pressures. In September we opened our new acute stroke service, 

centred on Ward 1, which virtually doubled the size of our facility, enabling us to 

significantly improve stroke care, in particular rapid diagnosis and assessment. 

Our new fertility service opened in September and is providing the best possible 

treatment for each individual couple and giving them the best chance of 

achieving a pregnancy. Extending the ICU to provide ten beds has enabled us to 

refurbish the Central Treatment Suite (CTS), providing extra ICU beds and a more 

streamlined CTS. 

And Chief Executive, Wendy Slaney 

This year’s report features several service developments that have delivered 

better care for patients. The establishment of the larger new Stroke Unit has 

enhanced the pathway for those suffering from a stroke. It has also enabled 

improved response to what is now recognised nationally as an acute emergency 

which can benefit from fast treatment. 

On the surgical front the adoption of the Enhanced Recovery Programme in 

Orthopaedics has been welcomed by patients and clinicians. This new way of 

working enables a shorter stay and a much improved experience for those 

undergoing hip and knee surgery. 

There has been an increased demand for emergency healthcare throughout 

the year, with particularly high levels of activity during the winter months. We 

always plan for an increase at this time but the surge in January and February 

was extreme and unusual. All healthcare providers experienced extreme 

emergency demand during this period which led to extra patients coming to 

acute hospitals. 

The level of demand resulted in poor patient experience in several areas which 

led to concerns being identified. A programme of actions is now underway to 

ensure that high quality essential care can be maintained at all times. 

The response of staff in all departments has been recognised, in delivering 

services against a difficult background, and this is greatly appreciated by the 

Board, Governors and our patients. Patients have also worked with us to 


identify and address concerns and make improvements to service through the 

Experience Based Design project. 

Over the year the Trust has achieved its financial and quality targets with the 

exception of 18 week waits for 100% of cases. The exceptional winter demand 

unfortunately meant that the elective surgery programme was affected, with 

some specialties not meeting this target. We have achieved a small surplus. This 

is necessary to enable continued investment in our services. 

The Trust has worked closely with partner organisations to develop new ways 

of working across health and social care. This work forms a key part of meeting 

the funding challenge in the public sector. Our staff have taken part, giving 

important clinical input to the service changes. 

The commitment of staff has been truly commendable during the year and I 

acknowledge the great contribution and achievement they have made. We 

have much to accomplish during the coming year to ensure that we continue to 

meet the needs of our community. Together we can take forward services and 

developments, building on those achieved during the last year. 

The Future 

The appointment of a Director of 

Operations will be a key component of 

the year ahead. The year on year increase 

in demand, both in terms of number 

of patients and their complex needs, 

requires that we recruit extra operational 

management support. This will in turn 

support our staff by ensuring effective 

management of pressure on our services in 

the future. 

In recent months we have revisited the Trust’s values, the guiding principles of 

the organisation and the standards for everything that we do. The four simple 

messages of Putting patients first, Aiming to get it right, Recognising that 

everybody counts and Doing everything openly and honestly are aligned to the 

strategic direction of the Trust and we want all our staff to ‘live’ them every day. 

Plans for a Palliative Care East resource centre and outreach service will continue 

to develop in the year ahead, providing a much needed care base for patients 

and families whose lives are affected by illnesses such as cancer or motor 

neurone disease. The resource centre and outreach service will deliver first class 

care for patients in the Great Yarmouth and Waveney area. 

The Trust will continue to focus on its engagement with staff and the wider 

community. We aim to be transparent with our staff and patients and invite 

them to be the same with us. It is their feedback and their confidence to be able 

to raise issues that can help ensure we get things right. This enables us to deliver 

continuous quality improvement and put the patient at the centre of everything 

we do. 

John Hemming 

Chairman 

Wendy Slaney 

Chief Executive 


About the Trust 

James Paget University Hospitals NHS Foundation Trust became a Foundation 

Trust in 2006. 

The hospital was built in 1981 to provide a full range of district general hospital 

services for the population of Great Yarmouth, Lowestoft and the surrounding 

areas. This includes the many visitors to this popular holiday destination. 

The acute care at the main site in Gorleston is supported by services at Lowestoft 

Hospital, the Newberry Clinic and other outreach clinics in the local area. The 

Trust also provides a range of community services. 

Our catchment population is 230,000 which is expected to steadily increase over 

the next 10 years. 

The health characteristics of the local population include: 

• A high (but reducing) level of health inequality across Great Yarmouth and 

Waveney 

• shorter life expectancy than other areas of England (actually Longer than 

England for Waveney, shorter than England for Gt Yarmouth) 

• significant proportion of the population aged over 75 

• high rates of limiting long-term illness and disability 

• high rates of teenage pregnancy 

• high smoking rates and obesity estimates greater than the national average. 

• Growing rates for alcohol-related admissions 

• High levels of incapacity benefits for mental illness in Great Yarmouth 

• High and growing rates of diabetes 

• High rates of seasonal (Winter) deaths. 

The Trust’s activities are governed by Monitor – the Independent Regulator of 

NHS Foundation Trusts – and by legislation. 

The Trust employs over 3000 members of staff and is the largest local employer in 

the area. 


Our Core Values 

Our values are the guiding principles of the organisation and provide a set of 

beliefs for the way we behave. They are aligned with both the strategic 

direction of the Trust and promises being made to staff, patients and 

stakeholders. 

Staff are the ambassadors for the Trust and the values underpin the work that 

all of us do – whatever our role and whoever we come into contact with. The 

Trust has undertaken a specific exercise this year to promote the Trust’s renewed 

values with particular reference to valuing the contribution made by all those 

working at the Trust – staff and volunteers. 

I intend to do the best I can by: 

Putting Patients First 

Provide the best possible care in a safe, clean and friendly environment 

Treat everybody with courtesy and respect 

Act appropriately with everyone 

Aiming to get it right 

Commit to my own personal development 

Understand my and other roles and 

responsibilities 

Contribute to the development of service 

Recognising that everybody counts 

Value the contribution and skills of others 

Treat everyone fairly 

Support development of colleagues 

Doing everything openly and honestly 

Be clear about what I’m trying to achieve 

Share information appropriately and effectively 

Admit to and learn from mistakes 

Management development sessions centred on the values have been held with 

senior management staff from across the Trust. Each division and department 

has been asked to compile action plans, in consultation with their staff, outlining 

how they would embed and ‘live’ the values in their area of work. The action 

plans will be regularly reviewed to ensure the objectives are being met and that 

all staff are adopting the values. 

To support the embedding process, a values DVD has been produced as a 

learning aid. The 12 short clips demonstrate how the values can sometimes be 

forgotten and when they are used well and the positive impact this can have. 

The films will be used in future training sessions around customer care and 

within the induction process for all new staff. 


Taking care of our patients 

Essential care 

Many of our patients and visitors have a positive experience, reflected in 

the number of letters and cards we receive. We have made a number of 

improvements in our services during the year, and more information on these 

can be found later in this report. 

We work hard to ensure that our care is regularly reviewed and changes made 

where necessary, particularly if on some occasions we have failed to meet 

people’s needs and expectations. 

In July 2010 a Chief Matron post was established to pull together many of the 

different strands of work and ensure a consistent approach across the Trust. Part 

of her role included the development of an accountability framework for nurses 

to support our work on patient safety. This is developing, with reporting to our 

Governors and Board of Directors. The framework ensures that areas of concern 

are reported and dealt with appropriately. 

A huge increase in the number of emergency admissions has put the Trust under 

significant pressure from early 2011. This additional pressure led to a number of 

concerns raised by patients and family members about standards of care. 

The intention of nursing leaders within the Trust is to focus on the fundamental 

needs of patients within our ward areas and ensuring these are met. Following a 

review of the concerns raised, an action plan has been developed. 

The actions are based around the key themes of patient nutrition, patient 

hydration, patient’s personal hygiene and communication. They are being 

universally recognised and adopted across all ward areas and by staff providing 

and supporting direct patient care. Our staff are determined to create an 

environment where every effort will be made for each patient to have a positive 

experience. 

£250,000 has been identified which will be used within the new financial year to 

support some of the proposals. 

www.jpaget.nhs.uk James Paget University Hospitals NHS Foundation Trust Annual Report 2010/11 Page 11

Those with dementia 

The increasing number of patients with dementia is a long term challenge for 

the Trust. 

Between 79 and 90 people per month are discharged with a confirmed diagnosis 

of dementia. This does not include the number of patients suspected to have 

dementia or those that die within the Trust. 

Ward areas have seen a significant increase in patients with dementia and in 

some cases up to 50% of the patients on a ward have been diagnosed with 

the condition. As the Trust looks to reduce patient length of stay, the issue of 

patients with dementia is a particular challenge. 

Significant work is already underway, with Matron Barry Pinkney 

leading a six month project funded by the Innovation in Nursing 

Midwifery Practice Project (INMPP). Since December 2010, a 

pathway has been piloted and awareness training has been given 

to over 90 multi disciplinary staff. 

The key component of this project has been the ‘More about Me’ 

information care package which focuses on improving hydration 

and nutrition for patients with dementia. This complements the ‘This is Me’ 

audit of data. Early indications suggest that documentation and adherence to 

the pathway are improving. In early April the ‘More 

About Me” package won the Health Enterprise East 

Spotlight Competition for Publications and Training 

Aids. The department received a cash prize to assist with 

training. 

The Trust is 

also involved in 

local dementia 

initiatives such 

as the PCT 

Mental Health 

and Learning 

Disability 

Programme Board, Clinical 

Dementia Group and Health Innovation 

Education Cluster (HIEC). The Trust was 

represented at the East of England 

Dementia Strategy Conference and 

represented acute trusts at the HIEC 

Dementia day in April. 

Strategic planning for the future is vitally 

important if the Trust is to meet the 

increasing demand being placed on its 

resources. The INMPP project should be 

rolled out across all wards and units over the next few months, with additional 

focus on communication with family carers. 


Patient safety 

A decision was made to establish a Patient Safety Project to support staff in 

finding ways to drive forward patient safety improvements so that our patients 

get the right care, at the right time by the right person. 

To be confident we are targeting our efforts in the right places, we have 

assessed the areas of service with high rates of adverse incidents or errors. We 

have also taken into account the specific requirements of regional and national 

patient safety programmes. 

As a result, a list of the Trust’s Top Ten Key Metrics has been developed. This is 

being used as the starting point for our Trust-wide project improvement work. 

Over the next five years, the overall aim for the organisation is to achieve a 50% 

reduction in avoidable harm events. 

The Journey so Far…..Patient Safety Month 

September was our official Patient Safety Month. A variety of events took place 

to get people involved and become more informed about the work that is 

taking place. 

th 

• Patient Safety Awareness Day – 8 September 

An impressive 185 members of staff attended. The aim was to raise awareness of 

the Top Ten Key Metrics and the individual workstream leads were on hand to 

talk to staff about the improvements. 

th 

• Using data to Improve Patient Safety – 9 September 

A significant amount of patient safety work involves the use of measurements. 

The way information is presented is also an important factor to consider. It can 

tell a more significant story than whether the number is higher or lower than 

before. 

Matt Tite, a Statistician and Associate from the Institute of Innovation and 

Improvement, visited the Trust to facilitate a study day on how we can ‘Use Data 

to Improve Patient Safety’. This focused on understanding what data is telling us 

and how we use it as part of our decision making processes. 

• Human Factors and the Science of Safety – 

23 rd September 

Martin Bromiley and retired Surgeon Professor 

Tony Giddings visited the Trust to share their 

experiences of human factors with 75 members 

of staff. Martin presented the story of his late 

wife’s journey and Professor Giddings provided 

a very entertaining but meaningful discussion 

on the Science of Safety. This included discussion 

about how human factors can influence us doing 

the right thing, at the right time, to the right patient in the right way. One 

key message was about increasing awareness of human factors and using this 

knowledge to improve understanding of how and why things go wrong. When 

we have this understanding it can help improve and inform patient safety. 

Full performance information on this project can be found in our Quality Report. 


Quality 

A full quality report can be found at page 89. It is available as a separate report, 

with a short easy to read summary. 

Infection prevention and control 

Patient safety is paramount and this includes the management of infection 

prevention and control. Key aims in this area are: 

• to have appropriate management systems 

in place 

• to provide and maintain a clean and 

appropriate environment for healthcare 

• to minimise nosocomial infections within 

the Trust. 

Our successes this year include: 

• sustaining a year-on-year reduction of 

MRSA bacteraemias – and being within 

our yearly target. The reduction has been 

due to robust infection prevention and 

control measures and the hard work 

of our staff. These measures include 

effective management of antibiotic 

prescribing, ensuring everyone cleans 

their hands, deep cleaning ward areas daily, screening the majority of 

elective and emergency admissions in line with national guidance and 

daily monitoring of any patients identified with MRSA 

• we are well within hospital-attributable Clostridium difficile targets and 

have seen year-on-year reductions. We have a six bedded cohort isolation 

ward for patients identified as having Clostridium difficile 

• we have achieved a Commissioning for Quality and Innovation (CQUIN) 

target relating to Clostridium difficile 

• a well managed outbreak of Group A Strep involving 10 patients in 4 

clinical areas. It was an unusual strain never seen in the UK before. It has 

caused considerable interest from the Health Protection Unit and a paper 

is being published 

• we continue to manage Norovirus well as an organisation, which helps to 

reduce its spread and the closure of wards 

• we work closely on new building and refurbishment projects to ensure 

that designs are user-friendly for clinical use in relation to infection 

control 

There have been changes in the Microbiologist consultants with the functions 

covered by long term locum staff. The Director of Infection Prevention and 

Control (DIPC) responsibilities are being covered at an Executive level. Long 

term arrangements are being taken forward in conjunction with partner 

organisations. 


Mothers and babies 

Helping women and their families during 

pregnancy and birth is one of the health 

service’s most important responsibilities. 

We strive to continually improve the service 

we provide to meet the individual clinical 

and emotional needs of mothers and their 

families. 

Appropriate staffing levels ensure that 

all women and their families will have 

continuity of care with a midwife that they 

know and trust. Arrangements are in place 

for co-ordination and ongoing midwifery 

support should the known midwife not be 

available. 

With the support of NHS Great Yarmouth 

& Waveney we have been able to increase 

our Midwifery and Support Worker 

establishment to provide services that are 

needed in our community. A specialist team of midwives has been set up to 

work with marginalised groups of women and their families to support them in 

making life changes. Additional Midwives are also working on the Delivery Suite 

to ensure that everyone receives 1:1 care when in established labour. 

Eliminating mixed sex accommodation 

Every patient has the right to receive high quality care that is safe, effective and 

respects their privacy and dignity. 

This Trust is pleased to confirm that we are compliant with the Government’s 

requirement to eliminate mixed-sex accommodation, except when it is in the 

patient’s overall best interest, or reflects their personal choice. 

We have the necessary facilities, resources and culture to ensure that patients 

who are admitted to our hospitals will only sleep in individual rooms, or in bays 

with other patients of the same sex, with same-sex toilets and bathrooms that 

will be located close to their bed area. Sharing with members of the opposite 

sex will only happen when clinically necessary (for example where patients need 

specialist equipment such as in ICU or when patients actively choose to share e.g. 

renal), all of which is in line with national guidance 

If our care should fall short of the required standard we will report it internally 

and externally to our commissioners. We will also set up an audit mechanism 

to make sure that we do not misclassify any of our reports. We will publish the 

results of that audit at the Trust’s Board of Directors. 


Education and Practice Development 

Staff are provided with the fundamental skills required to deliver quality, 

effective and safe care. 

All groups of clinical staff need preliminary and ongoing education and training. 

In line with the dramatic changes in the NHS and the increased pressures, 

education and training is being provided in different ways to meet the 

challenges and strive for excellence in care. 

Two intakes per year of preregistration 

student nurses gained 

their clinical experience at the Trust. 

Healthcare Assistants joining us 

are provided with a full induction 

programme. Once qualified, staff 

embark on a learning journey that 

will directly relate to their clinical 

practice. During the year 43 people 

undertook study days and 112 people undertook modules. 

Clinical Skills are developed through comprehensive training sessions provided 

by the team including cannulation, administration of intravenous drugs and 

accountability. The essentials of nursing care are addressed through the many 

programmes provided concerning dignity, communication and customer care. 

New roles are being developed to address the changing needs in the NHS. The 

role of the Assistant Practitioner will provide a skilled member of the team who 

can take on many additional skills. 

Patient pathways are evolving and lengths of stay reducing to improve the 

overall quality and experience that patients receive. The many education 

and practice development activities taking place all have a part to play in this 

process. 

Current projects include falls prevention, new multi-disciplinary documentation 

and the development and advancement of clinical skills and new techniques. 

Medical staff 

All medical staff have considerable opportunities for both in-house and external 

learning. 

Trainees and junior doctors in non-training grades have a full programme 

of in-house training which is planned well in advance and the programme 

circulated monthly. Different grades also have grade specific generic training. 

As an example all Foundation Trainees (those in their first two years of training) 

attend a bi-weekly half study day where aspects of the Foundation Curriculum 

are delivered. 

General Practice trainees have an afternoon per week of protected time to 

develop further knowledge and skills appropriate for them. 


Our Trust contributes towards the Deanery funding of external study leave 

for all training and non training junior posts. We have developed significant 

training facilities and trainer expertise over the last five years. 

The Specialty Doctor/Staff Grade and Associate Specialists are also able to 

access specific training due to additional deanery funding provided for career 

development, in addition to their annual funding. 

Senior Medical Staff have ten days of study leave per year and an individual 

allocation of funding towards course costs. 

Serious Untoward Incidents (SUIs) 

The number of SUIs relating to data loss has increased from one to three this 

year. 

Incident date Incident description Outcome 

24 June 2010 

24 July 2010 

10 February 2011 

The clinical details of patients 

were sent to the home address 

of two patient. The Trust was 

informed of the error and 

arrangements were made 

to retrieve the information 

immediately. 

Paperwork believed to be from 

the Trust was found in a burnt 

out vehicle. 

A packet of clinical filing was 

placed within the external mail. 

The filing was returned to the 

Trust. 

Full root cause 

analysis undertaken. 

No further action 

from Information 

Commissioner’s Office. 

Full root cause analysis 

undertaken and 

actions implemented. 

Investigation 

undertaken with 

immediate actions 

taken. Due for 

completion June 2011 

Dr Foster Hospital Guide 

The Trust worked closely with the authors of the Dr Foster Guide 2010 during 

the compilation of their report and prior to its publication in November. 

The figures relating to the Trust are positive overall and within the expected 

ranges. Those for post operative respiratory failure place us among the best 

performing hospitals for this category. 

The Trust’s HSMR (Hospital Standardised Mortality Ratio) has reduced from last 

year. The Board of Directors, our managers and clinicians closely monitor this. 

Any areas of concern are considered in great detail to ensure that issues are fully 

understood and any action is taken as soon as possible. 


Care Quality Commission regulations 

The Trust is fully compliant with all 16 CQC regulations – including standards 

of patient care, infection control and the professionalism of our staff – with no 

conditions. This confirms that we provide a high-quality service to our patients. 

Continued compliance is measured by self assessing during the year. The CQC 

also provides us with monthly information on comments received and reports 

written about the Trust. This is reviewed and action taken when necessary. 

If the CQC has concerns about any aspect of the care we provide, they will raise 

these with us and may undertake an unannounced visit. The Trust was visited 

in early April as part of the national programme. The report on this visit is still 

awaited. However no significant concerns were identified. 

Research 

Participation in clinical research demonstrates the Trust’s commitment to 

improving the quality of care we offer and to making our contribution to 

wider health improvement. Our clinical staff stay abreast of the latest possible 

treatment possibilities and active participation in research leads to successful 

patient outcomes. 

The Trust was involved in conducting 12 clinical research studies in Cancer 

during 2010/11. There were 44 (19 nurses and 25 doctors) members of clinical 

staff participating in research approved by the research ethics committee. These 

covered 14 medical specialties. Studies currently underway include 

Pain management Diabetes Dermatology 

Rheumatology Stroke Ophthalmology 

Gastroenterology General Surgery Oncology 

Haematology Neurology ITU 

A&E 


Health and safety 

Health and safety is of paramount importance to the Trust. Throughout 

2010/11 our staff, managers and dedicated team worked with the Health and 

Safety Executive and our Staff Side representatives on a number of key issues 

including: 

• the final implementation of our latex management plan 

• actions to reduce the number of assaults on staff, both verbal and physical 

and especially in A&E 

• improvements to our occupational health service and further 

improvements to our responses to RIDDORs. 

As part of a reorganisation of committee structures, changes have also been 

made to the ‘reporting-line’ for health and safety reports and concerns, and 

the Director of Workforce and Estates has taken on the lead executive role for 

health and safety management. 

Towards the end of 2010, a report from Norfolk’s Fire Officer indicated that we 

needed to upgrade our fire risk assessments and internal smoke alarm systems. 

We are now contracting out this necessary work and identifying the capital 

needed to make the improvements we have agreed to. The Fire Officer is being 

consulted on all the steps we are now taking and is satisfied with our responses 

to his report. 

During the latter part of the year we also commissioned an independent review 

of our health and safety system overall. This included our policies, processes and 

capacity to manage the tasks required of us. The outcome of this review is now 

being considered by Trust managers and an action plan in response to it will be 

prepared and presented to the Board of Directors early in 2011/12. 



Occupational Health Service 

A short guide for staff 


Listening and responding to our patients 

Patient feedback 

We take all comments and complaints, formal 

and informal, very seriously and welcome the 

opportunity they give us to find out what we 

can do better to improve the quality of the 

services we provide. 

We encourage patients, carers and relatives 

to talk to us on our wards and through 

our Patient Experience tool. This is our 

computerised touch screen device implemented 

in September 2009. The latest information 

shows very positive results. 

Year 1 

(Sept 2009–Aug 2010) 

Number of responses 3534 

54% from patients 

Questions: 

Year 2 Quarter 1 

(Sept-Dec 2010) 

696 



(Jan-Mar 2011) 

488 

48% from 

patients 

Felt safe 9 out of 10 9 out of 10 9 out of 10 

Had confidence and trust in 

staff 

Involved in decisions about 

their care and treatment 

Treated with respect and 

dignity 

Staff were professional, 

approachable and sensitive 

to their needs 

9 out of 10 9 out of 10 9 out of 10 




Hospital was clean 9 out of 10 9 out of 10 9 out of 10 

Enough privacy 9 out of 10 9 out of 10 9 out of 10 

Felt overall care they 

received was good to 

excellent 


Environment welcoming 8 out of 10 8 out of 10 8 out of 10 

Felt welcomed on arrival 8 out of 10 8 out of 10 8 out of 10 

Would recommend this 

hospital 

Found someone to talk to 

about worries/concerns 

Got answers to important 

questions they could 

understand 

Told who to contact if 

worried when at home 






Year 1 

(Sept 2009–Aug 2010) 

Number of responses 3534 



(Sept-Dec 2010) 

696 



(Jan-Mar 2011) 

488 

48% from 

patients 

Told about complications to 

watch for at home 

Rated hospital food as good 

or very good 



Delayed in clinic 4 out of 10 3 out of 10 2 out of 10 

Delays in clinic explained 3 out of 10 5 out of 10 4 out of 10 

Experienced staff talking 

in front of them as if they 

weren’t there 

Bothered by noise at night 

from patients 

Bothered by noise at night 

from staff 

Know the trust has a set of 

values they work by 




Not asked 5 out of 10 6 out of 10 

Can name them Not asked 2 out of 10 

1 out of 10 

What users think the Trust 

values are: 

Not asked 

Patient care 

foremost. 

Efficiency. Dignity 

Cleanliness. 

Respect 

Kindness. Privacy 

Compassion. 

Equality. 

Gentleness. 

Open & friendly, 

dignity, 

effective 

communication, 

respect. 

A number of changes have been made 

following feedback received 

‘Didn’t always feel safe’ 

We are working with the police to have 

an increased presence at the hospital 

We also have in-house security patrols. 

‘No staff at main reception’ 

From February 2010 there will be staff 

at the main reception, Monday to Friday 

between 8.00am and 8pm. 

‘Litter on the floor of the car park’ 

Litter is removed from the car park areas 

each morning. 

‘Hospital needs brightening up’ 

Clinical areas are being upgraded. These 

include Audiology and Dental waiting 

room, Out-patients and the Operating 

Suite. 


‘Coffee machine was broken’ 

Replaced with an upgraded version. 

‘Corridors are dark at night’ 

This is because the lights are triggered by motion sensors. If you start to walk 

along the corridor the lights will come on. 

‘Smells around the hospital’ 

Installed additional automatic air fresheners around the hospital. 

‘TV not working’ 

Replaced the television in A&E and are gradually updating televisions as wards 

are refurbished 

‘Hospital cleanliness is a priority’ 

During October 2010, zero infection rates for MRSA and Cdiff were recorded at 

the Trust. ‘The 0/0 rate shows how effective our infection prevention & control 

measures are. However we are not complacent. We want to ensure our infection 

rates remain among the lowest in the region’ Nick Coveney, Director of Nursing 

& Transformation. 

‘Cleanliness of toilets is a priority’ 

Toilets are cleaned, checked and re-stocked every two hours from 7am to 9pm 

daily. Please speak to a member of staff when additional cleaning is required. 

Local issues: 

Car parking: Car parking leaflet regularly reviewed and updated by Head of 

Support Services. 

Staff customer care – working group developing ‘Customer care’ resources (DVD, 

Vox pop, Remember I’m a patient … leaflet) and will be facilitating staff 

customer care training sessions during 2011. 

Public Car Parks 

These are controlled by barriers. 

• You will be issued with a ticket on entry. 

• Please take this ticket with you, do not leave it in the car. 

• When you are ready to leave pay at the pay machine in the 

Main Entrance – taking the validated ticket with you to your car. 

Parking Charges are as 

follows 

All stays under 30 minutes are free 

• Up to 2 hours - £2.50 

• 2 to 3 hours - £3.00 

• 3 to 4 hours - £4.00 

• Over 4 hours up to 24 hours - 

£6.00 

The machines take most coins (except 5p-2p-1p) 

as well as £5 and £10 notes. 

Frequent Visits 

A reduced tariff of 4 visits for £2.50 will be provided from the Patients Travel 

Office for: 

• Immediate family visiting long stay patients. 

• Immediate family visiting a critically ill patient. 

• Patients attending more than one appointment within a week will be 

charged 75p for the second or following visits. 

• Claimants who are unemployed or on means tested benefits visiting 

immediate family. 

• Patients attending physio for treatment will be issued with a car park 

authorisation slip from staff. 

Free passes will be provided in the following cases: 

(Speak to the Clinic or Ward staff for advice on how to get your ticket 

validated). 

• Parents visiting babies and children frequently (the ward will issue passes 

out of hours and weekends). 

• Patients attending the Bure Clinic. 

• Relatives assisting at meal times. 

• Patients attending for oncology or haematology (cancer treatment) at the 

Sandra Chapman Centre. 

Free/reduced passes will be issued by: 

• Your car park entry ticket will be validated for a free or reduced exit pass 

at the Patients Travel Office. 

• A reduced fee slip being provided by Ward staff. This slip will then be 

presented to the Patients Travel Office for your exit pass. 

• By presentation of your blue badge to the Patient Travel Office. 

PLEASE PRESENT YOUR SLIPS AND BADGES TO THE PATIENTS TRAVEL 

OFFICE WHICH IS SITUATED IN THE MAIN FOYER. 

Disabled Car Parking 

Registered disabled badge holders displaying a blue badge have access to 

spaces at the front of the hospital and on the front row of Car Park A. 

Blue badge holders are not required to pay for parking. 

Blue Badge Card Holders attending the following clinics can obtain 

free exit tickets if parked on Car Park A, from the clinic reception during 

normal clinic hours. 

• Breast Imaging Dept 

• Gynaecology Clinic 

• Broadland Suite 

• Ophthalmology Clinic 

• CT/MRI Dept 

• Orthopaedic Clinic 

• Dental Clinic/Audiology 

• Pathology Outpatients Clinic 

• Dermatology Clinic 

• Sandra Chapman Centre 

• ENT Clinic 

• X Ray Department 

• General Surgery/Urology Clinic • Department of Medicine 

For all other clinic areas, tickets can be validated for a free exit 

at the Travel Office. 

Blue badge card holders leaving after the clinic/travel office has closed should 

press the help button at the exit barrier. The Portering and Security staff will 

respond to open the barrier. 

Need Help 

• Help buttons linked by intercom to Portering and Security 

staff are available at each machine and barrier, including 

out of hours and are able to give advice on where to park 

and general queries. 

• The Patients Travel Office in the Main Entrance Foyer will 

assist with general car parking and travel enquiries. 

Clinics or appointments running late? 

Please take your car park ticket to the Travel Office 

and the standard £2.50 will be charged. 


National Inpatient Survey 

Analysis of the results identified key areas to focus on where improvements in 

the patient experience could be made. 

Discharge: 

Information at discharge on medication side effects/danger 

signs/contact if worried/purpose of medications/delays at 

discharge. 

Sessions of observation have occurred, written information 

used at discharge has been reviewed, pre-assessment 

information reviewed to ensure these aspects are contained 

within the information. 

EIDO www.patientfeedback.org leaflets contain generic 

information and have been implemented. 

Hospital food 

Noise at night 

CQUIN questions 

Temperature monitoring, menu details included in bedside 

folder, new patient menu launch. Random mystery food 

tasting by Governors. Range of menus available for special 

needs. 

Regular noise audits carried out with local action plans. 

Piloting and implementation in 2010 of ‘ear plugs’ available 

for patients to facilitate sleeping at night. 

Personalised individual ‘Take home information’ developed 

and piloted during 2010. 

Experience Based design events 

This technique, developed by the NHS Institute for Innovation & Improvement, 

was used in staff and patient events during 2010. Areas for improvement were 

identified and working groups of patients and staff formed. Sessions continue in 

2011. 

Complaints 

A total of 334 formal complaints were received by the Trust during 2010/11 on 

a range of issues. This equates to 4.2 complaints per 1000 admissions and is only 

slightly higher than the 325 received in 2009/10. 

All complaints are seen and responded to by the Chief Executive. We regularly 

review trends and change our practices as a direct result of this invaluable 

feedback. 

Further information can be found in our Quality Report. 


Patient Advice and Liaison Service - PALS 

This service supports patients, relatives, carers and members of the public who 

need information about the healthcare system. 

They deal with general enquiries about the healthcare 

services available, resolve problems by identifying the right 

people to talk to and explain how to make a complaint if 

your concern is unresolved. 

During 2010/11 there were 806 enquiries via PALS. This 

represented a significant increase from the previous year’s 

528 cases. It does demonstrate the value of the team in 

being able to support our patients to get the information 

that they need. 

Communications & Engagement 

Changes were made during the year to ensure the best use of resources to 

deliver effective communications and engagement. The strategy was revised in 

early 2011 and following comments from our Governors and Local Involvement 

Networks, was approved in March. It sets out how we will communicate and 

engage with our staff, Governors, members, patients and any groups that have 

an interest in the services we provide. 

Communications and engagement is central to what we do and helps us to 

achieve our objectives. 

There are legal requirements and also public expectations that views will be 

sought from those who use our services. The work that will take place over 

the coming months will ensure that we promote our services and enhance 

communications with our staff and stakeholders. This is in addition to the 

feedback we already get from our patients. 


Within all that we do, our principles will remain the same: 

• All communications will be accurate and honest, within our Core Values 

• Key messages will be simple, consistent and meaningful 

• Use of jargon will be kept to a minimum 

• We aim to keep staff informed about issues before external stakeholders 

• We will support our staff by publicising the good work that they do 

• We value the views of our staff, patients and stakeholders 

• Patient and staff confidentiality is paramount and will not be compromised 

• Diversity will be considered in all that we do to ensure our messages are 

reasonable and understandable for all groups 

• We will use a consistent professional form of communication, conforming 

to NHS identity guidelines 

• We will think ahead and prepare for issues that may impact on the Trust’s 

reputation 

• We will be cost effective in all that we do. 

Our objectives for the next three years are to: 

1. Protect the reputation of the hospital through building public and 

stakeholder confidence in the quality of care 

2. Clearly articulate strategic aims and proactively communicate to staff, 

patients, governors, members and stakeholders how the hospital is delivering 

against them 

3. Implement a proactive media engagement programme, developing effective 

mechanisms to highlight the work of our staff 

4. Market the role of the communications team and how they can assist our 

staff 

5. Encourage higher visibility of Board of Directors through regular staff 

briefings 

6. Ensure published Trust information is accurate and conforms to the James 

Paget corporate identity 

7. Develop communications with GPs 

8. Implement the process and principles of engagement Trust-wide 

9. Implement the annual Governor led membership strategy 

10. Enhance internal communications systems and mechanisms to ensure all staff 

have easy access to Trust information and are well informed 

11. Work with the Equality lead to ensure mechanisms are in place to reflect 

engagement with under represented and minority groups 

12. Revise the consultation policy and promote best practice 

13. Investigate the use of social marketing as a communications tool 

14. Implement a formal external stakeholder engagement policy. 


Consultations 

There have been no formal consultations undertaken during the year. However 

members of the Trust continue to work with Local Involvement Networks and 

meet with them regularly. 

The Head of Communications leads on engagement with Health Overview and 

Scrutiny Committees to ensure that Councillors from both Norfolk and Suffolk 

are kept up to date on developments at the hospital. 

A meeting was held with the Chairs of each Scrutiny Committee in January, with 

our Chairman and Chief Executive. We have agreed to repeat this annually. 

Patient and carer information 

A new Patient Information Policy has been implemented during the year to 

support all members of staff in preparing information for patients. It contains 

everything they need, including how to write it, what to include, and a range of 

leaflet templates. 

A readers’ panel helps us to ensure that the information is understandable for 

patients before the monthly Patient Information Group goes through the detail. 

We continue to update the Trust’s website and are working towards providing 

more information for the services that are not currently represented. 

NHS Choices has been used more this year by 

patients and families to record their opinions on 

the Trust. Where possible and appropriate, Trust 

responses have been added to ensure an accurate 

reflection of our services. This is particularly 

important where negative comments are made. If 

the individual can be identified we can then follow 

up with them personally to try and resolve the issue. 

If a patient or a member of their family has taken 

the time to make a positive comment, this is very 

much appreciated and is always passed on to the 

staff concerned. 


Operating and Financial Review 

Our Vision and objectives 

The Trust aims to provide 24 hour excellent care and treatment for the 

population of Great Yarmouth and Waveney and visitors to the area, and high 

quality education, training and research in healthcare to benefit patients, staff 

and students, all within financial targets. 

Our objectives this year were challenging but all were achieved. We involve our 

Governors and senior managers in setting these each year to ensure that all our 

staff work towards the same aim. 

1. 

Develop and implement a project plan for the Leading Improvement in 

Patient Safety (LIPS) scheme across the Trust. 

• The programme has become well established and projects have moved 

forward, showing real change within patient services. There has been 

improvement across the 10 key metrics with particular achievements in 

VTE assessment and falls prevention. 

• A range of learning from investigation and analysis has taken place 

involving review of patient notes, monitoring and review of HSMR and 

the implementation of a rapid investigation process. This work has led to 

changes in practice and patient management across several areas. 

• Methodology for patient safety projects is now well established and 

utilised for several schemes of work in the Trust. 

• Patient Safety Walkrounds have been undertaken across many 

departments resulting in the identification of issues and actions to 

improve patient care. Feedback on the walk rounds process has been 

positive from both service staff and Board members. The scheme is 

currently being updated for a second round. 

• Patient stories at Board meetings have been a particularly strong feature 

in the Board agenda. The presentations and discussion have led to specific 

investigation and consideration of service improvements with reports 

back to Board on a range of issues. Patients and staff have participated 

in this process and have been able to openly share real issues with Board 

members. 

• Several of the LIPS projects have featured as CQUINS and it is envisaged 

that this will occur again for 2011/12. 

• Progress on the LIPS work has featured at Governors Council and subcommittees 

and been reported to the PCT throughout the year. 

2. 

Develop and implement a project plan for QIPP (Quality Innovation 

Productivity Prevention), working with stakeholders on system wide 

improvement. 


• The work in QIPP development has two themes – the development of a 

QIPP plan for the system and the internal plan for our own transformation 

work. 

• The system wide QIPP plan was developed across all organisations in Great 

Yarmouth and Waveney and signed off as a direction of travel in March 

2011 at a presentation with NHS East of England. Much work has gone 

into this to try to account for a range of outcomes going forward. It is 

recognised that the result will depend upon all parts of the health care 

system delivering change. 

• The Clinical Transformation Board for the system has been a key factor 

in taking forward some of the pathway redesign work in several clinical 

areas. The Trust’s Medical Director holds vice-chairmanship of this 

group and has initiated a number of system events including the Clinical 

Summits held during the year. During 2010/11 much of the work has been 

around elective care pathways – for 2011/12 the focus will be emergency 

care pathways. 

• Within the Trust a Project Management Office (PMO) has been developed 

to manage our own QIPP programme utilising methodology devised 

by consultants for our use. Over time this has been refined to meet 

our requirements and we now have a well established PMO. Our own 

Transformation plans originally consisted of a large number of individual 

schemes which became unmanageable. These have been reviewed to 

form themed groups covering the critical delivery areas for this QIPP 

work. These key themes are underway with identified leads and executive 

sponsors and a number of changes have already been implemented. 

• The transformation work has necessitated substantial communications 

support for both internal and external plans. There is now a regular 

information flow through newsletter, notice boards, e-bulletins and 

through departmental briefing systems. In addition we ran a number 

of open meetings for staff to share information and allow them to 

understand proposals. This has been particularly important in respect 

of system wide QIPP as there are major implications for the format of 

services and manpower requirements in future. These events were well 

attended and provided the opportunity for good discussion with staff. 

• Within this work the Cost Improvement Programme has been challenging 

and some areas have a requirement carried over to 2011/12. The Trust 

has met its financial targets for 2010/11 but we recognise the additional 

challenge this places on 2011/12. 

3. 

Deliver all financial targets. 

Financial performance overall was consistent with the plan submitted to 

Monitor for 2010/11. The rating did reduce slightly at one point but this 

returned to level 4 in accordance with plan. Financial performance has 

been extensively reported to both the Board of Directors and Governors 

Council throughout the year. Referral and demand for services was sustained 

during 2010/11. However, the high emergency level during the period after 

Christmas led to loss of elective activity and associated loss of income. This 

was balanced by over activity against plan in emergencies. 


4. 

5. 

Demonstrate progress towards a reduction of carbon emissions at the Trust of 

20% by 2015. 

The Trust has made major achievements against its Carbon Management 

plan during the last year. The level of progress made has been recognised 

nationally in terms of commitment and delivery. The plan covers every 

area of the Trust including design and construction, utility usage, technical 

schemes, waste management and staff engagement. In addition to the major 

environmental impact this work has also led to major costs savings. The 

challenge set is ambitious and work will continue for several years to deliver 

the reductions needed by 2015. 

Take forward a number of initiatives within the Trust’s strategic priorities: 

• Maintaining and strengthening our core services 

Work to secure a joint hub for pathology with the Norfolk and Norwich 

University Hospital NHS Foundation Trust has been undertaken 

throughout the year and is now at the stage where detailed 

implementation plans can be developed. This project has been set in 

the context of the national and regional work to review and reorganise 

pathology services across the eastern region. The next phase will prepare 

for a joint bid to go forward within the tender process established by NHS 

East of England. 

Neonatal services work has included participation in two major reviews 

and joint working on patient flows between units. The outcome currently 

appears to be that James Paget University Hospitals NHS Foundation 

Trust will take babies from a later gestational age but that this will have 

a phased introduction. There remains some anxiety in relation to overall 

capacity within the system and these plans are still being finalised. The 

local Health Overview and Scrutiny Committees are due to debate the 

proposals in May 2011. 

A number of service developments have taken place within speciality 

areas and are detailed in this report. 

• Meeting the comprehensive needs of our high risk population 

The Trust has participated at every level in the system integrated care 

work to support the need for joint working across health, social care and 

the voluntary sector. This has spanned System Leadership Board, Clinical 

Transformation, Emergency Planning and Clinical Networks. 

The Trust’s proposals in respect of Community Service were not taken 

up nor did the tender process for this provision go ahead due to the 

intervention of the Department of Health in the PCT’s plans. To date the 

service remains with the PCT and will be assessed as to sustainability for 

social enterprise. Our offer to host or take on these services remains in 

place with the PCT and HealthEast CIC, the GP consortia. 

• Enhancing the overall experience of our patients 

The PET system is now well established with substantial usage by patients 

and carers. The feedback and actions have been presented to the Board 


of Directors and Governors Council on a regular basis through the year. A 

group has also been established to look at Experience Based Design with 

staff and patients working together to identify and influence a number of 

improvements to make services better for users. 

Some patient experience work was linked to CQUINS and has contributed 

to achieving this additional quality requirement for the 2010/11 year. 

• Being an excellent employer. 

There have been major achievements in the 2010/11 year in respect of 

human resources and employment issues. The work around Apprentices 

has been recognised nationally. The Project Search scheme has been very 

successful. The launch of the Trust Values and the new Appraisal scheme 

has been implemented with appropriate training sessions to support staff 

in adopting new procedures. Further work is planned, particularly for the 

Trust Values. 

There has been close working with Staff Side and the Local Negotiating 

Committee on the range of change and transformation schemes that are 

being developed, both locally and nationally. 

The Trust has supported and utilised the development programmes 

offered by Suffolk Partnership and provided several in house development 

courses for ward managers. This is in addition to the range of training 

offered for staff within speciality and mandatory fields. 

6. 

Achieve national performance standards that underpin the provision of 

excellent services to our community. 

• The Trust has achieved against a range of performance standards 

set nationally during 2010/11. The Trust also achieved CNST Level 2 

Accreditation for Maternity Services. Infection control targets have been 

achieved and comparative performance within the eastern region places 

the Trust in the mid range position. 

• The long term high levels of demand have however impacted on our 

ability to deliver high quality care at all times during the last six months. 

This has resulted in a number of concerns and complaints particularly 

related to essential care in ward areas. A plan of work to address this is 

underway and has been shared with Governors Council, MPs and the local 

media. This work will continue for some time to improve care across the 

entire organisation. 

• To date performance on the Hospital Standardised Mortality Ratio has 

been below 100 although rebasing has yet to be completed. During the 

year there has been close working with Dr Foster and senior clinical staff 

to identify and address any HSMR highlighted issues. 

• The Trust participated fully in the Emergency Preparedness work initiated 

by the Department of Health including several major exercises during 

early 2011. 


• The Trust was recently visited as part of the national programme by the 

Care Quality Commission. The report on this visit is still awaited. However 

no significant concerns were identified. 

7. 

Maintain the delivery of treatment waiting times targets in line with the NHS 

Constitution Patient Rights and Pledges. 

Access targets for A&E were generally met throughout the year in spite of 

high demand over a long period. The elective 18 week target was severely 

affected by the January and February surge in emergency activity. This 

resulted in high levels of cancellations and therefore 18 week breaches at the 

point of treatment when patients attended for their operation. The overall 

outcome was balanced due to high attainment earlier in year. However there 

will be some carry over of 18 week breaches to 2011/12. 

National targets for Cancer care were met for 2010/11 and reported to the 

relevant agencies. 


Our performance 

Regulatory Ratings 

As part of the Trust’s authorisation as a Foundation Trust, an annual plan is 

submitted to Monitor. The Trust is assessed quarterly on its performance against 

the plan. The outcome is published on the Monitor website and consists of three 

risk ratings: 

° financial risk rating (rated 1-5, where 1 represents the highest risk and 5 the 

lowest) 

° governance (rated red, amber or green). 

Details of the ratings and what they mean are set out by Monitor: 

Financial risk rating 

1. 

2. 

3. 

4. 

5. 

highest risk - high probability of significant breach of authorisation in shortterm, 

e.g.

Monitor has not been required to intervene on any issue. Further detail on the 

Trust’s financial risk rating can be found at page 41. 

Annual Plan 2009/10 Quarter 1 2009/10 Q2 2009/10 Q3 2009/10 Q4 2009/10 

Financial risk rating 4 4 4 4 

Governance risk rating Green Green Green Green 

Annual Plan 2010/11 Quarter 1 2010/11 Q2 2010/11 Q3 2010/11 

Q4 2010/11 

Estimated 

Financial risk rating 3 4 4 4 

Governance risk rating Green Green Green Green 

Key performance indicators 

The Board of Directors reviews the performance of the Trust against a number 

of indicators for agreed targets, covering patient experience, quality of services, 

finance and performance. The Trust has assessed its performance at month 12 as 

shown below: 

Indicator Measure National Standard 

Trust 

Position 

Core Standards (Better 

Standards for Health) 

To assess compliance against 

the core standards of safety, 

clinical and cost effectiveness, 

governance, patient focus, 

access and responsive care, 

care environment and 

amenities, public health. 

Compliant with all 

standards 

Compliant 

with all 

standards 

A&E – maximum wait 

of 4 hours 

% of patients waiting 4 hours 

or less in A&E from arrival 

to admission, transfer or 

discharge 

95% 97.21% 

Cancer – 2 week wait 

Maintain a 14 day maximum 

wait from urgent GP 

referral to first outpatient 

appointment for all urgent 

suspected cancer referrals 

93% 97.17% 

All cancers – 1 month 

target 


target 

Ensure a maximum waiting 

time of 31 days from 

diagnosis to treatment 



diagnosis to subsequent 

treatment of anti cancer drug 

regimen 

96% 99.35% 

98% 100% 


target 



diagnosis to subsequent 

treatment of surgery 

94% 

100% 



Trust 

Position 


target 

All cancers – 2 months 

target 



diagnosis to treatment for all 

pathways 

Achieve a maximum waiting 

time of 62 days from urgent 

referral to treatment 

96% 99.52% 

85% 88.37% 


target 



screening services referral to 

treatment 

90% 

98.37% 


target 


time of 62 days from referral 

to treatment for all pathways 

85% 

89.53% 

Breast Cancer – 2 week 

target 

MRSA Bacteraemias 

Clostridium difficile 

Achieve a 14 day maximum 

wait from GP referral to first 

outpatient appointment 

for patients with any breast 

symptoms 

To have no more than 4 

cases of MRSA bacteraemias 

diagnosed within the local 

healthcare system and 

to achieve year on year 

reduction 

To have less than 35 cases of 

Clostridium difficile (hospital 

attributable) and to achieve a 

year on year reduction 

93% 96.91% 

4 2 

35 29 

Smoking and 

Breastfeeding during 

Pregnancy 

Data completeness with no 

more than 5% of records 

incomplete 

95% smoking 

95% breastfeeding 

98.12% 

smoking 

98.60% 

breast 

feeding 

Smoking during 

Pregnancy 

Number of women smoking 

to be less than or equal to our 

2009/10 performance 

26.31% 

26.12% 

(-0.19%) 

Breastfeeding 

Initiation 

Number of women initiating 

breastfeeding 

65% by end of Q4 

67.04% (Q4) 

62.58% 

(10/11) 

Stroke Care 

Percentage of patients 

admitted to hospital 

following a stroke spending 

at least 90% of their stay on a 

stroke unit 

80% 

57.74% 

(For info - 

standards 

come into 

effect April 

2011) 



Trust 

Position 

% of admitted patients seen 

within 18 weeks (at March) 

90% 82.58% 

Waiting times 

% of non admitted patients 

seen within 18 weeks (at 

March) 

% of admitted patients seen 

within 18 weeks by specialty 

based on the performance in 

Quarter 4 

95% 98.19% 

90% 

All specialties 

4 specialties 

did not 

achieve 

criteria 

% of non admitted patients 

seen within 18 weeks by 

specialty based on the 

performance in Quarter 4 

95% 

All specialties 

All 

specialties 

achieved 

Waiting times for 

rapid access chest pain 

clinics 

% of patients seen within 14 

days of referral 

100% 99.5% 

Access to genitourinary 

medicine 

clinics 

Cancelled Operations 

All patients offered an 

appointment within 48 hours 

Operations that have been 

cancelled by the Trust after 

admission or on the day for 

non clinical reasons 

100% 100% 

0.8% 0.52% 

Delayed Transfers of 

Care 

% of patient delayed from 

discharge 

3.5% 2.25% 


Our commissioners 

The main commissioner relationship is with NHS Great Yarmouth and Waveney. 

Collaborative working this year has been a key feature of developing plans for 

the challenging QIPP environment. 

During this year we saw the first clinical summit, organised and lead jointly by 

the Trust and the PCT, which discussed the need to transform clinical pathways. 

Clinical pathway redesign is at the heart of achieving the challenging QIPP 

targets. The summit prioritised clinical specialties for review and specialty 

meetings between consultants and GPs have been established. These will be 

expanded over the next year. 

The level of emergency demand has been a major concern for the Trust during 

the year and the PCT has put in various measures to improve the situation. With 

significant investment in primary and community services the PCT strategy of 

investment in alternate settings for provision has been its main approach. The 

impact on the Trust has not yet been as great as originally expected but it is 

hoped that over the next year the schemes will come to fruition. 

The impact of the emergency demand has been felt on our elective programme. 

During January and February 2011 we cancelled nearly 600 procedures due 

to the lack of beds caused by increases in emergency admissions. These 

cancellations have impacted on delivery of our target for 18 week admitted care. 

For the year we achieved the 90% target for all our specialties in aggregate 

but failed to achieve the target in four specialities in Quarter 4; Trauma and 

Orthopaedics, General Surgery, Gynaecology and ENT – Ear, Nose and Throat. A 

single specialty failed to achieve its target for the year - ENT. 

The investments made by the PCT during the year have supported the 

development of the Early Supported Discharge team for stroke services and the 

clinical management for acute oncology services. 

Our stakeholders 

The key partnerships remain the local PCT. However national developments 

have expanded our commissioning relationships further. The creation of a GP 

consortia – HealthEast – as the future of commissioning, has been welcomed by 

the Trust. Clinical and managerial relationships have been developed throughout 

the year and will be formalised during 2011/12 as responsibilities transfer from 

the old structures to the new. 

In addition the PCT has now ‘clustered’ with NHS Norfolk. The independence of 

the local PCT is clearly maintained but managerial relationships will have to be 

established with NHS Norfolk and these have commenced. 

The Trust is keen to develop its educational links and the relationship with UEA. 

This year saw the appointment of our first Clinical Academic Consultant post in 

the ENT specialty. 

The Trust is a member of the System Leadership Board established to develop 

collaborative working across health and social care. This has supported joint 

working on a system QIPP plan for 2011 onwards. There is also participation 


in the Clinical Transformation Board with senior clinical staff fully engaged in 

service and pathway redesign. During 2010/11 projects focused on elective 

pathways. 

The work with the System Leadership Board and Clinical Transformation Board 

will continue into 2011/12 taking account of changes within the local health and 

social care arrangements. We will look to contribute to the provision of new 

pathways of care for our patients. The focus will be on emergency care and long 

term conditions. 

Clinical activity 

Activity 2010/11 2009/10 

Elective Inpatients 4,871 5,925 

Day Cases 20,872 22,726 

Non-elective 23,178 21,160 

Outpatients 232,106 201,021 

A&E 60,651 59,654 


Financial Performance 

The Trust achieved its financial targets for 2010/11 with a surplus of £2.64 million 

(2009/10: £3.48 million). 

Financial risk management objectives and policies 

The Trust is committed to a strategy which minimises risks to all its patients 

and stakeholders through a comprehensive system of internal controls. The 

management of risk is integrated into the culture of the organisation through 

the appliance of effective evidence based governance, policies, procedures and 

training appropriate to the Trust business. 

All members of staff and volunteers have an important role to play by 

identifying and minimising risk. All new ventures, equipment and procedures 

are risk assessed and registered within the overall Trust Risk Register. This is 

monitored on a monthly basis by the Board of Directors, and at each Safety 

and Quality Governance Committee (formerly the Healthcare Governance 

Committee). 

The Trust actively encourages input and feedback on our services from the 

communities we serve. We see this as an important part of the process to shape 

our services to the needs of our patients. To ensure that we have an inclusive 

discussion about risks and opportunities, there are patient representatives either 

present or invited to sit on a range of committees where risks are discussed, 

including the Safety and Quality Governance Committee which reports to the 

Board of Directors. 

We are keen to expand the number of patient volunteers that attend these 

meetings and will be pleased to hear from anybody that feels they would like to 

work closely with us in this way. 

The risk issues identified by the Trust are set out below: 

(i) Emergency Demand 

The Trust has seen unprecedented increases in Emergency admissions during 

the last year, with an overall increase for the year of 5.24% with January 2011 

increasing by over 12.9% against the same month last year. This has led to nearly 

600 planned operations being cancelled since Christmas. 

The management of the winter pressures has been considered by the Trust 

Management Team, Executives and Board of Directors and a proposed bed 

model to manage escalation is being finalised for implementation. The model 

will work alongside demand management schemes outlined by the PCT and 

schemes within the Trust to reduce the length of stay of emergency patients. 

(ii) 

Infection control 

The management of infection control in the Trust remains a high priority. 

The Trust met the targets set for hospital acquired infections and saw further 

improvement year on year in its overall performance. It recorded two cases of 

MRSA and 29 cases of Clostridium difficile. The Trust will continue with its robust 

approach to infection control management and will seek to further improve 

in 2011/12. The targets set nationally for us reflect a challenge to maintain our 

performance achieved in this year. 


The outbreak of Strep A in 2010/11 was well managed but clearly shows that 

infection remains a risk to any health provider. The maintenance of robust 

management techniques is essential to mitigate that risk. 

The Board of Directors considers infection control issues on a monthly basis. 

Matrons have the opportunity to raise their views with Board members 

quarterly. A more robust process is being implemented for the coming year for 

this meeting to cover a range of patient safety issues. 

(iii) Managing costs and delivering the planned levels of activity 

The NHS has to deliver £20bn worth of savings over the next four years. The 

system-wide QIPP plan, prepared by the PCT, outlines challenging targets and 

the direction of travel is well accepted by all partners. The NHS will receive small 

increases in funding over the next four years but this will not keep pace with the 

demands on the service. 

The Board has set a challenging cost improvement target of £8.2m for 2011/12 

and this is similar to that which was set and delivered in 2010/11. It will steer 

this programme through its own Transformation Board and with the Clinical 

Transformation processes established by the PCT. 

The challenge will only be met through system change which will take time and 

may not meet the profile currently outlined in the system wide QIPP plan. 

(iv) PCT Strategy 

The strategy to transfer care from the acute setting to primary and secondary 

care locations is aimed at transferring £16m worth of activity. The risk to the 

Trust is that the costs that flow with the income will be lower and the residual 

financial exposure will be the responsibility of the Trust. To ensure that this shift 

is successful the system will need to demonstrate alternative care settings that 

are capable of delivering the capacity required in a more cost effective setting. 

Income from activities 

The total income from patient care activities for the year 2010/11 was £151.7 

million (2009/10: £151.2 million). This represents 92% (2009/10: 93%) of total 

income for the year. 

The main sources of income within this category are Primary Care Trusts NHS 

Great Yarmouth and Waveney, NHS Norfolk and NHS Suffolk and the East of 

England Specialist Commissioning Group. 

Private patient income of £0.6m was received during the year. At 0.4% of total 

income, private patient income was well within the 1.3% permitted as part of 

the Trust’s authorisation as a Foundation Trust. 

In addition the Trust receives income for the education and training of University 

of Cambridge and University of East Anglia medical students, for research and 

development, and from services provided to other organisations and to staff, 

patients and visitors to the Trust. This includes residential accommodation to 

staff, catering and car park income. 


Patient Care Income 31 March 2011 

(£’000s) 

Foundation Trust Patient Care Income £'000 

2010/11 

Non-patient Care Income 31 March 2011 

(£’000s) 

Foundation Trust Non Patient Care Income 

£' 000 2010/11 

586 

28,347 

839 

712 

673 

829 

55,500 

826 

750 

38,956 

6,987 

831 

5,169 

23,162 

Elective Non Elective Outpatient 

A&E Other Private Patient 

Accommodation 

Donation Fund 

Car Parking 

Education and Training 

Services to other NHS bodies 

Other 

Cater ing 

Research & Development 

Other income 

Further information on this can be found on page 24 of the financial statements. 

Investments in services 

During 2010/11 the Trust invested in a range of services to strengthen and 

improve the quality of its patient care. Some of the investments were supported 

by the local Primary Care Trusts. The significant Trust-funded service investments 

are shown in the following table: 

Investments in service provision £’000 

Pulmonary Rehabilitation 98 

Sleep Apnoea equipment 78 

Early Support and Discharge development 

75 

Relieve pressures in A&E 452 

Activity-related business case in anaesthetics and related drug 

costs 

315 

Total 1,018 


Financial Risk Rating 

The Independent Regulator for NHS Foundation Trusts monitors the Trust’s 

financial performance on a quarterly basis using specific financial risk ratings. 

The Trust’s performance is shown below: 

Metric Weighting 2010/11 2009/10 

EBITDA margin 25% 3 3 

EBITDA % achieved 10% 5 5 

Return on assets 20% 5 5 

I&E surplus margin 20% 4 4 

Liquid ratio (days) 25% 5 4 

Weighted average rating 100% 4.3 4.1 

Cash 

Cash increased from £38 million to £41 million. A working capital facility of 

£10 million was also in place. This position equates to a liquidity risk rating by 

Monitor of 5. 

In 2010/11 the Trust finance leases reflect borrowing of £5,000 and long term 

interest free carbon trust loans through the Salix fund of £295,000. This totals 

£300,000 of loans against the prudential borrowing limit of £40.03m equating 

to only 0.74% of the available borrowing facility. The Salix loans are repaid from 

the savings generated by reduced energy costs and are in effect self-financing. 

The investment will also lead to longer reductions in carbon emissions and 

financial savings. 

Planned capital investments 

The Trust’s key capital investments for 2010/11 are shown below. A total of 

£5.2 million (2009/10: £8 million) was spent on medical equipment, ward 

reconfiguration, IT infrastructure and estates developments. These include 

the transfer of the central treatment suite and provision of additional High 

Dependency Unit beds, upgrading the fertility unit, provision of a midwifery led 

birthing unit, investment in a new E Rostering system and new energy efficient 

improvements including replacement of the combined heat and power unit. 


Capital investment 2010/11 £’000 

Transfer Central Treatment Suite and provision of additional High 

Dependency beds 

1,139 

Upgrade of Fertility unit 645 

Midwifery led birthing unit 290 

Theatre light improvements 165 

Energy related improvements including new combined heat and 

power unit 

479 

Ward reconfigurations 103 

E Rostering system 209 

IT investments including desktop replacement programme 200 

General estates work 541 

Equipment replacements 553 

Total 4,324 

Market value of fixed assets 

The Trust’s land, building and dwelling assets were last revalued by the Trust’s 

externally appointed independent valuers as at 31st January 2010, in accordance 

with the Modern Equivalent Asset valuation method. 

Accounting policies 

The financial statements have been prepared in accordance with the Annual 

Reporting Manual guidance issued by the independent regulator of NHS 

Foundation Trusts. 

The accounting policies are set out in the Statement of Accounting Officer’s 

responsibilities within the financial statements. 

The financial statements follow International Financial Reporting Standards 

(IFRS) and HM Treasury’s Financial Reporting Manual to the extent that they are 

meaningful and appropriate to NHS Foundation Trusts. 

The accounting policies for pensions and other retirement benefits are set out 

on page 16 of the financial statements. 

Auditors 

The auditors for the Trust were the Audit Commission. The Governors Council 

approved a one year extension to this contract for 2011/12 as this is the first 

year the Trust will need to produce financial statements in accordance with 

Accounting Standard 27: Consolidated and Separate Financial Statements 

(IAS 27). This accounting requirement had complex and potentially significant 

implications on the Trust’s financial reporting and it was therefore felt that 

changing auditors would impede a smooth transition to the new accounting 

regime. 

The Trust and its Governors will be tendering this service with effect from 1 April 

2012. 


The cost of audit work performed by the Audit Commission was £94,000. Other 

audit services to the value of £26,000 include additional audit work in respect of 

National Fraud initiatives, quality accounts and sustainability reporting. 

Significant events since the balance sheet date 

There are no significant events since the balance sheet date that are likely to 

have a material impact on both the Trust and financial statements for the year 

ending 31st March 2011. 

Counter Fraud 

The Trust is committed to maintaining an honest, open and well intentioned 

atmosphere. It is committed to the elimination of any fraud and the rigorous 

investigation of any cases of suggested theft, fraud or corruption. The Board of 

Directors encourages anyone having reasonable suspicions of fraud to report 

them. It is also the Board of Directors’ policy, which will be rigorously enforced, 

that no employee will suffer as a result of reporting reasonably held suspicions. 

During 2010/11 the Trust requested 30.5 proactive Local Counter Fraud Specialist 

(LCFS) days, which is consistent with previous accounting periods, and reflects 

the historically low incidence of fraud in the organisation. 

In addition to raising awareness across the Trust through participating in June’s 

Fraud Awareness Month and submitting articles for the intranet and Making 

Waves, the LCFS issued two dedicated fraud awareness newsletters during 

the year and also chaired the newly established Fraud Risk Group. This Group 

includes representatives from across the Trust and aims to identify and tackle the 

specific fraud risks currently being faced. 

Political or Charitable Donations 

No such donations were made by the Trust in 2010/11. The Trust continues to 

benefit from charitable donations received and is grateful for the efforts of 

fundraisers and members of the public for their support. Special thanks go to 

the League of Friends of the James Paget University Hospital and of Lowestoft 

Hospital for all their efforts in raising funds and supporting the Trust in 2010/11. 

More information can be found on page 63. 

Going Concern 

After due consideration by the Audit Committee and the Board of Directors, the 

Directors have a reasonable expectation that the Trust has adequate resources to 

continue in operational existence for the foreseeable future. For this reason they 

continue to adopt the going concern basis in preparing the accounts. 

Annual Governance Statement (formerly the Statement of Internal Control) 

The annual governance statement is set out in pages 3-6 of the financial 

statements. 

Remuneration of senior employees 

Details of senior employees’ remuneration can be found on page 79 within the 

remuneration report. Senior employees are considered to be the Chairman, all 

Executive Directors and all Non Executive Directors. 


Better Payments Practice 

During the year the Trust paid invoices totalling £60.0 million, of which 70% 

were paid within 30 days (2009/10 £61.6 million, of which 67% were paid within 

30 days). This comprised 46,125 bills, of which 64% were paid within 30 days 

(2009/10 45,465 separate bills, of which 62% were paid within 30 days). 

Management costs 

Expenditure on management and administration is measured annually using the 

definitions determined by the Department of Health, and is applied to all NHS 

organisations. Included within the definition are senior nurses and doctors with 

managerial responsibilities. For 2010/11 management costs were £8.6 million 

(5.3% of income). This compares to £8.6 million (5.3%) in 2009/10. 

Additional pension liabilities for retirement on ill health grounds 

Full details relating to additional pension liabilities for retirement on ill health 

grounds can be found in note 7.5 to the financial statements on page 29. 

Directors’ disclosure to auditors 

So far as the Directors are aware, there is no relevant audit information of which 

the auditors are unaware, and the Directors have taken all of the steps that 

they ought to have taken as Directors in order to make themselves aware of any 

relevant audit information and to establish that the auditors are aware of that 

information. 


Sustainability 

The Trust aims to minimise any adverse environmental impact and improve 

its environmental performance to help reduce pollution, climate change and 

damage to the natural world. Working practices are being refined where 

possible to ensure that they are sustainable for both patient care and the 

environment. 

A number of carbon reduction schemes have been implemented over the last 

year which were identified in our Carbon Management Plan. We were also 

successful in obtaining over £450,000 in interest free loans from Salix Finance 

to enable us to quickly implement some major schemes. The largest was a new 

“CHP” combined heat and power installation which will produce electricity for 

the hospital 24/7. 

Other schemes include lighting controls upgrades, steam trap management, 

boiler burner upgrades and computer power management. Carbon reduction 

opportunities have also been implemented in other areas such as transport/ 

travel, procurement and waste management. This is considered in all new 

builds and refurbishment of the hospital estate to ensure we become a more 

sustainable organisation. 

The Trust has committed to reduce carbon emissions from its operations by 20% 

from 2007/08 measured levels. To achieve this objective a capital investment of 

more than £1.6m is required over the next five years. 

We have identified six key priorities to focus on: 

• energy – reducing usage in all Trust buildings 

• building – efficiency and future sustainable development 

• water – usage reduction and conservation 

• waste – reduction and enhanced recycling 

• travel – reduced emissions from all transport streams 

• procurement – certain green procurement areas will be targeted. 

Performance against priorities in our Carbon Plan will be monitored by the 

Board of Directors and the Carbon Trust on a regular basis. 

We have just been successful in obtaining another £80,000 from Salix Finance to 

implement some more energy schemes in summer 2011. This should enable us to 

further reduce our carbon emissions and protect the environment. 

Climate change is one of the new Government’s top priorities. It is essential that 

we embed carbon management throughout the organisation. This will ensure 

we meet both our statutory and moral obligation in regard to climate change. 

As an organisation we want to lead by example within the local community and 

ensure that all our day to day activities have the minimal impact possible on the 

environment. 


Equality 

Over the last year significant progress has been made in relation to our Single 

Equality Scheme action plan targets. Our data and progress now forms a regular 

part of Board meetings. The Equality & Diversity group reports to the new 

Experience Committee and direct to the Board. Members of the group have 

received further training and participate enthusiastically in the debate on a 

quarterly basis. 

Staff training for a wide range of staff groups has been undertaken in relation 

to The Equality Act and individual responsibilities. 

We have improved our knowledge of patient groups in relation to equality and 

have used the Trust’s Patient Experience Tool data to do that. 

Currently the NHS is consulting on a national framework for Equality and 

Diversity (the EDS) – the first time such guidance has been proposed. 

Within the Eastern Region, the framework will be launched on 15 th June 2011. 

This will focus the work much more around the engagement of both our staff 

and patient stakeholders across all the strands of equality. There will also be 

clarity that our objectives are supported by the data and information we have 

about our population. It will provide assurances of consistency throughout the 

NHS. 

We are moving towards using an e-learning alternative to face to face training 

in 2011 to ensure our staff are aware of their responsibilities in relation to 

legislation. 

Our agenda for the coming year will be to refocus our work to meet the 

requirements of the EDS. Once the EDS is launched we will include the themes it 

provides in future training sessions. 


The Future 

Some of our objectives reflect the national position. The need to work within 

our financial resources, as you would expect, is always included. During the 

current difficult times is even more important. In 2011/12 we are prioritising the 

care of particular groups of patients to reflect the changes we have seen over 

recent months: 

1. 

2. 

3. 

4. 

5. 

6. 

Deliver further improvements against the 10 key metrics of the Leading 

Improvement in Patient Safety scheme across the Trust, e.g. infection and 

falls preventions. 

Improve the care and experience of patients, with a specific focus on older 

people and those with dementia, by working internally and with partner 

agencies. 

Continue to implement a range of transformation and quality improvements 

across all care pathways, with particular focus on length of stay. 

Deliver all financial targets. 

Demonstrate further progress towards a reduction in carbon emissions at the 

Trust of 20% by 2015. 

Achieve national performance standards that underpin the provision of 

excellent services to our community. 

These objectives to be supported by a framework of educational and 

development support for staff. 


A year in our life 

April 2010 

• Opening of Radiology waiting area 

• INMPP Event – Burrage Centre 

• Staff Excellence Awards 

May 

• Trust rated among best in country 

in national Inpatient Survey 

• New sleep apnoea service launched 

• New children’s meet and greet area 

launched in hospital foyer. 

June 

• Respiratory Sleep Apnoea Service 

celebrates its first anniversary 

July 

• Prof Pereira, breast surgeon, leads 

groundbreaking cancer research 

through national audit of patients 

• New kidney operation reduces patient 

length of stay 

• Bure Clinic extends opening hours to 

meet demand 

• Julia Hunt appointed Chief Matron 

• Annual Summer Fete 

August 

• Hospital volunteers fund new eye 

equipment for macular degeneration. 

• New A&E observation bay opens 

• Two new Governors elected to the 

Council 

December 

• Generous donations to Children’s 

ward over festive period 

• JPUH signs up to regional VTE 

campaign 

• Trust’s new combined heat and power 

system is commissioned 

January 2011 

• 24/7 Thrombolysis service launched 

• Hospital on Black Alert for prolonged 

period due to high emergency 

admissions 

• UEA Oncology Masters course 

launched led by Professor Pereira 

February 

• Palliative Care East Centre given the 

green light 

• Official unveiling of bench in memory 

of former Trust Chairman, John Wells 

• Trust recruits new volunteers to help 

as mealtime providers 

March 

• Director of Nursing, Nick Coveney, 

leaves Trust to join Norfolk and 

Norwich University Hospital 

• The Trust’s social club, Burrage Centre, 

formally closes 

• Hospital takes part in Exercise 

Aquarius - major incident training 

exercise. 

September 

• Annual General Meeting 

• Patient Safety Month launched 

• Hospital leads trials of new cancer 

drug, Bendamustine 

October 

• Zero infection rates recorded for 

MRSA and Cdiff 

• New stroke unit opens to patients 

November 

• Launch of the Orthopaedic Enhanced 

Recovery Programme 

• Peter Franzen OBE appointed as Non 

Executive Director 

• JPUH hosts international Hyperbaric 

Conference 2010 

• Dr Foster guide for 2010 published 


Service developments 

INMPP 

The Innovation in Nursing and Midwifery 

Practice Project has had another very 

successful year. 

Now in the midst of the 5 th call for ideas, 

INMPP has a number of successful projects running across a wide range of 

disciplines. 

Nurse led assessment in A&E, blood sampling for care of COPD patients, 

dementia care, breast cancer care and support for patients suffering from 

domestic violence are just some of the initiatives currently being developed. 

One of the projects ‘Teenage Kicks’, an 

information pack for pregnant young women, 

their partners and young mums and dads, was 

shortlisted for a Royal College of Midwives 

Award. 

There are plans being developed to ensure the 

long term future funding of INMPP to enable 

more nurses and midwives to contribute to 

improvements in patient care and to gain the 

recognition for doing so. 

Stroke Services 

A busy and productive year has seen us take huge 

strides towards the implementation of the standards 

for care laid out in the National Stroke Strategy. Most 

visibly, in September, we moved to a new 34 bedded 

unit on Ward 1. This gives us enough capacity to look 

after stroke patients during the hyper-acute, acute 

and rehabilitation phases of their stay in hospital. 

A new direct admission pathway, involving close 

work with colleagues in the Ambulance Service, 

A&E and Radiology, means most stroke patients are 

admitted directly from A&E to the stroke unit within 

four hours of arriving in hospital. This is following 

their assessment by a senior Stroke Nurse and, if 

necessary, having had an emergency head scan. 

Since November we have also extended our stroke Thrombolysis service to 

cover out of hours and weekends. This uses an innovative regional telemedicine 

scheme, allowing a stroke expert form elsewhere in East Anglia to assess the 

patient by video link and support our own staff in giving the treatment. 

Since June 2010 we having been running a daily rapid access Transient Ischaemic 

Attack Clinic (Mondays to Fridays). This allows us to assess and investigate 

patients at a high risk of stroke within 24 hours of referral. At weekends 


patients are admitted to our Emergency Assessment and Discharge Unit (EADU) 

where appropriate scanning is now available on Saturdays and Sundays. 

The recent improvements 

in our TIA service were 

recognised regionally 

when our poster on 

service improvement won 

the 1st prize at the East 

Anglian Stroke Forum. 

Finally, after a long 

planning stage, an Early 

Supported Discharge 

Team (ESD) for stroke 

patients will begin from 

the early May. The 

multidisciplinary team 

consisting of Physiotherapists, Occupational Therapists, Therapy Assistant 

Practitioners, Reablement support workers, a part time nurse, and a part time 

Speech and Language Therapist, will accept appropriate patients referred from 

the Stroke Unit, to receive their rehabilitation at home. 

Enhanced recovery programme 

Since its launch in November 2010 

the Orthopaedic Enhanced Recovery 

Programme (ERP) has seen over 220 

Total Hip and Total Knee replacement 

cases operated on and successfully 

discharged home within a maximum of 

four days. 

All total hip and total knee 

replacement patients receive better 

pre-operative education and attend 

a formal joint education class. Here 

they can find out more about their 

operation and discuss concerns about their surgery. Patients are also in charge of 

making their own preparations at home so they are ready for discharge. 

One of the key factors in the programme’s success is adequate pain relief. A 

special pump is used to administer local anaesthetic around the joint space and 

this remains in place upon the patient’s return to the ward. The pump device 

is small enough to be worn as a sling around the patient’s shoulder, allowing 

them, often for the very first time, to walk about “pain free”. 

Patients usually come in on the day of the operation, rather than the day 

before, and are usually out of bed and mobile within two hours of their surgery. 

They have intensive physiotherapy up to four times a day and generally feel 

much better and much more in control. Patients who have been through the 

programme are delighted to spend less time in hospital and get back to the 

comfort of their own homes. This also helps with the recovery process. 


Specialities involved are as follows, with the reductions in length of stay a real 

benefit. 

Specialty 

Procedures 

Previous LOS 

March 2010 

Current LOS 

March 2011 

Variation 

Orthopaedics 

THR 

TKR 

9.4 days 

10.6 days 

3.8 days 

4.2 days 

↓5.6 days 

↓6.4 days 

Urology 

Laparoscopic 

Nephrectomy 7 days 3 days ↓4 days 

General 

Surgery 

General 

Surgery 

Colorectal 

Surgery 11.2 days 5.8 days ↓5.4 days 

Breast Surgery 

(Non–reconstruction) 3.1 days 1.6 days ↓1.5 days 

Theatre Reconfiguration 

We are planning a major upgrade of the main theatre complex to improve both 

the air flow and bring the size of each theatre up to current recommended 

standards. We are also planning for the long term closure of one theatre 

(Theatre 8), without the loss of activity, by changing working practices to 

improve efficiencies. These changes will allow us to hopefully introduce a 24 

hour CEPOD theatre, move private patient activity into the working day and also 

to move elective Obstetrics into main theatres. 

The first stage of the upgrade involved the closure of theatres 5 and 6 and 

the move to a longer working day. A new theatre template was devised that 

provided an additional 4.5 operating hours per week. 

This began in November 2010. There were inevitably a few teething problems 

whilst we got used to new start times and co-ordination of breaks. 

The pressure on the Trust in early 2011 led to significant elective activity being 

cancelled. These patients are now being rebooked, with additional theatre lists 

during the week and at weekends. Hopefully once these cases have been dealt 

with we will be able to get a true feel for how the changes to the extended 

working day have been embedded. 

The transition of theatre staff to their new rotas was a success and theatre 

staff continue to be happy with the changes in working practices. More major 

cases have been dealt with on the extended operating lists – particularly in 

Orthopaedics and Gynaecology. 


Midwifery-led Birthing Unit (MLBU) 

The national policy on the improvement and development of maternity services 

was set out in the Department of Health’s Maternity Matters document. There is 

a strong emphasis on the provision of choice of care, location of delivery and the 

promotion of normal birth. 

It stated that women will be able to choose between: 

• A home birth 

• Birth in a local facility, including a hospital, under the care of a midwife 

• Birth in a local hospital supported by a local maternity care team including 

midwives, anaesthetists and consultant obstetricians. For some women this 

will be safest option. 

In Towards the Best Together, NHS East of England pledged to: 

• Ensure all 17 acute trusts in the region keep an obstetric unit, with a colocated 

midwife-led unit; and 

• Promote normality of birth and guarantee women choice on where to give 

birth, based on an assessment of safety for mother and baby. 

They have defined a co-located midwife-led unit (MLBU) as being in the same 

building as, but independent of, the obstetric unit. Women will have direct 

access to the MLBU via a separate entrance. 

Funding has been provided by the Trust for an MLBU 

adjacent to the Central Delivery Suite. 

The unit is due to open in late April 

with an official ceremony to mark the 

occasion on 10 th May when it will be 

named the Dolphin Suite. 

Dolphin Suite 

The unit has a reception area and 

three en-suite birthing rooms. Two 

of these have a facility for water 

birth plus a small sitting room with 

facilities for drinks and snacks. 

Discreet access to emergency 

equipment for adult and neonatal resuscitation is also 

available. The unit will offer a relaxed environment to 

facilitate normal labour and birth. 

Expected outcomes 

The new MLBU will bring a number of benefits for the women who give birth 

here: 

• An increase in the number of women who experience a normal labour and 

birth without medical intervention. 

• An increase in maternal satisfaction, improved breastfeeding initiation 

rates 

• Value for money and efficiency savings 

• Promotion of the normality of birth and reduced medical interventions 

• Reduced Lower Segment Caesarean Section (LSCS) rates. 

• The best use of professional skills and resources 

• Increased satisfaction rates for women and their families. 


Sleep Apnoea 

The Respiratory Sleep Apnoea Service celebrated its first anniversary in June 

2010. Over 450 local patients who could potentially die from obstructive sleep 

apnoea and sleep disordered breathing/heavy snoring were being assessed and 

provided with possible life-saving treatment by the Trust. 

Thanks to the patient centred management team, the hospital has an efficient 

sleep service and is supplying patients with specific treatment using continuous 

positive airways pressure (CPAP). This comprises of a soft nose or face mask 

attached to a small pump that generates a flow of air to keep the airways open 

and reduce snoring. 

Patients in the Great Yarmouth and Waveney area previously had to travel 

to Papworth Hospital – often involving several trips for consultations, diagnostic 

sleep study, results and treatment. 

Fertility services 

The Waveney Suite moved to its new accommodation in September 2010. This 

followed an increase in secondary fertility care since the new contract in April 

2009. An increase has been seen in the numbers of couples having transport IVF 

in partnership with the Bourn Hall Clinic. 

The new accommodation provides an excellent environment for fertility patients 

to be cared for. Access is private and the consultation rooms and treatment areas 

have been designed to a high specification. 

In addition an outreach clinic was opened in August 2010 at the Norfolk and 

Norwich University Hospital. This allows new couples to be seen closer to their 

home before having treatment at the James Paget. 


Support Services 

The areas that provide support to our clinical staff are: 

• Catering Services 

• Portering and Security 

• Car Park Management 

• Domestic Services 

• Switchboard 

• Linen Services 

• Residential Accommodation. 

Catering Services provides 2000 meals to patients, visitors and staff each day – all 

are home cooked on site using local ingredients and suppliers wherever possible. 

The team works closely with the Great Yarmouth Environmental Health Officers 

to ensure compliance with the Food Safety Act. Unannounced inspections are 

made by them every six months. 

This year both inspections have resulted in the Trust being commended for its 

high standards of hygiene and record keeping. 

Domestic Services employs 240 domestic staff providing a cleaning service 24 

hours a day. The daily deep clean remains in place on Wards 1, 2, 3, 4, 5, 6, 7, 9, 

12, 14, 15, 18 & EADU, covering all furniture, beds and equipment within each 

bay and side room. The staff work closely with the infection control team to 

ensure a safe and clean environment for patients, visitors and staff. 

Information Technology (IT) 

Much of the year was devoted to the consolidation of significant investments 

that were made in staff and infrastructure the previous year. A significant 

amount of change including hardware investment, improvement of processes, 

a training programme, and performance enhancement was brought to a 

conclusion with the appointment of a permanent Head of department and the 

acceptance of the IT strategy in March 2011. 

The most effective way for the IT department to help in the wellbeing and 

recovery of patients was to improve the availability and reliability of the IT 

services that our clinical and nursing staff rely upon. This was achieved through 

reducing the number of faults occurring in the first place and resolving those 

that did occur much more quickly. Service availability and response figures have 

reached the high levels identified in the table opposite. 


Service Desk first time fix rate 63% 

High priority service affecting 

outages 

Over 90% service resumption within 4 hours 

A series of new applications and services have also been delivered including: 

Colposcopy system 

Paediatric 

Diabetes Database 

Hospital wireless 

working 

Neonatal 

monitoring 

Voice recognition 

software 

Sleep Apnoea 

system 

Oncology 

prescription 

printing 

Upgrade to 

Rapidcomm blood 

gas analyser 

system 

A patient and clinical support database to aid in the recording, 

reporting and analysis of patient colposcopy treatment 

Enables efficient and accurate data capture within the 

department, that reports upon patient care and costing 

information as required in NICE guidelines 

A stable and secure wireless network allowing hospital devices 

such as laptops, telephones and blood tracking systems to be 

used across the site 

A new application that supports training, audit, data modeling, 

quality and any other business change with regard to neonatal 

information processing. It further allows annual performance 

and costing information to be produced and aids the Trust in 

making longer term decisions regarding future demands. 

A transcription system, linked to other clinical applications, 

which means that letters and reports can be produced more 

quickly. It is also pre-loaded with many clinical terms to improve 

the accuracy of the letters produced. 

An application that enables the management of patient 

information regarding symptoms, treatment given, and results. 

It provides research material so that patient treatment can 

be improved in the future. Having the information instantly 

available means that time is saved and more patients can be 

treated. 

An interim solution to enable staff to print chemotherapy 

prescriptions from the Pathology outpatients clinical rooms. This 

supports compliance with National Chemotherapy Prescribing 

Group recommendations. 

The upgraded system now enables remote access and 

maintenance of the blood gas analysers, allowing laboratory 

staff to carry out diagnostics much more quickly. It further allows 

audit and checks to be carried out to ensure system and output 

accuracy. Missing results and alarms regarding invalid results 

can now be quickly identified and appropriate corrective action 

taken. 


Our staff 

The Trust is the largest employer in the Great Yarmouth area with over 3000 

people working here. Staff turnover is below the national average and the 

hospital is generally regarded by its staff as a good place to work. 

In 2010 we had an overall sickness absence rate of 3.6% against a Trust target of 

3.75%. Sickness absence the previous year was 4.25% against a target of 3.75%. 

The Trust aims to support staff who become disabled whilst in employment 

where possible, and to retain them in employment for as long as possible. 

Working with the individual and appropriate agencies, we look to make 

adjustments to the workplace and to provide additional support and training 

where appropriate. 

This year we have been working closely with Project Search to promote the 

employment of individuals with learning difficulties within the Trust. This has 

proved to be a valuable and rewarding exercise. More information can be found 

at page 62. 

Staff engagement 

The Trust continues to strive for excellent relationships with our recognised 

trade unions. We hold regular joint consultation meetings between staff side 

representatives and managers. 

All staff receive a briefing following the monthly Board of Directors meeting, 

mostly via email but also on paper for those staff without access to email. This 

includes reporting on the Trust’s performance and any areas of concern. Regular 

updates are also provided regarding our in-house transformation programme 

and other patient safety developments. A process of gaining ‘Bright Ideas’ 

from staff for making quality and financial improvements has been operating. 

Members of the Executive Team also undertook some staff meetings in 

December and January to ensure that members of staff had the opportunity to 

hear about what was happening and provide any comments. 

A quarterly magazine, Making Waves, is produced to provide more in-depth 

updates on our successes and challenges and to run features on the work of the 

Trust’s staff. This is also used externally and is available on our website. 

Additional briefings by ‘communications’ emails are given weekly and more 

often when required, particularly if the Trust is being featured in the local 

media. This ensures that staff are informed of the latest news usually before it 

becomes widely known. 

In this year’s staff survey the Trust scored in the top 20% of all NHS Trusts on 

an overall indicator of staff engagement. We do recognise that further work is 

needed and this will continue to develop during 2011/12. 


Remarkable People 

The Trust has established a staff recognition and 

reward scheme – ‘Paget’s Remarkable People’. 

We recognise the importance of great personal 

treatment by individuals and how the people 

who need our care appreciate it. This scheme 

allows us to reward those people who really make 

a difference, whether it is achieving something 

extraordinary, making patients feel special or going the extra mile in their daily 

working lives. 

Any member of staff or volunteer may be nominated, either by a patient, 

patient’s visitor/friend/relative or a fellow colleague. 

The awards will be yearly and presented in September. 

What our staff say about the Trust and their working lives 

We are proud of our staff, who work extremely hard in challenging 

circumstances. We recognise that satisfied, motivated, well-trained and involved 

staff are much more likely to make a positive difference to our patients. 

For the Trust to provide even better care and services we need to understand 

how our staff feel. We need to engage them in an ongoing dialogue about 

their working lives and the services they provide. Feedback from our staff, via 

the annual NHS Staff Survey, reaffirms that the Trust’s workforce is committed, 

fulfilled and engaged. 

The survey provides NHS Trusts with direct feedback from staff on the 

effectiveness of their employment and management policies and practices. In 

the last survey in late 2010 this Trust was rated among the highest in the country 

– in the top 20% – in a number of key areas, including 

• staff saying hand washing materials are always available 

• staff believing that the Trust provides equal opportunity for all in career 

progression or promotion 

• Trust commitment to staff work-life balance. 

The Trust was also rated ‘above average’ in a number of areas including: 

• job satisfaction 

• good communication between senior managers and staff 

• Occupational health and safety. 

Our areas of greatest improvement locally since last year’s survey are: 

• staff feeling supported by immediate line managers 

Paget’s 

Remarkable 

People✓ 

Staff Reward & Recognition Scheme 

• staff believing that the Trust takes effective action following incidents of 

violence or harassment 

• The Trust’s ongoing commitment to supporting a work–life balance. 


In 2010, the staff response rate to the survey was 58% – compared to 54% 

nationally by other acute trusts. This was up 1% on our response in 2009. 

Our future priorities to help staff at work are based on the Trust’s four worst 

ranking scores relating to the following questions: 

1. 

Percentage of staff reporting errors, near misses or incidents witnessed in 

the last month 

The Director of Workforce and Estates is working with the Head of Risk 

Management & Governance to ensure that the Trust’s policies on handling 

errors, near misses and incidents are transparent and communicated to all 

staff. 

2. 

Percentage of staff receiving job relevant training, learning or 

development in the last 12 months 

The Executive Team are working to look at ways to increase the number 

of staff able to attend training sessions including the use of e- learning. 

The Trust’s appraisal scheme has also been reviewed with one key aim to 

increase the number of staff receiving appropriate training each year. 

3. 

Effective team working 

The Chief Executive will be working with the Executive Team and other 

senior managers to make sure that our communication processes are 

further improved and that key messages are communicated effectively to 

all staff. She will also continue to share the Trust’s strategic vision for the 

future with staff as well as keeping them informed of any major projects 

that may develop. 

4. 

Percentage of staff agreeing that their role makes a difference to 

patients. 

Further action is being taken to ensure that staff are involved in planning 

service changes and that they regularly receive feedback from the results 

of our patient survey programmes. 

Further detail on our performance over the last two years can be found overleaf. 


2009/10 2010/11 

Trust 

improvement/ 

deterioration 

Trust 

National 

average 

Trust 

National 

average 

Response rate 

Top 4 ranking scores 

Percentage of staff 

experiencing discrimination at 

work in the last 12 months 

Percentage of staff saying 

hand washing materials are 

always available 

Percentage of staff believing 

the Trust provides equal 

opportunities for career 

progression or promotion 

Impact of health and 

wellbeing on ability to 

perform work or daily 

activities 

57% 51% 58% 54% 

Due to changes in 

the format of the 

survey questions, 

comparison scores 

for 2009 were not 

available 

7% 13% 

81% 69% 79% 67% 

89% 90% 96% 90% 

1.47 1.57 1.47 1.57 

4% 

improvement 

against national 

score 

6% 

improvement 


score 

12% 

improvement 


score 

6% 

improvement 


score 

0.1% difference 


score 

Bottom 4 ranking scores 

Percentage of staff reporting 

errors, near misses or 

incidents witnessed in the last 

month 

Effective team working 

Percentage of staff receiving 

job relevant training, learning 

or development in the last 12 

months 

Percentage of staff agreeing 

that their role makes a 

difference to patients. 

93% 95% 91% 95% 

Due to changes in 

the format of the 

survey questions, 

comparison scores 

for 2009 were not 

available 

3.61 3.69 

78% 78% 76% 78% 

89% 90% 89% 90% 

4% 

deterioration 


score 

0.08% 

deterioration 


score 

2% 

deterioration 


score 

1% 

deterioration 


score 


Occupational health 

Our occupational health providers play a key role in supporting infection 

prevention and control – particularly in relation to staff. 

One of their main achievements in the last year was administering the combined 

swine flu/seasonal flu vaccination to hundreds of frontline staff in priority 

groups and those with direct patient contact, ensuring widespread protection 

coverage. 

They are located on site, providing easy access for all staff. 

Work experience, careers and educational events 

A new joint post has been funded by NHS East of England to co-ordinate work 

experience and placements in the NHS in the Great Yarmouth & Waveney area. 

Since commencement in July 2010 the co-ordinator has received 91 requests 

for work experience placements and successfully arranged 79. The remaining 

12 have either been unsuccessful in finding appropriate work experience or 

were unable to commit their time. The requests include those from charities, 

unemployment agencies, centralised school networks and ad hoc requests. 

Work experience has been varied and includes medical observation, 

physiotherapy shadowing and placements in pathology, medical records, estates 

and support service roles. We evaluate all work experience opportunities and 

gain positive feedback about the relevance and content of the placements and 

career progression routes available 

The Trust has also been represented at many careers and education events at 

schools and colleges to inform young people about possible career choices and 

work experience opportunities in the NHS. Some of these were in-house, such as 

the Nursing and Midwifery Education event held on site aimed at young people 

looking to go into the profession. This particular event had the co-operation of 

two other Trusts to deliver a good overall experience for the young people. 

In addition, the Trust organises tours of various departments to provide an 

insight into the work of the hospital. Our staff have also helped local schools to 

meet their Health and Social Care curriculum requirements by providing talks on 

safeguarding, health and safety and infection control. 


Apprenticeships 

The Trust is working in partnership with NHS Great Yarmouth & Waveney 

and Norfolk & Waveney Mental Health NHS Foundation Trust to address skills 

gaps and develop their staff by offering nationally accredited apprenticeship 

qualifications to those in Bands 1-4. Over 130 members of staff are undertaking, 

or have completed, the qualification in subjects such as Health, Business 

Administration, Customer Services, IT and Pharmacy. 

Acquiring new qualifications has not only been of benefit to the patients and 

the organisation but also to the individual’s career progression. 

As well as offering existing staff the opportunity to undertake an Apprenticeship 

the NHS East of England has funded eight new supernumerary posts at the 

Trust. The apprentices are working in clinical support roles in the wards and in 

administration roles. A comprehensive support system has been developed for 

the supernumerary apprentices including mentoring and training. There is a 

high demand for the roles and the calibre of applicants is very high. 

The apprentices are making a valuable contribution to the organisation and are 

receiving high quality NHS training and experience to prepare them for their 

future careers in the NHS or local healthcare sector. 

Case Study – Princes Trust to Apprenticeship 

The Trust provided a cohort of jobless young people with two week work 

placements in conjunction with the Princes Trust ‘Get into Hospital Services’ 

Scheme. 

The scheme involved holding a ‘Taster Day’ attended by 32 unemployed young 

people. 13 were chosen to join the programme. These young people were given 

the opportunity to start a two week programme of learning followed by a two 

week work placement. The learning programme involved interviewing and CV 

skills, communication skills and Adult Literacy and Numeracy. 

The 13 placements were supported by Estates, Domestic Services, Pathology, 

Medical Secretaries – Elective Division and NHS Great Yarmouth & Waveney 

Northgate Hospital operations department. Each placement involved basic 

administrative or manual work and proved to be very interesting and varied for 

each individual. 

Every young person who completed the 

programme attended the final event 

where they were awarded with their 

completion certificates and supported 

by their colleagues from the work 

placements. 

From this scheme we have had several 

positive outcomes. One participant has 

been appointed to an apprenticeship role 

providing essential care to patients and 

another is working in Domestic Services. The Trust stays in regular contact with 

the young people regarding job opportunities and references. 


Case Study – Project Search 

The Trust is one of only a handful of organisations in the country chosen to pilot 

a new scheme to provide training in the workplace for students with learning 

difficulties and disabilities. 

This unique education to work transition programme gives young people with 

learning difficulties real life work skills in a business over a year. 

The James Paget provides the work placements and the students are supported 

by a tutor from Great Yarmouth College and Remploy Job Coach, both based full 

time at the hospital. 

In September nine students joined the programme, with a structured day 

consisting of an hour in the on site classroom at the start and end of the day, 

and rotations in different areas over a 13 week period. Each student covers 

three rotations over 12 months in areas such as Pharmacy, Ward Housekeeper, 

Stores, Catering, Waste collection, Linen Services, Health Records, Department of 

Medicine and Human Resources and Administration. 

Due to the success of the scheme several job opportunities have been made 

available for this year’s students. This includes a full time position on Band 1 for 

a year’s contract in the Health Records department. 

The Trust will be running the scheme again in September 2011. 


Our Volunteers/Fundraising 

Our Volunteers 

Volunteers at the James Paget University Hospital provide an invaluable service 

and the number of people getting involved continues to grow. 

Volunteers participate and support a wide variety of activities including: 

• meeting and greeting visitors 

• helping them to find their way around the hospital 

• making drinks for patients 

• acting as mealtime service providers 

• helping patients that need to be moved in a wheelchair to get to clinics 

• delivering records to clinics and departments and 

• assisting administrative staff. 

During 2011/12 we will be working to ensure that our volunteers are fully 

involved in what is happening at the hospital as part of our communications and 

engagement strategy. 

Fundraising 

League of Friends 

The League of Friends raises funds to support and improve facilities for all 

patients and users of the hospital. 

Over the last 12 months, the League has made and promised donations totalling 

around £36,000 including: 

• £15,000 towards the purchase of sensor alarms for chairs and beds 

• £5,000 on improvements in Endoscopy 

• £4,725 for intubation equipment 

• £1,200 towards a wheelchair that can be used within the MRI scanner 


Lowestoft Hospital League of Friends 

The League of Friends continues to raise funds towards improving facilities at 

Lowestoft Hospital. 

In the last year, the League has funded four new television sets for the hospital 

and held two major fundraising events: 

• £3,800 at the Lowestoft Carnival 2010 

• Over £600 at the Summer Fayre 

WRVS 

There are over 60 WRVS volunteers at the hospital, who between them give up 

to 200 hours a week to support the Trust. 

Last year, the WRVS donated £100,000 to purchase a state of the art digital 

camera for use in the detection of wet macular degeneration. This made the 

James Paget one of the first places in East Anglia to use the new equipment. 

Palliative Care East Centre 

Plans for a Palliative 

Care East resource 

centre and outreach 

service, based at the 

James Paget University 

Hospital, have taken 

a significant step 

forward this year. 

The Board of Directors 

has given the go 

ahead to develop 

and build the centre, 

providing a much needed care base for patients and families whose lives are 

affected by illnesses such as cancer or motor neurone disease. 

This is an ambitious and innovative project around the Marie Curie Delivering 

Choice (MCDC) programme for end of life care co-ordinated by NHS Great 

Yarmouth and Waveney. 

The Trust’s enormously successful fundraising campaign has already reached £1.3 

million towards the £1.5 million target. NHS Great Yarmouth and Waveney is 

providing core funding to support the operating costs and will play a key role in 

the future development of services. Other groups and organisations have also 

made a significant contribution in getting the project to this next stage. 

The resource centre and outreach service will deliver first class care for patients 

in the Great Yarmouth and Waveney area. It will also be the base for supporting 

service delivery in satellite locations including patients’ homes. 

A Project Board has been established, chaired by Chairman, John Hemming. The 

Board comprises key stakeholders with expertise in providing palliative care 

services and will deliver plans for the design, build and running of the resource 

centre and outreach service. 


Governance 

The Trust aims to comply with all Monitor guidance and benchmarks against best 

practice and guidance, making changes to processes as appropriate. This includes 

compliance with the Code of Governance. 

Conflicts of Interest 

A Register of Interests is in place for both the Board of Directors and Governors 

Council. On appointment, new Board members/Governors are required to 

complete a declaration. Any changes during the year must be declared to the 

Trust Secretary immediately and formally at the next meeting. 

This is reviewed annually and at the start of each meeting members are required 

to declare any interests that may relate to the papers considered. 

Both Registers are available on request from the Trust Secretary and on our 

website. 

Board of Directors 

The Trust’s Non Executive Directors are considered to be independent in 

character and judgement and are required to confirm any relationships or 

circumstances that may affect, or could appear to affect their judgement. 

The declarations that are relevant for all Board members are: 

• Mr Kirk Lower, Director of Workforce & Estates, is a Trustee of Yare Valley 

Citizens Advice Bureau and a Governor of the new Lowestoft Sixth Form 

College; 

• Mr Hugh Roberts, Non Executive Director, declared professional dealings 

with Helen Nellis from Perrett Laver, who were commissioned by the Trust 

to undertake Board level recruitment. He is also currently Interim Finance 

Director at the Royal College of Paediatricians; 

• Dr Michael Field, Non Executive Director, Chairs the Corporation at Great 

Yarmouth College which undertakes a small amount of training for the 

Trust. This is a voluntary position involving no financial interests. 

No significant changes have been declared that would affect the Chairman’s 

ability to carry out his role. 

The process for determining Non Executive Director independence is the annual 

review of Interests considered by the Board of Directors. Notwithstanding the 

declarations made in-year, the independence of the Non Executive Directors is 

confirmed 


Our directors 

As a Foundation Trust, James Paget University Hospital is run by a Board of 

Directors. It is governed by the Trust’s Terms of Authorisation and Corporate 

Governance Framework, both of which are considered annually and revised 

where necessary. 

The Board of Directors comprises a Non Executive Chairman, five Executive 

Directors and five Non Executive Directors. This will be supplemented during 

2011/12 with the appointment of a Director of Operations and an additional 

Non Executive Director in line with good governance practice. 

The Board provides active leadership of the Trust. As a unitary board, the Non 

Executive Directors share responsibility with the Executive Directors for ensuring 

the resources are in place to meet the objectives set. In an emergency powers 

are exercised by the Chief Executive and Chairman after having consulted at 

least two Non Executive Directors. 

The Board meets formally on a monthly basis, in private. A summary of the 

discussions is circulated to staff and Governors and from July 2010 has been 

available on the Trust’s website. The Board reports to the Governors Council on 

its performance and the future direction of the Trust is considered with Council 

members to ensure their views are taken account of. 

The responsibility for the day to day running of the organisation is delegated to 

the Chief Executive and the Executive Team. Each Division is led by a Divisional 

Manager and Divisional Director as clinical lead, reporting to an Executive 

Director. The Management Team consists of Executive Directors, Divisional 

Managers, Divisional Directors and the Head of Communications. Other Heads of 

Department attend as required. 

Appointments to the Board 

The Board of Directors considers its performance on an annual basis, reviewing 

its Committee structure and Terms of Reference. The Trust Secretary manages 

the Board’s annual programme and ensures that appropriate items are 

considered, actions followed up and the Board’s reporting requirements adhered 

to. 

A full appointment and induction process is in place for new Board members, 

both Executive and Non Executive. Posts and structures are reviewed prior to any 

position being advertised with the Board considering the skills required going 

forward. 

During the year, Dr Bernard Brett, Medical Director, was appointed on a 

permanent basis following his period as Acting Medical Director. Peter Franzen 

also joined us following Annette Stannard’s departure. 


Directors’ profiles and attendance 

Where attendance does not include a full year this reflects the meetings that the 

post holder was eligible to attend. 

John Hemming – Chairman 

Appointed by Governors Council 

to July 2012 

Chairman of Board of Directors; 

Chairman of Governors Council 

and Committees 

An ex Managing Director of 

a manufacturing firm for analytical instruments. 

Experienced in turning around businesses, 

his portfolio included market analysis, lean 

manufacturing and product design and appropriate 

organisational change. 

Currently involved in local charitable work and 

membership of Rotary. 

Board attendance: 12 out of 12 meetings 

Wendy Slaney - Chief Executive 

Acting Chief Executive for two 

periods during 2007. Appointed 

from May 2009 for a 12 month 

period. Permanent from 1st April 

2010 

Responsibilities: Accounting 

Officer 

Medical Director from April 2003. Previous Clinical 

Director for the Community Dental Service. Trust 

Board experience as the Director of Corporate 

Development when employed by Anglian Harbours 

NHS Trust. 

Board attendance: 12/12 

Mark Madden - Director of 

Finance & Performance 

Appointed September 2009 

Responsibilities: All financial 

services, capital planning 

and monitoring, information 

technology, contracting and 

procurement, performance management and 

information, cancer lead. 


Nick Coveney - Director of 

Nursing & Transformation 

Appointed September 2002. Left 

Trust 30 April 2011 

Joined the Trust from Ipswich 

Hospitals NHS Trust where he was 

Associate Director of Emergency 

Services. He qualified as a nurse from Dundee and 

Angus School of Nursing and Midwifery and pursued 

his career in London before coming to East Anglia. 

Responsibilities: Trust lead for nursing, midwifery, 

AHPs, Risk and Governance (joint accountability 

with the Medical Director), bed management and 

operations, infection prevention, patient safety, 

support services, local security management service. 

Board attendance: 11/12 

Dr Bernard Brett - Medical 

Director 

Appointed for 12 months from 

May 2009. Permanent from 

September 2010 

Dr Brett, Consultant 

Gastroenterologist and General 

Physician at the Trust from 

October 2001. Divisional Director for the Emergency 

Division from April 2004. Main clinical interests are 

therapeutic endoscopy and bowel cancer screening, 

with a strong interest in training, education and 

communication skills. 

Responsibilities: Medical staff management, 

Research and Development, Risk and Governance 

(joint with the Director of Nursing), Caldicott 

Guardian, patient safety. 

Board attendance: 9/12*** 

Kirk Lower - Director of 

Workforce and Estates 

Appointed March 2008 

A strong background in public 

sector management and 

education, having been Assistant 

Principal (Human Resources) at 

City College in Norwich for ten years where he led 

on strategic HR and workforce development. 

Responsibilities: workforce planning, education 

and training; HR professional and support services; 

organisational development; trade union liaison; 

health and safety; estates and environmental 

management including carbon reduction; the 

promotion of equality and diversity; chaplaincy 

services. 

Board attendance: 10 /12 


Non Executive Directors 

Jean Mason - Vice Chair, Senior 

Independent Director, Chair of 

Safety, Quality & Governance 

(previously Healthcare 

Governance) Committee 

NED Lead for Older People NSF, 

Essence of Care, Older Person 

dignity champion, Board sponsor 

for dementia project 

Appointed by Governors Council to November 2011 

Local business experience as Managing Director 

of establishments within the private healthcare 

sector. Previous Chair of Community Health Council. 

Charitable Trustee. Vice Chairman of local Volunteer 

Centre. 


Kenneth Gaylard - Chair of Audit 

Committee 

NED lead for Local Security 

Management Service 


to February 2014 

Qualified accountant. Ex 

Managing Director of major international leisure 

company. Past member of Navigation Committee of 

the Broads Authority. Chairman of the Broads Hire 

Boat Federation to October 2007. Trustee of two 

local charities. 


Hugh Roberts – Non Executive 

Director 

NED lead for Communications, 

Values, Board development 

Appointed by Governors 

Council to October 2012 

Qualified Accountant. Past Chief Executive of 

Sunderland Football Club. Previously Finance 

Director and Managing Director of a major 

UK independent brewer; coach in business 

and consultancy (including marketing) and 

interim Director of Finance for Royal College of 

Paediatricians. 


Dr Michael Field OBE – Non 


NED lead for carbon reduction, 

attracting younger people to 

Trust membership, protecting 

vulnerable adults, Board 

development 

Appointed by Governors Council to May 2012 

Originally trained in architecture and building 

construction before moving into teaching and 

research in higher education. Chair of Governors at 

Great Yarmouth College. Active at a national level 

in sustainability and environmental matters in the 

further education sector. 


Peter Franzen OBE – Non 


NED lead for Being Open and 

Child Safeguarding 


to October 2013 

Editor of Eastern Daily Press 

for 16 years to 2009. Involved with a range of 

organisations locally including Norwich City Council 

as Independent Chair, Standards Committee; 

Independent Member, South Norfolk District 

Council remuneration panel; Vice patron of 

Norfolk Community Foundation; Trustee of Open 

Youth Project and Norwich SOS bus; Member of 

International Development Media Panel; Associate 

governor Open Academy; Founder, with others, of 

the EDP We Care Appeal. 



Attendance at Board of Directors Committees and Governors Council is set out 

below. The Executive Nomination & Remuneration Committee is included within 

the Remuneration Report at page 79. 

Name 

Number of 

meetings 

Audit 

Charitable Fund 

Committee 

Governors 

Council (incl 

AGM) 

Healthcare 

Governance 

Committee 

(now Safety, 

Quality & 

Governance) 

6 3* 6 7 

John Hemming ** 3 6 ** 

Michael Field 4 ** 5 ** 

Peter Franzen ** ** 2 ** 

Ken Gaylard 6 3 4 6 

Jean Mason 4 3 6 7 

Hugh Roberts ** ** 2 ** 

Wendy Slaney ** ** 4 ** 

Bernard Brett*** ** 1 5 5 

Nick Coveney ** ** 4 4 

Kirk Lower ** ** 5 4 

Mark Madden 6 3 6 2 

* one meeting cancelled – not quorate 

** not part of membership 

***due to clinical commitments 

Review of performance 

Thorough annual performance reviews are undertaken for all Board members 

and objectives and personal development plans agreed in line with Trust 

objectives. The Chief Executive and the Executive Team regularly review capacity 

and make additional arrangements should further assistance be required. 

Once the new Board was in place in late 2010, it was an appropriate time to 

consider how the Board works and the information available was reviewed to 

ensure it was as effective as possible. 

This had previously been undertaken in-house. This year the NHS Institute 

of Innovation and Improvement undertook this process. Building on the 

existing work through the NHS Institute’s Board Development Tool, the Board 

Development team used a recently developed leading edge version of the 

tool specifically for Foundation Trusts. Its aim is to provide a framework for 

reviewing and improving NHS Board performance. 

The Board Effectiveness Model is based on good practice statements which are 

known to contribute to Board effectiveness. The model describes three core 

roles of any highly effective Board: (1) gaining insight; (2) defining expectations; 

and (3) holding to account. 


Feedback has been received and the Board is addressing a number of issues 

before reflecting on the process with the Institute team in July 2011. 

The Board also meets on a monthly basis in addition to the formal Board 

of Directors meetings. This enables debate of key strategic issues and for 

members to receive presentations from staff. Non Executive Directors have the 

opportunity to raise any matters of interest or concern in addition to the Board 

meeting. Quarterly workshops are also scheduled. 

Board training and development 

An annual programme of Board training is undertaken to support continued 

compliance with the Trust’s Care Quality Commission registration and NHS 

Litigation Authority requirements. Any training not undertaken by individual 

Board members is followed up by the Trust Secretary. 

This is supplemented by briefings/training in-year and individuals’ attendance 

at training events and networks in line with their role and area of interest/ 

responsibility. 


Audit Committee 

Mr Kenneth Gaylard, Non Executive Director, chairs the Committee. The Director 

of Finance and Performance, the Head of Internal Audit and a representative of 

the External Auditors normally attend. The Trust Chairman and Chief Executive 

attend by invitation. 

Meetings are held not less than five times a year, with at least one meeting 

held jointly with the Safety and Quality Governance Committee (formerly the 

Healthcare Governance Committee). The Committee, in conjunction with the 

Safety and Quality Governance Committee, reviews the adequacy of: 

• all risk and control related disclosure statements (in particular the Annual 

Governance Statement (formerly the Statement of Internal Control) and 

declarations of compliance with the Essential Standards of care regulated by 

the CQC), together with any accompanying Head of Internal Audit statement, 

prior to endorsement by the Board of Directors; 

• the underlying assurance processes that indicate the degree of achievement 

of corporate objectives, the effectiveness of the management of principal 

risks and the appropriateness of the above disclosure notices; 

• the policies for ensuring compliance with relevant regulatory, legal and code 

of conduct requirements; and 

• the policies and procedures for all work related to fraud and corruption as 

set out in the Secretary of State Directions and as required by the Counter 

Fraud and Security Management Service. 

Assurance is sought from a number of areas, concentrating on the over-arching 

systems of integrated governance, risk management and internal control, 

together with indicators of their effectiveness: 

• the work of Internal Audit; 

• External Audit; 

• through the directors and managers as appropriate; and 

• the findings of other significant assurance functions, both internal and 

external to the Trust, i.e. reviews by Department of Health Arms Length 

Bodies or Regulators/professional bodies. 

An Assurance Framework is in place and considered by the Board of Directors on 

a quarterly basis to guide the Trust and the Committee’s work. 

Attendance figures can be found within the our directors section at page 79. 


Our governors 

The Governors Council is chaired by the Chairman of the Trust supported by the 

Deputy Chairman and Lead Governor of the Council, Hugh Sturzaker. 

The Council comprises 35 Governors, eight appointed, 20 public and seven 

staff. Meetings are held at least five times each year to fit into the annual 

planning cycle. Members of the public have an opportunity to ask questions of 

the Governors and any Directors in attendance. Representatives of the Health 

Overview and Scrutiny Committee and Local Involvement Networks regularly 

attend. Public meetings last up to 2½ hours, with short private sessions to 

consider strategic issues. 

Governors are responsible for representing the interests of members and partner 

organisations in the governance of the Trust and holding the Board of Directors 

to account for its performance. The Council manages its work through four 

Committees: 

• Membership 

• Governors Council Nomination & Remuneration 

• Review & Planning 

• Patient Standards Committee. 

Policies are in place for all aspects of the Council and are revised annually or 

bi-annually. Our processes have been benchmarked against Monitor’s Code of 

Governance and Your statutory duties: A reference guide for NHS foundation 

trust governors to ensure the Council is as effective and efficient as possible and 

follows best practice. 

The meetings of the Council continue to improve and reflect its development 

over the last five years. It is a challenge to ensure that sufficient time is given 

to each subject. The Review & Planning Committee has enhanced Governors’ 

ownership of the agenda and meets to reflect on the previous meeting and plan 

the next agenda. 

The Committees are an effective way of managing the workload and allowing 

for significant discussion of issues that is not possible at the full Council 

meetings. 

Governors continue to value presentations at each meeting as an effective way 

of quickly understanding how services work and how they are developing. 

This year Governors have heard about a range of issues as a small part of their 

agenda: 

• Cardiac Care Pathway 

• Audit Commission – the role of the external auditor 

• Patient Safety 

• Marie Curie Delivering Choice programme 

• Finance briefing 

• How we deal with patients with a visual impairment. 

The Trust’s Performance Management Report is provided at each meeting, with 

quarterly Human Resources performance updates. 


In December, the Council meeting gave the Trust the opportunity to brief 

Governors and members following publication of the Dr Foster Hospital Guide. 

The Chairman reported that the two areas the Trust had exceeded in were; 

ensuring people have positive experiences of care – worries and fears about 

talking to staff are very low –and privacy and dignity. 

The Deputy Chairman is involved in any issues relating to the Council including: 

• Lead Governor with Monitor 

• leading on Council responses to consultations 

• liaising with the Foundation Trust Governors’ Association 

• co-ordinating the Council’s input to the Care Quality Commission 

• leading on the Council’s comments on the Trust’s Quality Account 

• final Council input into the Governors Council agenda 

• ensuring annual meetings take place without management 

representatives to review progress 

• leading on membership recruitment in year, and particularly during the 

summer membership events jointly with the Trust Secretary 

• attending all Governors meetings and Committees, dealing with individual 

governors as required. 

Members of the Board of Directors attend Council regularly and the minutes are 

considered at the Board meetings. Governor attendance at meetings is reviewed 

on a regular basis, together with the reasons for apologies being received. The 

Chairman, Deputy Chairman of Governors and the Head of Communications, 

Engagement and Foundation deal with attendance issues on an individual basis, 

in line with the Governors’ Code of Conduct. 

Communications between Governors and Trust staff are managed through the 

Head of Communications, Engagement and Foundation and the Chairman. Both 

also attend the Board of Directors. This ensures that Governors’ interests are 

raised and that appropriate information is presented to the Council at the right 

time to enable Governors to carry out their duties effectively. 

Communication with Governors continues to evolve. The outcome of any issue 

raised is circulated to all through the continued use of the bi-monthly ‘Governors 

Only’ newsletter. The restructuring of the communications team has enabled 

more focused support to be provided to the Governors and engagement with 

our membership. 

If there are issues of concern, additional Council meetings are held. This has 

happened once during the year, with a further meeting held in April. Governors 

were concerned about the additional Executive Director being appointed and 

the process surrounding this, and more recently, issues of essential care that had 

appeared in the local media. 

On both occasions, a number of Governors attended to hear from the Chairman, 

Chief Executive and other members of the Board. These meetings were very 

successful in allowing full discussion of the issues and all concerns to be raised 

and responded to. 


Elections 

Governors standing for the Staff or Public Constituency are elected by the 

process set out in the Trust’s Constitution, using the single transferable vote 

system. 

The Trust ran elections during 2010 for four Public Governors carried out by 

the Electoral Reform Services. All Public places were filled with effect from 1 

August 2010 for a one year term of office. In the Staff Constituency, three Staff 

Governors were elected uncontested. 

Over the last few years we have been moving towards electing Governors on 

a three yearly basis, for a three year term of office. This was partly to consider 

efficiency savings, but mainly to ensure more consistency and to avoid a small 

number of new Governors each year. All public and staff places are open for 

election during the summer of 2011, with the nomination process opening in 

May. 

Details of the process for Governor declarations of interest can be found in the 

Governance section on page 65. 

There have been seven meetings of the Council including the Annual General 

Meeting and the extraordinary meeting, with attendance as follows: 

Name 

Term of 

Office 

Start Date 

End of Office 

Date 

Council 

attendance 

Appointed Governors: 

Norfolk County Council 

Cllr Tom Garrod 

Suffolk County Council 

Cllr Tony Goldson 

UEA 

Professor Richard Gray 

NHS Great Yarmouth & Waveney 

Chair David Edwards 

DPH Alistair Lipp 

Great Yarmouth Borough 

Council 

Cllr Bryan Watts 

Waveney District Council (annual 

renewal) 

Cllr Sue Allen 

Volunteers: James Paget League 

of Friends 

Dennis Cave 

3 year term 

01/09/09 August 2012 0/7 

01/08/09 July 2012 2/7 

01/11/08 October 2011 2/7 

01/04/09 

01/11/07 

Reappointed 


March 2012 

October 2013 

5/7 

2/7 

01/04/08 March 2011 3/7 

01/08/06; 

last review 

06/09 

01/08/06; 

Reappointed 

08/09 

June 2012 3/7 

August 2012 6/7 

Public: 

All Governors 

31 st July 2011 

Martin Arnold 2 01/08/09 4/7 

Timothy Barrett 1 

01/08/07 

Re-elected 2010 

5/7 

Lesley Bruin 3 01/08/08 5/7 

Paul Chilvers 3 01/08/08 4/7 

Alan Coleman 3 01/08/08 2/7 

Terence Easter 2 01/08/09 2/7 


Wulfram Forsythe-Yorke 2 

01/04/06 

Shadow FT 

1/8/06 

Re-elected 2009 

Jean Freeth 2 01/08/09 

6/7 

4/7 

Jean Goffin 1 01/08/10 5/5 

Liz Harrison 2 

FT 01/08/06 

Shadow FT 

1/8/06 


3/7 

Sheila Howlett 2 01/08/09 5/7 

Mick Mayhew 3 01/08/08 4/7 

Sue Meecham 3 

Richard Morling 2 

FT 01/08/06 

Shadow FT 

1/8/06 


FT 01/08/06 

Shadow FT 

1/8/06 


John Pope 1 01/08/10 4/5 

Terry Rymer 2 01/08/09 5/7 

Hugh Sturzaker 2 

Christine Smith 2 

FT 01/08/06 

Shadow FT 

1/8/06 


FT 01/08/06 

Shadow FT 

1/8/06 


Dilly Turton 2 01/08/09 5/7 

Angela Woodcock 2 01/08/09 2/7 

5/7 

6/7 

6/7 

3/7 

Staff: 

Dr Karl Blenk 3 01/08/08 3/7 

Justine Goodwin 2 01/08/09 4/7 

Francis Hayward 2 01/08/09 4/7 

Laurie Howarth 3 01/08/07 3/7 

Keith Wilson 2 01/08/09 4/7 

Mandy Hoadley 1 01/08/10 4/5 

Marina Gibson 1 01/08/10 3/5 

* Non attendance discussed and agreed with Trust 

Shadow refers to the period April – July 2006 prior to authorisation as an NHS Foundation 

Trust. 


Our members 

The Trust has two membership constituencies. The Public constituency is those 

individuals who live in the area of the Trust, specified as the electoral wards 

covered by Norfolk and Suffolk County Councils, and who are 16 years of age or 

older. 

The Staff Constituency is those individuals who are employed under a contract 

of employment by the Trust or who are not so employed but who nevertheless 

have exercised functions for the purposes of the Trust for at least 12 months. 

The membership as at 31 March 2011 is 9,982 Public constituency and 3,481 Staff 

constituency, giving a total of 13,463. 

The Governors Council Membership Committee manages the annual 

membership strategy, considering membership data at each of its meetings. 

The Committee consists of a majority of Governors representing the public 

constituency, but also representatives from staff and stakeholder organisations. 

This year’s objectives are set out. 

Maintain membership in the 16-35 age group 

Enhance communication with local Colleges and Youth Centres to increase 

engagement with Young People 

Increase public membership in under represented areas, working with local 

supermarkets/community groups/membership events, focusing on Southtown 

and Cobholm; Kirkley and Harbour Wards 

• Actively recruit with membership stand events 

• Participate in a system meeting to manage public expectations re financial 

situation 

Replace the current membership database 

• Obtain FT specification for comparison; work with IT to resolve in-house 

(funding not available for external solution) 

• Maintenance of membership 

Review and revise all Membership communications 

• Implement new Trust membership form 

• Review benefits of becoming a member 

• MP surgeries 

• Consider whether to continue attending Patient Participation Group 

meetings 

• 3 x Membership events 

• LINks 

• Visual impairments 

• Implement and enhance regular communication with Members on email 

• Clarify appropriate communications for young people 

• Modes of communication 

• Young people specific written material 


Parish/Town Councils 

Continue work with Parish Councils and Governor engagement with Beccles, 

Southwold, Martham and Filby, supplemented by articles in parish magazines as 

the main focus 

Staff Governors to increase their visibility within the Trust 

Meeting with Chief Executive – clear role needed 

Report from Governors Council via email or Making Waves 

Roll out of Trust values as Ambassadors 

Confirm Appointed Governors processes for exchange of information between 

organisations 

Voluntary sector – James Paget League of Friends 

Norfolk County Council 

Suffolk County Council 


Great Yarmouth Borough Council 

Waveney District Council 

UEA 

Recent analysis confirms that the 2010/11 membership targets for the 16-35 age 

group and Southtown and Cobholm areas were achieved. Unfortunately the 

Kirkley and Harbour areas still remain under represented; however a significant 

increase was seen in comparison to 2009/10. 

The replacement of the current membership database remains unachieved. The 

specification was prepared last year but, due to the appropriate prioritisation of 

clinical systems within the Trust’s IM&T Steering Group, it has not been possible 

to take this forward. However a data cleanse has begun to ensure membership 

data is accurate. 

Changes made within the Communications & Foundation team during 2010 have 

allowed for a more robust approach in enhancing the existing engagement, 

both with its staff and members. Our governors have also seen more support 

than was previously possible which has been reflected in our membership 

achievements this year. Activity undertaken this year includes: 

• Report instituted to track progress during the year 

• Sexual health/teenage pregnancies forum, working with NHS Great 

Yarmouth & Waveney and local Colleges. A very successful student forum 

took place on 14th February 2011 with 80+ students/tutors from Great 

Yarmouth and Lowestoft Colleges 

• Two new posters developed to attract various age groups of members, 

with matching membership forms. These will be displayed in youth clubs/ 

community areas 

• A successful membership events programme during summer 2010 

• Restructured communications team managing all information across the 

Trust to ensure old leaflets are not used and membership/PALS information 

is available in each area. Leaflet racks are being updated and reviewed 

quarterly 

• Process established to convert ex-staff members to public members. 


• Tracker form developed to record engagement with staff and public 

• Benefits of becoming a member reviewed and NHS discounts implemented 

• Visits across the Trust with the visually impaired involvement group and an 

action plan developed 

• Continued to submit trust news to local Parish Councils and community 

newsletters for inclusion within publications 

• Staff Governors established a regular meeting with Chief Executive, 

Chairman and Trust Secretary to discuss potential issues from staff and 

enhance their visibility across the Trust 

• Regular Staff Governors article included in quarterly Making Waves 

magazine 

• News from the Board of Directors meeting circulated to all Trust members 

on e-mail from March 2011. 

Communicating with our members 

YOUR Trust news, the Trust’s membership newsletter, continues to be circulated 

to all membership households in April and October. We are also now sending 

out the Board of Directors briefing to those members who have a valid email 

address. This has been added to our website since July 2010 and is in addition to 

our public reporting of Trust performance at our public Governors Council. 

Communication with the Trust is via the FT & Engagement Officer or Trust 

Secretary who can put a member in touch with a specific Governor as required. 

This is in addition to all the opportunities that Governors take to engage with 

members during their day to day lives. 

Contact details are included on all Foundation Trust publications. This includes 

the foundation trust email address foundationtrust@jpaget.nhs.uk. 

Staff members can contact staff governors either directly or through the use of 

the dedicated staff governor email address. As part of the annual membership 

strategy we are working to enhance their role. Our staff governors are working 

together very well as a group and now ensure a standing item in our staff 

magazine. 

We have worked with the Primary Care Trust, NHS Great Yarmouth and Waveney 

during the year to make the most of any joint events to engage with local 

people and Trust members. We are grateful for their support. 


Remuneration report 

The Trust has two Committees, one dealing with Executive remuneration and 

appointments and the other with Non Executive Directors. 

Executive Nomination and Remuneration 

Membership includes the Chairman, Chief Executive and all Non Executive 

Directors. The Trust Secretary acts as minute taker. The Director of Workforce & 

Estates provides advice to the Committee as required. 

Attendance during the year is set out below: 

Executive Director appointments/contracts 

All Executive Director contracts are substantive, with a six month notice period 

required. A new Director of Nursing will take up post in July 2011. At the time 

of writing, an interim appointment is being made to the post of Director of 

Operations. 

Further information on managing Executive Director performance is included in 

the our directors section at page 66. 

Special payments are considered on an exceptional basis and are only agreed 

following HM Treasury approval. This would be recommended after detailed 

consideration of the facts and where the Trust concludes that this is the most 

appropriate way forward in line with Monitor’s guidance. 


Governors Council Nomination and Remuneration 

Membership of the Committee includes public, staff and appointed governors, 

and is supported by the Director of Workforce & Estates, the Trust Secretary and 

the FT & Engagement Officer. The Committee is attended by the Chairman’s 

Personal Assistant as minute taker. Attendance is set out: 

Chairman and Non Executive Director performance 

The performance management of the Chairman and Non Executive Directors 

has previously been extensively reviewed by Governors and a robust process 

implemented. 

The Chairman’s review involves Governors, Executive Directors and selected 

members of staff completing a questionnaire rating the Chairman’s 

performance. The Deputy Chairman of Governors undertakes the performance 

review, led by the Senior Independent Director. 

The Chairman undertakes the Non Executive Directors’ performance reviews and 

reports in full to this Committee. 

A rating scale is utilised for both performance reviews; Needs Improvement/ 

Developing Performer, Meets Expectations, Exceeds Expectations, and 

Outstanding. Achievement of a Needs Improvement/Developing Performer 

rating would be dealt with promptly by the Chairman. 

The outcome of all reviews is presented to the Governors Council. 

Removal of the Chairman or another Non Executive Director requires the 

approval of three-quarters of the members of the Governors Council. 


Non Executive Director appointments 

In line with Governors Council approval and subject to a successful term of 

office and a performance assessment of Meets Expectations or greater, a Non 

Executive Director may be reappointed for a second term without competition. 

Appointments are for a three year term of office. 

Following publication of the revised Code of Governance in March 2010, 

the Trust has reviewed its processes against the changes, with the Code 

recommending terms longer than six years only in exceptional circumstances. 

A forward plan for Non Executive Director appointments ensures appropriate 

succession planning arrangements are in place with sufficient time for 

recruitment should an individual not wish to continue for a further term. The 

Chairman discusses this at performance reviews so intentions are clarified where 

possible. The Council approves the process for selection on a bi-annual basis. 

To secure a replacement for Annette Stannard, an advert was placed during 

Spring 2010 but an appointment was not made. The Council appointed 

executive search specialists Perrett Laver to provide potential candidates 

following Annette’s departure at the end of July. 

The process consisted of: 

• A full search of potential candidates resident in Norfolk and Suffolk. 

• An informal meeting with candidates and representatives from the Board of 

Directors and Governors Council on Tuesday 28 th September 2010. 

th 

• A competence based interview by a selection panel on Monday 4 October 

2010. 

The preferred candidate was considered in the private section of the Governors 

Council meeting on 15 th October 2010 and a public announcement made on 

completion of the process. Peter Franzen was appointed for a three year term 

from 1 st November 2010. 

Ken Gaylard has been appointed for a further three year term from 1 st March 

2011. 


Trust Remuneration Policy 

Executive Directors 

The Trust remuneration policy for Executive Directors is set by the Executive 

Nomination & Remuneration Committee. 

The policy is to pay market rate. This is defined as being between the lower and 

upper quartile range of salaries as indicated in the Capita survey of boardroom 

pay in the NHS, and also reflective of the organisational and individual 

performance. The exact salary is determined by the Committee based on the 

Trust’s performance and the individual’s contribution. This is presented by the 

Chief Executive for the Executive Directors and the Chairman for the Chief 

Executive, using the annual performance review as the basis for decision. 

Pay scales should be uplifted annually on 1 April in line with the general 

inflation increase for other staff in the NHS. During periods of economic 

difficulty, this will be reviewed. 

Senior Managers’ salaries, benefits and pension entitlements are published in 

the Trust’s annual report. 

The national Agenda for Change NHS pay system applies to the first layer of 

management below Board level. 

Chairman and Non Executive Directors 

The Governors Council has responsibility for setting the remuneration, 

following the recommendations of the Governors Nomination & Remuneration 

Committee. 

The current range is set out: 

Trust Chairman £35,000 - £60,000 

Trust Vice Chair £14,000 - £17,000 

Chair, Audit Committee £14,000 - £17,000 

Chair, Safety, Quality & Governance Committee £14,000 - £17,000 

Non Executive Directors £12,800 - £14,000 

These rates reflect current rates of pay in other NHS Foundation Trusts and take 

account of market data collected from the Foundation Trust Network. Where the 

posts of Vice Chair and Chair of the Safety, Quality & Governance Committee are 

held by the same person, only one of these posts will be recognised for payment. 

The pay scales should be uplifted annually on 1 st April in line with the general 

inflation increase for other staff in the NHS. During periods of economic 

difficulty, this will be reviewed. 

In March 2011, in both cases, the Committees confirmed the Directors’ wish 

that there should be no annual increase. This was the second year running 

for Executive Directors and the third year with no increase for Non Executive 

Directors. 

Wendy Slaney 



Senior managers’ salaries and benefits 

The following audited figures are presented. 


Senior managers’ pension entitlements 

The Senior following managers' audited figures pension are presented. entitlements 

Year 

Year 

Ended As at As at As at Ended 

31st March 31st March 31st March 31st March 31st March 

2011 2011 2011 2010 2011 

Real increase Total accrued Cash Cash Real increase 

in pension pension equivalent equivalent / (decrease) 

& lump sum & lump sum transfer value transfer value in cash 

at age 60 at age 60 equivalent 

(bands of (bands of transfer value 

£2,500) £5,000) 

£ 000 £ 000 £ 000 £ 000 £ 000 

Dr B Brett 5 - 7.5 120 - 125 417 453 (36) 

Medical Director 

Mr N Coveney 5 - 7.5 155 - 160 614 668 (54) 

Director of Nursing & Transformation 

Mr K Lower 2.5 - 5 125 - 130 571 608 (38) 

Director of Workforce and Estates 

Mr M Madden 5 - 7.5 110 - 115 435 470 (34) 

Director of Finance and Performance 

Mrs W Slaney 10 - 12.5 255 - 260 1,325 1,369 (44) 


As Non-Executive members do not receive pensionable remuneration there will be no entries in respect of pensions 

for Non-Executive members. 

A Cash Equivalent Transfer Value (CETV) is the actuarially assessed capital value of the pension scheme benefits 

accrued by a member at a particular point in time. The benefits valued are the member's accrued benefits and any 

contingent spouse's pension payable from the scheme. A CETV is a payment made by a pension scheme, or 

arrangement to secure pension benefits in another pension scheme or arrangement when the member leaves a 

scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to 

the benefits that the individual has accrued as a consequence of their total membership of the pension scheme, not 

just their service in a senior capacity to which the disclosure applies. The CETV figures, and from 2004-05 the other 

pension details, include the value of any pension benefits in another scheme or arrangement which the individual has 

transferred to the NHS pension scheme. They also include any additional pension benefit accrued to the member as 

a result of their purchasing additional years of pension service in the scheme at their own cost. CETVs are 

calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries. 

Real Increase / (decrease) in CETV - This reflects the movement in CETV effectively funded by the employer. It 

takes account of the increase in accrued pension due to inflation, contributions paid by the employee (including the 

value of any benefits transferred from another pension scheme or arrangement) and uses common market valuation 

factors for the start and end of the period. 

Senior managers' pension entitlement disclosures are subject to external audit. 

Remuneration Tables #3FACA9.xls Page 1 Pension Disclosure 


Independent Assurance Report to the Governors Council of James 

Paget University Hospitals NHS Foundation Trust on the Annual 

Quality Report 

I have been engaged by the Governors Council of James Paget University 

Hospitals NHS Foundation Trust to perform an independent assurance 

engagement in respect of the content of James Paget University Hospitals 

NHS Foundation Trust’s Quality Report for the year ended 31 March 2011 (the 

‘Quality Report’). 

Scope and subject matter 

I read the Quality Report and considered whether it addresses the content 

requirements of the NHS Foundation Trust Annual Reporting Manual, and 

consider the implications for my report if I become aware of any material 

omissions. 

Respective responsibilities of the Directors and auditor 

The Directors are responsible for the content and the preparation of the Quality 

Report in accordance with the criteria set out in the NHS Foundation Trust 

Annual Reporting Manual 2010/11 issued by the Independent Regulator of NHS 

Foundation Trusts (‘Monitor’). 

My responsibility is to form a conclusion, based on limited assurance procedures, 

on whether anything has come to my attention that causes me to believe that 

the content of the Quality Report is not in accordance with the NHS Foundation 

Trust Annual Reporting Manual or is inconsistent with the documents. 

I read the other information contained in the Quality Report and considered 

whether it is materially inconsistent with: 

• Board minutes for the period April 2010 to March 2011 

• Papers relating to Quality reported to the Board over the period April 2010 

to March 2011 

• Feedback from the Commissioners (April 2011) 

• Feedback from Governors dated April 2011 

• Feedback from LINKS was sought by the Trust but none received 

• The trust’s complaints report published under regulation 18 of the Local 

Authority Social Services and NHS Complaints Regulations 2009, dated March 

2011; 

• The 2011 national patient survey 

• The 2011 national staff survey 

• The Head of Internal Audit’s annual opinion over the trust’s control 

environment. 

• Care Quality Commission quality and risk profiles dated October and 

December 2011. 

I considered the implications for my report if I became aware of any apparent 

misstatements or material inconsistencies with those documents (collectively, the 

‘documents’). My responsibilities do not extend to any other information. 

This report, including the conclusion, has been prepared solely for the Governors 

Council of James Paget University Hospitals NHS Foundation Trust as a body, 

to assist the Governors Council in reporting James Paget University Hospitals 

NHS Foundation Trust’s quality agenda, performance and activities. I permit the 


disclosure of this report within the Annual Report for the year ended 31 March 

2011, to enable the Governors Council to demonstrate it has discharged its 

governance responsibilities by commissioning an independent assurance report 

in connection with the Quality Report. To the fullest extent permitted by law, 

I do not accept or assume responsibility to anyone other than the Governors 

Council as a body and James Paget University Hospitals NHS Foundation Trust for 

my work or this report save where terms are expressly agreed and with my prior 

consent in writing. 

Assurance work performed 

I conducted this limited assurance engagement in accordance with International 

Standard on Assurance Engagements 3000 (Revised) – ‘Assurance Engagements 

other than Audits or Reviews of Historical Financial Information’ issued by the 

International Auditing and Assurance Standards Board (‘ISAE 3000’). My limited 

assurance procedures included: 

• Making enquiries of management; 

• Comparing the content requirements of the NHS Foundation Trust Annual 

Reporting Manual to the categories reported in the Quality Report; and 

• Reading the documents listed above. 

A limited assurance engagement is less in scope than a reasonable assurance 

engagement. The nature, timing and extent of procedures for gathering 

sufficient appropriate evidence are deliberately limited relative to a reasonable 

assurance engagement. 

Limitations 

It is important to read the Quality Report in the context of the criteria set out in 

the NHS Foundation Trust Annual Reporting Manual. 

Conclusion 

Based on the results of my procedures, nothing has come to my attention that 

causes me to believe that, for the year ended 31 March 2011, the content of 

the Quality Report is not in accordance with the NHS Foundation Trust Annual 

Reporting Manual. 

Rob Murray 

Officer of the Audit Commission 

3rd Floor, Eastbrook, 

Shaftesbury Road, 

Cambridge, 

CB2 8BF 

31 May 2011 


A&E 

AGM 

AHPs 

Audit 

BMA 

Baseline 

CHP 

CIP 

COPD 

CPAP 

CQC 

CTS 

Caldicott 

Guardian 

Capital 

Commissioning 

CQUIN 

DH or DoH 

EADU 

EDP 

ENT 

Elective surgery 

FOI 

GMC 

GP 

GUM 

Group A Strep 

HCAI 

HIEC 

HSE 

Abbreviations 

Accident and emergency 

Annual General Meeting, a requirement, usually held 

in September when the annual report and accounts are 

presented 

Allied Health Professionals 

A continuous process of assessment, evaluation and 

adjustment 

British Medical Association 

The continuous level of funding, year on year, before 

additional resources are taken into account 

Combined heat and power installation 

Cost improvement programme – identifies what is needed to 

deliver the NHS financial shortfall 

Chronic obstructive pulmonary disease 

Continuous positive airways pressure 

Care Quality Commission 

Central Treatment Suite 

The named officer responsible for delivering and 

implementing the recommendations of the Caldicott report, 

which examined NHS Confidentiality and patient information 

systems 

Spending on land and premises and provision, adaptation, 

renewal, replacement or demolition of buildings, equipment 

and vehicles 

Process of acquiring/buying services to meet the health needs 

of the local population 

Quality and innovation payment framework - The CQUIN 

payment framework enables commissioners (PCT) to reward 

excellence, by linking a proportion of healthcare providers’ 

income to the achievement of local quality improvement 

goals 

Department of Health 

Emergency Assessment and Discharge Unit 

Eastern Daily Press, Norwich daily paper 

Ear, nose and throat 

An operation which is planned ahead and for which the 

patient will be given a date to be admitted to hospital 

Freedom of information – the 2000 act gives anyone access 

to a wide range of information held by public authorities, 

including the NHS. 

General Medical Council 

General Practitioner 

Genito-urinary medicine (clinic) 

A bacterium commonly found on the skin or throat where it 

can live without causing infection. Under particular 

circumstances this organism can cause disease. 

Healthcare Acquired Infection Rates 

Health Innovation and Education Cluster, a collaborative 

partnership in Norfolk and Suffolk and involving health, 

academia and industry 

Health and Safety Executive 


HSMR 

ICU 

IG 

IT 

Inpatient 

INTRAN 

JPUH 

KPI 

LCFS 

LINks 

LIPS 

LOS 

MAJAX 

MRSA 

NED 

NHS 

NICE 

NNUH 

NSF 

OP 

PbR 

PCT 

PET 

PMO 

QIPP 

SES 

SHA 

SUI 

THR/TKR 

TIA 

VTE 

Abbreviations continued 

Hospital Standardised Mortality Ratio 

Intensive care unit 

Information governance - Guidance on the range of legal and 

professional obligations that affect the management, use and 

disclosure of NHS information 

Information technology 

A patient admitted to hospital for a period of treatment or to 

undergo an operation. Patients would stay in hospital for 24 

hours or more 

Translation service for patients 

James Paget University Hospital 

Key performance indicator – identifies achievable and 

acceptable levels of performance 

Local Counter Fraud Specialist 

Local Involvement Networks 

Leading Improvement in Patient Safety 

A patient’s length of stay in hospital 

Major Incident 

Methicillin-resistant Staphylococcus aureus 

Non Executive Director 

National Health Service 

National Institute for Health and Clinical Excellence, an 

organisation that promotes clinical and cost effectiveness and 

produces and circulates clinical guidelines 

Norfolk and Norwich University Hospital 

National service framework 

Outpatient, provided on an appointment basis without the 

need to be admitted to or stay in hospital, e.g. assess need for 

further treatment, follow up appointment after a period of 

treatment 

Picture archiving and communications system 

Payment by results - calculates by tracing resources actually 

used by a patient and the associated costs incurred by the 

organisation 

Primary care trust 

Patient experience tool 

Project management office 

Quality Innovation Productivity Prevention – a programme 

that demands action at regional, and national level to drive 

up quality while meeting financial demands and making the 

best use of scarce resources 

Single Equality Scheme 

Strategic Health Authority 

Serious Untoward Incident 

Total hip replacement/total knee replacement 

Transient ischaemic attack – the term used for stroke 

symptoms that fully resolve within 24 hours with no residual 

deficit. It is a warning of a more serious stroke 

Venous Thromoembolism 


Useful contacts and how to get here 



Lowestoft Road 

Gorleston 

Great Yarmouth 

Norfolk 

NR31 6LA 

Main switchboard: 01493 452452 

Website: www.jpaget.nhs.uk 

Email: firstname.lastname@jpaget. 

nhs.uk 

Communications & Foundation 

Team: 

Ann Filby 

Head of Communications, 

Engagement & Foundation 

01493 452162 

General email: 

foundationtrust@jpaget.nhs.uk 

Patient Advice & Liaison Service 

01493 453240 

PALS@jpaget.nhs.uk 




Quality Account 

2010/11 

Toward excellent Where you quality come care, first together

Foreword 

Statement on Quality by Chief Executive 

The year has featured both achievement and challenge for the Trust across 

all service areas, with major developments set against an increasing demand 

for healthcare in our community. The Trust and its staff have responded 

strongly to meet the need for change and improvement. 

There has been an increased demand for emergency healthcare throughout 

the year, with particularly high levels of activity during the winter months. We 

always plan for an increase at this time but the surge in January and 

February was extreme and unusual. All healthcare providers experienced extreme 

emergency demand during this period which led to extra patients coming to acute hospitals. 

The level of demand contributed to some patients having a poor experience in several of our 

clinical areas, which led to concerns being identified. Some wards had particularly high 

numbers of patients who required assisted feeding and/or increased supervision which wards 

with standard nursing ratios would find difficult to manage. A programme of actions is now 

underway to ensure that high quality essential care can be maintained at all times. Part of 

this programme will deliver enhanced staffing levels, particularly at meal times. 

The Essential Care Project brings renewed focus on the wellbeing and fundamental care of 

patients and relatives during a hospital stay. This work supports the maintenance of high 

quality care at all times, whilst meeting high demand across the system. There is also work 

ongoing to aid the care of dementia patients who require acute medical and surgical 

intervention to make their experience better and recovery quicker, giving quality and 

efficiency benefits. 

The Leading Improvement in Patient Safety scheme (LIPS) has been implemented and well 

established. Further development of safety across 10 key metrics remains a Trust objective 

for the coming year. There have already been improvements including VTE assessment, 

patient falls and pressure sores. The Patient Experience project has greatly expanded to 

include patient feedback, Experience Based Design Group and the incorporation of specific 

issues from regular Patient Story presentations to the Board of Directors. 

During the year our Maternity Services achieved Level 2 status against the new Clinical 

Negligence Scheme for Trusts (CNST) standards, reflecting the quality service provided for 

mothers and babies locally. 

Over the year the Trust has achieved its financial and quality targets with the exception of 18 

week waits for 100% of cases. The exceptional winter demand unfortunately meant that the 

elective surgery programme was affected, with some specialties not meeting this target. The 

response of staff in all departments to deliver services against a difficult background has 

been recognised and is greatly appreciated by the Board, Governors and our patients. 

The Trust has worked closely with partner organisations to develop new ways of working 

across health and social care provision. This work forms a key part of meeting the funding 

challenge in the public sector. Our staff have participated in this work, giving important 

clinical input to the service changes. The commitment of staff has been truly commendable 

during the year and I acknowledge the great contribution and achievement they have made. 

We have much to accomplish during the coming year to ensure that we continue to meet the 

needs of our community. Together we can take forward services and developments, building 

on those achieved during the last year. 

Wendy Slaney, Chief Executive 

James Paget University Hospitals NHS Foundation Trust 

Quality Account 2010/11 Page 1 of 62

Contents 

Page 

Foreword by Chief Executive 1 

Part 1 

Introduction 3 

Statement of Directors’ Responsibilities 6 

Part 2 

Priorities for 2010/11 7 

Board Statements of Assurance 17 

Review of Services 18 

Participation in Clinical Audits 19 

NICE Compliance 26 

Research 27 

Data Quality 27 

NHS Number and GMC coding validity 28 

Information Governance Toolkit 28 

Clinical Coding Error Rate 29 

What others say about the Trust 30 

Part 3 

Review of Quality Performance 31 

Patient Safety 31 

Clinical Outcomes and Effectiveness 43 

Patient Experience 46 

Endorsement 59 

Glossary of abbreviations 61 




Quality Account 2009/10 

Part 1 

1 Introduction 

Welcome to the third Quality Account report for James Paget University Hospitals NHS 

Foundation Trust. Quality Accounts are a means to improve organisational accountability, to 

enable review of services and identify areas for improvement and to demonstrate change. 

They provide an opportunity for providers of healthcare to work with clinicians to rigorously 

analyse the quality of care that is being delivered in order to assure commissioners, patients 

and the public that trust boards are continuously scrutinising the quality of their services. 

Quality Accounts are also an opportunity to drive forward our local quality improvement plans 

and to be accountable to the public and stakeholders for these improvements. 

This year has again seen a period of unprecedented demand for the Trust’s services; there 

has been a 5.2% increase in emergency admissions and a 1.7% increase in Accident and 

Emergency (A&E) attendances over the year; and yet we have still provided high quality care 

for our patients and are continuing to strive to improve services further. During 2010/11 we 

cared for the following numbers of patients: 

Elective admissions 29,590 

Emergency admissions 26,682 

Day cases 24,147 

1 st outpatient appointments 65,206 

Follow up outpatient appointments 162,910 

A&E attendances 65,665 

This equates to an average of 512 emergency admissions each week (73 each day) and an 

average of 1,260 attendances each week (180 each day) at our Accident and Emergency 

Department. To achieve this, the Trust has utilised 9,076 escalation bed 1 days. This equates 

to an average of 25 escalation beds per day this year with the Trust on ‘Black Alert’ 2 on 131 

occasions. In order to appropriately care for emergency admissions to the Trust we have 

postponed nearly 600 operations this year. Furthermore, our society is changing with our 

local population living longer. 

An additional factor we need to highlight is that our local population is living longer. The area 

of Great Yarmouth and Waveney has a greater proportion of older people than England or 

East of England averages, a smaller proportion of working age people between 20 and 50 

and a smaller proportion of children under 10. The population is forecast to age, with the 65+ 

age band likely to increase the most in future years. 

1 Escalation beds: extra beds put in place to cope with unexpected increase in demand. 

2 Black alert: The status of the hospital when it is full to capacity, escalation beds are in use, patients are waiting 

in A&E for beds, routine surgery is cancelled and the Trust is working with community partners to discharge 

patients. 



The old and the very young are known to increase demand on health. This Quality Account 

summarises some of the quality achievements and initiatives undertaken throughout 

2010/11, despite all of the pressures highlighted above. It demonstrates our continued 

commitment to the three key quality drivers: 

1. Patient Safety; 

2. Clinical Outcomes and Effectiveness; 

3. Patient Experience. 

This report will be published on the NHS Choices website and the Trust’s own website by 30 

June 2011. The report can be made available in different languages and formats if required. 

Please contact Anna Hills, Assistant Director of Governance, Safety and Compliance on 

(01493) 453684, anna.hills@jpaget.nhs.uk. 

If you would like to provide feedback regarding this Quality Account or make suggestions for 

the content of future years’ reports please contact the Assistant Director of Governance, 

Safety and Compliance as above. 

Please also see the James Paget University Hospitals NHS Trust Annual Report 2010/11 

which can be obtained from the Trust website or the Trust Secretary ann.filby@jpaget.nhs.uk 

from August 2011. 

Trust Objectives 2011/12 

The Trust has developed a five year strategy through to 2014/15. 

This strategy outlines our vision for continuing to work towards excellent quality care set out 

in four key priorities for the Trust in the coming five years; 

1 Maintaining and strengthening our core services to achieve year onyear 

improvements in clinical, operational and financial performance of the acute and 

community services that form the backbone of our Trust. 

2 Meeting the comprehensive needs of our high risk population. 

We aim to take a proactive role in managing and delivering care pathways for growing 

patient populations, in particular the elderly and those suffering from long term 

conditions. This includes working in partnership with others to address the needs of 

the community and support NHS Great Yarmouth and Waveney in reducing health 

inequalities. 

3 Enhancing the overall experience of our patients to ensure all patients of the Trust 

experience high quality care in a professional environment, treated with dignity and 

respect. Listening to the experience of our patients will be key to further improving our 

services. 

4 Being an excellent employer. We want to be recognised as an employer that is 

committed to the development of our staff, recruiting the most capable and dedicated 

employees who share our vision for excellent patient care. Clear and consistent 

leadership for our staff and investment in their ongoing training and development are 

important commitments we aim to deliver during this period. 



We have ensured our strategy is in line with the direction and priorities set out in national, 

regional and local health strategies; Lord Darzi’s Next Stage Review, the NHS East of 

England’s ‘Towards the Best, Together’ and NHS Great Yarmouth and Waveney’s local 

strategy. 

We believe that pursuing this strategy will result in excellent services that will deliver better 

outcomes for the people of Great Yarmouth and Waveney and will contribute towards 

building a healthier community for the future. 

The Trust has agreed a number of strategic objectives for the coming year which will promote 

delivery of the five year strategy and directly cascade to team and individual objectives: 

1. Improve the care and experience of patients, with a specific focus on older people 

and those with dementia, by working internally and with partner agencies. 

2. Deliver further improvements against the 10 key metrics of the Leading Improvement 

in Patient Safety scheme across the Trust, e.g. infection and falls preventions 

3. Continue to implement a range of transformation and quality improvements across all 

care pathways, with particular focus on length of stay. 

4. Deliver all financial targets. 

5. Demonstrate further progress towards a reduction in carbon emissions at the Trust of 

20% by 2015. 

6. Achieve national performance standards that underpin the provision of excellent 

services to our community. 

These objectives to be supported by a framework of educational and development 

support for staff. 



Statement of directors' responsibilities in respect of the quality accounts 

The directors are required under the Health Act 2009 and supporting regulations to prepare 

Quality Accounts for each financial year. In preparing these accounts, directors are required 

to take steps to satisfy themselves that: 

• the Quality Accounts present a balanced picture of the NHS foundation trust’s 

performance over the period covered; 

• the performance information reported in the Quality Accounts is reliable and accurate; 

• there are proper internal controls over the collection and reporting of the measures of 

performance included in the Quality Accounts, and these controls are subject to 

review to confirm that they are working effectively in practice; 

• the data underpinning the measures of performance reported in the Quality Accounts 

is robust and reliable, conforms to specified data quality standards and prescribed 

definitions, and is subject to appropriate scrutiny and review; and 

• the Quality Accounts have been prepared in accordance with relevant requirements 

and guidance issued by Monitor. 

The directors confirm to the best of their knowledge and belief that they have complied with 

the above requirements in preparing the Quality Accounts. 

........................................................................................... Chairman 

........................................................................................… Chief Executive 



Part 2 

Priorities for improvement 2011/12 

Our Quality Strategy continues to focus on the three key areas of patient safety, clinical 

outcomes and effectiveness, and patient experience. Hence, our four key priorities for 

2011/12 are as follows: 

• Patient safety – Reduction in In-Patient Falls; 

• Patient safety – Reduction in standardised mortality rates; 

• Patient Experience – To embed the Trust Values; and 

• Clinical Outcomes and Effectiveness – Achievement of the CQUIN goals. 

Delivery of these priorities will be overseen by the Transformation Board which is responsible 

for delivery of the productivity and effectiveness, patient safety and patient experience 

agendas via three project streams. Each project stream is driven by a dedicated project 

director and a clinical champion who oversees delivery of an action plan, underpinned by 

‘lean’ methodology. 

The Transformation Board monitors delivery of the action plans and reports directly to the 

Board of Directors of the Trust as well as contributing to the system wide Great Yarmouth 

and Waveney Transformation Board and the East of England arrangements. 

Priority 1a: Patient safety – Reduction in In-Patient Falls 

AIM: To reduce in-patient falls by 10% 

This will be measured via the Patient Safety Programme key metrics. The percentage 

reduction in falls will be measured against the 2010/11 baseline using the per 1000 bed days 

calculation. 

Executive Sponsor: Director of Nursing 

Responsible officer: Patient Safety Project Director 

During 2010/11 there were 1063 in-patient falls across the Trust compared to 1149 in 

2009/10 (7.5% reduction). Nationally there were 283,438 slips, trips and falls reported to the 

National Patient Safety Agency (NPSA) between October 2008 and September 2009. Inpatient 

falls continued to be the Trust’s highest category of adverse incidents reported during 

2010/11. 

During 2010/11 there was a Local Improvement Aim linked to a CQUIN 3 to achieve: 

1. 20% reduction in the number of in-patient falls. 

2. The use of risk assessments across the Trust to ensure patients are appropriately 

assessed and preventative measures introduced as a result of their level of risk of falls. 

3 The Commissioning for Quality and Innovation (CQUIN) payment framework is a national framework for locally agreed quality 

improvement schemes. 



Current position: 

Patient Falls 

120 

111 

Monthly Total (Total = 1063) 

Trajectory 

111 

Number of Incidents 

100 

80 

60 

40 

99 

96 

92 91 

88 

85 

83 

78 

76 76 76 76 76 76 76 76 76 76 76 75 76 

49 

20 

0 

Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 

Month and Year 

During 2010/11 18 patients suffered a fracture as a result of a fall whilst in our care; 14 hip 

fractures, 1 fractured nose, 1 fractured shoulder and 2 fractured wrists. All of these incidents 

were comprehensively investigated. 

A number of significant improvements have been achieved during 2010/11 to help reduce inpatient 

falls. These include: 

• Significantly raised awareness 

• 10 Key Responsibilities for falls prevention 

• Revised documentation in all ward areas 

• Communication cascade regarding falls prevention care 

• Assistive Technology – Sensor Care Trigger Alert 

• Patient Safety Action Planning & Development Day for nursing staff 

• Dedicated resource to support the change process 

• Refocussed Trust Falls Steering Group 

• Redesign of mandatory training package and inclusion of falls prevention in induction 

• Hospital at night (H@N) team link nurse involvement to achieve promotion of the 

standards 24/7 

• Allocation of Strategic Workforce Investment Fund for Tomorrow (SWIFT) funding for 

falls prevention 

• Increased regional networking – proposal for standardised practice expectation 

across Norfolk. 

However, there remain a number of concerns including: 

• Volume of in-patient falls; 

• Volume of fractures sustained as a result of an in-patient fall; and 

• Current capacity and demand issues and perceived impact on ability to maintain 

prevention standards. 



The further reduction in in-patient falls will be achieved by embedding the 10 key 

responsibilities below: 

Case Study 1: Assistive Technology 

Technology is also a part of our falls prevention work. The Trust has recently invested in a 

sensitivity trigger alarm system called Sensor Care. 

The Sensor Care Alarm System is a device that has been developed to alert staff when a patient 

at risk of falls has moved from their bed or chair. 

The device works by having a sensitivity plate under the bed mattress or chair cushion. The 

sensitivity level on the plate is programmed in accordance with the patient’s size. When the 

patient stands up or moves sufficiently to change the sensitivity level an alert is created through 

a bleep which is specifically paired with the plate or cushion e.g. if bleep 1 alarmed, it would be 

telling you that the patient on mattress 1, is trying to get out of bed or has succeeded. This acts 

as an alert to investigate what the patient is doing and therefore reduce the level of risk of the 

patient falling if you didn’t know they were moving. 

At the current time we have enough systems to cover the top floor of the hospital. A bid is being 

developed to try to extend this to cover all areas of the hospital. Lowestoft Hospital already has 

the sensor care system in place. 



Priority 1b: Patient safety – Reduction in mortality rates 

AIM: To integrate HSMR measures into clinical and managerial 

processes 

The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that 

measures whether the death rate at a hospital is higher or lower than you would expect. Like 

all statistics, HSMRs are not perfect. If a hospital has a high HSMR, it cannot be said for 

certain that this reflects failings in the care provided by the hospital. However, it can be a 

warning sign that things are going wrong. 

The HSMR compares the expected rate of death in a hospital with the actual rate of death for 

a number of diagnoses, for example, heart attacks, strokes or broken hips. For each group 

of patients it is possible to work out how often, on average, across the whole country, they 

survive their stay in hospital. This is achieved by taking into account their age, the severity of 

their illness and other factors, such as whether they live in a more or less deprived area. This 

provides a figure for how many patients we would expect to die at each hospital. This is then 

compared with the number of patients that actually die. If the two numbers are the same, the 

hospital gets a score of 100. If the number of deaths is ten per cent less than expected they 

get a score of 90. If it is ten per cent higher than expected, they score 110. 

Care is needed in interpreting these results. Just through chance, some hospitals will have a 

higher mortality rate and some a lower rate. It is inevitable that half the hospitals will have a 

worse than average result and that some will be quite a lot worse than the average. It is 

important to focus on "outliers". These are hospitals where the results lie outside the normal 

range, or particular groups of conditions where results lie outside the normal range, for a 

particular hospital. 

An HSMR 14 point action plan has been approved by the Trust’s Board of Directors and 

Management Team, to integrate the use of HSMR data with other tools. Specialties with a 

higher than average mortality rate can understand why this has occurred and take any 

necessary steps to improve. The action plan will be owned by the Trust’s Management Team 

and progress against the actions will be monitored through the existing performance 

management processes. A regular update on progress will be provided to both the Board of 

Directors and Management Team throughout the year. 

Executive Sponsor: Medical Director 

Responsible officer: Deputy Director of Performance 

Objectives: The Trust aims to reduce its overall and specialty specific HSMR to less than 

100 throughout 2011/12. 



Current position: 

Hospital Standardised Mortality Ratio (HSMR) for 2010/11 

100 

90 

80 

70 

Relative risk 

60 

50 

40 

30 

20 

10 

0 


Actual 94 98.6 86.8 81.1 92.8 87.7 100.5 75.5 74.5 

Priority 2: Patient Experience – To embed the Trust Values 

AIM: To improve the patient experience by embedding the Trust 

values into all that we do 

This will be measured by the Trust Values Steering Group. 

Executive Sponsor: Director of Workforce and Estates 

Responsible officer: Head of Learning and Organisational Development 

The Trust has received feedback from our patients and the public via complaints, PALS 

enquiries and other sources which has indicated that at times our communications require 

improvement. 

In response to this the Trust has agreed a set of core values which it expects all staff to 

demonstrate in order to improve the experience of our patients and visitors. 

The Board is determined to see the Trust’s values as a critical and integral part of the Paget 

experience. The values must be understood by all staff and embedded in the organisation 

resulting in patients and service users experiencing these values when they are in contact 

with our staff. A steering group has been established to ensure this happens and to monitor 

progress. 

The steering group comprises key senior individuals from across the organisation including a 

Non Executive Director. It has been established to develop and implement a set of action 

plans that will ensure the Trust’s values are embedded in the organisation. It will monitor and 

evaluate the effectiveness of the action plans and report on progress to the Board during the 

year. 


Quality Account 2010/11 Page 11 of 62

Five work streams have been agreed and steering group members have responsibility for 

each area: 

• Human Resources processes and procedures 

• Internal and external Communication 

• Organisational processes and policies 

• Patient and Stakeholder experience of values 

• Leadership and values. 

The objectives for 2010/11 were: 

• 80% of employees will be able to articulate the values; 

• 50% of patients will know about our values; 

• The values will be incorporated in all people management and development 

processes; and 

• The Board will be assured that the values are integral to a patient safety 

culture. 

A baseline audit was conducted from September to December 2010 and questions on the 

values were added into the Patient Experience Tool (PET). 52% of the 696 respondents 

indicated that they knew the Trust had a set of values, however only 18% could name them. 

Staff knowledge of the values was measured in a variety of ways during March 2011, which 

included: 

• Face to face sessions with staff 

• Intranet survey 

• Paper questionnaires distributed to 300 members of staff 

• Patient experience tool situated in the staff restaurant 

• Questioning staff at training sessions and after induction. 

The total number of staff who participated or responded was 1043; 734 (86%) were able to 

articulate the values. 

The Values Steering Group will continue to function during 2011/12. The focus of the group 

will be to continue to raise awareness of the values with staff through embedding the values, 

concentrating on the behavioural change required and supporting senior managers and 

clinicians in the role modelling of the values. 

James Paget University Hospitals NHS Foundation Values: 

Putting patients first, and they will: 

Provide the best possible care in a safe clean and friendly environment, 

Treat everybody with courtesy and respect, 

Act appropriately with everyone. 

Aiming to get it right, and they will: 

Commit to their own personal development, 

Understand theirs and others roles and responsibilities, 

Contribute to the development of services 

Recognising that everyone counts, and they will: 

Value the contribution and skills of others, 

Treat everyone fairly, 

Support the development of colleagues. 

Doing everything openly and honestly, and they will: 

Be clear about what they are trying to achieve, 

Share information appropriately and effectively, 

Admit to and learn from mistakes. 



Priority 3: Clinical Outcomes and Effectiveness – Achievement of the CQUIN 

goals. 

AIM: To utilise the CQUIN scheme to drive quality improvements 

across a number of specific areas 

Achievement of the CQUINs will be monitored via the Transformation Board. 

Executive Sponsor: Medical Director 

Responsible officer: Project Lead for Effectiveness and Productivity 

The Commissioning for Quality and Innovation (CQUIN) payment framework is a national 

framework for locally agreed quality improvement schemes. It makes a proportion of provider 

income conditional on the achievement of ambitious quality improvement goals and 

innovations agreed between commissioner and provider, with active clinical engagement. 

The CQUIN framework is intended to reward excellence, encouraging a culture of continuous 

quality improvement in all providers. 

A CQUIN scheme is the locally agreed package of quality improvement goals and 

indicators, which in total, if achieved, enables the provider to earn its full CQUIN 

payment (calculated as 1.5% of the Actual Outturn Value of the provider contract in 

2011/12). A CQUIN scheme should address the three domains of quality: safety, 

effectiveness and patient experience; and reflect innovation. 

A CQUIN goal describes a quality improvement objective which is being incentivised 

through a CQUIN scheme. A goal may be measured using several indicators. 

A CQUIN indicator is a measure which determines whether a goal or an element of the 

goal has been achieved, and on the basis of which payment is made. 

CQUIN targets were agreed between the Trust and the commissioning PCT, NHS Great 

Yarmouth and Waveney, at the beginning of the financial year. Achievement of these was 

monitored throughout the year. 

The table overleaf describes achievement of the CQUINs for 2010/11 at the time of writing 

this report. The total value of the CQUIN scheme for 2010/11 was £1.8 million. 



No 

Commissioning for 

Quality and Innovation 

(CQUIN) 

CQUIN GOAL 

CQUIN INDICATOR 

Achieving 

Not Currently Achieving 

On Plan to Achieve 

Area of Concern 

1 

2 Dementia 

3 Patient Responsiveness 

4 End of Life - choice 

5 

Maternity Services user 

responsiveness 

8 Day Case Basket 

9 Reduce falls in hospital 

10 Case note audits 

Reduce avoidable death, disability and 

chronic ill health from Venousthromboembolism 

(VTE) 

Development and implementation of an 

integrated Dementia Pathway across 

mental health & learning disability, 

community and acute sectors: 

Improve response to personal needs of 

patients 

Provide Palliative and End of Life care 

using the nationally defined end of life 

care tools 

Maternity user responsiveness 

Improve rate for Audit Commission 

basket of 25 procedures performed as a 

day case 

Reducing Falls whilst in Hospital 

Mortality audits and case note reviews 

for harm events 

1. % of all adult inpatients 

who have had a VTE risk 

assessment on admission 

to hospital using the 

national tool 

2. % of inpatient & 

obstetric patients excluding 

non obstetric day cases 

who have had appropriate 

thrombopropyhlaxis 

Leading and working on 

Acute Trust elements of 

the pathway in partnership 

with all key stakeholders. 

The indicator will be a 

composite, calculated from 

5 survey questions. Each 

describes a different 

element of the overarching 

theme: “responsiveness to 

personal needs" 

1. Provision of palliative 

and EOL care using the 

nationally defined EOL 

care tools 

2. Reduction in the number 

of palliative/EOL patients 

dying in the acute care 

setting 

Introduction of ongoing 

user survey and 

subsequent audit/response 

to improve patient 

experience. 

% of all operations from 

the Audit Commission 

basket of 25 procedures 

performed as a day case 

Reduce in-patient falls by 

20% compared to 2009/10 

baseline. 

1. Baseline review: 

Mortality 100 sets of notes 

& Harm events, 40 sets of 

notes 

2. Ongoing monthly 

reviews: Mortality 20 sets 

of notes & Harm events, 20 

sets of notes. 



No 



(CQUIN) 

CQUIN GOAL 


Achieving 





12 

Pressure ulcers 

Patient safety walk 

rounds 

13 C. difficile 

Measurable reduction in hospital 

acquired pressure ulcers 

Patient Safety Walkrounds – these are 

recommended by LIPS, Patient Safety 

First and IHI and are clear drivers for 

quality improvements. These would 

greatly enhance the safety culture of the 

organisation. 

Enhanced surveillance: Hosting and 

maintaining a system-wide 

register/database of C. difficile cases 

using HPA’s web-based EPIDATA 

database. 

20% reduction in the rate 

between the final indicator 

period and the 2009/10 

baseline for inpatient 

hospital acquired pressure 

ulcers 

24 patient safety 

walkrounds to be 

conducted during 2010/11 

Need to reduce C. difficile 

infections across the whole 

system. HPA guidance 

suggests whole-system 

case register of C difficile 

patients 

14 Accrediting practitioners 

15 

16 

17 

Innovation - pathways & 

delivery of care - 

Diabetes 

Participation on Clinical 

Transformation Board 

Weekend TIA carotid 

imaging 

Accrediting and ongoing supervision of 

practitioners in primary and community 

care with a special interest 

To develop and implement a dataset in 

Diabetes clinic in JPUH to support high 

quality care 

Support to clinical transformation 

strategy 

Weekend TIA service 

1. Accreditation and 

learning needs of new 

primary & community care 

practitioners supported. 

2. Ongoing supervision 

and learning needs met. 

3. Evidenced by records of 

interactions. 

Implement and utilise a 

data capture system for 

outpatient management of 

Diabetes. 

Integration and 

involvement of Trust 

clinicians in delivery of 

NHS GY&W Strategy and 

Operating Plan 

1. Percentage of high risk 

TIAs presenting at 

weekends receiving carotid 

imaging within 24 hours. 

2. Percentage of all high 

risk TIAs assessed and 

investigated within 24 

hours of first NHS contact 

(excluding admitted TIAs). 

18 

Psychological 

assessment 

To deliver access to psychological 

assessment (including cognitive 

assessment) and support for Stroke 

Proportion of Stroke 

patients who have had 

specialist psychological 

assessment or treatment 

by 6 months post stroke (at 

least 75% of which need to 

be undertaken as an 

inpatient) 



No 



(CQUIN) 

CQUIN GOAL 


Achieving 




19 Preventable strokes 

20 

21 

Stroke - managing high 

risk TIA patients 

Stroke - Direct 

admissions to stroke 

ward 

22 Stroke - Access to CT 

23 Demand Management 

The number of these patients who were 

discharged on anticoagulation or with a 

date to commence anticoagulation via 

anticoagulation team documented on 

discharge summary 

Management of high risk TIA patients - 

Clinic Appointment 

Timely access to acute stroke units 

prevents death and increases 

independence 

Access to timely imaging for eligible 

patients admitted having had a stroke 

Development and implementation of 

demand management initiatives and 

pathway redesign across primary, 

secondary, community and social care 

sectors 

Proportion of patients 

presenting with stroke with 

AF anti-coagulated on 

discharge or with clear 

plans documented in the 

discharge communication 

to commence 

anticoagulation at a 

clinically appropriate time 

post discharge 

Number of High Risk TIA 

patients investigated and 

treated within 24 hours of 

first NHS contact excluding 

those admitted 

Patients admitted within 4 

hours to the stroke unit 

Eligible patients admitted 

having had a stroke who 

receive CT within 60 

minutes of admission 

Leading and working on 

acute trust elements of the 

pathway in partnership with 

all key stakeholders 

A proportion of James Paget University Hospitals NHS Foundation Trust’s income in 

2010/11 was conditional on achieving quality improvement and innovation goals 

agreed between James Paget University Hospitals NHS Foundation Trust and any 

person or body entered into a contract, agreement or arrangement with for the 

provision of NHS services, through the Commissioning for Quality and Innovation 

payment framework. 



Board Statements of Assurance: 

Review of services 

The National Health Service (Quality Accounts) Regulations 2010 require that a number of 

statements are included within the Quality Account so that there is common content between 

providers making the accounts comparable. These statements are contained within the 

boxes which follow: 

During 2010/11 the James Paget University Hospitals NHS Foundation Trust provided and/or 

sub-contracted the NHS services listed in the table on page 18. 

The James Paget University Hospitals NHS Foundation Trust has reviewed all the data 

available to them on the quality of care in all of these NHS services. 

The income generated by the NHS services reviewed in 2010/11 represents 100% percent of 

the total income generated from the provision of NHS services by the James Paget 

University Hospitals NHS Foundation Trust for 2010/11. 

The James Paget University Hospitals NHS Foundation Trust provides services to the whole 

population of Great Yarmouth and Waveney at two locations: 

1. James Paget University Hospital; and 

2. Lowestoft Hospital. 

As well as a number of community clinics. 

The service types provided at these locations are: 

1. Acute services; 

2. Hospice services; 

3. Community healthcare services; and 

4. Dental services. 

The regulated activities which the Trust is registered to provide, as defined by the Health and 

Social Care Act 2008 (Regulated Activities) Regulations 2009 schedule 1, and carried out by 

the Trust are as follows: 

• Personal care; 

• Treatment of disease, disorder or injury; 

• Surgical procedures; 

• Diagnostic and screening procedures; 

• Maternity and midwifery services; 

• Termination of pregnancies; and 

• Family planning services. 



The services provided by James Paget University Hospitals NHS Foundation Trust include 

the following: 

Division 

Emergency 

Elective 

Women & Child Health 

Core Clinical 

Specialties and services: 

Accident and Emergency (A&E) 

General Medicine 

Gastroenterology 

Endocrinology 

Diabetes 

Haematology 

Cardiology 

Dermatology 

Nephrology and renal dialysis 

Genitourinary Medicine 

Rheumatology 

Respiratory Medicine 

General Surgery 

Vascular Surgery 

Breast Surgery 

Gastro-intestinal Surgery 

Urology 

Trauma and Orthopaedics 

Ear, Nose and Throat 

Oral Surgery 

Ophthalmology 

Gynaecology 

Obstetrics 

Maternity services 

Community midwifery 

Neonatology 

Parentcraft 

Antenatal screening 

Fertility services 

Diagnostic Imaging 

• X-ray services 

• Specialist Imaging 

• Ultrasound services 

• Mammography services 

• MRI & CT services 

Medical illustration 

Pharmaceutical services 

Lowestoft Hospital 

Care of the elderly 

GP beds 

Care of the Elderly 

Diabetic Liaison 

Clinical Measurement 

Coronary Care 

Endoscopy 

Rehabilitation 

Intensive Care Services 

Hyperbaric services 

Oncology 

Sandra Chapman Centre (day treatment 

for adults with haematological disease 

and cancer) 

Therapies e.g. physiotherapy 

Anaesthetics 

Clinical Specialties of Continence and 

Stoma Care 

Audiology 

Dental and Orthodontics 

Community Dental Services 

Pain Management 

Palliative Care 

Paediatrics 

Paediatric Surgery 

Children’s Centre 

Community Paediatric Service 

School Nursing (GY) 

Safeguarding children 

Community services 

Chemical Pathology 

Immunology and Serology 

Microbiology 

Haematology 

Blood Transfusion 

Bereavement Services 

Pharmaceutical Services 

Social Work Support 

Reviews of the quality of services provided by the Trust for all its locations and all of the 

service types and regulated activities have taken place during 2010/11. The processes used 

are described in Part 3 of this report. 

A number of external assessments were conducted during 2010/11, including: 

• Health and Safety Executive review of Microbiology laboratory; 

• National Cancer Peer Review 

• Clinical Negligence Scheme for Trusts (CNST) review of Maternity Services 

• External Quality Assessment of the Diabetic Retinal Screening Service 

• Human Fertilisation and Embryology Authority (HFEA) review of Fertility Service 

• Intensive Care Unit/High Dependency Unit peer review audits 

• Care Quality Commission Review of Support for Families with Disabled Children 

• Fire Risk Assessments Trust-wide 

• Patient Environment Action Team 

• Environmental health. 



During 2011/12 a number of further service reviews are planned which will be aligned to the 

Trust’s CQUIN targets with our commissioners and the Quality Innovation, Productivity and 

Prevention projects (QIPP). 

Participation in Clinical Audits 

During 2010/11, 33 national clinical audits and two national confidential enquiries covered NHS 

services that the James Paget University Hospitals NHS Foundation Trust provides. 

During that period James Paget University Hospitals NHS Foundation Trust participated in 88% 

(29/33) of the national clinical audits and 100% of the national confidential enquiries which it was 

eligible to participate in. 

The national clinical audits and national confidential enquiries that James Paget University Hospitals 

NHS Foundation Trust was eligible to participate in during 2009/10 are listed in the table overleaf. 

The national clinical audits and national confidential enquiries that James Paget University Hospitals 

NHS Foundation Trust participated in, and for which data collection was completed during 2010/11, 

are listed in the table on page 20. This includes the number of cases submitted to each audit or 

enquiry as a percentage of the number of registered cases required by the terms of that audit or 

enquiry 4 . 

The table overleaf describes the list of national audits drawn up by the National Clinical Audit 

Advisory Group of the Department of Health. Although national audits are not mandatory, 

Trusts are recommended to participate in those audits of services which they provide. 

The CQC uses information from national audits in its Quality and Risk Profiles to identify 

whether a Trust is at risk of not complying with the registration requirements. There is now a 

formalised process in place whereby the Clinical Effectiveness Committee reviews national 

audits to make a corporate decision whether or not participation is cost effective and 

achievable. 

4 Where this information was available at the time of reporting 



Clinical Audits 

Audit Name Applicable Trust Lead Percentage of Cases 

Submitted 

Peri - and Neonatal 

Perinatal Mortality (CEMACH) 

Neonatal intensive and special care (NNAP) 

Children 

 

 

 

Carol Mutton 100% 

Laurie Howarth 100% 

Paediatric pneumonia 

(British Thoracic Society) 

John Chapman Data collection ongoing 

Paediatric asthma 

John Chapman Data collection ongoing 


 

Paediatric fever 

Donna Wade Data collection ongoing 

(College of Emergency Medicine) 

Childhood epilepsy 

Dr Nirmal Data collection ongoing 

(RCPH National Childhood Epilepsy Audit) 

Paediatric Intensive Care (PICANet) John Chapman No participation 

Paediatric Cardiac surgery 

(NICOR Congenital Heart Disease Audit) 

Diabetes 

(RCPH) National Paediatric Diabetes Audit) 

Acute Care 

Emergency use of oxygen 


Adult community acquired pneumonia 


Non-invasive ventilation (NIV)-adults (British 

Thoracic Society) 

Pleural procedures 

(British Thoracic Society 

Cardiac Arrest 

(National Cardiac Arrest Audit) 

Vital signs in majors 

(College of Emergency Medicine) 

Adult Critical Care 

(Case Mix Programme) 

Potential donor audit 

(NHS Blood & Transplant) 

Long Term Conditions 

Diabetes 

(National Adult Diabetes Audit) 

Heavy Menstrual bleeding 

(RCOG National Audit of HMB) 

Chronic Pain 

(National Pain Audit) 

Ulcerative colitis & Crohn’s disease 

(National IBD Audit) 

Parkinson’s disease 

(National Parkinson’s Audit) 

 

 

 

 

 

 

 

 

 

 

 

 

John Chapman 

Dr Raman 

Dr Cotter 

Dr Cotter 

Dr Cotter 

Dr Cotter 

Pam Cushing 

Dr Crawfurd 

Donna Wade 

Adam Devany 

Dr Karlikowski 

Lynn Everett 

No participation 

Data collection ongoing 





65 cases submitted 

100% 

100% 

Jean Jennings 100% 

Mrs Rashid 

Dr Notcutt 

Dr DeSilva 

Dr Huston forward 

Dr Woodward 

Dr Shields 









Submitted 

COPD 

(British Thoracic Society/European Audit) 

Adult Asthma 


Bronchiectasis 


Elective Procedures 

Hip, knee and ankle replacements (National 

Joint Registry) 

Elective Surgery 

(National PROMs Programme) 

Cardiothoracic Transplantation (NHSBT UK 

Transplant Registry) 

Liver Transplantation 

(NHSBT UK Transplant Registry) 

Coronary angioplasty 

(NICOR Adult cardiac interventions audit) 

Peripheral vascular surgery 

(VSGBI Vascular Surgery Database) 

Carotid interventions 

(Carotid Intervention Audit) 

CABG and valvular surgery 

(Adult cardiac surgery audit) 

Cardiovascular disease 


Quality Account 2010/11 Page 21 of 62 

 

 

 

 

 

Dr Cotter 

Dr Cotter 

Dr Cotter 

Caroline Scarll 

Helen French 

Dr Ryding 

Dr Ryding 

Dr Ryding 

Dr Ryding 





Proms Results April 

2009 – Sept 2010 

Site 

Varicose 

Vein 

Participation 

rate JPUH 

Pre-op 

questionnaires 

51% 

Groin hernia 65.7% 

Knee 88.7% 

Hip 79.6% 

All 

procedures 







Familial hypercholesterolaemia (National 

Dr Ryding No participation 

Clinical Audit of Mgt of FH) 

Acute Myocardial Infarction and other ACS 

Dr Ryding Data collection ongoing 

(MINAP) 

Janet Shreeve 

Heart Failure 

(Heart Failure Audit) Janet Shreeve 100% 

Pulmonary hypertension 


(Pulmonary Hypertension Audit) 

Acute Stroke (SINAP) 


Dr George 

Stroke Care 

Evie Cooper 100% 

(National Sentinel Stroke Audit) 

Renal Disease 

Renal replacement therapy 

(Renal Registry) 

Mark Prentice 

75.5% 

Data included in Norfolk 

and Norwich University 

Hospitals NHS 

Foundation Trust 

return. 

Renal Transplantation Mark Prentice No participation.

(NHSBT UK Transplant Registry) 


Submitted 

Patient transport 

(National Kidney Care Audit) 

Renal Colic 

(College of Emergency Medicine) 

Cancer 

Lung cancer 

(National Lung Cancer Audit) 

Bowel Cancer 

(National Bowel Cancer Audit Programme) 

Head & Neck Cancer (DAHNO) 

Trauma 

Hip fracture 

(National Hip Fracture Database) 

Severe trauma 

(Trauma Audit & Research Network) 

Falls and non-hip fractures 

(National Falls & Bone Health Audit) 

Psychological conditions 

 

 

 

 

 

 

 

 

 

Mark Prentice 100% 

Donna Wade 

Dr Mahadevan 

Linda Hayes 

Steve Wright 

Mr Premachandra 

Tracey Church 




100% 

Louise Hebdon 100% 

Louise Hebdon 

Dr Zaidi 



Depression & anxiety 

(National Audit of Psychological Therapies) 

Kirk Lower 

Occ Health 


Prescribing in mental health services 

No participation – 

(POMH) 

Mental Health 

National Audit of Schizophrenia (NAS) No participation – 

Mental Health 

Blood Transfusion 

O neg blood use 

(National Comparative Audit of Blood 

Transfusion) 

Platelet use 

(National Comparative Audit of Blood 

Transfusion) 

 

 

Julie Jackson 

Julie Jackson 





Locally developed clinical audits are reviewed at various multidisciplinary meetings across 

the Trust. During 2010/11 the following numbers of local audits were reviewed and 

discussed at internal meetings and actions to improve clinical services were subsequently 

agreed: 

Paediatric Audit Meeting 13 

Perinatal Morbidity & Mortality Meeting 2/3 case presentations per meeting 

Emergency Clinical Governance Meeting 4 

Combined Audit Elective Division 

7 (+ Surgical Mortality Review cases) 

The following case studies provide examples of where clinical audits have directly led to 

improvements in patient services. 

Case Study 1: Re-audit Compliance with Trust Antibiotic Guideline 

Objectives 

• To investigate compliance with the Trust Antibiotic Guideline 

• To highlight any possible areas of improvement. 

Following this audit the following actions were agreed: 

Action Plan 

• Educate new doctors in the right way of prescribing antibiotics via induction training 

sessions. 

• Drug chart to be redesigned for antibiotic prescribing which would include a space for 

review date and indication for the antibiotics. 

• A separate antibiotic sticker to be trialled in EADU which indicates a review/stop date 

and the indication for prescribing. 



Case Study 2: Upper Gastrointestinal Bleed Audit 

Aim 

A re-audit of the management of Upper Gastrointestinal bleeds (UGIB) according to the 

SIGN (Scottish Intercollegiate Guidelines Network) guidelines (also adopted by Royal 

College of gastroenterology and NICE) in view of implementing Trust guidelines. 

Objectives 

100% of patients admitted with suspected upper GI bleed should meet the criteria set out 

below: 

1 Assessed using an upper GI bleed scoring system to categorise risks 

2 Observations including BP and pulse 

3 Blood tests including Hb and Urea 

4 Rectal examination performed at time of first assessment 

5 Patients scoring 0 on Blatchford score are discharged for outpatient endoscopy 

6 Clo test results clearly documented and acted on 

7 Receive early endoscopy, defined as being performed on the day or following day 

of request being made 

8 Use of proton pump inhibitors (PPIs) if there is no 24 hour endoscopy service 

available or PPI have been recommended post endoscopy by the endoscopist 

Conclusions 

• Significant improvement in use of UGIB scoring system 

• Education of junior doctors required regarding rectal examination at first 

assessment, awareness of significance of Clo Testing and treatment 

• Documentation throughout medical notes could be improved 

• Concise Trust guidelines for the management of patients admitted with Upper GI 

Bleed are required. 



Case Study 3: Patient Hospital Paper Health Records Documentation Audit 2010 

Objectives 

Comparative audit for Trust and specific areas; to highlight adherence to NHS and JPUH 

policy criteria 

Rationale: Ongoing audit (NHSLA) of correctness of Patient Paper Health Records 

Audit Sample: 5 sets of notes were reviewed per Specialty; covering 31 Specialties, out 

of a possible 46 (67%), which resulted in 319 professional entries being individually 

assessed for compliance with criteria 

Data collection: 

Data Source: 

Data Collection: 

Retrospectively 

(admissions reviewed from 10th June to 8th December 2010) 

Patient Paper Health Records 

Undertaken by Junior Doctors, Nurses and Clinic Staff 

Results compare 2008, 2009 + 2010 audits 

Conclusions 

• There has been a year on year improvement since 2008 in the quality of Health 

Care Files 

• Timings of entries is only 70% 

• All entries (including alterations/additions) identify author by reference to Nursing 

Accountability Record is only 55% 

• Common anecdotal complaints of numerous documents not filed correctly, not in 

chronological order or loose etc are untrue with 90%+ being correct. Still room for 

improvement! 

• Allergy notation has greatly improved 

Overall conclusions 

• Shows that progress made with the documentation work streams around the 

Trust and that the importance of correct documentation can now be shown to be 

a vital part of improving patient safety and patient outcomes 

Recommendations: 

• To evaluate the audit paperwork to make it easier to understand 

• To evaluate the audit process so it is embedded into the Trust and that key staff 

groups are signed up to undertake the audit work rather than the ad hoc 

approach at present 

• To disseminate the findings and create an action plan of actions and hence 

improvements in areas of need 



The Trust has a dedicated lead for National Confidential Enquiry into Patient Outcome and 

Death (NCEPOD) who provides regular reports regarding the Trust’s progress with 

implementing the recommendations from the published reports. Self assessments have 

been carried out using the NCEPOD tools and action plans are in place to ensure 

implementation of the recommendations. 

There were three confidential enquiries published by NCEPOD during 2010/11, two of which 

were applicable to the Trust: 

• Parenteral nutrition; and 

• Elective and Emergency Surgery in the Elderly. 

The Trust is in the process of implementing the recommendations detailed within these two 

confidential enquiries. 

There were no reports published by the Centre for Maternal and Child Enquiries (CMACE) 

during 2010/11. 

There were no reports published by the National Confidential Inquiry into Suicide and 

Homicide by People with Mental Illness (NCI/NCISH) during 2010/11 applicable to the Trust. 

National Institute for Health and Clinical Excellence (NICE) compliance 

A NICE Implementation Group is in place and meets regularly to review new guidance, 

technology appraisals, interventional procedures and other guidance issued by NICE. This 

group also monitors those publications which are relevant for our patients but have yet to be 

fully implemented due to barriers such as funding, training needs or facilities required. This 

ensures that robust action plans are in place and progress is being made towards 

implementation. 

The table below details the number of materials issued by NICE to date and the Trust’s 

status in terms of compliance. For guidelines/guidance which has yet to be fully implemented 

plans are in place to expedite this. 

NICE 

Number issued by end 

of March 2011 

(relevant to JPUH) 

Compliance rate at 

end of March 2011 

Technology Appraisal Guidance 106 88.7% 

Interventional Procedure Guidance 46 71.7% 

Clinical Guidelines 101 73.3% 

Patient Safety Guidance 2 50% 

Public Health Guidance 26 57.7% 



Research 

The number of patients receiving NHS services provided or sub-contracted by the 

James Paget University Hospitals NHS Foundation Trust in 2010/11, that were recruited 

during that period to participate in research approved by a research ethics committee, was 

712. 

Participation in clinical research demonstrates the James Paget University Hospitals NHS 

Foundation Trust’s commitment to improving the quality of care we offer and to making 

our contribution to wider health improvement. Our clinical staff stay abreast of the latest 

possible treatment possibilities and active participation in research leads to successful 

patient outcomes. 

The James Paget University Hospitals NHS Foundation Trust was involved in conducting 

12 clinical research studies in Cancer during 2010/11. It is not possible at the time of 

writing this report to provide data relating to mortality amenable to healthcare/mortality 

rate from causes considered preventable as these studies are not yet completed and the 

data has not yet been analysed. The participation in such studies at the Trust 

demonstrates a commitment to clinical research which it is anticipated will lead to better 

treatments for patients. 

There were 44 (19 nurses and 25 doctors) of clinical staff participating in research 

approved by a research ethics committee at the James Paget University Hospitals NHS 

Foundation Trust during 2010/11. These staff participated in research covering 14 of 

medical specialties. 

In the last three years, we are unaware of any publications that have resulted from our 

involvement in NIHR research as most studies are long term and have yet to complete. It 

is likely that there have been publications generated by Chief investigators from other 

Trusts where we have acted solely as additional research sites. We are largely a trial 

hosting site and are not in receipt of any NIHR grants at present. Our engagement in 

multi-centre studies also demonstrates the James Paget University Hospitals NHS 

Foundation Trust commitment to testing and offering the latest medical treatments and 

techniques. 

Data Quality 

James Paget University Hospitals NHS Foundation Trust will be taking the 

following actions to improve data quality : 

• Monthly meetings with NHS Great Yarmouth and Waveney to discuss data quality 

issues. These are minuted and an action log is maintained to ensure all issues are 

recorded and left open until resolved; 

• Data Quality report to the Information Governance Action Group based on the SUS 

Data Quality Dashboard provided by the Health and Social Care Information 

Centre. This report includes recommendations to the Board which are followed up 

at the next meeting; and 

• Regular reports are sent to the clinical Divisions identifying data quality issues that 

need resolving at source before being submitted to SUS. This is monitored via a 

local reporting system that mirrors the SUS Data Quality Dashboard. 



NHS number and GMC code validity 

James Paget University Hospitals NHS Foundation Trust submitted records during 

2010/11 to the Secondary Uses Service for inclusion in the Hospital Episode Statistics 

which are included in the latest published data. 

The percentage of records in the published data which included the patient’s valid NHS 

number was: 

99.81% for admitted patient care; 

99.80% for outpatient care; and 

99.02% for accident and emergency care. 

The percentage of records in the published data which included the patient’s valid 

General Medical Practice Code was: 

100% for admitted patient care; 

100% for out patient care; and 

98.40% for accident and emergency care. 

This data is based on the latest published figures up to Month 10. 

Information Governance Toolkit 

James Paget University Hospitals NHS Foundation Trust Information Governance Toolkit 

assessment score. Overall score for 2010/11 was 45/45. 

Information governance is a systematic approach to ensuring that all aspects of the 

processing of personal and sensitive information, both paper and electronic, meet 

prescribed standards. It aims to ensure that performance is subject to continuous 

improvement. The Information Governance framework has four dimensions: 

• Management: structures, policies, procedures, etc. 

• Systems: access controls, application security, validation, etc. 

• Processes: protocols, records management, data quality, etc. 

• People: education, training, development, guidance, etc. 

As a key part of the Information Governance agenda, the Department of Health and NHS 

Connecting for Health jointly produced an Information Governance Toolkit. The current 

version of the Toolkit is scored using a simple Red/Green (Satisfactory/Unsatisfactory) 

metric. The Toolkit is designed to assist organisations to achieve the aims of Information 

Governance and currently encompasses: 

• Information Governance Management 

• The NHS Confidentiality Code of Practice 

• The Caldicott Guidelines 

• Data Protection Act 1998 

• Information Security Management NHS Code of Practice 



• Information Quality Assurance 

• Records Management NHS Code of Practice 

• Freedom of Information Act 2000 

It is the tool by which organisations can assess their compliance with current legislation, 

standards and national guidance. The Trust achieved a Level 2 score in 45 of the 45 

requirements in the Toolkit Assessment, which is rated as ‘Satisfactory’ performance. 

Clinical Coding Error rate 5 

James Paget University Hospitals NHS Foundation Trust was subject to the 

Payment by Results clinical coding audit during 2010/11 by D&A Clinical 

Coding Consultancy Limited. The error rates reported in the latest published 

audit for that period for diagnoses and treatment coding (clinical coding) 

were: 

• Primary Diagnoses Incorrect 9.5%; 

• Secondary Diagnoses Incorrect 13.8%; 

• Primary Procedures Incorrect 4.9%; and 

• Secondary Procedures Incorrect 4.5%. 

The table below shows the coding accuracy overall results in comparison to the 2010 

audit. Please note different specialties were audited each year. 

Correct (%) 2009/10 Correct (%) 2010/11 

Primary Diagnosis 92.50 90.50 

Secondary Diagnosis 92.13 86.21 

Primary Procedures 95.83 95.04 

Secondary Procedures 88.89 95.52 

The 2010 audit reviewed the following specialties: 

Gynaecology 

General Surgery 

Trauma and orthopaedics 

Ophthalmology 

General Medicine. 

5 Please note: These results should not be extrapolated further than the actual sample audited. 



What others say about the Trust 


James Paget University Hospitals NHS Foundation Trust is required to register with the 

Care Quality Commission and its current registration status is registered without 

conditions. 

The Care Quality Commission has not taken enforcement action against James Paget 

University Hospitals NHS Trust during 2010/11. 

James Paget University Hospitals NHS Foundation Trust has not participated in any 

special reviews or investigations by the CQC during the reporting period. 

The Trust has been registered with the Care Quality Commission without conditions since 

April 2010 for the following services: 

• Termination of pregnancies at James Paget Hospital; 

• Family planning at James Paget Hospital; 

• Maternity and midwifery services at James Paget and Lowestoft Hospitals; 

• Diagnostic and screening procedures at James Paget and Lowestoft Hospitals; 

• Surgical procedures at James Paget Hospital; and 

• Treatment of disease, disorder or injury at James Paget and Lowestoft Hospitals. 

Patient Environment Action Team (PEAT) 

The table below demonstrates the PEAT results 2011 for environment, food, privacy and 

dignity for each hospital within the Trust. This demonstrates an improvement on the 2010 

scores where the Trust scored ‘good’ in all areas. 

Environment 

Privacy & 

Food Score 

Site Name 

Score 

Dignity Score 

Lowestoft Hospital Good Excellent Good 

James Paget Hospital Good Excellent Good 

Health and Safety Executive (HSE) 

The Trust was visited by the HSE in November 2010 to conduct a routine review of the 

Trust’s Microbiology laboratory. This resulted in a very positive report with only minor areas 

for improvement identified. All of the improvements suggested have since been 

implemented. 

A follow up visit was also conducted in March 2011 to ensure that appropriate actions had 

been taken following a small formaldehyde spillage in Theatres. The inspector was very 

pleased with our response to this incident and closed the investigation without any further 

recommendations. 



Part 3 

Review of Quality Performance 

Patient Safety 

Leading Improvement in Patient Safety (LIPS) 

LIPS is a nationally led safety improvement programme developed and delivered by the 

Institute of Innovation and Improvement. The programme is designed to support NHS Trusts 

to develop robust organisational plans that will facilitate measurable and sustainable 

improvements in patient safety throughout the organisation. 

The Trust’s Patient Safety Project formally commenced in March 2010. It complements the 

national and international drive to make demonstrable improvements that will reduce the 

volume of harm events experienced by patients in our care. In the UK it is currently estimated 

that harm events are experienced by 1 in 10 patients (National Patient Safety Agency - 

NPSA 2007). LIPS offers a variety of improvement tools to help increase capacity and 

capability to make these achievements. In particular, we are using the Model for 

Improvement as a framework for setting the objectives and targets of the overall project plan. 

This is complemented with the use of Plan, Study, Do and Act (PDSA) cycles as a means for 

performing small tests of change prior to more wide scale implementation. 

Following thorough analysis of local incident data and exploration of relevant national and 

regional driving forces, improvement aims for the Trust were agreed. These have been 

categorised as high level and system level aims. 

High Level Improvement Aims 

• Year on year reduction in harm events of at least 10% 

• Overall reduction in harm events of ≥ 50% over five years 

• 25% reduction in all falls by March 2011. 

10 work streams have been set up to deliver the high level aims. The work around Falls 

prevention has been described in part 2. The other metrics are detailed below. 

Metric 2 – Pressure Ulcer Prevention 

National Context: 

High Impact Actions (2010) estimated 4 -10% of patients admitted to hospital experience a 

pressure ulcer grade 2 6 or above. 

Local Improvement Aim (and CQUIN): 

1. 25% reduction of the 2009/10 baseline of hospital acquired grade 2 and above. 

2. 60% of all inpatients receive Waterlow risk assessments on admission. 

6 There are four recognised grades of pressure ulcers in the European Pressure Ulcer Advisory Panel (EPUAP) 

Wound Classification system which health professionals use to describe the severity of pressure ulcers. 



Current Position: 

Inpatient Pressure Ulcers Grade 2 and above (inc.'not stated April and May 10) 

25 


20 

15 

10 

20 

19 

18 

17 17 

16 

16 

13 

14 

13 13 


13 12 

14 

13 13 14 

13 13 13 13 13 13 

10 

9 

8 

Grade 2 

Grade 3 

Grade 4 

Practice Development 

Trajectory 

5 

0 

0 0 0 0 0 0 

1 

0 0 

1 

0 0 0 0 



During March 2011 87.6% of patients had a pressure ulcer risk assessment (Waterlow) on 

admission. 

Successes: 

• Significantly raised awareness 

• Review of evidence base 

• Review of Trust documentation 

• Working on the principle of 8 Key Responsibilities for pressure ulcer prevention 

• Revised documentation in all ward areas 

• Communication cascade regarding pressure ulcer prevention care 

• Hospital at Night team link nurse involvement – promotion of standards 24/7 

• Dedicated resource to support change process 

• Inclusion of pressure ulcer prevention training as part of Trust Practice Development 

Training Programme. 

Concerns: 

• Reporting system(s) ineffective 

• Under reporting 

• Inaccurate reporting 

• Under use of the mattress loan store 

• Pressure ulcer classification tool used inaccurately 

• Volume of patients admitted with existing pressure ulcer. 





Metric 3 – Venous Thromboembolism (VTE) 

An all Party Parliamentary Thrombosis Group in 2005 estimated there were 25,000 

preventable deaths per annum nationally due to VTE. 

Local Improvement Aim (and CQUIN) 

1. 90% of patients receive an admission VTE risk assessment. 

2. 80% of inpatient and obstetric patients receive appropriate thromboprophylaxis. 

Current Position: 

VTE Risk Assessment Compliance Rates 2010/11 

100 

90 

80 

70 

% Compliance 

60 

50 

40 

Monthly Compliance 

Trajectory % 

30 

20 

10 

0 

Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 


Data collected from medication charts indicates a consistent achievement of between 90- 

95% compliance with appropriate thromboprophylaxis prescribing. 

Successes: 

• The Trust has achieved VTE Exemplar Site status 

• Bespoke IT system developed to register risk assessment completion 

• Inclusion of VTE on induction and mandatory training 

• General raised awareness of VTE 

• Attendance at external training attendance 

Concerns: 

• Delays in registration of risk assessment 

• Variation in compliance with risk assessment completion 

• Process for supporting Waveney GPs when patients are transferred to Lowestoft 

Hospital 

• Lack of resources within Patient Safety Team to support implementation of remaining 

NICE VTE Quality Standards. 



Metric 4 – Documentation and Record Keeping 

“The purpose of a medical record is to provide a clear account of patient management so as 

to facilitate current treatment and to establish a reliable past medical history and thereby 

provide healthcare professionals with evidence supporting the adequacy of their care”. 

Guidance provided by John Chapman, Trust Solicitor, June 2010 

Local Improvement Aims: 

1. Documentation will be multidisciplinary by the end of March 2012 

2. Format and style enables each episode of care to create chronological history 

3. Complete review of nursing documentation. 

Successes: 

• Essentials of nursing care record sheet trial completed and roll out commenced 

January 2011 

• Specific care plans completed for falls, pressure ulcer prevention and tracheostomy 

• Specific pieces of documentation being reviewed e.g. fluid charts, observation chart 

• Early stages of drafting multidisciplinary record 

• Standardising ‘inpatient episode’ folder throughout Trust 

• Multidisciplinary engagement. 

Excellent progress continues to be made with the development of a multidisciplinary 

healthcare record. Significant changes have been introduced to nursing documentation. The 

principle is to simply but effectively evidence the patient’s journey and their individual care 

needs. The notion that the reliability of a safety intervention is increased by standardising 

and reducing variation has been applied to all new pieces of documentation that guide 

practice. The aim is that all patients, regardless of where their care is being delivered, should 

receive consistent standards of essential care that is generic to the majority of patients in 

hospital. 

Metric 5 – Infection Prevention 

Matching Michigan is a quality improvement project based on a model developed in the 

United States which, over 18 months, saved around 1,500 patient lives. It took place at 

Intensive Care Units (ICUs) in Michigan and introduced technical interventions (changes in 

clinical practice) and non-technical interventions (linked to leadership, teamwork and culture 

change). When applied together they have been shown to significantly reduce the incidences 

of Central Venous Catheter bloodstream infections (CVC-BSIs). 

The Matching Michigan target is no more than 1.4 CVC – BSI per 1000 catheter days. 



Monthly CVC BSI Rates 

14 

12 

Rate of CVC BSI 1000 Catheter days 

10 

8 

6 

4 

Series1 

2 

0 

Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 

Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 

Surviving Sepsis is a campaign that has been introduced to reduce mortality and morbidity 

associated with delays in recognition and treatment of sepsis. If not treated in a timely way, 

sepsis can become a medical emergency. Evidence suggests that a specific bundle of care 

interventions, initiated at point of diagnosis improve patient outcomes. The Trust focus at the 

current time is to improve sepsis recognition. Initiation treatment is being focussed on A&E 

and EADU. Plans are in place to roll out the ‘sepsis bundle’ throughout the Trust this year. 

Surgical Site Infection Surveillance is mandatory, with periodic surgical site surveillance 

undertaken following hip and knee joint replacement surgery. Results issued last year report 

that over the preceding five year period the following infection rates were seen: 

• national average for hip replacement 1.1% (JPUH = 1.2%) 

• national average for knee replacement 1.1% (JPUH = 1.3%) 

Some changes to practice have been implemented that should further improve wound care in 

the orthopaedic areas. 

World Health Organisation (WHO) Surgical Safety Checklist - In England and Wales, 

129,419 incidents relating to surgical specialities were reported to the NPSA from 1 st January 

– 31 st December 2007. The WHO Surgical Checklist is designed to reduce the number of 

errors and complications resulting from surgical procedures. There are ten core standards 

that WHO recommend should remain, even if local adaptation to the checklist is made. At the 

James Paget we have integrated the checklist into our electronic theatre information system 

and have introduced a visual prompt in each. Audit results from October 2010 to March 2011 

demonstrate that more than 99% of the checklist has been appropriately completed. 



Metric 6 – Mortality and Case Note Reviews (using Global Trigger Tool) 

50% of harm events are thought to be avoidable (NPSA 2007). The use of triggers to identify 

adverse events during a manual record review has been used extensively to measure the 

overall level of harm in health care organisations. 

Local Improvement Aims: 

1. 100 baseline random mortality reviews to be completed by end March 2010. 

2. 40 baseline random case note reviews (harm events) to be completed by end March 

2010. 

3. 20 random mortality reviews to be completed every month from April 2010 onwards. 

4. 20 random non mortality case note reviews to be completed every month from April 2010 

onwards. 

Successes: 

• Excellent learning opportunities identified 

• Highlighted trends that are being incorporated into improvement projects e.g. delays in 

appropriate escalation of concerning patients, poor fluid management and completion of 

fluid charts, poor clinical record keeping 

Concerns: 

• Medical capacity to commit to review process 

• Overlap with existing mortality review groups 

• Timely administrative process to arrange reviews. 

Metric 7 – Medicines Management 

Between September 2006 and June 2009 27 deaths, 68 severe harms and 21,383 other 

patient safety medicines incidents were reported to the NPSA nationally. 

Local Improvement Aim: 

1. Ensure reasons for drug admissions are appropriately documented on the drug chart 

2. Improve pain management processes and patient outcomes 

3. To evidence other medicines management actions required from adverse event trends. 

Successes: 

• Multidisciplinary focus 

• Working on the principle of 7 key responsibilities for medicines management 

• Working directly with Medicines Management Action Group. 

Concerns: 

Although progress has been made there is room for further improvements. As a result 

medicines management will have a more targeted focus in the forthcoming year to identify 

ideas and innovations and how we can make more of a difference. 



Metric 8 – Nutrition & Hydration 

Malnutrition (in the form of under nourishment) affects over 3 million people in the UK. It is 

often unrecognised and untreated. This metric links very closely with the deteriorating 

patient project work stream and the Trust’s dementia care project. 


1. Malnutrition Universal Screening Tool (MUST) Nutritional Risk Assessment completed 

on admission 

2. MUST Nutritional Risk Assessment reviewed at least every seven days 

3. 100% of patients who require food/fluid charts have them completed correctly 

4. 100% compliance with the Trust’s Nil By Mouth policy. 

Successes: 

• Building on work of Trust Nutrition Group and Nutrition Link Group 

• Multi disciplinary focus 

• Linking in with Trust Dementia project 

• ‘Hospital at Night’ link nurse involvement to promote the standards 24/7. 

Concerns: 

Improvements have been made. However the standards required remain unmet and work to 

further improve outcomes from this metric will be more targeted in the coming year. This will 

involve a complete review of some of the systems we currently have in place to manage and 

prevent malnutrition/dehydration and ensure we reliably deliver best practice nutritional care. 



Metric 9 – Executive Leadership Patient Safety Walk Rounds 

National Perspective: Executive Leadership Patient Safety Walk Rounds are a nationally 

and internationally recognised methodology for increasing engagement with frontline staff on 

issues that impact on their ability to provide care in a safe environment. 

Local Improvement Aim (CQUIN): 

1. A minimum of 24 walk rounds to be performed during 2010/11 

2. Up to three safety actions will result from each walk round. 

The target of 24 walk rounds has been significantly exceeded and the benefits are 

noticeable. In particular the presence of Executive and Non Executive Directors on the shop 

floor has made staff feel they are being given an opportunity to share their experiences 

regarding patient safety. 

Patient Safety team 

Metric 10 – Observations and the Deteriorating Patient 

National Context: 

Clinical deterioration can occur at any time in a patient’s illness but is more common 

following an emergency admission, during recovery from serious illness and following 

operations. 


1. Increase compliance with observation policy to 100% by end December 2010 

2. Increase compliance with Early Warning Score (EWS) escalation to 100% by end July 


The improvement aims for this metric have not been achieved in the timescales originally 

agreed. However, the aims and objectives of this work stream were reviewed part way 

through 2010 to establish if the targets we had set ourselves were realistic and achievable. It 

was agreed that the timescales should be extended and since that time good progress has 

been made with the vital sign and EWS observations elements of this metric. 



Patient Safety Incidents 

As at 18 th May 2011 the graphs below detail the number and type of adverse incidents 

reported via the Trust internal reporting mechanisms. 

350 

PSI Incidents 10/11 

Number of PSI Incidents 

300 

250 

200 

150 

236 

303 

242 

265 266 

244 

272 

281 

234 

288 

194 

205 

100 

01.04.10 to 31.03.11 (Total Number = 3030) 

50 

0 



PSI Incidents by Category 

1200 

01.04.10 to 31.03.11 (Total = 3030) 

1065 

1000 


800 

600 

400 

200 

0 

2 

255 

99 

127 

66 

6 

71 

47 

5 

133 

5 

80 

16 

247 

2 

122 

1 

403 

172 

7 28 

8 

63 

Anaesthetics 

Assessment,Diagnosis,Scans,Tes 

Consent, Confidentiality,Commu 

Health & Safety 

Information Governance 

IT 

Medical Equipment (Electrical) 

Neonatal 

Paediatrics (Inc Community) 

Records Management 

Security And Fraud 

Theatres (Inc Anaesthetics) 

Cause Group 

All adverse incidents are investigated to ascertain the root causes and appropriate 

improvement actions are then taken. 



For all Serious Untoward Incidents (SUIs) a full root cause analysis investigation is 

undertaken and a detailed action plan is developed and monitored to ensure that any 

learning is implemented into practice across the Trust. The number and type of SUIs 

reported to the PCT and Strategic Health Authority during 2010/11 are set out below. 

SUI's 10/11 

6 

01.04.10 to 31.03.11 (Total Number = 

29) 

5 

5 

4 

4 


3 

2 

2 

3 

2 

3 

2 

3 3 

1 

1 

1 

0 



SUI's by Category 

12 

10 


10 


8 

6 

4 

2 

2 

3 

5 

1 1 1 1 

4 

1 

0 

Appts, Admission, Discharge, T 

Assessment,Diagnosis,Scans,Tes 

Clinical/Medical Treatment/Pro 

Consent, Confidentiality,Commu 

Infection Control 

Information Governance 

Cause Group 

Medicines Management (Inc Gase 

Patient Care,Monitoring, Revie 

Records Management 

Slips, Trips And Falls 



Never Events 

Never Events are serious, largely preventable patient safety incidents that should not occur if 

the available preventative measures have been implemented. 

The core list of Never Events for 2010/11 is detailed. This has been increased to a list of 25 

for 2011/12: 

• Wrong site surgery 

• Retained instrument post-operation 

• Wrong route administration of chemotherapy 

• Misplaced naso or orogastric tube not detected prior to use 

• Inpatient suicide using non-collapsible rails 

• Escape from within the secure perimeter of medium or high secure mental health 

services by patients who are transferred prisoners 

• In-hospital maternal death from post-partum haemorrhage after elective caesarean 

section 

• Intravenous administration of mis-selected concentrated potassium chloride. 

The Trust has introduced a number of control measures to prevent Never Events from 

occurring. However, during 2010/11 there were two Never Events, both of which involved 

the retention of a small swab following suturing after an instrumental vaginal delivery. A 

detailed programme of training, awareness and checklists has now been introduced to 

prevent a similar occurrence in the future. An audit will be conducted during summer 2011 to 

ensure these improvements have been embedded into practice. 

Case Study: Patient Fall (SUI) 

Incident: Patient found on the floor beside the bed having been recently transferred from 

the admissions unit (within one hour of transfer). Patient was diagnosed with a fractured 

neck of femur (broken hip). The family were informed and the incident was investigated 

formally using Root Cause Analysis techniques. 

Findings: Patient was transferred into the ward at lunchtime when staff were busy with 

medicine administration and feeding patients, hence all falls prevention options were not 

considered upon admission. 

Improvements: 

Patients at high risk of falls are now cohorted into one bay and staff are allocated to monitor 

the patients (additional staff are booked). 

Staff are encouraged to consider the use of falls prevention equipment such as falls beds 

and sensocare equipment. 

Falls risk assessments are conducted on admission and then weekly; each bay has an 

allocated day for the assessment to be completed which is advertised at the end of each 

bay. 



Patient Safety Alerts 

At the time of this report the Trust is compliant with all patient safety alerts which are 

monitored by the Central Alert Service. The Trust has a robust process in place for ensuring 

that alerts are received and circulated to the relevant individuals promptly so that any 

necessary actions can be taken within the timescales prescribed. 

NHSLA and CNST 

The Trust was assessed and achieved NHS Litigation Authority (NHSLA) Level 2 in May 

2008. The Trust will be reassessed against the 2011/12 standards for acute trusts in early 

May 2011 when it is hoped that Level 2 will be retained. 

The Maternity Service was reassessed in March 2011 against the Clinical Negligence 

Scheme for Trusts (CNST) 2010/11 Maternity Standards. The service achieved Level 2 

against these standards. 

Clinical Outcomes and Effectiveness 

Accountability Framework – Nursing Care Metrics 

A key piece of work undertaken by the Chief Matron and the Patient Safety Project Director, 

to support the aims of the Patient Safety project, has been the development of an 

Accountability Framework for nursing staff. The primary aim of the framework is to provide 

clarity for staff regarding the standard of practice that is expected. Secondly, that any 

variation in the standards of care our patients receive will reduce, and our organisational and 

departmental approaches will become appropriately standardised. 

The framework consists of 15 Care Metrics within which there are 77 evidence based Key 

Performance Indicators (KPIs). Performance is monitored on a monthly basis via audit data 

collection. Feedback is provided to the relevant Ward Manager and Matron. The first audits 

took place in November 2010 and this data has been used as the baseline. As expected, the 

first set of results were variable amongst the different areas included. However, it is already 

evident that Ward Managers are embracing the concept of the framework as a tool to 

strengthen their team’s performance and capability to improve patient outcomes. 

Once we have established and embedded the Nursing Accountability metrics and KPIs into 

practice we will introduce a further set of metrics at ward level that will reflect other patient 

sensitive areas where Allied Health Professionals and medical colleagues lead e.g. 

medicines management and documentation. In addition we need to ensure that the Nursing 

Accountability Framework links clearly with the Divisional performance score cards and 

performance meetings led by the Director of Finance and Performance. 



Existing Commitments and National Priorities 2010/11 

2009/10 2009/10 2010/11 2010/11 

Target Performance Target Performance 

Total Time In A&E : 4 hours or Less 98% 98.34% 95% 97.21% 

Cancelled Operations 0.80% 1.04% 0.80% 0.52% 

Delayed Transfers of Care 

No Target set 

by CQC 1.50% 3.50% 2.25% 

Access To GUM Clinics: offered an 

appointment within 48 hours 98% 100% 100% 100% 

Access To GUM Clinics: Seen within 

48 hours 95% 96% 95% 96.68% 

Time To Reperfusion For Patients who 

have had a heart attack 

Rapid Access Chest Pain Clinic 98% 

Elective Inpatient Waiting Times 

Outpatient Waiting Times 

99% 

No >26wk 

waits 0% 

No >13wk 

waits 

0% 

100% 99.5% 

All Cancers - 2 Week Wait 93% 93.21% 93% 97.17% 

2 Week Breast symptoms urgent 

referral to first outpatient appointment 

waiting times 93% 

96.91% 

All Cancers - 1 Month Diagnosis To 

Treatment 96% 100% 96% 

99.35% 

All Cancers - 2 Month GP Urgent 

Referral To Treatment 85% 90.92% 85% 

88.37% 


Treatment Of Anti Cancer Drug 

100% 

Regimen 98% 


Treatment Of Surgery 94% 100% 

All Cancers - 2 Month From Consultant 

Upgrade to Treatment 86% 91.18% 

All Cancers - 2 Month From Screening 

Services Referral To Treatment 90% 98.37% 

Incidence of MRSA 10 4 4 2 

Incidence of Clostridium Difficile 60 36 35 29 

18 Week Referral to Treatment: 

Admitted Patients (at March) 90% 90.92% 90% 94.50% 



2009/10 

2009/10 

Performance 

2010/11 2010/11 

18 Week Referral to Treatment: Non 

Admitted Patients (at March) 95% 97.82% 95% 99.06% 

Smoking during pregnancy - data 

completeness 95% 97% 95% 98.12% 

Smoking during pregnancy 29.03% 26.31% 

Patient Experience 

National In-patient Survey 2010 

476 responses were received which equates to 57% of surveys distributed. 

Question Area 

Admission 

The Hospital and Ward 

Doctors 

Nurses 

Care and Treatment 

Operations and 

Procedures 

Leaving Hospital 

Overall 

Conclusions 

Trust scores in relation to other Trusts on patient admission are 

generally higher. 

Overall Trust scores on patient admission issues have fallen back since 

last year. 

Trust scores in relation to other Trusts on issues relating to the hospital 

and ward environment are mixed. 

Overall Trust scores on hospital and ward environment issues have 

improved since last year. 

Trust scores in relation to other Trusts on issues relating to doctors are 


Overall Trust scores on doctors have fallen back since last year. 

Trust scores in relation to other Trusts on issues relating to nurses are 


Overall Trust scores on nurses have fallen back since last year. 

Trust scores in relation to other Trusts on issues relating to care and 

treatment are generally higher. 

Overall Trust scores on care and treatment have fallen back since last 

year. 

Trust scores in relation to other Trusts on issues relating to operations 

and procedures are generally lower. 

Overall Trust scores on operations and procedures have fallen back 

since 

last year. 

Trust scores in relation to other Trusts on issues relating to leaving 

hospital are generally lower. 

Overall Trust scores on leaving hospital have improved since last year. 

Trust scores in relation to other Trusts on issues relating to the patients’ 

overview of their stay are generally lower. 

Overall Trust scores on the patients’ overview of their stay have fallen 

back since last year. 

The following chart shows the range of responses on some key questions in the survey. It 

shows three things: 

• The range of scores achieved by all Trusts surveyed by Quality Health on a 

particular group of questions. The range is graded from green to red. 

• The national mean score achieved by all Trusts for each of the questions. This is 

shown as a blue arrow pointing toward each scale. 

• The Trust’s score on each key question. This is shown on the scale as a yellow 

diamond. 

The national mean score and the Trust’s score is shown without any weighting or 

standardisation of the data. 



Our best scores (15 areas) – the Trust scored in the top 20% of acute trusts in England for 

the following: 

• Being treated with respect and dignity 

• Having enough privacy when being examined or treated 

• Patient feeling they waited the right amount of time on the waiting list 

• Patients not having their admission date changed 

• Short length of time to get to a bed on the ward 

• Not sharing a sleeping area with patients of the opposite sex 

• Cleanliness of ward areas 

• Cleanliness of toilets and bathrooms 

• Rating hospital food as very good 

• Patients being given enough help from staff to eat their meals 

• Patients having confidence and trust in the nurses 

• Patients having confidence and trust in the doctors 

• Nurses washing hands between patients 

• Having enough privacy when discussing condition or treatment 

• Not needing to complain about their care in hospital. 



An action plan has been developed for those areas where the Trust scored less well: 

Issue 

For being bothered by noise at 

night from staff 

Action 

Continue with initiatives commenced in 2010: ear plugs 

offered at night to suitable patients and a regular noise 

audit. 

Information to be placed in patient lockers to raise patient 

awareness. 

For always being offered a 

choice of food 

Staff completely explaining 

how the operation had gone in 

a way the patient could 

understand 

To review menu provision on EADU to implement normal 

ward menu and increase choice offered. 

Staff reminded to check patient understanding following 

information giving (Remember I’m a patient leaflet) 

Values (customer care) training 

Encourage patient responsibility through posters in clinics/ 

ward areas ‘Have you understood what was said to you? 

Do you need to ask again/do you need to ask any other 

questions?’ 

Staff completely telling 

patients how they would feel 

after the operation/treatment 


risks and benefits before the 

operation 


what would happen during 

operation/treatment 

Staff completely answering 

questions before the operation 

in a way the patient could 

understand 

Staff completely telling 

patients what danger signals to 

watch for at home 

Staff completely giving family/ 

someone close to the patient 

information on how to help care 

for them 

Patient being asked to give 

their views on care quality 

As above 

As above 

As above 

As above 

Posters to be developed: ‘Red means danger – if the 

wound feels hot or red following the procedure contact the 

ward or GP’ 

Review discharge leaflets. 

Pilot information: ‘Discharge from hospital into care setting’ 

– covering medications, diagnosis, skin condition, 

treatment to be adapted for family/carer use. 

Add information to website asking patients to give their 

views on the quality of care using the PET devices. 

Link to NHS Choices website on Trust website. 



Experience Based Design 

Experience based design (EBD) is a method of designing better experiences for patients, 

carers and staff and captures the experiences of those involved in healthcare services. The 

approach has been produced through the work of the NHS Institute for Innovation and 

Improvement (www.institute.nhs.uk/ebd) working in collaboration with NHS organisations and 

external agencies. This approach focuses on the experience of care. 

Experience based design uses four key steps: 

1. Capture the experience; getting patients and staff involved 

2. Understand the experience; identifying emotions, mapping highs and lows, finding 

touchpoints 

3. Improve the experience; co-design, turning experience into action; and 

4. Measure the improvement; evaluate and sustain the improvement. 

Trust staff were invited to approach patients to ask if they would like to be involved in the 

work to improve their experience of care at the Trust. Norfolk LINks, Suffolk Family Carers, 

Deaf Connexions and Norfolk and Norwich Association for the Blind were also approached 

for interested participants. This resulted in 25 staff and 14 patients/carers attending an 

experience event. 25 staff and patients were also involved in co-design events. 

Feelings and experience were captured by asking everyone to complete an experience 

questionnaire. This questionnaire is a tool to gather people’s emotions at certain points along 

the patient journey through the hospital. We adapted the questionnaire to reflect the inpatient 

journey and the out-patient journey so patients could share their experiences of either 

or both. The staff were asked to reflect on how they felt about the care they gave at particular 

points along the patient journey. 

Separate staff and patient events were held followed by a joint co-design event where the 

results were discussed, collated, themed and ranked. 

The findings were merged into three main action groups: 

1. Special needs training/carer involvement 

2. Environment/car parking 

3. Communication/attitudes/team working/resource pressures/clinics/technology 

The information gained has been fed into a number of Trust projects/action plans: 

• Carer involvement links into the Dementia project 

• Mental health training and special needs training for staff 

• Values and Customer Care training 

• Understanding how Choose & Book works and patient information 

• Car parking 

• Discharge information given to patients. 



Maternity National Survey 

The response rate for the Trust was 47% (116 usable responses from a final sample of 245). 

Question Area Conclusions Recommended Actions 

Early Pregnancy 

Antenatal Check-ups 

Tests and Scans 

During Pregnancy 

Trust scores in comparison to other 

Trusts on issues relating to care at 

the start of pregnancy are more 

positive. 

Trust scores on issues relating to 

care at the start of pregnancy have 

improved compared to 2007. 


Trusts on issues relating to 

antenatal check-ups are more 

positive. 


antenatal check-ups have improved 

in respect of staff continuity 

compared to 2007. 


Trusts on issues relating to tests 

and scans are about the same. 


Trusts on issues relating to care 

during pregnancy are mixed. 


care during pregnancy have 

remained about the same compared 

to 2007. 

Increase the number of women who 

are given a choice of where to have 

their baby including a home birth. 

Ensure that information is given 

about the choices available to women 

on where to have their baby. 

Ensure all women who need one are 

given a copy of The Pregnancy Book. 

Ensure that all women are given 

information about the NHS Choices 

website. 

Ensure that women are given as 

much choice as is possible about 

where they have their antenatal 

check-ups and who will do them. 

Increase continuity of care from 

midwives so that women see the 

same midwife as often as possible. 

Look at ways of increasing the 

continuity of care from hospital 

doctors so that women see the same 

doctor as often as possible. 

Ensure that all women have a choice 

about whether they have a screening 

test for Down’s syndrome. 

Take action to improve explanations 

about the reasons for testing for 

Down’s syndrome. 

Ensure that women get clear 

explanations about the reasons for 

dating scans and mid-trimester scans 

and feel they have a choice about 

having these scans. 

Ensure that all women are given a 

contact number in case they are 

worried during their pregnancy. 

Ensure that both verbal and written 

information is easily understood by 

women, and that all information and 

explanations required are given. 

Ensure that all women are treated 

with respect and dignity, kindness 

and understanding during their 

pregnancy. 

Ensure that women are involved as 

much as possible in decisions about 

their care. 




Antenatal Classes 

During Labour 

The Baby’s Birth 


Trusts on issues relating to 

antenatal classes are more positive. 


antenatal classes have improved 



Trusts on issues relating to labour 

are about the same. 

The Trust score on getting the pain 

relief wanted has remained about 

the same. 


Trusts on issues relating to the birth 

of the baby are about the same. 

Review the provision of NHS 

antenatal classes given the high 

proportion of women not attending 

NHS classes and in particular, those 

not attending any classes at all. 

Examine alternative times and places 

for classes given the number of 

women saying they were not 

convenient. 

Ensure that women are told when 

partners/others can attend classes 

with them. 

Ensure that there are enough classes 

to meet women’s needs. 

Ensure that women are given a 

choice as far as is possible about 

whether they are induced. 

Examine ways of increasing the 

number of women able to move 

around and choose the position that 

makes them most comfortable during 

labour. 

Ensure that women are given pain 

relief in a timely manner to meet their 

needs. 

Consider whether the Trust’s level of 

caesarean sections can be brought 

down. 

The Staff 


the birth of the baby have improved 



Trusts on issues relating to the staff 

are mixed. 


the staff are mixed compared to 

2007. 

Ensure that women are cared for by 

the same midwives as far as is 

possible during labour and the birth 

of their baby and if possible by 

midwives they have met previously. 

Ensure that husbands and partners 

are able to be present for the whole 

of labour and the birth of the baby if 

requested. 

Examine reasons why some women 

feel they are left alone at times which 

they find worrying. 



women, and that all the information 

and explanations required are given. 



and understanding during labour and 

the birth of their baby. 




Post-natal Hospital 

Care 

Feeding Baby 

Care at Home After 

Birth 


Trusts on issues relating to hospital 

care after the birth are more 

positive. 


hospital care after the birth have 

fallen back compared to 2007. 


Trusts on issues relating to feeding 

baby are less positive. 


feeding baby have remained about 

the same compared to 2007. 


Trusts on issues relating to care at 

home 

after the birth are more positive. 


care at home have improved in 

respect of the overall rating of care 


Examine ways of increasing the 

number of women who feel involved 

in decisions about their care during 

labour and the birth of their baby. 

Examine reasons why some women 

think their stay in hospital was too 

short. 

Ensure that women are given all the 

information they require about their 

own recovery after the birth of their 

baby. 

Ensure that all babies have a 

newborn examination before 

discharge. 



women, and that all the information 

and explanations required are given. 



and understanding during their 

postnatal stay in hospital. 

Ensure that women have infant 

feeding discussed with them during 

their pregnancy by midwives. 

Ensure that women are given full 

support and encouragement, 

practical help and consistent advice 

about feeding their baby, particularly 

in relation to breast feeding. 

Look at ways of increasing the 

number of women breast feeding 

Ensure that women have a contact 

number in case they are worried by 

anything when at home after the 

baby’s birth. 

Review the number and frequency of 

midwives visits in the light of 

respondents’ views. 

Review the provision of information 

about looking after baby in the light of 

the number of women who say they 

either did not get information or that 

they only got it to some extent. 

Ensure that all women have postnatal 

check-ups for their own health. 



Compliments and Complaints 

As a Trust we are encouraged that our patients, their families 

and visitors can access ways to provide us with feedback and 

we welcome their comments. 

A total of 334 formal complaints were received by the Trust 

during 2010/11 on a range of issues as detailed in the graphs 

below. This equates to 4.2 complaints per 1000 admissions. 

All complaints are seen and responded to by the Chief 

Executive and we regularly review trends and change our 

practices as a direct result of this invaluable feedback. For an 

example of changes to practice following a complaint see case 

study below. 

Complaints 2010/2011 

40 


38 

Number of Complaints 

35 

30 

25 

20 

15 

35 

31 

26 

29 

20 

23 23 

33 

21 

28 

27 

10 

5 

0 



Complaint Issues 2010/2011 

300 

250 

262 

01.04.11 to 31.03.11 (Total Number = 576) 

Number of Complaint Issues 

200 

150 

100 

84 

91 

50 

0 

25 

8 

6 

30 

1 

20 

10 

4 4 1 

16 

1 

7 3 2 1 

Admiss, Disch & 

Trans Arrang 

Aids, Appliance 

Equit, Premise 

All Aspects Clinical 

Treatment 

Appoints 

Delay/cancel (IP) 

Appoints 

Delay/cancel (OP) 

Attitude Of Staff 

Comms/Inf To 

Patients 

Dementia 

Essence Of Care 

Failure To Follow 

Procedures 

Hotel Services 

Infection Control 

Other 

Paitent 

Privacy/Dignity 

Patient 

Discrimination/Status 

Patients Property & 

Expenses 

Personal Records 

(Inc Medical) 

Policy & Systems 

Transport (Amb & 

Other) 

Category Type 



Case Study: Health Service Ombudsman 

During 2010/11 five cases were referred to the Health Service Ombudsman for review. 

None were accepted for investigation. However, one complaint was upheld and investigated by 

the Ombudsman in 2010 although it was reported in 2009. 

The Trust received a complaint from the relatives of a lady who was taken ill whilst on holiday in 

the area. She attended a local GP who telephoned our Emergency Assessment and Discharge 

Unit (EADU) for advice as this lady had a rare congenital disorder. The Consultant gave advice 

over the telephone that the patient should see her specialist on her return home. The patient 

returned home immediately but passed away the next day. 

The family complained and stated the patient died because she was not admitted to hospital for 

assessment. The case was referred to the Health Service Ombudsman who investigated the 

complaint and the complaint was upheld, as the Trust was unable to provide sufficient evidence of 

the conversation between our consultant and the GP on the telephone. 

As a result of the Ombudsman’s report into this complaint the Trust developed an action plan to 

prevent a similar occurrence in the future. This included: 

Telephone Advice: The Trust had no information on the patient because it was a telephone 

enquiry for advice which had not been documented in EADU. The patient was on holiday and 

therefore had no hospital notes. The Trust now utilises the EADU referral forms to document 

telephone advice given to GP's which are retained on the unit. The Trust now ensures that when 

GPs telephone the unit they are given advice regarding what to do if a patient deteriorates, 

including a reminder that GPs are able to admit directly to EADU if they are concerned. 

The Trust accepted the Ombudsman’s recommendations and a copy of the action plan was 

shared with the family, together with an apology. 

A number of complaints were received by the Trust throughout February and March 2011, 

which resulted in some negative media reports, where the standard of care at the Trust was 

being questioned. 

Maintaining the reputation of the Trust, our staff and the services we provide is a priority at all 

times. We have, where possible, provided accurate information to the media without 

compromising patient confidentiality. We have also acknowledged where mistakes have been 

made, apologised where appropriate and agreed on ways forward to resolve the issues. 

We have also received many positive comments and compliments from users of our services 

via thank-you cards, letters, emails and correspondence on the NHS Choices website: 

“What impressed me most was that I was treated as an individual.” 

“Throughout I was nursed with care and compassion.” 

“Thanks for everything. 

I could not have wished for better treatment. 

The staff were great, all of them. 

The Food was excellent. 

The bed was very comfortable. 

The level of care un-surpassable.” 



PALS 

The Patient Advice and Liaison Service (PALS) supports patients, relatives, carers and 

members of the public who need information about the healthcare system. They deal with 

general enquiries about the healthcare services available, resolve problems by identifying the 

right people to talk to and explain how to make a complaint if a concern is unresolved. 

During 2010/11 there were 806 enquiries via PALS, as demonstrated by the graphs below. 

100 

90 

86 

PALS Enquiries 10/11 

01.04.10 to 31.03.11 (Total Number = 

755) 

80 

80 

Number of Enquirers 

70 

60 

50 

40 

56 

64 

67 

61 

63 

60 

38 

48 

65 

67 

30 

20 

10 

0 



Case Study 4: 

Patients and visitors raised with PALS the lack of staff available at lunchtimes to 

give help to patients (to encourage patients with confirmed dementia/or the 

inability to eat their main hot meal). 

Family members sometimes cannot attend during the week, due to work or family 

commitments, and the staff do not always have the time to assist all the patients 

who require one on one support at lunchtimes. With this in mind we decided to 

have mealtime service providers that are given training and liaise with the sister 

on the ward to find out which patients need encouragement or some help. 

Patients who require assistance at mealtimes have red jugs and red trays so they 

can be easily identified. We now have a strong team of nine volunteers that 

attend at lunchtimes Monday – Friday and are in the process of recruiting more 

meal time helpers. 

This will improve the wellbeing of our patients by stimulating and encouraging 

them to eat their main lunchtime meal. This aids a quicker recovery and makes 

the patient’s journey through the hospital that little bit easier for them and their 

families. 



Patient Experience Measures 

Patient experience measures 2009/10 Actual 2010/11 Actual 

PROMS - % of questionnaires completed 

(All surgeries - April to October 2009) 

• Hip replacement surgery 

April to October inclusive rates only available 

• Knee replacement surgery 


• Varicose vein surgery 


• Groin hernia surgery 


Patient Feedback – % patients who would recommend 

this hospital to friends or family 

National Inpatient survey score for cleanliness – 

bathrooms/toilets/wards (Q 22) 

National Inpatient Survey – number of question areas 

where responses are ‘better’ than other trusts 

National Inpatient Survey – number of question areas 

where responses are in the top 20% compared to other 

trusts 

National Inpatient Survey score for dignity and respect 

(Q 72) 

National Inpatient Survey score rating for hospital food 

(Q 28) 

National Inpatient Survey score rating for patients 

experiencing a delay to discharge (Q 61) 

National Inpatient Survey score for patients 

understanding answers to important questions from 

doctors (Q 31) 

Patient feedback – having confidence and trust in the 

staff treating them (Q 32) 

National Inpatient Survey score for length of time on 

waiting list before admission (Q 9) 

April 09 to 75.5% 

October 09 data 

67% 

73% 79.6% 

77% 88.7% 

37% 51% 

40% 65.7% 

80% 2009/10 Local 

PET tool score 8 

out of 10 (80%) 

92 91 

9 0 

‘about the same’ 

on all areas 

34 15 

91 90 

64 63 

73 76 

84 83 

90 91 

87 87 

Formal Complaints – total number 325 334 



Staff Experience 

Staff Survey 2010 

The findings can be summarised as follows: 

• The Trust scored better than its 2009 score and/or than other trusts in 49 questions 

• The Trust scored the same as its 2009 score and/or than other trusts in 14 questions 

• The Trust scored lower than its 2009 score and/or than other trusts in 44 questions 

• The Trust scored better than its 2009 score but lower than other trusts in 10 questions 

The table below details some of the questions within the staff survey and the responses 

received compared to the average score for all other trusts: 

Item 

2010 Trust 

Data 

Work Life Balance 

% of staff working more than 11 unpaid hours a week 2% 3% 

% of staff agree that the Trust committed to helping staff balance 47% 35% 

home and work life 

% of staff who can approach their immediate manager to talk openly 51% 43% 

about flexible working 

% of staff who agree their manager gives clear feedback on their work 43% 38% 

% of staff who agree that team members have shared objectives 62% 62% 

% of staff who agree that the team regularly meets to discuss 

43% 45% 

effectiveness 

% of staff who agree that team members have to communicate closely 55% 57% 

to achieve the team’s objectives 

% of staff who agree that they often think about leaving the trust 16% 20% 

% of staff who agree that they will leave the Trust once they have 5% 9% 

found another job 

% of staff who have seen any errors, near misses or incidents that 18% 21% 

could have hurt staff 

% of staff who have reported a staff error, near miss or incident 43% 52% 

% of staff who have seen any errors, near misses or incidents that 25% 29% 

could have hurt patients 

% of staff who have reported a patient error, near miss or incident 58% 59% 

% of staff who agree that the Trust treats staff who are involved in an 43% 40% 

error, near miss or incident are treated fairly 

% of staff who agree that the Trust encourages staff to report errors, 

near misses or incidents 

68% 66% 

The chart below shows three things: 

Mean score 

for all Trusts 

• The range of scores achieved by all trusts surveyed on a particular group of questions. 

The range is graded from green to red. 

• The National mean score achieved by all trusts for each of the questions. This is shown 

as a blue arrow pointing toward each scale. 

• The Trust score on each question, shown as a yellow diamond. 



• 

100 

Key Scores Comparison 

90% 

80% 

70% 

60% 

50% 

40% 

30% 

20% 

10% 

0% 

Trust help 

staff work 

Appraisal/re 

view in last 

Have 

planned 

Disagree 

cannot meet 

conflicting 

Satisfied 

with extent 

Trust values 

Senior 

managers 

Care of 

patients top 

Management 

/ staff 

communicatio 

n effective 

No work 

related 

stress in last 

Local Staff Feedback 

The local Patient Experience Tool (electronic survey device) has been utilised within the 

Trust to ascertain staff opinion and input into a range of areas. The devices have been 

positioned in the staff canteen and main foyer and analysis is pending. 

Involvement 

This Quality Account has been developed in close collaboration with the Governors Council, 

who represent the Trust members, our patients and the local population. 

A draft version of this document was shared with our main commissioners during 2010/11, 

NHS Great Yarmouth and Waveney, the local GP commissioners Health East CIC, Local 

Involvement Networks (LINks) and the Health and Overview Scrutiny Committees for their 

comments. The following statements have been provided by these organisations for 

inclusion in this report. 



Endorsement 


Norfolk LINk and Suffolk LINk thanks the James Paget University Hospital Trust 

Board for the opportunity to comment on the Quality Account for 2010 - 2011. 

It was pleasing to see that cognisance had been taken of the previous comments 

made. The report was well presented with appropriate language for the general 

public to understand. 

The Trust is making good use of the national guidelines, CQUINN, and internal 

audits, etc to measure progress against defined targets when assessing progress 

against their four stated objectives of Reduction in Falls/ Reduction in Patient 

Mortality/ Patient Safety/ and Clinical Outcomes and Effectiveness. 

The Trust proposals are built upon the progress of the previous year and utilising 

specific equipment regarding falls throughout the hospital. This approach within the 

Trust and across the locality can only be good for patients and is pleasing to see. 

Improved patient safety has been put as a high value within the work across the Trust 

and this is to be commended. Norfolk LINk and Suffolk LINk look forward to the 

improved patient experience across the Trust. 

Internal audits are essential for the improvement of services. 

Norfolk LINk and Suffolk LINk are pleased to see the Trust is looking to ensure that 

the NICE Guidelines are embedded in all aspects of the work and commends the 

Trust on its recent good PEAT inspection and other external audits. 

Norfolk LINk and Suffolk LINk look forward to working with James Paget University 

Hospital NHS Foundation Trust in 2011/2012 and hearing of the continued 

improvements in the services that the hospital provides. 

Marion Fairman-Smith 

Suffolk LINk Chairman 

Patrick Thompson 

Norfolk LINk Chairman 

Health Overview and Scrutiny Committee 

The Norfolk Health Overview and Scrutiny Committee has decided not to comment on any of 

the Norfolk NHS Trusts Quality Accounts for 2010/11 and would like to stress that this should 

in no way be taken as a negative statement. 

The Suffolk Scrutiny Committee is confident with the relationships built up with NHS trusts in 

Suffolk over the past year. This work should be developed to ensure delivery of the best 

possible health services for the people of Suffolk. The Suffolk Scrutiny Committee has 

decided not to comment on any of the Suffolk provider NHS trust's Quality Accounts for 

2010/11 and would like to stress that this should in no way be taken as a negative comment. 

The Committee has taken the view that it is appropriate for Suffolk's Local Involvement 

Network (LINk) to consider the Quality Account and comment accordingly. 




NHS Great Yarmouth & Waveney thanks the James Paget University Hospitals NHS 

Foundation Trust for the opportunity to comment on their Quality Account for 2010/2011. 

NHS Great Yarmouth & Waveney confirms that the Quality Account is based on a 

reasonable interpretation of available data. 

The continued involvement of the trust in the NHS Great Yarmouth & Waveney Patient and 

Carer Experience Board was welcomed. Going forward in 2011/12, with NHS Great 

Yarmouth & Waveney’s revised Patient Safety Experience and Quality Committee, we hope 

to build on this partnership with all stakeholders to ensure that patient safety and experience 

are promoted. 

We note the continued reductions in Healthcare Associated Infection, the introduction of 

executive-led patient safety walk-rounds, and the James Paget University Hospitals NHS 

Foundation Trust’s innovation in the 2010/11 CQUIN Programme. We note the embedding of 

the Leading Improvement in Patient Safety Programme. 

The Trust also continued to demonstrate a reduction in Hospital Standardised Mortality Ratio 

rates. We acknowledge James Paget University Hospitals NHS Foundation Trust’s 

involvement in planning for the management of the demand on local services across the 

system. We welcome the continued partnership with James Paget University Hospitals NHS 

Foundation Trust in the Clinical Transformation Board, as the Trust transforms its local 

services through increasing clinical engagement and leadership, and look forward to the 

Trust’s active engagement in the System Leadership Board, whose prime purpose is to set 

the strategic direction for health and social care in Great Yarmouth and Waveney, and 

oversee the delivery of the area’s transformation, governance, QIPP and workforce plans. 

Going forward in 2011/2012 NHS Great Yarmouth & Waveney will encourage clear and 

reported outcome measures for patients. A particular focus will be reducing avoidable harm, 

and ensuring lessons and good practice are shared, through the Leading Improvement in 

Patients Safety Programme, and the analysis of patient experience, clinical incidents and 

complaints. 

The Board of NHS Great Yarmouth & Waveney will continue to monitor and review all 

relevant providers against the Mid-Staffordshire recommendations, the Ombudsman’s Report 

‘Care and Compassion and Maintaining Quality Through Transition’ and associated 

initiatives, and note that the Board of Directors of James Paget University Hospitals NHS 

Foundation Trust is monitoring this key area. 

NHS Great Yarmouth & Waveney look forward to encouraging further quality achievements 

in 2011/2012 with James Paget University Hospitals NHS Foundation Trust and to receiving 

the next Quality Account. 

Andrew Morgan 


NHS Great Yarmouth and Waveney 

Governors Council 

This report shows that in spite of an increasingly aged population, a great increase in the 

number of emergency admissions and having to make vast financial savings, the Trust 

continues to deliver an excellent service of a high standard to the majority of its patients and 

provides a good working environment for its staff. 

In any organisation there are bound to be criticisms and it is note worthy that the number of 

formal complaints has increased this year. However, it is important that people make known 



their concerns so that the matters can be investigated and actions put in place to make 

certain they do not recur. 

The Governors have been particularly keen that the patient should come first in all matters 

and this has been taken on board by the organisation. Much time and effort has been put 

into improving the patient’s experience and care and it is good to see that again national 

surveys have shown that in the majority of measures the Trust remains in the top 20% of 

trusts. Where this is not the case action plans have been developed to improve the 

performance. 

Each year the number of emergency admissions increases and this has been particularly 

severe this year. As a result, nearly 600 elective operations were postponed. This is very 

distressing for patients and their carers and puts added strain on all grades of staff. In 

addition, extra time and money has to be spent to find alternative times to perform these 

operations. Enabling the admission of patients for elective operations without cancelling 

emergency admissions is one of the biggest challenges facing the Trust. 

In spite of these pressures the Hospital Standardised Mortality Ratio remains low indicating 

an overall very good standard of care. 

In these particularly challenging times the Trust is to be congratulated that it has managed to 

maintain its high standards – and in some instances to improve upon them. The Governors 

welcome the frequent and open exchanges which they have with management and are 

pleased to play their part in helping to maintain and improve standards. 



Glossary of Abbreviations 

A&E 

C diff 

CMACE 

CQC 

CQUIN 

CRT 

EWS 

GUM 

H@N 

HFEA 

HSE 

HSMR 

ICAS 

IHI 

IOG 

LINks 

LIPS 

LOS 

MCDC 

MUST 

NCEPOD 

NCISH 

NHSLA 

NICE 

NIHR 

NSF 

PCT 

PEAT 

PET 

PROMs 

QIPP 

SUS 

SWIFT 

TIA 

TTO 

VTE 

Accident and Emergency Department 

Clostridium difficile 

Centre for Maternal and Child Enquiries 


Commissioning for Quality and Innovation 

Customer Research Technology 

Early Warning Score 

Genitourinary medicine 

Hospital at Night 

Human Fertilisation & Embryology Authority 

Heath and Safety Executive 

Hospital standardised mortality rate 

Independent Complaints Advocacy Service 

Institute for Health Improvement 

Improving outcomes guidance 


Leading Improvement in Patient Safety programme 

Length of stay 

Marie Curie Delivering Choice programme 

Malnutrition Universal Screening Tool 

National Confidential Enquiry into Patient Outcome and Death 

National Confidential Enquiry into Suicide and Homicide 

National Health Service Litigation Authority 

National Institute for Health and Clinical Excellence 

National Institute of Health Research 

National Service Framework 

Primary Care Trust 

Patient Environment Action Team 

Patient Experience Tool 

Patient Reported Outcome Measures 

Quality, Innovation, Productivity and Prevention 

Secondary Uses Service 

Strategic Workforce Investment Fund for Tomorrow 

Transient Ischaemic Attack 

To Take Out (medications) 

Venous thromboembolism 





Financial Statements 

for the year ended 31st March 2011 

Where you come first 

Page 2 Making Waves Newsletter March 2011 www.jpaget.nhs.uk

Contents 

Page 

Statement of Accounting Officer's Responsibilities 2 

Annual Governance Statement 3 

Independent Auditor's Report to the Governors Council of James 

Paget University Hospitals NHS Foundation Trust 

7 

Foreword to the Accounts 9 

Statement of Comprehensive Income 10 

Statement of Financial Position 11 

Statement of Changes in Taxpayers' Equity 12 

Statement of Cash Flows 14 

Notes to the Accounts 15

Statement of Accounting Officer's Responsibilities 

Statement of the Chief Executive's responsibilities as the Accounting Officer of the James 

Paget University Hospitals NHS Foundation Trust 

The National Health Service Act 2006 ("2006 Act") states that the Chief Executive is the Accounting Officer of the 

NHS Foundation Trust. The relevant responsibilities of the Accounting Officer, including their responsibility for the 

propriety and regularity of the public finances for which they are answerable, and for the keeping of proper accounts, 

are set out in the NHS Foundation Trust Accounting Officers' Memorandum issued by the Independent Regulator of 

NHS Foundation Trusts ("Monitor"). 

Under the NHS Act 2006, Monitor has directed the James Paget University Hospitals NHS Foundation Trust to 

prepare for each financial year a statement of accounts in the form and on the basis set out in the Accounts Direction. 

The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of the James 

Paget University Hospitals NHS Foundation Trust and of its income and expenditure, total recognised gains and 

losses and cash flows for the financial year. 

In preparing the accounts, the Accounting Officer is required to comply with the requirements of the NHS Foundation 

Trust Annual Reporting Manual and in particular to: 

- Observe the Accounts Direction issued by Monitor, including the relevant accounting and disclosure 

requirements, and apply suitable accounting policies on a consistent basis; 

- Make judgements and estimates on a reasonable basis; 

- State whether applicable accounting standards as set out in the NHS Foundation Trust Annual 

Reporting Manual have been followed, and disclose and explain any material departures in the financial 

statements; and 

- Prepare the financial statements on a going concern basis. 

The Accounting Officer is responsible for keeping proper accounting records which disclose with reasonable accuracy 

at any time the financial position of the Foundation Trust and to enable her to ensure that the accounts comply with 

the requirements outlined in the above mentioned Act. The Accounting Officer is also responsible for safeguarding 

the assets of the Foundation Trust and hence for taking reasonable steps for the prevention and detection of fraud 

and other irregularities. 

To the best of my knowledge and belief, I have properly discharged the responsibilities set out in Monitor's NHS 

Foundation Trust Accounting Officer Memorandum. 


27th May 2011 


Financial Statements for the year ended 31st March 2011 Page 2

Annual Governance Statement 

Scope of responsibility 

As Accounting Officer, I have responsibility for maintaining a sound system of internal control that supports the 

achievement of the NHS Foundation Trust‟s policies, aims and objectives, whilst safeguarding the public funds and 

departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I 

am also responsible for ensuring that the NHS Foundation Trust is administered prudently and economically and that 

resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS 

Foundation Trust Accounting Officer Memorandum. 

The purpose of the system of internal control 

The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of 

failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of 

effectiveness. The system of internal control is based on an ongoing process designed to identify and prioritise the 

risks to the achievement of the policies, aims and objectives of James Paget University Hospitals NHS Foundation 

Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage 

them efficiently, effectively and economically. The system of internal control has been in place in James Paget 

University Hospitals NHS Foundation Trust for the year ended 31 March 2011 and up to the date of approval of the 

annual report and accounts. 

Capacity to handle risk 

The Trust has in place a Risk Management Strategy which makes it clear that whilst overall responsibility for risk 

management is placed with the Chief Executive, responsibility for specific risk management areas has been delegated 

to the following key Committees and Groups: 

- Safety and Quality Governance Committee (formerly the Healthcare Governance Committee) and Audit 

Committee; 

- Transformation Board; 

- Safety Committee (formerly Risk & Safety Action Group and Clinical and Medical Review Action Group); 

- Adverse Event Review Group; 

- Information Governance Action Group; and 

- Divisional Boards. 

The Strategy also identifies individual Executive Directors, Divisional Managers/Directors, managers and employees 

and clearly defines their role and responsibilities within the risk management framework. 

A range of risk management training is provided to staff and there are policies in place to describe their roles and 

responsibilities in relation to the identification and management of risk. The Trust also records and manages risks 

using a computer software package, specifically designed to record and track progress of risks electronically in real 

time and nominated key staff are responsible for ensuring this system is kept up to date. 

All relevant policies are available on the Trust's intranet. Written guidelines are also disseminated, covering all 

components of risk management. 

The risk and control framework 

The James Paget University Hospitals NHS Foundation Trust has a comprehensive Risk Management Strategy and 

Assurance Framework Strategy in place, both of which are reviewed by a joint Audit Committee and Safety and Quality 

Governance Committee meeting held annually. The Risk Management Strategy, and associated policies, set out the 

key responsibilities for managing risk within the organisation, including the ways in which the risk is identified, 

evaluated, updated and controlled. 

All staff are responsible for responding to incidents, hazards, complaints and near misses in accordance with the 

appropriate policies. Local Clinical Governance and Risk Groups are responsible for identifying and managing local 

risks and overseeing the management of adverse incidents. Management teams are responsible for reviewing risk 

action plans and ensuring they are implemented through business planning and other established routes. 




continued 

The Board of Directors has delegated responsibility to the Safety and Quality Governance Committee for monitoring 

and reviewing risk processes. Other key features include: 

- 

- 

- 

There is an integrated reporting system, including the identification within all terms of reference of all 

committees, action groups and other working groups which requires every type of risk and adverse 

event to be reported; 

The Safety and Quality Governance Committee and the Audit Committee receive reports and instigate 

action to deal with risks which have been identified; and 

There is a comprehensive Risk Register which is presented at each meeting of the Board of Directors 

and the top five risks and any changes to the risks register over the previous month are highlighted. 

The Trust‟s Assurance Framework Strategy sets out the principal risks to delivery of key priorities and objectives 

against Trust wide initiatives. The Executive Director with delegated responsibility for managing and monitoring each 

risk is clearly identified. The Assurance Framework Strategy identifies the assurances available to the Board of 

Directors in relation to the achievement of the Trust's key priorities and objectives. The principal risks to the delivery of 

these objectives are mapped to key controls. The Board of Directors requires both the assurance that the Board 

Assurance Framework identifies those actions required to address gaps in control and assurance, and the 

development and implementation of action plans. 

A risk appetite and tolerance system is in place and a risk estimation matrix has been developed for use throughout 

the Trust for identifying risks, maintaining progress and monitoring the risk register and plans. This includes the 

method for determining which risks will be managed, assigned priorities for remedial action, and whether risks are to 

be accepted or not. The full risk register is available to the Board of Directors at each meeting. The Safety and Quality 

Governance Committee reviews all high and extreme risks at each meeting. 

Quality governance arrangements are embedded within the Trust‟s overarching governance structure. Quality is 

assessed as part of the Divisional Board structure with regular performance monitoring occurring at department and 

ward level. Also quality is reported and considered by the Board of Directors on a monthly basis. 

Assurance is assessed weekly in respect of compliance with CQC registration requirements via the Trust‟s External 

Assessment and Performance Group with membership from Executive, Non Executive Directors and senior managers. 

This group will prioritise and take appropriate action to address any CQC requirements. 

The Trust‟s major risks for 2010/11 and beyond are as follows: 

1. 

Patient safety, in particular patient falls and pressure ulcers. All patient safety risks are identified and monitored 

via the robust risk reporting mechanisms. All incidents are investigated and appropriate action plans developed 

and actions taken. During 2010/11 the Trust has developed a patient safety programme lead by a project 

director. Improvements in patient safety are being addressed via ten key work streams, as follows: 

- Pressure ulcers – reduce hospital acquired cases; 

- VTE – prevention; 

- Falls – prevention and reduction; 

- Documentation and record keeping – improvement; 

- Mortality & Case note reviews – gain intelligence and target future patient safety work; 

- Medicines management – reduce errors and omissions for inpatients, medicines reconciliation and issuing; 

- Nutrition & Hydration – improvement action plan; 

- Patient flow – reduce movement, reduce length of stay and improve discharge; 

- Infection Prevention – reduce HCAI; and 

- Observations and the deteriorating patient – improved early detection and treatment of the deteriorating 

patient. 

Patient safety continues to be one of our key priorities for 2011/12 and the Board of Directors will continue to 

support the patient safety project and other initiatives to reduce patient safety risks. 

2. The Trust saw unprecedented levels of emergency activity during the 2010/11 winter period, which in turn put 

pressure on delivering both the national 18 week target for admitted patient care and to maintain A&E 4 hour 

wait targets. The achievement of these key targets and cancer waiting times will continue to be a challenge to 

the Trust if emergency demand does not abate. This risk is monitored by the Trust information services team 

and reported through performance reports to departments, divisions, the External Assessment and 

Performance group weekly and monthly to the Board of Directors. This will continue to be one of the key 

priorities for 2011/12 including ensuring our services are in line with the NHS Constitution. The existing 

framework to manage and control this risk will remain in place going forwards. 




continued 

3. 

4. 

Achievement of the Cost Improvement Programme. This is monitored by the Trust Finance and Transformation 

teams with progress being reported monthly to the Board of Directors. This will continue to be one of the key 

priorities for 2011/12. 

The PCT strategy to transfer care from the acute setting to primary and secondary care locations is aimed at 

transferring £16m worth of activity. The risk to the Trust is that the costs that flow with the income will be lower 

and the residual financial exposure will be the responsibility of the Trust. To ensure that this shift is successful 

the system will need to demonstrate alternative care settings that are capable of delivering the capacity 

required in a more cost effective setting. 

Risks to information are managed by the Information Governance Action Group, chaired by the Medical Director who 

also acts as Caldicott Guardian and is supported by the Senior Information Risk Officer. The Trust also has an 

Information Risk Management Policy in place to manage and control data security risks and provides training to staff 

on the matter of Information Governance. Further assurance was provided by the achievement of a „satisfactory‟ 

rating in the Information Governance Assessment for 2010/11, continuing the Trust‟s performance of achieving a 

„green‟ rated achievement score. 

Risk management is embedded throughout the organisation at every level. The Trust also records and manages 

incidents using a computer software package, specifically designed to record and track progress of incidents 

electronically in real time and nominated key staff are responsible for ensuring this system is kept up to date. 

The public and patients are involved in identifying risk and bringing this to the attention of the Foundation Trust in a 

variety of ways: 

- The Governors have been involved in setting the priorities within the Quality Account for 2010/11; 

- Local Involvement Networks; 

- The Board of Directors considers a patient story at the start of each monthly meeting to help identify, 

manage and mitigate key risks; 

- Patients and relatives are involved in addressing issues identified through complaints, claims, Patient 

Advice and Liaison (PALS) and incidents via involvement in action planning; 

- Patient and/or Governor representatives are members of key trust governance committees; 

- Governors raise issues of concern received from Trust members / patients and carers; 

- Trust Community Involvement Group; 

- Patient Satisfaction Surveys; and 

- Complaints, claims and Patient Advice and Liaison concerns. 

Public Stakeholders are involved in managing risk which impacts on them, for example: 

- There are Foundation Trust meetings at all levels with members of the Primary Care Trust at which risk 

is assessed; 

- Health Overview and Scrutiny Committees; 

- Partnership working with Social Services; and 

- Joint working with other Trusts i.e. Norfolk & Norwich University Hospitals NHS Foundation Trust, East 

of England Ambulance Service NHS Trust and Norfolk and Waveney Mental Health NHS Foundation 

Trust. 

The Foundation Trust is fully compliant with the registration requirements of the Care Quality Commission. 

As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to 

ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring 

that deductions from salary, employers'contributions and payments into the Scheme are in accordance with the 

Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales 

detailed in the Regulations. 

Control measures are in place to ensure that all the organisation's obligations under equality, diversity and human 

rights legislation are complied with. 

The Foundation Trust has undertaken risk assessments and Carbon Reduction Delivery Plans are in place in 

accordance with emergency preparedness and civil contingency requirements, as based on UKCIP 2009 weather 

projects, to ensure that this organisation‟s obligations under the Climate Change Act and the Adaptation Reporting 

requirements are complied with. 




continued 

Review of economy, efficiency and effectiveness of the use of resources 

The Trust targets some internal audit work on the overall performance of specific areas within the Trust. During 

2010/11 Orthopaedics and a specific review of the Trust‟s IT data centre project were reviewed. Whilst the emphasis 

is primarily on risk management, governance and internal controls, the individual assignments consider issues 

relating to economy, efficiency and effectiveness. Where scope for improvement in terms of value for money was 

identified, appropriate recommendations were made and action plans agreed with management for implementation. 

The Board of Directors has also received assurances on the use of resources from agencies outside the Trust 

including Monitor. Monitor requires the board of directors to self assess on a quarterly basis. Monitor scores the 

assessment on a traffic light system. 

The Trust further obtains assurance of its systems and processes and tests efficiency through benchmarking by 

membership of the Foundation Trust Network where other Foundation Trusts share good practice. 

Review of effectiveness 

As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review 

of the effectiveness of the system of internal control is informed by the work of the internal auditors, clinical audit and 

the executive managers and clinical leads within the NHS Foundation Trust who have responsibility for the 

development and maintenance of the internal control framework. I have drawn on the content of the quality report 

attached to this Annual report and other performance information available to me. My review is also informed by 

comments made by the external auditors in their management letter and other reports. 

My review is also informed through confirmation by Monitor via quarterly monitoring that the Trust is compliant with 

Monitor‟s regime with a financial risk scoring of 3 in the first quarter followed by a scoring of 4 for the remainder of the 

year and a governance score of green throughout the year. 

I have been advised on the implications of the results of my review of the effectiveness of the system of internal 

control by the Board, Audit Committee, and Safety and Quality Governance Committee and a plan to ensure 

continuous improvement of the system is in place. 

The Board of Directors reviewed the 2010/11 Board Assurance Framework throughout the year. The Board of 

Directors has received regular reports on risk management, performance management and clinical governance. 

The Audit Committee has provided the Board of Directors with an independent and objective review of financial and 

corporate governance and internal financial control within the Trust. The Committee has received reports from 

external and internal audit. Internal audit has reviewed and reported upon control, governance and risk management 

processes, based on an audit plan approved by the Committee. The work included identifying and evaluating controls 

and testing their effectiveness, in accordance with NHS Internal Audit Standards. When scope for improvement was 

found, recommendations were made and appropriate action plans agreed with management. 

In particular, work during the year has focussed on addressing Human Resources controls that were identified during 

2009/10 where a number of issues relating to employment were identified. The Trust developed a robust action plan 

and there has been an improvement in controls during 2010/11. Further work will continue in this area during 2011/12 

to continue to enhance controls around employment. 

Conclusion 

There have been no significant internal control issues identified other than those reported above. 





Independent Auditor's Report to the Governors Council of 


I have audited the financial statements of James Paget University Hospitals NHS Foundation Trust for the year 

ended 31 March 2011 under the National Health Service Act 2006. The financial statements comprise the Statement 

of Comprehensive Income, the Statement of Financial Position, the Statement of Changes in Taxpayers‟ Equity, the 

Statement of Cash Flows and the related notes. These financial statements have been prepared under the 

accounting policies set out in the Statement of Accounting Policies. 

I have also audited the information in the Remuneration Report that is subject to audit, being: 

- the table of salaries and allowances of senior managers and related narrative notes on page 83; and 

- the table of pension benefits of senior managers and related narrative notes on page 84. 

This report is made solely to the Governors Council of James Paget University Hospitals NHS Foundation Trust in 

accordance with paragraph 24(5) of Schedule 7 of the National Health Service Act 2006. My audit work has been 

undertaken so that I might state to the Governors Council those matters I am required to state to it in an auditor‟s 

report and for no other purpose. To the fullest extent permitted by law, I do not accept or assume responsibility to 

anyone other than the Foundation Trust as a body, for my audit work, for this report or for the opinions I have formed. 

Respective responsibilities of the Accounting Officer and auditor 

As explained more fully in the Statement of Accounting Officer‟s Responsibilities, the Accounting Officer is 

responsible for the preparation of the financial statements and for being satisfied that they give a true and fair view. 

My responsibility is to audit the financial statements in accordance with applicable law, the Audit Code for NHS 

Foundation Trusts and International Standards on Auditing (UK and Ireland). Those standards require me to comply 

with the Auditing Practice‟s Board‟s Ethical Standards for Auditors. 

Scope of the audit of the financial statements 

An audit involves obtaining evidence about the amounts and disclosures in the financial statements sufficient to give 

reasonable assurance that the financial statements are free from material misstatement, whether caused by fraud or 

error. This includes an assessment of: whether the accounting policies are appropriate to the Trust‟s circumstances 

and have been consistently applied and adequately disclosed; the reasonableness of significant accounting 

estimates made by the Trust; and the overall presentation of the financial statements. I read all the information in the 

annual report to identify material inconsistencies with the audited financial statements. If I become aware of any 

apparent material misstatements or inconsistencies I consider the implications for my report. 

Opinion on financial statements 

In my opinion the financial statements: 

- 

- 

give a true and fair view of the state of affairs of James Paget University Hospitals NHS Foundation 

Trust‟s affairs as at 31 March 2011 and of its income and expenditure for the year then ended; and 

have been properly prepared in accordance with the accounting policies directed by Monitor as being 

relevant to NHS Foundation Trusts. 

Opinion on other matters 

In my opinion: 

- the part of the Remuneration Report subject to audit has been properly prepared in accordance with 

the accounting policies directed by Monitor as being relevant to NHS Foundation Trusts; and 

- the information given in the Annual Report for the financial year for which the financial statements are 

prepared is consistent with the financial statements. 



Independent Auditor's Report to the Governors Council of 


continued 

Matters on which I report by exception 

I have nothing to report in respect of the Annual Governance Statement on which I report to you if, in my opinion the 

Annual Governance Statement does not reflect compliance with Monitor‟s requirements. 

Certificate 

I certify that I have completed the audit of the accounts of James Paget University Hospitals NHS Foundation Trust in 

accordance with the requirements of the National Health Service Act 2006 and the Audit Code for NHS Foundation 

Trusts issued by Monitor. 

Rob Murray 

Officer of the Audit Commission 

The Audit Commission's Audit Trust Practice 

3rd Floor, Eastbrook, 

Shaftesbury Road, 

Cambridge, CB2 8BF 

31st May 2011 



Foreword to the Accounts 


These accounts for the year ended 31 March 2011 have been prepared by the James Paget University Hospitals NHS 

Foundation Trust in accordance with paragraphs 24 and 25 of schedule 7 to the National Health Service Act 2006. 





Statement of Comprehensive Income 

Year Ended Year Ended 

31st March 31st March 

2011 2010 

Note £ 000 £ 000 

Operating income from continuing operations Note 4.2 164,167 163,039 

Operating expenses of continuing operations Note 5 (160,749) (158,649) 

Operating surplus 3,418 4,390 

Finance costs 

Finance income Note 8 551 571 

Finance expense - financial liabilities Note 9 - (1) 

Finance expense - unwinding of discount on provisions Note 20.1 (18) (14) 

Public Dividend Capital - dividends payable (1,308) (1,466) 

Net finance costs (775) (910) 

Share of Profit/(Loss) of Associates/Joint Ventures accounted for using the 

equity method 

- - 

Corporation tax expense - - 

Surplus/(Deficit) from continuing operations 2,643 3,480 

Surplus/(deficit) of discontinued operations and the gain/(loss) on disposal 

of discontinued operations 

- - 

Surplus/(Deficit) for the year 2,643 3,480 

Other comprehensive income 

Impairments (112) (3) 

Revaluations - (6,527) 

Receipt of donated assets 199 523 

Asset disposals (14) (24) 

Share of comprehensive income from associates and joint ventures - - 

Movements arising from classifying non current assets as Assets Held for Sale - - 

Fair Value gains/(losses) on Available-for-sale financial investments - - 

Recycling gains/(losses) on Available-for-sale financial investments - - 

Other recognised gains and losses - - 

Actuarial gains/(losses) on defined benefit pension schemes - - 

Other reserve movements (353) (364) 

Total comprehensive income/(expense) for the year 2,363 (2,915) 

All income and expenditure is derived from continuing operations, and all surplus and comprehensive income / 

expense is attributable to the owners of the parent. 

The notes on pages 15 to 41 form part of these accounts. 



Statement of Financial Position 

As at 

As at 



Note £ 000 £ 000 

Non-current assets 

Intangible assets Note 11 931 854 

Property, plant and equipment Note 12 62,701 64,878 

Investment property - - 

Investments in associates and jointly controlled operations - - 

Other investments - - 

Trade and other receivables Note 14.2 634 964 

Other financial assets - - 

Tax receivable - - 

Other assets - - 

Total non-current assets 64,266 66,696 

Current assets 

Inventories Note 13 2,743 2,595 

Trade and other receivables Note 14.1 15,598 13,065 

Other financial assets - - 

Tax receivable - - 

Non-current assets held for sale and assets in disposal groups - - 

Cash and cash equivalents Note 22 41,190 37,634 

Total current assets 59,531 53,294 

Current liabilities 

Trade and other payables Note 15.1 (15,934) (16,266) 

Borrowings Note 17.1 (125) (5) 

Other financial liabilities - - 

Provisions Note 20.2 (5,536) (4,839) 

Tax payable Note 15.1 (2,198) (2,215) 

Other liabilities Note 16.1 (12,994) (12,797) 

Liabilities in disposal groups - - 

Total current liabilities (36,787) (36,122) 

Total assets less current liabilities 87,010 83,868 

Non-current liabilities 

Trade and other payables Note 15.2 (1,093) (1,339) 

Borrowings Note 17.2 (300) (5) 

Other financial liabilities - - 

Provisions Note 20.3 (2,488) (1,666) 

Tax payable - - 

Other liabilities Note 16.2 (2,418) (2,510) 

Total non-current liabilities (6,299) (5,520) 

Total assets employed 80,711 78,348 

Financed by taxpayers' equity 

Minority interest - - 

Public dividend capital 48,189 48,189 

Revaluation reserve Note 21 6,404 6,585 

Donated asset reserve 2,694 2,866 

Available for sale investments reserve - - 

Other reserves - - 

Merger reserve - - 

Income and expenditure reserve 23,424 20,708 

Total taxpayers' equity 80,711 78,348 

The financial statements on pages 10 to 41 were approved by the Board on 27th May 2011 and signed on its behalf 

by: 


Director of Finance 


Financial Statements for the year ended 31st March 2011 Page 11


Financial Statements for the year ended 31st March 2011 

Page 12 

Statement of Changes in Taxpayers' Equity 

Public Donated Available for Sale Income and 

Minority Dividend Revaluation Asset Investment Other Merger Expenditure 

Interest Capital Reserve Reserve Reserve Reserves Reserve Reserve Total 

£ 000 £ 000 £ 000 £ 000 £ 000 £ 000 £ 000 £ 000 £ 000 

Taxpayers' equity at 1 April 2010 - 48,189 6,585 2,866 - - - 20,708 78,348 

Surplus/(Deficit) for the year - - - - - - - 2,643 2,643 

Impairments - - (109) (3) - - - - (112) 

Revaluations - - - - - - - - - 

Receipt of donated assets - - - 199 - - - - 199 

Asset disposals - - - (15) - - - 1 (14) 

Share of comprehensive income from associates and joint 

ventures 

Revaluation gains/(losses) and impairment losses on 

intangible assets 

Movements arising from classifying non current assets as 

Assets Held for Sale 

Fair Value gains/(losses) on Available-for-sale financial 

investments 

Recycling gains/(losses) on Available-for-sale financial 

investments 

- - - - - - - - - 

- - - - - - - - - 

- - - - - - - - - 

- - - - - - - - - 

- - - - - - - - - 

Other recognised gains and losses - - - - - - - - - 

Actuarial gains/(losses) on defined benefit pension 

- - - - - - - - - 

schemes 

Public Dividend Capital received - - - - - - - - - 

Public Dividend Capital repaid - - - - - - - - - 

Public Dividend Capital written off - - - - - - - - - 

Other reserve movements - - (72) (353) - - - 72 (353) 

Taxpayers' equity at 31 March 2011 - 48,189 6,404 2,694 - - - 23,424 80,711



Page 13 

Statement of Changes in Taxpayers' Equity 

continued 

Public Donated Available for Sale Income and 

Minority Dividend Revaluation Asset Investment Other Merger Expenditure 

Interest Capital Reserve Reserve Reserve Reserves Reserve Reserve Total 

£ 000 £ 000 £ 000 £ 000 £ 000 £ 000 £ 000 £ 000 £ 000 

Taxpayers' equity at 1 April 2009 - 48,189 12,754 3,190 - - - 17,130 81,263 

Surplus/(Deficit) for the year - - - - - - - 3,480 3,480 

Impairments - - (3) - - - - - (3) 

Revaluations - - (6,068) (459) - - - - (6,527) 

Receipt of donated assets - - - 523 - - - - 523 

Asset disposals - - - (24) - - - - (24) 

Share of comprehensive income from associates and joint 

ventures 

Revaluation gains/(losses) and impairment losses on 

intangible assets 

Movements arising from classifying non current assets as 

Assets Held for Sale 

Fair Value gains/(losses) on Available-for-sale financial 

investments 

Recycling gains/(losses) on Available-for-sale financial 

investments 

- - - - - - - - - 

- - - - - - - - - 

- - - - - - - - - 

- - - - - - - - - 

- - - - - - - - - 

Other recognised gains and losses - - - - - - - - - 

Actuarial gains/(losses) on defined benefit pension 

- - - - - - - - - 

schemes 

Public Dividend Capital received - - - - - - - - - 

Public Dividend Capital repaid - - - - - - - - - 

Public Dividend Capital written off - - - - - - - - - 

Other reserve movements - - (98) (364) - - - 98 (364) 

Taxpayers' equity at 31 March 2010 - 48,189 6,585 2,866 - - - 20,708 78,348

Statement of Cash Flows 

Year Ended 

31st March 

Year Ended 

31st March 


£ 000 £ 000 

Cash flows from operating activities 

Operating surplus/(deficit) from continuing operations 3,418 4,390 

Operating surplus/(deficit) of discontinued operations - - 

Operating surplus 3,418 4,390 

Non-cash income and expense: 

Depreciation and amortisation 5,657 6,066 

Impairments 1,433 1,200 

Reversals of impairments - (25) 

Transfer from the donated asset reserve (367) (387) 

Amortisation of government grants (100) (88) 

Amortisation of PFI credit - - 

(Increase)/decrease in trade and other receivables (2,178) 1,306 

(Increase)/decrease in other assets - - 

(Increase)/decrease in Inventories (148) (260) 

Increase/(decrease) in trade and other payables (515) 453 

Increase/(decrease) in other liabilities 197 (730) 

Increase/(decrease) in provisions 1,501 671 

Tax (paid) / received (17) 176 

Movements in operating cash flow of discontinued operations - - 

Other movements in operating cash flows 118 120 

Net cash generated from operating activities 8,999 12,892 

Cash flows from investing activities: 

Interest received 540 569 

Purchase of financial assets - - 

Sales of financial assets - - 

Purchase of intangible assets (300) (204) 

Sales of intangible assets - - 

Purchase of property, plant and equipment (4,984) (7,846) 

Sales of property, plant and equipment 1 33 

Cash flows attributable to investing activities of discontinued operations - - 

Cash from acquisitions of business units and subsidiaries - - 

Cash from disposals of business units and subsidiaries - - 

Net cash (used in) investing activities (4,743) (7,448) 

Cash flows from financing activities: 

Public dividend capital received - - 

Public dividend capital repaid - - 

Loans received 480 - 

Loans repaid (60) - 

Capital element of finance lease rental payments (5) (13) 

Capital element of Private Finance Initiative obligations - - 

Interest paid - - 

Interest element of finance lease - (1) 

Interest element of Private Finance Initiative obligations - - 

PDC Dividend paid (1,322) (1,553) 

Cash flows attributable to financing activities of discontinued operations - - 

Cash flows from/(used in) other financing activities 207 1,339 

Net cash generated from/(used in) financing activities (700) (228) 

Increase/(decrease) in cash and cash equivalents 3,556 5,216 

Cash and cash equivalents at 1 April 37,634 32,418 

Cash and cash equivalents at 31 March 41,190 37,634 



Notes to the Accounts 

1 Significant Accounting policies and other information 

Monitor has directed that the financial statements of NHS Foundation Trusts shall meet the accounting 

requirements of the NHS Foundation Trust Annual Reporting Manual which shall be agreed with HM Treasury. 

Consequently, the following financial statements have been prepared in accordance with the 2010/11 NHS 

Foundation Trust Annual Reporting Manual issued by Monitor. The accounting policies contained in that 

manual follow International Financial Reporting Standards (IFRS) and HM Treasury‟s Financial Reporting 

Manual to the extent that they are meaningful and appropriate to NHS Foundation Trusts. The accounting 

policies have been applied consistently in dealing with items considered material in relation to the accounts. 

1.1.1 Accounting convention 

These accounts have been prepared under the historical cost convention modified to account for the revaluation 

of property, plant and equipment, intangible assets, inventories and certain financial assets and financial 

liabilities. 

1.1.2 New and revised IFRSs applied in the current year 

There are no new or revised IFRSs applied in the current period that have affected amounts reported or 

disclosed in these financial statements. 

1.1.3 New and revised IFRSs in issue but not yet effective 

The following list of new or revised IFRSs have been issued but are not yet effective and have not been early 

adopted by the Trust in the current period. These new or revised IFRSs are either not relevant to the 

organisation or are not expected to have a material impact on the amounts reported or disclosed in future 

financial statements. 

- 

- 

- 

- 

- 

- 

- 

Amendments to IFRS 7 Financial Instruments: Disclosures 

IFRS 9 Financial Instruments 

Amendments to IAS 12 Income Taxes 

Amendments to IAS 24 Related Party Disclosures 

Amendments to IFRIS 14 IAS 19: The limit on a defined benefit asset, minimum funding requirements 

and their interaction 

IFRIC 19 Extinguishing Financial Liabilities with Equity Instruments 

Annual improvements 2010 

1.2 Income 

Income in respect of services provided is recognised when, and to the extent that, performance occurs and is 

measured at the fair value of the consideration receivable. The main source of income for the Trust is contracts 

with commissioners in respect of healthcare services. Where income is received for a specific activity which is 

to be delivered in the following financial year, that income is deferred. Income from the sale of non-current 

assets is recognised only when all material conditions of sale have been met, and is measured as the sums due 

under the sale contract. 

1.3 Expenditure on employee benefits 

1.3.1 Short-term employee benefits 

Salaries, wages and employment-related payments are recognised in the period in which the service is received 

from employees. The cost of annual leave entitlement earned but not taken by employees at the end of the 

period is recognised in the financial statements to the extent that employees are permitted to carry-forward 

leave into the following period. 




continued 

1.3.2 Retirement benefits 

Past and present employees are covered by the provisions of the NHS Pensions Scheme. The scheme is an 

unfunded, defined benefit scheme that covers NHS employers, general practices and other bodies, allowed 

under the direction of Secretary of State, in England and Wales. It is not possible for the NHS Foundation 

Trust to identify its share of the underlying scheme liabilities. Therefore, the scheme is accounted for as a 

defined contribution scheme. Employers' pension cost contributions are charged to operating expenses as 

and when they become due. 

Additional pension liabilities arising from early retirements are not funded by the scheme except where the 

retirement is due to ill-health. The full amount of the liability for the additional costs is charged to the operating 

expenses at the time the Trust commits itself to the retirement, regardless of the method of payment. 

1.4 Expenditure on other goods and services 

Expenditure on goods and services is recognised when, and to the extent that they have been received, and is 

measured at the fair value of those goods and services. Expenditure is recognised in operating expenses 

except where it results in the creation of a non-current asset such as property, plant and equipment. 

1.5 Property, plant and equipment 

1.5.1 Recognition 

Property, plant and equipment is capitalised where: 

- 

- 

- 

- 

- 

it is held for use in delivering services or for administrative purposes; 

it is probable that future economic benefits will flow to, or service potential be provided to the Trust; 

it is expected to be used for more than one financial year; 

the cost of the item can be measured reliably; and 

assets meet the following capitalisation threshold and grouping criteria: 

• assets individually have a cost of at least £5,000; or 

• form a group of assets which individually have a cost of more than £250, collectively have a cost 

of at least £5,000, where the assets are functionally interdependent, they had broadly 

simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are 

under single managerial control; or 

• form part of the initial setting-up cost of a new building or refurbishment of a ward or unit, 

irrespective of their individual or collective cost. 

Where a large asset, for example a building, includes a number of components with significantly different asset 

lives e.g. plant and equipment, then these components are treated as separate assets and depreciated over 

their own useful economic lives. 

1.5.2 Measurement 

Valuation 

All property, plant and equipment assets are measured initially at cost, representing the costs directly 

attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it 

to be capable of operating in the manner intended by management. 

All assets are measured subsequently at fair value, using the following methods for determining fair value; 

- 

The fair value of land and buildings is determined from reference to market based evidence by appraisal 

for non-specialised operational property, and on the basis of the Depreciated Replacement Cost of a 

Modern Equivalent Asset for specialised operational property where market based evidence does not 

exist. The valuations are carried out by professionally qualified valuers, and are performed with 

sufficient regularity to ensure that the carrying value does not differ significantly from fair value at the 

statement of financial position date. The latest land and building asset valuation undertaken was 

carried out by Montagu Evans LLP, and was applied on 31 January 2010. 




continued 

- 

- 

Assets in the course of construction are valued at cost and are valued by professional valuers at the 

same time as other land and building assets after they are brought into use. 

Non-property assets are carried at depreciated historic cost as a proxy for fair value. 

Subsequent expenditure 

Subsequent expenditure relating to an item of property, plant and equipment is recognised as an increase in 

the carrying amount of the asset when it is probable that additional future economic benefits or service 

potential deriving from such item will flow to the enterprise and the cost of the item can be determined reliably. 

Where a component of an asset is replaced, the cost of the replacement is capitalised if it meets the criteria for 

recognition above. The carrying amount of the part replaced is de-recognised. Other expenditure that does not 

generate additional future economic benefits or service potential, such as repairs and maintenance, is charged 

to the Statement of Comprehensive Income in the period in which it is incurred. 

Depreciation 

Items of property, plant and equipment are depreciated over their remaining useful economic lives in a manner 

consistent with the consumption of economic or service delivery benefits. Freehold land is considered to have 

an infinite life and is not depreciated. Assets in the course of construction are not depreciated until the asset is 

brought into use. 

For each class of asset, the estimated useful life is as follows: 

Buildings 

Dwellings 

Plant and machinery 

Transport equipment 

Information technology 

Furniture and fittings 

30 to 150 years 

60 years 

3 to 16 years 

8 years 

5 years 

8 to 11 years 

Revaluation gains and losses 

Revaluation gains are recognised in the revaluation reserve, except where, and to the extent that, they reverse 

a revaluation decrease that has previously been recognised in operating expenses, in which case they are 

recognised in operating income. 

Revaluation losses are charged to the revaluation reserve to the extent that there is an available balance for 

the asset concerned, and thereafter are charged to operating expenses. 

Gains and losses recognised in the revaluation reserve are reported in the Statement of Comprehensive 

Income as an item of „other comprehensive income‟. 

Impairments 

In accordance with the FT ARM, impairments that are due to a consumption of economic benefits or service 

potential in the asset are charged to operating expenses. A compensating transfer is made from the 

revaluation reserve to the income and expenditure reserve of an amount equal to the lower of (i) the 

impairment charged to operating expenses; and (ii) the balance in the revaluation reserve attributable to that 

asset before the impairment. Other impairments are treated as revaluation losses. Reversals of „other 

impairments‟ are treated as revaluation gains. 

This treatment represents a change from the previously adopted accounting policy which was to always first offset 

impairments against any realuation reserve balance, irrespective of the cause of the impairment, before 

then charging the remainder to operating expenses. The retrospective application of this change in accounting 

policy has had no impact on the current or prior period financial statements. 

1.5.3 De-recognition 

Assets intended for disposal are reclassified as „Held for Sale‟ once all of the following criteria are met: 

- 

- 

the asset is available for immediate sale in its present condition subject only to terms which are usual 

and customary for such sales; 

the sale must be highly probable i.e.: 

• management are committed to a plan to sell the asset; 

• 

• the asset is being actively marketed at a reasonable price; 




continued 

1.5.4 Donated assets 

• the sale is expected to be completed within 12 months of the date of classification as „Held for 

Sale‟; and 

• the actions needed to complete the plan indicate it is unlikely that the plan will be dropped or 

significant changes made to it. 

Following reclassification, the assets are measured at the lower of their existing carrying amount and their „fair 

value less costs to sell‟. Depreciation ceases to be charged and the assets are de-recognised when all 

material sale contract conditions have been met. 

Property, plant and equipment which is to be scrapped or demolished does not qualify for recognition as „Held 

for Sale‟ and instead is retained as an operational asset and the asset‟s economic life is adjusted. The asset is 

de-recognised when scrapping or demolition occurs. 

Donated assets are capitalised at their current value on receipt and this value is credited to the donated asset 

reserve. Donated assets are valued and depreciated as described above for purchased assets. Gains and 

losses on revaluations are also taken to the donated asset reserve and, each year, an amount equal to the 

depreciation charge on the asset is released from the donated asset reserve to the income and expenditure 

account. Similarly, any impairment on donated assets charged to the income and expenditure account is 

matched by a transfer from the donated asset reserve. On sale of donated assets, the net book value of the 

donated asset is transferred from the donated asset reserve to the income and expenditure reserve. 

1.6 Intangible assets 


Intangible assets are non-monetary assets without physical substance which are capable of being sold 

separately from the rest of the Trust‟s business or which arise from contractual or other legal rights. They are 

recognised only where it is probable that future economic benefits will flow to, or service potential be provided 

to, the Trust, where the cost of the asset can be measured reliably. 

Internally generated intangible assets 

Internally generated goodwill, brands, mastheads, publishing titles, customer lists and similar items are not 

capitalised as intangible assets. 

Expenditure on research is not capitalised. 

Expenditure on development is capitalised only where all of the following can be demonstrated: 

- 

- 

- 

- 

- 

- 

the project is technically feasible to the point of completion and will result in an intangible asset for sale 

or use; 

the Trust intends to complete the asset and sell or use it; 

the Trust has the ability to sell or use the asset; 

how the intangible asset will generate probable future economic or service delivery benefits e.g. the 

presence of a market for it or its output, or where it is to be used for internal use, the usefulness of the 

asset; 

adequate financial, technical and other resources are available to the Trust to complete the 

development and sell or use the asset; and 

the Trust can measure reliably the expenses attributable to the asset during development. 

Software 

Software which is integral to the operation of hardware e.g. an operating system, is capitalised as part of the 

relevant item of property, plant and equipment. Software which is not integral to the operation of hardware e.g. 

application software, is capitalised as an intangible asset. 




continued 

1.6.2 Measurement 

Intangible assets are recognised initially at cost, comprising all directly attributable costs needed to create, 

produce and prepare the asset to the point that it is capable of operating in the manner intended by 

management. 

Subsequently intangible assets are measured at fair value. Revaluation gains and losses and impairments are 

treated in the same manner as for Property, Plant and Equipment. Software licences are carried at amortised 

historic cost as a proxy for fair value. 

1.6.3 Amortisation 

Intangible assets are amortised over their expected useful economic lives in a manner consistent with the 

consumption of economic or service delivery benefits. The estimated useful economic life of software licences 

is six years. 

1.7 Government grants 

Government grants are grants from Government bodies other than income received as payment for the 

provision of services. Where the Government grant is used to fund revenue expenditure it is recognised in 

operating income to match that expenditure. Where the grant is used to fund capital expenditure the grant is 

held as deferred income and released to operating income over the life of the asset on a basis consistent with 

the depreciation charge for that asset. 

1.8 Inventories 

Inventories are valued at the lower of cost and net realisable value. 

1.9 Financial instruments and financial liabilities 


Financial assets and financial liabilities which arise from contracts for the purchase or sale of non-financial 

items (such as goods or services), which are entered into in accordance with the Trust‟s normal purchase, sale 

or usage requirements, are recognised when, and to the extent which, performance occurs i.e. when receipt or 

delivery of the goods or services is made. 

Financial assets or financial liabilities in respect of assets acquired or disposed of through finance leases are 

recognised and measured in accordance with the accounting policy for leases described below. 

All other financial assets and financial liabilities are recognised when the Trust becomes a party to the 

contractual provisions of the instrument. 

1.9.2 De-recognition 

All financial assets are de-recognised when the rights to receive cash flows from the assets have expired or 

the Trust has transferred substantially all of the risks and rewards of ownership. 

Financial liabilities are de-recognised when the obligation is discharged, cancelled or expires. 

1.9.3 Classification and measurement 

Financial assets are categorised as „loans and receivables‟ and financial liabilities are classified as „other 

financial liabilities‟. 

1.9.4 Loans and receivables 

Loans and receivables are non-derivative financial assets with fixed or determinable payments which are not 

quoted in an active market. They are included in current assets. The Trust‟s loans and receivables comprise: 

cash and cash equivalents; NHS receivables; accrued income and „other‟ receivables. 




continued 

Loans and receivables are recognised initially at fair value, net of transaction costs, and are measured 

subsequently at amortised cost, using the effective interest method. The effective interest rate is the rate that 

discounts estimated future cash receipts through the expected life of the financial asset or, when appropriate, a 

shorter period, to the net carrying amount of the financial asset. 

Interest on loans and receivables is calculated using the effective interest method and credited to the 

Statement of Comprehensive Income. 

1.9.5 Financial liabilities 

All financial liabilities are recognised initially at fair value, net of transaction costs incurred, and measured 

subsequently at amortised cost using the effective interest method. The effective interest rate is the rate that 

discounts exactly estimated future cash payments through the expected life of the financial liability or, when 

appropriate, a shorter period, to the net carrying amount of the financial liability. 

They are included in current liabilities except for amounts payable more than twelve months after the 

Statement of Financial Position date, which are classified as long-term liabilities. 

Interest on financial liabilities carried at amortised cost is calculated using the effective interest method and 

charged to Finance Costs. Interest on financial liabilities taken out to finance property, plant and equipment or 

intangible assets is not capitalised as part of the cost of those assets. 

1.9.6 Impairment of financial assets 

At the Statement of Financial Position date, the Trust assesses whether any financial assets are impaired. 

Financial assets are impaired and impairment losses are recognised if, and only if, there is objective evidence 

of impairment as a result of one or more events which occurred after the initial recognition of the asset and 

which has an impact on the estimated future cash flows of the asset. 

For financial assets carried at amortised cost, the amount of the impairment loss is measured as the difference 

between the asset‟s carrying amount and the present value of the revised future cash flows discounted at the 

asset‟s original effective interest rate. The loss is recognised in the Statement of Comprehensive Income and 

the carrying amount of the asset is reduced through the use of a bad debt provision. 

When an asset‟s carrying value is written-down using a bad debt provision, this is determined based upon 

knowledge of the operating environment and experience of past cash flows. A bad debt provision against an 

asset's carrying value is only written off when all reasonable efforts to recover the carrying value have been 

exhausted. 

1.10 Leases 

1.10.1 Finance leases 

Where substantially all risks and rewards of ownership of a leased asset are borne by the NHS Foundation 

Trust, the asset is recorded as property, plant and equipment and a corresponding liability is recorded. In a 

manner consistent with the Trust‟s accounting policy on capitalisation of non-current assets, finance leases are 

recognised where assets individually have a cost of at least £5,000. The value at which both the asset and 

liability are recognised is the lower of the fair value of the asset or the present value of the minimum lease 

payments, discounted using the interest rate implicit in the lease. 

The asset and liability are recognised at the commencement of the lease. Thereafter the asset is accounted 

for an item of property plant and equipment. The annual rental is split between the repayment of the liability 

and a finance cost so as to achieve a constant rate of finance over the life of the lease. The annual finance 

cost is charged to Finance Costs in the Statement of Comprehensive Income. The lease liability, is derecognised 

when the liability is discharged, cancelled or expires. 

1.10.2 Operating leases 

Other leases are regarded as operating leases and the rentals are charged to operating expenses on a straightline 

basis over the term of the lease. Operating lease incentives received are added to the lease rentals and 

charged to operating expenses over the life of the lease. 




continued 

1.10.3 Leases of land and buildings 

Where a lease is for land and buildings, the land component is separated from the building component and the 

classification for each is assessed separately. Leased land is treated as an operating lease. 

1.11 Provisions 

The NHS foundation trust recognises a provision where it has a present legal or constructive obligation of 

uncertain timing or amount; for which it is probable that there will be a future outflow of cash or other 

resources; and a reliable estimate can be made of the amount. The amount recognised in the Statement of 

Financial Position is the best estimate of the resources required to settle the obligation. Where the effect of 

the time value of money is significant, the estimated risk-adjusted cash flows are discounted using HM 

Treasury‟s discount rate of 2.2% in real terms, except for early retirement provisions and injury benefit 

provisions which both use the HM Treasury‟s pension discount rate of 2.9% in real terms. 

1.11.1 Clinical negligence costs 

The NHS Litigation Authority (NHSLA) operates a risk pooling scheme under which the NHS Foundation Trust 

pays an annual contribution to the NHSLA, which, in return, settles all clinical negligence claims. Although the 

NHSLA is administratively responsible for all clinical negligence cases, the legal liability remains with the NHS 

Foundation Trust. The total value of clinical negligence provisions carried by the NHSLA on behalf of the NHS 

Foundation Trust is disclosed at note 20.3, but is not recognised as a liability in the Foundation Trust's 

accounts. 

1.11.2 Non-clinical risk pooling 

The NHS Foundation Trust participates in the Property Expenses Scheme and the Liabilities to Third Parties 

Scheme. Both are risk pooling schemes under which the Trust pays an annual contribution to the NHS 

Litigation Authority and in return receives assistance with the costs of claims arising. The annual membership 

contributions, and any „excesses‟ payable in respect of particular claims are charged to operating expenses 

when the liability arises. 

1.12 Public dividend capital 

Public dividend capital (PDC) is a type of public sector equity finance based on the excess of assets over 

liabilities at the time of establishment of the predecessor NHS Trust. HM Treasury has determined that PDC is 

not a financial instrument within the meaning of IAS 32. 

A charge, reflecting the cost of capital utilised by the NHS Foundation Trust, is payable as PDC dividend. The 

charge is calculated at the rate set by HM Treasury (currently 3.5%) on the average relevant net assets of the 

NHS Foundation Trust during the financial year. Relevant net assets are calculated as the value of all assets 

less the value of all liabilities, except for donated assets, cash held with Government Banking Service 

accounts, and any balanceof PDC dividend receivable or payable. Average relevant net assets are calculated 

as the mean of opening and closing relevant net assets. 

1.13 Value Added Tax 

Most of the activities of the NHS Foundation Trust are outside the scope of VAT and, in general, output tax 

does not apply and input tax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant 

expenditure category or included in the capitalised purchase cost of non-current assets. Where output tax is 

charged or input VAT is recoverable, the amounts are stated net of VAT. 

1.14 Corporation Tax 

Income from commercial activities is subject to corporation tax under section 519A Income and Corporation 

Taxes Act 1988 (519A ICTA 1988), as amended by section 148 of the Finance Act 2004. However, provision 

of Healthcare authorised under section 43 of the National Health Service Act 2006 is not treated as 

commercial income. The total non-healthcare related activities carried out by the Foundation Trust during the 

period which are deemed to be commercial activities do not fall to be subject to corporation tax because 

annual taxable profits are below the deminimus limit of £50,000. 




continued 

1.15 Foreign exchange 

The functional and presentational currencies of the trust are sterling. A transaction which is denominated in a 

foreign currency is translated into the functional currency at the spot exchange rate on the date of the 

transaction. Where the trust has assets or liabilities denominated in a foreign currency at the Statement of 

Financial Position date monetary items are translated at the spot exchange rate on 31 March. Exchange gains 

or losses on monetary items (arising on settlement of the transaction or on re-translation at the Statement of 

Financial Position date) are recognised in income or expense in the period in which they arise. 

1.16 Third party assets 

Assets belonging to third parties (such as money held on behalf of patients) are not recognised in the accounts 

since the Foundation Trust has no beneficial interest in them. However, they are disclosed in a separate note 

to the accounts in accordance with the requirements of HM Treasury‟s FReM. 

1.17 Losses and special payments 

Losses and special payments are items that Parliament would not have contemplated when it agreed funds for 

the health service or passed legislation. By their nature they are items that ideally should not arise. They are 

therefore subject to special control procedures compared with the generality of payments. They are divided 

into different categories, which govern the way that individual cases are handled. Losses and special 

payments are charged to the relevant functional headings in expenditure on an accruals basis, including 

losses which would have been made good through insurance cover had NHS trusts not been bearing their own 

risks (with insurance premiums then being included as normal revenue expenditure). 

However the losses and special payments note is compiled directly from the losses and compensations 

register which reports on an accrual basis with the exception of provisions for future losses. 




continued 

2 Segmental reporting 

Under the definitions of operating segments contained within International Financial Reporting Standard 8, the 

Trust has a single operating segment where the revenues are derived from the provision of healthcare 

services. 

The products and services provided to external customers are identified in notes 4.1 and 4.2 below under the 

headings “Income from activities analysed by service” and “Other operating income”. 

All revenues from external customers are derived from within the UK, and all non-current assets are located in 

the UK. Revenues from transactions with entities under the control of the UK Government amount to £158.7m 

(2009/10 - £158.0m), and are reported within the single healthcare segment. 

3 Subsidiaries 

The James Paget University Hospitals NHS Foundation Trust acts as the corporate Trustee of the James 

Paget University Hospitals Charitable Fund and in accordance with the charity‟s declaration of trust, members 

of the Foundation Trust‟s Board of Directors act as ex-officio Trustees of the Charitable Funds. 

This Trustee arrangement satisfies the relevant tests of control under IAS 27 and therefore the Charitable 

Fund is a subsidiary of the Foundation Trust. However, in accordance with the dispensation set out in the 

2010/11 Foundation Trust Annual Reporting Manual, the Foundation Trust has not prepared group accounts 

for the year ended 31 March 2011. 

The James Paget University Hospitals Charitable Fund is a registered charity located in England, and the 

Foundation Trust as the sole corporate Trustee has 100% of the voting rights. The Foundation Trust does not 

have any financial investment in the Charitable Fund. 

The ability of the subsidiary to transfer funds to the Foundation Trust is significantly restricted by the charitable 

objects and the legal requirement for the Trustees to act independently and ensure that all funds are spent in 

accordance with the donors‟ wishes. 

4 Operating income 




£ 000 £ 000 

4.1 Income from activities analysed by service type 

Elective income 28,347 28,146 

Non elective income 38,956 39,912 

Outpatient income 23,162 21,687 

A&E income 5,169 5,436 

Other NHS clinical income 55,500 55,469 

Private patient income Note 4.4 586 531 

Note 4.2 151,720 151,181 




continued 




£ 000 £ 000 

4.2 Analysis of operating income by source 

Income from activities 

NHS Foundation Trusts 100 105 

NHS Trusts 45 34 

Strategic Health Authorities 269 189 

Primary Care Trusts 149,693 149,274 

Department of Health - 99 

NHS Other - - 

Non NHS: 

Private patients 586 531 

NHS injury scheme * 511 468 

Other 516 481 

Total income from activities Note 4.3 151,720 151,181 

Other operating income 

Research and development 839 349 

Education and training 6,987 6,627 

Charitable and other contributions to expenditure 462 432 

Transfers from donation reserve in respect of depreciation on donated 

assets 

367 387 

Non patient care services to other NHS bodies 673 690 

Other income: 

Catering 832 814 

Accommodation 712 701 

Car parking 750 755 

Miscellaneous 825 1,103 

Total other operating income 12,447 11,858 

Total operating income 164,167 163,039 

* NHS Injury Scheme income is subject to a provision for doubtful debts of 11.7% (2009/10 - 14.6%) to reflect 

expected rates of collection. 




continued 

4.3 

Income from activities arising from 

mandatory and non-mandatory services 




£ 000 £ 000 

Mandatory services 151,134 150,650 

Non-mandatory services 586 531 

151,720 151,181 

4.4 Private patient income 

Year Ended Year Ended Base 

31st March 31st March Year 

2011 2010 2002/03 

£ 000 £ 000 £ 000 

Private patient income 586 531 1,084 

Total patient related income 151,720 151,181 84,481 

Proportion 0.39% 0.35% 1.28% 

Section 44 of the NHS Act 2006 requires that the proportion of private patient income to the total patient 

related income of a Foundation Trust should not exceed its proportion whilst the body was an NHS Trust in 

2002/03 (the base year). The Foundation Trust has complied with this requirement during the year ended 31 

March 2011. 

4.5 

Operating lease income 




£ 000 £ 000 

Rents recognised as income in the period 110 128 

Contingent rents recognised as income in the period - - 

110 128 

Future minimum lease payments receivable: 

Within 1 year 117 135 

Between 1 and 5 years 204 389 

After 5 years 435 560 

756 1,084 




continued 

5 Operating expenses 




£ 000 £ 000 

Services from NHS Trusts 1 - 

Purchase of healthcare from non-NHS bodies 15 8 

Employee expenses - executive directors 793 798 

Employee expenses - non-executive directors 127 129 

Employee expenses - staff 108,562 107,263 

Drug costs 13,665 11,806 

Supplies and services - clinical (excluding drug costs) 15,718 16,560 

Supplies and services - general 2,117 2,419 

Establishment 1,847 2,103 

Transport 172 136 

Premises 5,074 4,582 

Bad debts (856) 266 

Depreciation on property, plant and equipment 5,443 5,791 

Amortisation on intangible assets 214 275 

Impairments of property, plant and equipment Note 10 1,433 1,200 

Reversal of impairments on property, plant and equipment - (25) 

Audit fees - statutory audit* 94 75 

Other auditor's remuneration* 26 13 

Clinical negligence 2,605 1,752 

Loss on disposal of intangible assets ** 1 1 

Loss on disposal of property, plant and equipment ** 117 119 

Legal fees 84 113 

Consultancy costs 227 574 

Training, courses and conferences 678 742 

Patient travel 1,605 1,533 

Insurance 91 87 

Other contracted services 211 186 

Losses, ex gratia and special payments 6 16 

Other 679 127 

160,749 158,649 

* There is no specified limitation on auditor's liability. 

** The Trust has not disposed of any protected assets during the year. 




continued 

6 Operating leases 




£ 000 £ 000 

6.1 Lease payments recognised as an expense in the period 

Minimum lease payments 275 238 

Contingent rents - - 

Sublease payments - - 

275 238 

6.2 

Total of future minimum lease payments under non 

cancellable operating leases which expire: 




£ 000 £ 000 

Within 1 year 235 238 

Between 1 and 5 years 303 352 

After 5 years 8 23 

546 613 

7 Employee expenses and numbers 

Year Ended 

31st March 2011 

Year Ended 

31st March 

Permanent Other Total 2010 

£ 000 £ 000 £ 000 £ 000 

7.1 Employee expenses 

Salaries and wages 84,480 - 84,480 84,379 

Social security costs 6,894 - 6,894 6,712 

Employer contributions to NHS Pensions 10,262 - 10,262 9,695 

Agency / contract staff - 7,719 7,719 7,275 

101,636 7,719 109,355 108,061 

7.2 Directors' remuneration 




£ 000 £ 000 

Directors' remuneration 776 833 

Employer contributions to NHS Pensions Agency 89 88 

Total number of directors to whom benefits are accruing under 

defined benefit pension schemes 

5 7 

Further details on directors' remuneration are given in the remuneration report on page 83 and 84 of the 

Annual Report. 




continued 

7.3 Average number of employees 

Year Ended 

31st March 2011 

Year Ended 

31st March 

Permanent Other Total 2010 

Number Number Number Number 

Medical and dental 131 155 286 276 

Administration and estates 454 23 477 469 

Healthcare assistants and other support staff 425 18 443 441 

Nursing, midwifery and health visiting staff 1,026 41 1,067 1,048 

Scientific, therapeutic and technical staff 280 22 302 305 

Bank and agency staff - 165 165 170 

2,316 424 2,740 2,709 

7.4 Staff exit packages 

During the year ended 31 March 2011 the Trust implemented a Voluntary Severance Scheme (VSS). The 

scheme enables those employees who wish to leave to receive a financial payment providing certain criteria 

are met. The scheme is voluntary and brings to an end an employee‟s contract of employment by mutual 

agreement. 

Total number 

Number of Number of of exit 

compulsory other agreed packages by 

redundancies departures cost band 

Exit package cost band 

< £10,000 nil 3 3 

(2009/10 nil) (2009/10 nil) 

£10,000 - £25,000 nil 6 6 

(2009/10 nil) (2009/10 nil) 

£25,001 - £50,000 nil 2 2 

(2009/10 nil) (2009/10 nil) 

£50,001 - £100,000 nil - - 

(2009/10 nil) (2009/10 nil) 

Total number of exit packages by type nil 11 11 

(2009/10 nil) (2009/10 nil) (2009/10 nil) 

Cost of Cost of Total cost 

compulsory other agreed of exit 

redundancies departures packages 

£ 000 £ 000 £ 000 

Total resource costs - 152 152 

(2009/10 £nil) (2009/10 £nil) (2009/10 £nil) 




continued 

7.5 Retirements due to ill-health 

During the year ending 31 March 2011 there were four (2009/10 - three) early retirements from the Trust 

agreed on the grounds of ill-health. The additional pension costs of these ill-health retirements (calculated 

on an average basis and borne by the NHS Pension Scheme) will be £225,000 (2009/10 - £117,000). These 

retirements represent 1.31 (2009/10 - 1.02) per 1,000 active scheme members. 

7.6 Retirement benefits 

Past and present employees are covered by the provisions of the NHS Pensions Scheme. The scheme is an 

unfunded, defined benefit scheme that covers NHS employers, general practices and other bodies, allowed 

under the direction of Secretary of State, in England and Wales. It is not possible for the NHS Foundation 

Trust to identify its share of the underlying scheme liabilities. Therefore, the scheme is accounted for as a 

defined contribution scheme. Employers pension cost contributions are charged to operating expenses as 

and when they become due. 

The scheme is subject to a full actuarial valuation every four years. The main purpose of this valuation is to 

assess the level of liability in respect of the benefits due under the scheme (taking into account its recent 

demographic experience), and to recommend the contribution rates to be paid by employers and scheme 

members. The last such valuation upon which scheme contribution rates are currently based, had an 

effective date of 31 March 2004 covering the period from 1 April 1999 to that date. It was published in 

December 2007 and is available on the Pensions Agency website at the following address: 

http://www.nhsbsa.nhs.uk/Pensions/Documents/Pensions/NHSPS_funding_valuation_report_at_31_3_04_- 

_final_.pdf. Between the full actuarial valuations, the Government Actuary provides an annual update of the 

scheme liabilities for accounting purposes. 

The conclusion of the 2004 investigation was that the scheme had accumulated a notional deficit of £3.3 

billion against the notional assets as at 31 March 2004. This is after making some allowance for the one-off 

effects of pay modernisation, but before taking into account any of the scheme changes which come into 

effect on 1 April 2008. The conclusion of the valuation was that the scheme continues to operate on a sound 

financial basis. 

Taking into account the changes in the benefit and contribution structure effective from 1 April 2008, 

employer contributions could continue at the existing rate of 14% of pensionable pay. On advice from the 

actuary, scheme contributions may be varied from time to time to reflect changes in the scheme‟s liabilities. 

Up to 31 March 2008 employees paid contributions at the rate of 6% (manual staff 5%) of their pensionable 

pay. From 1 April 2008, employees will pay contributions according to a tiered scale from 5% up to 8.5% of 

their pensionable pay depending on total earnings. 

The Scheme is a "final salary" scheme. Annual pensions are normally based on 1/80th of the best of the last 

three years' pensionable pay for each year of service. A lump sum normally equivalent to 3 years' pension is 

payable on retirement. Annual increases are applied to pension payments at rates defined by the Pensions 

(Increase) Act 1971, and are based on changes in retail prices in the twelve months ending 30 September in 

the previous calendar year. On death, a pension of 50% of the member's pension is normally payable to the 

surviving spouse. 

Early payment of a pension, with enhancement, is available to members of the Scheme who are permanently 

incapable of fulfilling their duties effectively through illness or infirmity. A death gratuity of twice final year's 

pensionable pay for death in service, and up to five times their annual pension for death after retirement, less 

pension already paid, subject to a maximum amount equal to twice the member's final year's pensionable 

pay less their retirement lump sum for those who die after retirement, is payable. 

Additional pension liabilities arising from early retirements are not funded by the scheme except where the 

retirement is due to ill-health. The full amount of the liability for the additional costs is charged to the 

operating expenses at the time the Trust commits itself to the retirement, regardless of the method of 

payment. 

The Scheme provides the opportunity to members to increase their benefits through money purchase 

Additional Voluntary Contributions (AVCs) provided by an approved panel of life companies. Under the 

arrangement employees can make contributions to enhance their pension benefits. The benefits payable 

relate directly to the value of the investments made. 




continued 

8 Finance income 




£ 000 £ 000 

Interest on cash deposits 551 571 

551 571 

9 Finance costs - interest expense 




£ 000 £ 000 

Finance leases - 1 

- 1 

10 Impairment of assets recognised as operating expenses 




£ 000 £ 000 

Unforeseen obsolescence 34 981 

Other 1,399 219 

1,433 1,200 




continued 

11 Intangible assets 

11.1 Intangible assets 2010/11 

Assets Under Software Total 

Construction Licences 

£ 000 £ 000 £ 000 

Cost or valuation at 1 April 2010 48 2,165 2,213 

Additions - purchased 26 243 269 

Additions - donated - 31 31 

Reclassifications (48) 40 (8) 

Disposals - (2) (2) 

Cost or Valuation at 31 March 2011 26 2,477 2,503 

Amortisation at 1 April 2010 - 1,359 1,359 

Provided during the year - 214 214 


Amortisation at 31 March 2011 - 1,572 1,572 

Opening net book value at 1 April 2010 

Purchased 48 787 835 

Donated - 19 19 

Total NBV at 1 April 2010 48 806 854 

Closing net book value at 31 March 2011 



Total NBV at 31 March 2011 26 905 931 

11.2 Intangible assets 2009/10 

Cost or valuation at 1 April 2009 - 1,982 1,982 

Additions - purchased 48 130 178 

Additions - donated - 4 4 

Reclassifications - 70 70 


Cost or Valuation at 31 March 2010 48 2,165 2,213 

Amortisation at 1 April 2009 - 1,104 1,104 

Provided during the year - 275 275 


Amortisation at 31 March 2010 - 1,359 1,359 

Opening net book value at 1 April 2009 

Purchased - 859 859 


Total NBV at 1 April 2009 - 878 878 

Closing net book value at 31 March 2010 



Total NBV at 31 March 2010 48 806 854 





Page 32 


continued 

12 Property, plant and equipment 

12.1 Property, plant and equipment 2010/11 

Land Buildings Dwellings Assets Plant Transport Information Furniture Total 

(excluding under and Equipment Technology and as at 

dwellings) construction Machinery Fittings 31st March 

£ 000 £ 000 £ 000 £ 000 £ 000 £ 000 £ 000 £ 000 £ 000 

Cost or valuation at 1 April 2010 6,479 41,101 3,431 1,620 17,094 383 9,542 1,089 80,739 

Additions - purchased - 1,649 - 2,440 488 43 103 30 4,753 

Additions - donated - - - 44 79 - 25 20 168 

Reclassifications - 1,011 - (1,256) 19 - 222 12 8 

Impairments - (109) - - (3) - - - (112) 

Other revaluations - - - - - - - - - 

Disposals - - - - (818) (8) (48) (40) (914) 

Cost or Valuation at 31 March 2011 6,479 43,652 3,431 2,848 16,859 418 9,844 1,111 84,642 

Accumulated depreciation at 1 April 2010 - 612 18 260 8,671 141 5,646 513 15,861 

Provided during the year - 2,358 112 - 1,565 43 1,281 84 5,443 

Impairments - 1,399 - 22 12 - - - 1,433 

Other revaluations - - - - - - - - - 

Disposals - - - - (713) (8) (45) (30) (796) 

Accumulated depreciation at 31 March 2011 - 4,369 130 282 9,535 176 6,882 567 21,941 

Opening net book value at 1 April 2010 

Purchased 6,479 39,069 3,413 1,352 7,069 242 3,891 505 62,020 

Finance leased - - - - 11 - - - 11 

Donated - 1,420 - 8 1,343 - 5 71 2,847 

Total NBV at 1 April 2010 6,479 40,489 3,413 1,360 8,423 242 3,896 576 64,878 

Closing net book value at 31 March 2011 

Purchased 6,479 37,898 3,301 2,523 6,207 242 2,934 460 60,044 

Finance leased - - - - 5 - - - 5 

Donated - 1,385 - 43 1,112 - 28 84 2,652 

Total NBV at 31 March 2011 6,479 39,283 3,301 2,566 7,324 242 2,962 544 62,701 

12.2 Analysis of property, plant and equipment at 31 March 2011 

Analysis of net book value at 31 March 2011 

Protected 5,418 38,763 - - - - - - 44,181 

Unprotected 1,061 520 3,301 2,566 7,324 242 2,962 544 18,520 

Total at 31 March 2011 6,479 39,283 3,301 2,566 7,324 242 2,962 544 62,701



Page 33 


continued 

12.3 Property, plant and equipment 2009/10 

Land Buildings Dwellings Assets Plant Transport Information Furniture Total 

(excluding under and Equipment Technology and as at 

dwellings) construction Machinery Fittings 31st March 

£ 000 £ 000 £ 000 £ 000 £ 000 £ 000 £ 000 £ 000 £ 000 

Cost or valuation at 1 April 2009 6,021 50,461 2,890 1,983 16,861 212 7,129 1,108 86,665 

Additions - purchased - 2,479 - 1,406 1,318 157 1,503 32 6,895 

Additions - donated - 194 - 8 302 - - 15 519 

Reclassifications - 754 31 (1,774) (63) 56 926 - (70) 

Impairments - - - (3) - - - - (3) 

Other revaluations 458 (12,787) 510 - - - - - (11,819) 

Disposals - - - - (1,324) (42) (16) (66) (1,448) 

Cost or Valuation at 31 March 2010 6,479 41,101 3,431 1,620 17,094 383 9,542 1,089 80,739 

Accumulated depreciation at 1 April 2009 - 2,759 88 - 7,546 139 4,458 492 15,482 

Provided during the year - 2,788 92 - 1,586 36 1,204 85 5,791 

Impairments - 219 - 260 721 - - - 1,200 

Other revaluations - (5,154) (162) - - - - - (5,316) 

Disposals - - - - (1,182) (34) (16) (64) (1,296) 

Accumulated depreciation at 31 March 2010 - 612 18 260 8,671 141 5,646 513 15,861 

Opening net book value at 1 April 2009 

Purchased 6,021 45,954 2,802 1,983 7,939 73 2,663 553 67,988 

Finance leased - - - - 24 - - - 24 

Donated - 1,748 - - 1,352 - 8 63 3,171 

Total NBV at 1 April 2009 6,021 47,702 2,802 1,983 9,315 73 2,671 616 71,183 

Closing net book value at 31 March 2010 

Purchased 6,479 39,069 3,413 1,352 7,069 242 3,891 505 62,020 

Finance leased - - - - 11 - - - 11 

Donated - 1,420 - 8 1,343 - 5 71 2,847 

Total NBV at 31 March 2010 6,479 40,489 3,413 1,360 8,423 242 3,896 576 64,878 

12.4 Analysis of property, plant and equipment at 31 March 2010 

Analysis of net book value at 31 March 2010 

Protected 6,219 38,269 - - - - - - 44,488 

Unprotected 260 2,220 3,413 1,360 8,423 242 3,896 576 20,390 

Total at 31 March 2010 6,479 40,489 3,413 1,360 8,423 242 3,896 576 64,878


continued 

12.5 Analysis of property, plant and equipment (continued) 

Land, building and dwelling assets were last revalued by the Trust's externally appointed independent valuers 

as at 31 January 2010. 

Of the total impairments and other revaluations of £1,545,000 (2009/10 - £7,706,000), £1,433,000 (2009/10 - 

£1,175,000) has been recognised in operating expenses, and £112,000 (2009/10 - £6,531,000) has been 

recognised directly in equity during the period. 

13 Inventories 

Total Total 

as at as at 



£ 000 £ 000 

Materials 2,743 2,595 

14 Trade and other receivables 

14.1 Current trade and other receivables 

Total 

as at 

31st March 

Total 

as at 

31st March 


£ 000 £ 000 

NHS receivables 13,641 12,216 

Other receivables with related parties 213 310 

Provision for impaired receivables (761) (1,754) 

Prepayments 714 756 

Accrued income 744 507 

PDC dividend receivable 101 87 

Other receivables 946 943 

14.2 Non-current trade and other receivables 

15,598 13,065 

NHS receivables - 88 

Provision for impaired receivables (105) (74) 

Prepayments 198 386 

Other receivables 541 564 

634 964 

NHS receivables include: 

£11,460,000 (31 March 2010 - £10,885,000) relating to invoices raised in advance in respect of contract 

income due to the Foundation Trust in April 2011. 




continued 

14.3 Provision for impairment of receivables 

Total 

as at 

31st March 

Total 

as at 

31st March 


£ 000 £ 000 

Provision at 1 April 1,828 1,579 

Increase in provision 588 1,669 

Amounts utilised (106) (17) 

Unused amounts reversed (1,444) (1,403) 

Provision at 31 March 866 1,828 

14.4 Analysis of impaired receivables 

Aging of impaired receivables: 

Up to three months 371 251 

In three to six months 40 897 

Over six months 455 680 

Total at 31 March 866 1,828 

Aging of non-impaired receivables: 

Up to three months 15,163 13,110 

In three to six months 218 642 

Over six months 851 1,838 

Total at 31 March 16,232 15,590 

15 Trade and other payables 

15.1 Current trade and other payables 

Total 

as at 

31st March 

Total 

as at 

31st March 


£ 000 £ 000 

NHS payables 444 621 

Amounts due to other related parties 1,547 1,781 

Trade payables - capital 535 598 

Other trade payables 2,206 2,866 

Taxes payable 2,198 2,215 

Other payables 4,915 5,844 

Accruals 6,287 4,556 

18,132 18,481 

15.2 Non-current trade and other payables 

Amounts due to other related parties 351 1,339 

Other payables 742 - 

Amounts due to other related parties include: 

1,093 1,339 

£507,000 (31 March 2010 - £1,739,000) for payments due in future years under arrangements to buy out the 

liability for fifteen (31 March 2010 - twenty seven) early retirements over five instalments and £1,247,000 (31 

March 2010 - £1,213,000) outstanding pension contributions at 31 March 2011. 




continued 

16 Other liabilities 

16.1 Other liabilities - current 

Total 

as at 

31st March 

Total 

as at 

31st March 


£ 000 £ 000 

Deferred income 12,894 12,697 

Deferred government grant 100 100 

16.2 Other liabilities - non-current 

12,994 12,797 

Deferred government grant 2,418 2,510 

Deferred income includes: 

2,418 2,510 

£11,460,000 (31 March 2010 - £10,885,000) relating to invoices raised in advance in respect of contract 

income due to the Foundation Trust in April 2011. 

Government grants represent contributions towards the purchase of property, plant and equipment, received 

from UK government organisations. 

17 Borrowings 

17.1 Current borrowings 

Total 

as at 

31st March 

Total 

as at 

31st March 


£ 000 £ 000 

Other loans 120 - 

Obligations under finance leases Note 18 5 5 

17.2 Non-current borrowings 

125 5 

Other loans 300 - 

Obligations under finance leases Note 18 - 5 

300 5 

18 Finance lease obligations 

Total 

as at 

31st March 

Total 

as at 

31st March 


£ 000 £ 000 

Minimum finance lease payments due: 

no later than one year 5 6 

later than one year and no later than five years - 5 

later than five years - - 

Gross finance lease liabilities 5 11 

Finance charges allocated to future periods - (1) 

Net finance lease liabilities 5 10 

Net finance lease liabilities are due: 

no later than one year 5 5 

later than one year and no later than five years - 5 

later than five years - - 

5 10 




continued 

19 Prudential borrowing limit 

The NHS Foundation Trust is required to comply and remain within a prudential borrowing limit. This is made 

up of two elements: 

- 

- 

the maximum cumulative amount of long-term borrowing. This is set by reference to the four ratio tests 

set out in the Prudential Borrowing Code for NHS foundation trusts. The financial risk rating set under 

Monitor‟s Compliance Framework determines one of the ratios and therefore can impact on the long 

term borrowing limit; and 

the amount of any working capital facility approved by Monitor. 

Further information on the NHS Foundation Trust Prudential Borrowing Code can be found on the website of 

Monitor, the Independent Regulator of Foundation Trusts. 

Year Ended 

31st March 

Year Ended 

31st March 


£ 000 £ 000 

Total long term tier 1 borrowing limit set by Monitor 30,300 31,000 

Working capital facility 10,000 10,000 

Total prudential borrowing limit 40,300 41,000 

Long term borrowing at 1 April 5 10 

Net actual borrowing/(repayment) in year - long term 295 (5) 

Long term borrowing at 31 March 300 5 

During the year ended 31 March 2011 the Trust drew funding of £480,000 (2009/10 - £nil) from an interest 

free borrowing facility to fund carbon reduction capital investments. The Trust also continued to hold a small 

number of finance leases which gives rise to a small level of debt and debt service charge. 

Actual Approved Actual Approved 

ratios tier 1 ratios ratios tier 1 ratios 

Year Ended Year Ended Year Ended Year Ended 

31st March 31st March 31st March 31st March 

2011 2011 2010 2010 

Minimum dividend cover 7.3x >1x 7.5x >1x 

Minimum interest cover 33,015.4x >3x 12,387x >3x 

Minimum debt service cover 146.5x >2x 777x >2x 

Maximum debt service to revenue 0%


continued 

20.2 Current provisions 

Total Total 

as at as at 



£ 000 £ 000 

Pensions - other staff 60 69 

Other legal claims 89 124 

Other 5,387 4,646 

At 31 March 5,536 4,839 

20.3 Non-current provisions 

Pensions - other staff 934 903 

Other 1,554 763 

At 31 March 2,488 1,666 

20.4 Clinical negligence liabilities 

£17,892,000 is included in the provisions of the NHS Litigation Authority at 31 March 2011 (31 March 2010 

- £9,247,000) in respect of clinical negligence liabilities of the Foundation Trust. 

21 Revaluation reserve 

Property, plant 

Property, plant 

and equipment Total and equipment Total 

2011 2011 2010 2010 

£ 000 £ 000 £ 000 £ 000 

At 1 April 6,585 6,585 12,754 12,754 

Impairments (109) (109) (3) (3) 

Revaluations - - (6,068) (6,068) 

Other reserve movements (72) (72) (98) (98) 

At 31 March 6,404 6,404 6,585 6,585 

22 Cash and cash equivalents 

As at As at 



£ 000 £ 000 

At 1 April 37,634 32,418 

Net change in year 3,556 5,216 

At 31 March 41,190 37,634 

Broken down into: 

Cash at commercial banks and in hand 121 125 

Cash with the Government Banking Service 41,069 37,509 

Cash and cash equivalents as in SoFP 41,190 37,634 

Bank overdraft - - 

At 31 March 41,190 37,634 




continued 

23 Financial instruments 

Loans and Total 

receivables 

£ 000 £ 000 

23.1 Analysis of financial assets and liabilities by category 

Assets as per Statement of Financial Position 

Financial assets as at 31 March 2011 

Trade and other receivables excluding non financial assets 15,219 15,219 

Cash and cash equivalents 41,190 41,190 

Total financial assets as at 31 March 2011 56,409 56,409 

Financial assets as at 31 March 2010 

Trade and other receivables excluding non financial assets 12,800 12,800 

Cash and cash equivalents 37,634 37,634 

Total financial assets as at 31 March 2010 50,434 50,434 

£856,000 of impairment gains on loans and receivables (31 March 2010 - £266,000 loss) has been recognised 

within operating expenses during the year under the heading 'bad debts' within note 5. 

Liabilities as per Statement of Financial Position 

Other Total 

financial 

liabilities 

£ 000 £ 000 

Financial liabilities as at 31 March 2011 

Borrowings (excluding finance leases) 420 420 

Obligations under finance leases 5 5 

Trade and other payables excluding non financial assets 17,027 17,027 

Total financial liabilities as at 31 March 2011 17,452 17,452 

Financial liabilities as at 31 March 2010 

Obligations under finance leases 10 10 

Trade and other payables excluding non financial assets 17,605 17,605 

Total financial liabilities as at 31 March 2010 17,615 17,615 




continued 

23.2 Fair value of financial assets and liabilities 

Financial assets 

Non current trade and other receivables excluding non financial 

assets 

Book value Fair value 

as at 

as at 


2011 2011 

£ 000 £ 000 

436 436 

Total 436 436 

Financial liabilities 

Non current trade and other payables excluding non financial 

liabilities 

1,093 1,093 

Loans 300 300 

Total 1,393 1,393 

The fair value of financial assets and liabilities is not significantly different from the book value. 

The carrying values of other short-term receivables and payables are a reasonable approximation of the fair 

value. 

The Trust has limited exposure to interest rate risk, currency risk, credit risk and other specific price risks, 

and therefore does not actively seek to manage risk in these areas. The Foundation Trust has managed its 

liquidity risk by securing a £10,000,000 working capital facility in accordance with the prudential borrowing 

limit set by Monitor (see note 19). 

24 Losses and special payments 

There were eighty one cases (31 March 2010 - sixty four) of losses and special payments totalling £213,000 

(31 March 2010 - £54,000) approved during the year ended 31 March 2011, including the staff exit packages 

described in note 7.4. These amounts are reported on an accruals basis but exclude provisions for future 

losses. 2010/11 figures also include for the first time the costs of public and employer liability claims up to 

the value of the insurance excess which the Trust pays. 

25 Third party assets 

The Foundation Trust held £4,000 cash at bank and in hand at 31 March 2011 (31 March 2010 - £6,000) 

which relates to monies held on behalf of patients. This has been excluded from the cash at bank and in 

hand figure reported in the accounts. 

26 Capital commitments 

The Foundation Trust had contractual capital commitments of £166,000 as at 31 March 2011 (31 March 

2010 - £763,000). 

27 Related party transactions 

27.1 Key management personnel compensation 

Year Ended 

31st March 

Year Ended 

31st March 


£ 000 £ 000 

Salaries and other short term benefits 855 920 

Post employment benefits 89 88 

Total 944 1,008 




continued 

27.2 Related party payments, receipts and balances 

During the year none of the Board members or members of the key management staff, or parties related to 

them, have undertaken any material transactions (other than employment benefits) with the James Paget 

University Hospitals NHS Foundation Trust. 

All bodies within the scope of the Whole Government Accounts (WGA) are considered to be under common 

control, and are therefore considered to be related parties. The James Paget University Hospitals NHS 

Foundation Trust also acts as the corporate Trustee of the James Paget University Hospitals Charitable Fund 

and in accordance with the charity‟s declaration of trust, members of the Foundation Trust‟s Board of 

Directors act as ex-officio Trustees of the Charitable Funds. Therefore the Charitable Fund is also 

considered as a related party. The values of transactions with these entities are detailed below: 

Payments Payments Receipts Receipts 


2011 2010 2011 2010 

£ 000 £ 000 £ 000 £ 000 

Value of transactions with other related parties 

Department of Health - - 1 121 

Other NHS bodies 11,662 21,536 158,485 157,597 

Other non-NHS WGA bodies 16,899 7,584 171 280 

Value of transactions with Charitable Funds - - 655 927 

Value of balances with related parties written off as 

bad debts during the year 

101 9 - - 

Amounts Amounts Amounts Amounts 

payable payable receivable receivable 


2011 2010 2011 2010 

£ 000 £ 000 £ 000 £ 000 

Value of balances with other related parties 

Department of Health - 10 1 88 

Other NHS bodies 19,552 24,650 13,670 11,066 

Other non-NHS WGA bodies 4,099 2,345 128 259 

Value of balances with Charitable Funds - - 84 50 

Value of balances with related parties in relation to 

doubtful debts 

- - 645 1,648 

None of the related party balances are secured or guaranteed, and all of the transactions are carried out 

under the Trust's normal trading terms and conditions. 




Lowestoft Road, Gorleston, Great Yarmouth, Norfolk NR31 6LA 

Page 6 Making Waves Newsletter March 2011 www.jpaget.nhs.uk

Annual Report & Accounts 2010/11 - James Paget University Hospitals

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