Annual Report and Accounts 2012/13 - Hillingdon Hospital NHS Trust

The Hillingdon Hospitals NHS Foundation Trust
Annual Report and Accounts 2012/13

The Hillingdon Hospitals NHS Foundation Trust
Annual Report and Accounts 2012/13
Presented to Parliament pursuant to Schedule 7,
paragraph 25(4)(a) of the National Health Service Act 2006

CONTENTS
Page
Introduction from the Chair and Chief Executive
2
Directors’ report 1
4
Governance report 2
34
Remuneration report
52
Quality report
59
Statement of Accounting Officer’s responsibilities
97
Statement of Directors’ responsibilities in respect
of the accounts
98
Annual governance statement
99
Independent Auditor’s report
110
Annual accounts 2012/13
112
1 Including management commentary, staff survey, regulatory ratings, and public interest disclosures
2 Including disclosures set out in the NHS Foundation Trust Code of Governance
1

INTRODUCTION FROM THE CHAIR AND CHIEF EXECUTIVE
The Hillingdon Hospitals NHS Foundation
Trust has strong links with the local
community, with around 80% of our patients
being drawn from within the Borough of
Hillingdon.
During the last year the Trust’s clinical
performance remained strong despite the
prolonged and extremely busy winter. Our
clinical and non-clinical staff performed
admirably under the most severe pressures
and we remained compliant against all
Monitor targets for each quarter, including
the challenging Accident & Emergency
(A&E) access target and infection control
targets. We managed to deliver these, whilst
delivering our financial plan and retaining
our financial risk rating at an acceptable
level.
The annual report and accounts outline some
of the successes and achievements over the
last year. These achievements would not
have been possible without the hard work
of our staff who are the lifeblood of this
organisation. The Trust also benefits from
the support of our Governors who have
an increasingly important role at the Trust,
and our volunteers and charity workers
who play an important role in fundraising
and supporting patients and staff on the
Hillingdon and Mount Vernon Hospital sites.
It is thanks to the dedication of all of these
people that the lives of many thousands of
patients are saved and services maintained
and improved each year.
The commitment, skill, care, and hard work
exhibited by all our staff is all the more
impressive given the massive challenges
currently facing the NHS.
The NHS has just completed one of the
biggest reorganisations in recent years.
Under the strategic umbrella of a new
national organisation, NHS England, from
1st April 2013 the day-to-day responsibility
for the bulk of healthcare commissioning
has been delegated to local Clinical
Commissioning Groups (CCGs) comprising of
local GPs. Hillingdon CCG wishes to reduce
the money that they spend at the hospital,
in addition to the nationally set reductions
in the ‘tariff’ that determines the income the
Trust receives for each instance of patient
treatment. This means that we must continue
to balance tight control over finance with
rising demand and increasing political and
patient expectations on quality.
To help balance these issues, the Trust is
working in partnership with GPs to redesign
clinical pathways, help to integrate care
across community and hospital boundaries,
and work more in the community to improve
patient care and to make best use of scarce
resources.
Further significant changes affecting the
Trust’s future development are outlined
in the North West London clinical strategy
‘Shaping a Healthier Future’. The proposals,
approved in February 2013, set out the
direction for the reshaping of health services
in North West London to improve quality,
cope with rising demand, and ensure health
services are affordable. They aim to reshape
health services by increasing investment in
community services and diverting activity
out of the hospital environment. If successful
the plan will reduce the number of major
hospitals in this part of London. It is to the
credit of our staff that Hillingdon Hospital
has been identified as a major acute hospital
and a fixed point in the overall plans and
we anticipate the greater use of Hillingdon
Hospital by Ealing GPs and residents.
Against this massive programme of change
we will continue to focus on our prime
purpose of delivering high quality patient
care and improving the patient experience.
We have recieved over £12m Public Dividend
Captial from the Department of Health
to invest in our emergency care services
and over £0.7m to refurbish the birthing
environment in our maternity unit. Much of
this work will be undertaken during 2013/14
2
Introduction

and represents significant investment in our
services.
The national concerns over poor patient
care, exemplified in the Public Inquiry on
Mid Staffordshire NHS Trust are a salutary
reminder to all hospitals that clinical quality,
patient safety and patient experience are
of paramount importance and must never
be placed secondary to achieving financial
balance. The Trust’s CARES values launched in
May 2012, were designed by staff and go to
the heart of everything we do.
By embedding CARES throughout the
organisation we will ensure that the needs
of our patients always come first and that
staff can work in a culture that encourages
openness and transparency. The Board
and Governors are clear that we as an
organisation will continue to put patient care
at the very top of our agenda. We are clear
that the Trust must not compromise clinical
quality and safety despite the financial
pressures facing the NHS nationally and
locally.
Introduction
3

DIRECTORS’ REPORT
About us
• 24,633 admissions were made for planned
the Trust (25,267 in 2011/12) 3 operations and day surgery (23,385 in
The Hillingdon Hospitals NHS Foundation
2011/12).
Trust was established on 1st April 2011 when
Monitor authorised The Hillingdon Hospital
NHS Trust to be an NHS Foundation Trust.
The Trust provides health services at two
hospitals in North West London: Hillingdon
and Mount Vernon. Hillingdon Hospital is the
only general hospital in the London Borough
of Hillingdon and offers a wide range of
services including accident and emergency,
inpatient care, day surgery, outpatient clinics
and maternity services. The Trust’s services
at Mount Vernon Hospital include routine
In recent years our vision has been ‘to be
the best general hospital in the country’.
Given the significant amount of changes
underway in the environment in which we
operate, the Board agreed that there was a
need to update the Trust’s vision. Following
consultation with staff, in May 2013 the
Board agreed a new vision for the Trust that
will inform the 2013/14 business planning: ‘To
put compassionate care, safety and quality at
the heart of everything we do’.
day surgery at a modern treatment centre,
a minor injuries unit, and outpatient clinics.
The Trust also acts as a landlord to a number
of other organisations that
provide health services at Mount Vernon,
including East & North Hertfordshire NHS
Trust’s Cancer Centre.
The Trust’s turnover in 2012/13 was over
£190m and we employ over 2,500 staff.
The majority of our patients live in the
London Borough of Hillingdon but we
also provide healthcare to people living in
the surrounding areas of Ealing, Harrow,
Buckinghamshire and Hertfordshire, giving
us a total catchment population of over
350,000 people.
In 2012/13:
• 110,354 attendances were made to our
accident & emergency department and
minor injuries unit (108,719 in 2011/12)
• 4,205 babies were born in our maternity
unit (4,218 in 2011/12)
• 289,041 attendances were made as
outpatients (296,606 in 2011/12)
• 24,271 admissions were made for
emergency treatment across all parts of
3 This figure reflects all emergency admissions to the Trust; emergency admissions to inpatient wards increased (see page 7
for further information)
4 Directors’ report

Our performance against key targets
The following table summarises the Trust’s performance in 2012/13 against the targets used
by Monitor to calculate the governance risk rating 4 :
Indicator Target Performance Achieved
Clostridium difficile 24 (maximum) 23
MRSA 3 (maximum) 1
All cancers: 31 days for second or subsequent
94% 100%
treatment (surgery)
All cancers: 31 days for second or subsequent
98% 100%
treatment (anti-cancer drug treatments)
All cancers: 62 days for first treatment from
85% 93.3%
urgent GP referral for suspected cancer
All cancers: 62 days for first treatment from NHS 90% 93.9%
Cancer Screening Service referral
Maximum time of 18 weeks from point of referral 90% 97.5%
to treatment – admitted
Maximum time of 18 weeks from point of referral 95% 98.8%
to treatment – non admitted
Maximum time of 18 weeks from point of
92% 97.3%
referral to treatment – patients on an incomplete
pathway
All cancers: 31 days diagnosis to first treatment 96% 99.2%
Cancer: two week wait from referral to date first 93% 97.9%
seen for all urgent referrals (cancer suspected)
Cancer: two week wait from referral to date first 93% 98.0%
seen for symptomatic breast patients (cancer not
initially suspected)
A&E: Total time in A&E less than 4 hours (Accident 95% 96.7%
& Emergency, Minor Injuries Unit, Urgent Care
Centre)
Self-certification against compliance with
Fully Compliant Fully Compliant
requirements regards access to healthcare for
people with a learning disability
Moderate Care Quality Commission (CQC)
No declared risk No declared risk
concerns regarding the safety of healthcare
provision
Major CQC concerns regarding the safety of No declared risk No declared risk
healthcare provision
Failure to rectify a compliance or restrictive No declared risk No declared risk
condition(s) by the date set by CQC within the
condition(s) (or as subsequently amended with
the CQC’s agreement)
Published NHSLA & CNST Maternity level Level 1 or higher 1
4
Definitions for the indicators are included in Monitor’s ‘Compliance Framework’ (available on
www.monitor-NHSft.gov.uk)
Directors’ report
5

Infection control
The Trust continued to drive forward the
infection prevention and control agenda
and met the performance targets for both
MRSA and Clostridium difficile (C-diff) in
2012/13. One MRSA bloodstream infection
was reported against a threshold of three,
which is a significant improvement from
the previous year’s performance when we
finished with four reported cases of MRSA.
The Trust reported 23 cases against a
threshold of 24 for C-diff infections. Whilst
this meant we met the target, the Trust saw
an increase in reported cases from quarter
three resulting in the Trust remaining close
to the target.
All C-diff patients had detailed multidisciplinary
root cause analysis (RCA)
undertaken involving the Microbiologists,
the patient’s clinical team (Consultant and
nursing staff), the infection control team and
other members of the multi-disciplinary team
(MDT) as required. Key learning from RCAs
undertaken for 2012/13 cases included:
• Antimicrobial prescribing: clinical
indication must be documented and
the antimicrobials reviewed at every
ward round.
• Documentation (both nursing &
medical) needs to be thorough and
contemporaneous.
• There is a need for improved
communication between teams,
especially when the patient is an
outlier with regard to specialty.
• Specimen results are checked as soon
as possible by ward staff after sending
to the laboratory.
• There should be senior clinical
decision-making in sending samples.
• Patients with diarrhoea on admission
require specimens and isolation at the
earliest opportunity.
These themes were shared widely across the
organisation to ensure that the key learning
was shared and used to shape future
practice.
The Trust faces an increased challenge for
the new financial year with a target of zero
for MRSA and 14 for C-diff. We do however
believe that the learning from the root cause
analysis and the continued work around
education and close monitoring will enable
the Trust to meet these more stringent
targets.
Cancer
A comprehensive action plan was
implemented in 2011/12 to strengthen
management arrangements within the
cancer services. As a result of which, the Trust
delivered strong performance on all cancer
targets in 2012/13.
Referral to Treatment waiting times
All 18 week targets for both admitted and
non-admitted patients were achieved and
exceeded. The strong performance across
elective (planned treatment) waiting time
standards continues to ensure that the Trust
remains one of the top performing hospitals
in North West London on these targets which
seek to minimise patients’ waiting time for
treatment.
Accident and Emergency (A&E)
waiting times
The Trust achieved the target for 95% (all
types) of patients to have a total time in
A&E of less than four hours, with a mean
performance throughout the year of 96.6%.
A majority of Trusts in London have been
challenged in delivering the A&E standard
throughout the last quarter of the year.
Unprecedented numbers of ambulance
arrivals and increased acuity of patients
made delivery of the target particularly
challenging. Ambulance arrivals increased
6 Directors’ report

400
TRUST TOTAL - ADMISSIONS
Non-Elective Admissions
Excluding: Observation, Specialist, Maternity, Paediatrics & Daniels Wards
Avg 10/11: 256
Avg 11/12: 273
Avg 12/13: 287
2010/2011
2011/2012
2012/2013
350
300
250
Count of Admissions
200
150
100
50
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52
APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR
Week Number
by 3.9% between January and March 2013,
which resulted in more acutely unwell
patients attending the hospital and receiving
care in the resuscitation unit. Patients
admitted to the resuscitation unit are acutely
unwell and require a medical team to meet
their clinical needs. This can deplete staff
in the ‘minors’ area, and as a consequence,
performance was affected. The Trust did
however still manage to deliver the 95%
standard during January to March which was
our busiest time.
The chart above tracks the increased level of
emergency admissions to our adult inpatient
wards.
Additional funds were made available
by the Department of Health to support
Trusts over the winter period. Furthermore,
the Trust invested significant funds to
ensure patients continued to be seen and
treated in a timely manner and to restore
performance by increasing the number of
medical, nursing and clinical support staff in
the A&E department. An additional Senior
Sister was allocated to every shift to organise
and co-ordinate patient flows through the
department.
Extra medical staff were also allocated to
the Emergency Admission Unit (EAU), which
significantly improved flows through the
A&E department by ensuring there were
sufficient beds available in the Trust to meet
surges in activity.
The chart on the next page demonstrates
a substantial increase in the number of
patients that were discharged from the EAU
rather than admitted to one of our inpatient
wards.
Access to healthcare for people with
learning disabilities
The Trust continues to fully comply with the
requirements regarding access to healthcare
for people with a learning disability.
CQUIN delivery
Commissioning for Quality and Innovation
(CQUIN) is a national framework for locally
agreed quality improvement schemes. It links
a proportion of healthcare income to the
achievement of local quality improvement
goals. The financial value of the available
CQUINs for 2012/13 was 2.5% of the Trust’s
clinical activity income.
CQUINs are divided between those that
are set nationally for all hospitals, those
which are set regionally, and those are
agreed locally between the Trust and
Directors’ report
7

120
Emergency Assessment Unit (EAU)
SHORT STAY ADMISSIONS
The number of admissions to EAU, who are also discharged from EAU
2010/2011
2011/2012
2012/2013
100
80
No of Admissions
60
40
20
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52
APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR
Week No
commissioner. The table below outlines the
overall achievement of the CQUINs across the
year. The variation across the year reflects
that the regional and local CQUINs become
progressively more challenging as the year
progresses.
Q1: Achieved
100%
The anticipated final outcome is 76%
achievement.
Further detail on the individual CQUINs is
outlined below:
National
Q2: Achieved
100%
Q3: Achieved
93%
Q4: 52%
(anticipated)
• VTE
The Trust exceeded the 90% standard
on assessment for risk of venous
thromboembolism (VTE) every month in
2012/13.
• Patient experience
The Trust achieved 20% of the patient
experience CQUIN which focuses on
improving response rates in the national
patient experience survey. The Trust
improved on all of the survey questions
measured for this CQUIN with the
exception of ‘did a member of staff
explain the potential side effects of
your medication’. A review on how staff
explain side effects to patients is being
undertaken and further training will be
provided if necessary.
• NHS Safety Thermometer
The Trust achieved 100% of the NHS
Safety Thermometer CQUIN which focused
this year on collection and return of data.
The intention of this CQUIN for 2012/13
was to create systems to monitor staff
training and to collect data to establish
baselines to set trajectories for 2013/14. In
2013/14 the CQUIN will focus on pressure
ulcers and will measure performance of all
health and social care providers.
• Dementia screening
The Trust made considerable progress
in implementing systems to ensure that
patients received the necessary dementia
screening assessment. However, due to
the difficulties with the IT system it was
not possible to provide the necessary data.
As a consequence, the Trust did not meet
the required standards for this CQUIN.
Regional
• North West Formulary
The Trust achieved 100% of the North
West London Formulary CQUIN, which
focuses on implementing a standard
formulary for the prescribing of drugs.
The purpose of the formulary is to
8 Directors’ report

educe the risk of drug errors by ensuring
clinicians and pharmacists are familiar
with the medicines they prescribe and
dispense.
• Real time
The Trust anticipates that it will achieve
81% of the ‘Real Time’ CQUIN. The
purpose of this CQUIN was to promote
the use of an electronic process to speed
up communication between primary and
secondary care, including the sending
of outpatient letters and discharge
summaries following a hospital visit or
admission.
Local
• Consultant assessment
Considerable investments were made to
achieve 50% of the 12 hour Consultant
assessment CQUIN. There was a significant
investment in paediatrics where two
additional Consultants have been
appointed. The Trust also appointed an
additional Consultant to the Emergency
Admissions Unit to ensure more patients
received senior review within 12 hours
of an emergency admission. The Trust
is committed to fully achieving the
standards set out in this CQUIN which also
supports the emerging Emergency Care
Clinical Quality Standards for London.
• Diabetes care
The Trust achieved 100% of the Diabetes
Care CQUIN by significantly increasing
specialist care given to patients with
diabetes.
• End of life care
The Trust achieved 87% of the End of Life
Care CQUIN. This was an important new
CQUIN developed between the Trust and
local commissioners. The purpose of the
CQUIN was to establish a database and
a better understanding of the needs of
patients who require care at this time of
their lives. The information gathered will
help the commissioners and the Trust to
better design and co-ordinate services
more aligned to patients’ needs.
Our finances
Overview of financial performance
The organisation’s second year as a standalone
Foundation Trust regulated by Monitor
was, without doubt, even tougher than its
first. The solid financial foundations laid
down over the last ten years were therefore
required more than ever as both the national
economic context and more pertinently
the local commissioning financial context
impacted on the Trust to an even greater
extent than in the past. Faced with this
context, in May 2012 the Board reluctantly
approved an annual forward financial plan
of a £1.9m income and expenditure deficit
for the financial year 2012/13. However, the
Trust had just enough financial headroom
that it was able to maintain a financial risk
rating of 3 in each quarter of the 2012/13
financial year. The Trust achieved its financial
plan for the year and although clearly
disappointing, the deficit represented only
1% of total turnover. This performance
though must be viewed within the context
of increased patient expectation, higher
clinical standards and service demands,
and the economic pressures facing the
organisation. When added to the severe local
commissioning financial restrictions, the fact
more healthcare was delivered to a high
standard was a notable achievement.
Overall surplus for the year
The £1.9m deficit included two significant
non-recurrent transactions. These were
charges for fixed asset impairments of
£0.5m that are not included in Monitor’s
financial risk rating metrics and a gain on the
revaluation of its investment properties of
£1.7m. 5
5 Investment properties are those held by the Trust to earn rentals and/or capital appreciation rather than used to provide
healthcare
Directors’ report
9

Clinical activity levels, which were higher
than contracted by healthcare commissioners,
increased overall Trust operating revenue by
2.2% for the year. This drove operating costs
higher for the year by 0.8%. In addition, the
Trust underachieved on its efficiency savings
target of £7m by £0.7m – a delivery rate of
90%.
The Trust’s Earnings Before Interest, Tax,
Depreciation, and Amortisation (EBITDA)
were boosted by bringing catering and
cleaning services back into direct Trust
management, and the award to the
Trust, after a competitive exercise, of the
contract to run pathology services for GPs in
Hounslow.
Cash flow
The Trust generated £12.8m cash from
operating as a healthcare provider for the
year. From this £6.3m was used to purchase
new assets and a further £3.3m was required
to service the outstanding debt and interest
from loans and leases. A net £1.2m of
Public Dividend Capital was repaid to the
Department of Health. This resulted in the
Trust increasing its cash levels at the yearend
by £2m when the plan at the start of
the year had been to reduce them by £1.5m.
This meant that against the plan of £0.4m it
ended the year with £3.9m cash.
This increase in cash will serve two important
objectives. First, it will allow £1.8m to be
used to finance committed capital schemes
that did not complete as planned by the end
of the current financial year and second, it
will provide some additional cash headroom
for the Trust going forward.
Capital investment
The Trust’s own cash resources to invest
were supplemented by £12.4m of new Public
Dividend Capital received from DH in respect
of a successful business case to upgrade and
better integrate emergency care facilities on
the Hillingdon Hospital site. This project will
continue throughout the 2013/14 financial
year and will form a major element of the
estate investment programme in 2013/14 (see
the later section on capital developments).
Apart from major development projects, the
largest area of investment during the year
was again the estate. This centred on the
Trust’s plan to prioritise investment to keep
operational buildings safe, fit for purpose,
and compliant with statutory legislation.
Given the nature of the Trust’s estate this
will inevitably be a long-term process, and
there is a programme in place to continue
with this investment for the foreseeable
future focused on the highest risk areas.
Other significant projects included the
refurbishment of one of the Trust’s busiest
emergency wards and the start of a public
toilets upgrade programme.
In addition to investing in the physical
infrastructure of the organisation, the Trust
also continued to invest in updating its
medical equipment across a range of clinical
services.
Investment in information technology
infrastructure and capability also remained a
priority with system upgrades in Maternity,
Pharmacy and Pathology. Another important
project saw the Trust implement new
hardware and software with enhanced
capabilities to better integrate patient
information between hospital systems. Other
investment focused on improving network
infrastructure.
Looking to the future
The Trust’s 2013/14 Forward Plan will again
be set in the context of a UK economy that
looks like it will remain suppressed for the
foreseeable future. This is having a direct and
ever increasingly tough financial impact on
all UK public services.
The NHS in England is no different and
reductions in the prices providers can charge
commissioners for services under the national
10 Directors’ report

tariff look set to remain. After two years
of general restraint, pay levels for all staff
look set to increase by 1% in the coming
financial year adding further pressure to
Trust finances.
The national tariff (which determines how
much Trusts receive for providing specific
treatments) seems likely to continue to set
providers the challenge of achieving at least
a 4% efficiency saving in effect to ‘standstill’.
Other pressures on acute providers brought
about by restrictions on payment of
emergency admissions and readmissions
together with tough penalties for failing to
meet national standards is expected to add
at least a further 1% to the total efficiency
savings required to be achieved in 2013/14.
With the formal abolition of Primary Care
Trusts, Clinical Commissioning Groups (CCG)
are taking on the roles and responsibilities
and forming new organisations with GPs
taking a front seat. Locally, Hillingdon
Clinical Commissioning Group (HCCG) was
authorised and will operate within a cluster
of four adjoining outer North West London
CCGs in Brent, Harrow and Ealing.
As Hillingdon Primary Care Trust ended the
2012/13 financial year requiring significant
external financial support to break-even,
Hillingdon CCG is implementing an ambitious
three-year financial recovery plan. This is
aligned to their out of hospital strategy and
will reduce the amount of work this Trust
will undertake for them as more healthcare
provision is moved to alternative local
settings.
The impact of this could be as high as 10%
in 2013/14, and over the three year recovery
plan period could see the Trust’s clinical
revenue reduced by up to £30m. This is in
addition to the efficiency savings already
required by the national tariff and will
undoubtedly put margins under the severest
strain. Conversely, should the commissioners’
out of hospital strategy not be as successful
at reducing activity as planned, then
potentially the Trust will have to treat
patients and not be fully paid. As highlighted
elsewhere in the report, this is one of the
key risks facing the Trust. To help mitigate
this risk, the Trust and CCG are working
with PricewaterhouseCoopers to review the
sustainability of the local health economy.
As outlined earlier in the report, the level
of payment linked to delivering specific
demonstrable quality improvement (CQUINs)
will remain at 2.5% of the Trust healthcare
contract revenue for the coming year. This
amounts to around £4.3m of income that will
be at risk especially as it is likely to require
the Trust to make significant targeted
investment to meet the improvement in
standards required. To ensure the Trust
achieves the most it can from the payments,
CQUINs will remain a key focus for clinicians
and managers.
These increased financial risks and efficiency
saving requirements together with a very
financially challenged local commissioner
will continue to mean improvements in
productivity and efficiency will remain
a significant point of focus for the
management team. Clearly, this will have
to be achieved whilst national and local
quality standards are at the very least
maintained and increasingly will require the
complete transformation of Trust services.
The continued rigorous assessment of the
clinical impact of all significant Trust plans
will therefore remain a crucial focus for
management.
The Trust is embarking on a comprehensive
transformation programme that will alter
the way we provide almost all services within
the hospital. The focus is on improving the
quality of the services we provide, which will
in turn improve both the patient experience
and delivery of the required efficiencies.
Some of the proposed changes will affect
inpatient pathways. Quality initiatives, such
as earlier Consultant review and better
discharge planning, will improve the patient
experience and reduce the length of time
Directors’ report
11

patients spend in hospital, which will in
turn mean the Trust will need less beds.
Critical to this will be the way we work with
our local health, social and voluntary care
partners to deliver an integrated system of
care. Improvements to the way we schedule
our theatres will reduce the number of
operations cancelled and consequently make
significant savings. The scale of savings and
transformation required means that the
coming year will be extremely challenging,
but one where we are fully committed to
improving both the quality and experience of
the services we provide.
In this challenging external context the
Board of Directors will remain focused
on the considerable challenge of how
the organisation can continue to meet its
continuity of services licence condition, which
requires the Trust to ensure it remains a
going concern. In particular, work will focus
on finding alignment between the Trust’s
activity plans and Hillingdon CCG’s QIPP and
identifying opportunities for the Trust to
re-provide services planned to be moved to
an out of hospital setting. The Board will
also further strengthen the Trust’s project
management of efficiency savings and review
options to reinforce its cash headroom.
Work will also concentrate on how best
to secure sufficient capital investment so
Trust facilities remain fit-for-purpose and
the organisation can gain from the clinical
and operational efficiencies technology can
deliver within both medical equipment and
information technology.
Non-NHS income
Section 43(2A) of the NHS Act 2006 (as
amended by the Health and Social Care Act
2012) requires that the Trust’s income from
the provision of goods and services for the
purposes of the health service in England
must be greater than its income from the
provision of goods and services for any
other purposes. In 2012/13, the Trust met
this requirement, with 97% (£188.7m) of the
Trust’s income generated by activities for the
purpose of the health service in England.
As the vast majority of Trust income is
categorised as generated by activities for the
purpose of the health service in England, it is
the Board’s view that other income does not
detract from NHS provision to any material
extent. Where other income is generated it
supports the Trust to make optimum use of
all its assets and is used to directly support
principal patient care activities.
Comparative financial performance
The table below outlines how the Trust
compared to the Foundation Trust sector
on a range of key financial performance
indicators. 6
The Hillingdon
Hospitals NHS FT
All Foundation Trusts
Average
Financial risk rating 7 – Acute Trusts 2.8 3.0
Financial risk rating – Small acute Trusts
2.8 2.8
(total turnover less than £200m)
EBITDA 8 margin 5.7% 6.0%
Cost improvement plans delivery 92.2% 83.8%
Capital spend to turnover 3% 4%
Cash balances £3.2m £27.0m
6 The above comparative performance table is based on the Regulator, Monitor’s most recent available review of the
Foundation Trust sector, of which 81 were acute, as at quarter 3 2012/13. To enable a direct comparison, the THH figures
reflect performance as at end of quarter 3 2012/13.
7 See ‘Regulatory ratings’ for further information on the financial risk rating
8 Earnings Before Interest, Taxes, Depreciation, and Amortisation
12 Directors’ report

Regulatory ratings
Monitor, the independent Regulator of
Foundation Trusts, assigns Foundation Trusts
two risk ratings each quarter:
• A financial risk rating (rated 1-5, where
1 represents the highest risk and 5 the
lowest); and
• A governance risk rating (rated red
(highest risk), amber-red, ambergreen
or green (lowest risk)).
The financial risk rating is based on a range
of metrics across four areas: achievement
of plan, underlying performance, financial
efficiency, and liquidity. The governance
risk rating is based on a combination of:
service performance (measured on the
Trust’s performance against key performance
indicators selected by Monitor from
the Department of Health’s Operating
Framework); the views of third parties such
as the Care Quality Commission and NHS
Litigation Authority; the provision of the
mandatory services that Foundation Trusts
must provide; and other instances where the
Board may fail to accurately certify on their
performance or governance. In addition,
Monitor retains the discretion to amend the
governance risk rating should a Foundation
Trust fail to meet the statutory requirements
of other bodies.
The Trust’s risk ratings for 2011/12 and
2012/13 are presented below.
The Trust had planned for a risk rating of
four for the 2011/12 financial year. However,
the rating of three for each quarter of the
year was due to two of the four financial
criteria being one rating below the planned
level. These were in respect of achievement
of plan and financial efficiency. The
reason the actual rating in these cases was
below plan was the Trust only made a surplus
before impairments of £262k when the
plan was for a surplus of £2.542m. This was
primarily due to three factors: (a) a shortfall
on the Trust’s planned efficiency savings; (b)
the Trust undertook an amount of activity
that under the terms of its contracts with
commissioners it was not going to be paid
for either in part or full 10 ; and (c) price
inflation on goods and services required by
the Trust had a greater impact on operating
costs than originally planned. Monitor
therefore requested that the Trust reforecast
its financial position and capital programme.
Annual Plan
2011/12
Q1 2011/12 Q2 2011/12 Q3 2011/12 Q4 2011/12
Financial risk rating 4 3 3 3 3
Governance risk rating Green Amber-red Amber-green Green Green
Annual Plan
2012/13
Q1 2012/13 Q2 2012/13 Q3 2012/13 Q4 2012/13 9
Financial risk rating 3 3 3 3 3
Governance risk rating Green Green Green Green Green
9 The Q4 risk ratings are based on the Trust’s submission to Monitor at the end of April 2013: the Trust does not have
Monitor’s confirmed Q4 ratings at the time of finalisation of the report (May 2013).
10 These included in areas such as emergency activity, readmitted patients, follow-up outpatient appointments, and
Consultant to Consultant referrals.
Directors’ report
13

At the start of the 2011/12 year, the Trust
had a governance risk rating of green based
on its risk assessment when submitting the
annual plan to Monitor. The amber-red
rating in Q1 was due to the Trust failing
to meet the 62 day cancer target 11 for the
quarter and that the Trust declared a risk of
failing the annual C-diff target. The Trust’s
risk rating improved to amber-green in Q2:
whilst the C-diff performance improved, the
Trust again failed to meet the 62 day cancer
target for the quarter. The Trust’s rating for
Q3 improved to green as the Trust met all
healthcare targets for the quarter, as it did in
Q4.
The Trust planned for a risk rating of 3 for
the 2012/13 year, which included a planned
financial deficit. The Trust maintained this
risk rating throughout the year, but was
requested by Monitor to reforecast the
capital expenditure given the variance to
plan. Based on the performance that was
being sustained from the second half of
2011/12, the Trust declared a risk rating of
green for governance for the 2012/13 year.
This was maintained for each quarter of the
year, with the Trust meeting the required
targets (as outlined in the table at the start
of the report).
Following the submission of the Trust’s
2012/13 annual plan, Monitor commissioned
a ‘stage 2 review’ of the Trust’s annual
plan. The review, undertaken by
PricewaterhouseCoopers (PwC) sought
to examine the risks around the Trust’s
financial stability. The review confirmed the
challenging and delicate nature of the Trust’s
financial position, particularly in respect of
its cash position, and recommended that
the Trust’s programme management office
arrangements be substantially strengthened
in light of the level of savings required. The
Trust developed an action plan in response
to the report’s recommendations, which
included a significant strengthening of
the arrangements for the delivery of the
efficiency savings programme, and increased
Board reporting on cash flow and liquidity.
In addition, the Board continues to explore
longer-term options for further increasing
the Trust’s liquidity and ensuring the Trust’s
future sustainability.
There have been no formal interventions by
Monitor at the Trust.
Environmental performance:
Sustainability
Sustainable development management
plan
The Sustainability Steering Group has been
created for the purpose of ensuring a whole
Trust approach to meeting the organisation’s
sustainability obligations. Sustainability is
now used in procurement specifications and
is accounted for as an evaluation scoring
element in all new capital, estates, food,
transport, energy and waste contracts.
During 2013 the Trust plans to trial a
‘sustainable ward’ with a focus on waste
reduction, energy management, recycling
and procurement. The trial will seek to
quantify the reduction in carbon footprint
and identify the highest impact schemes
which can be extended across other wards at
the Trust.
Reducing our energy use
Another key element of the action plan is
to reduce the Trust’s energy use. The Carbon
Reduction Commitment Energy Efficiency
Scheme (often referred to as simply ‘the CRC’)
is a mandatory scheme aimed at improving
energy efficiency and cutting emissions in
large public and private sector organisations.
The scheme features a range of reputational,
behavioural and financial drivers, which
aim to encourage organisations to develop
energy management strategies that promote
a better understanding of energy usage.
11 Percentage of patients receiving first definitive treatment within 62 days of referral from an NHS Cancer Screening Service
14 Directors’ report

The table below summarises the Trust’s energy use in Gigajoules (GJ):
2008/09 2009/10 2010/11 2011/12 2012/13
Electricity 59,548 61,173 59,851 58,518 56,703
Gas 121,241 89,369 89,327 66,806 87,551
Steam (incinerator) 75,923 79,990 79,991 79,991 69,990
Oil 0 0 0 0 0
Total 256,712 230,532 229,169 205,315 214,244
The Trust is on track for an absolute carbon
reduction target of 10% by 2015 against a
2007 baseline assessment.
During 2011/12 the Trust reduced the total
energy use by 23,854 Gigajoules (GJ) from
the previous year. This was attributed
to good incinerator reliability providing
steam for the Hillingdon Hospital site and
a relatively mild winter. The level of gas
consumption in 2012/13 increased from the
previous year due to the extent and length of
the winter weather conditions, and essential
repair works to the incinerator which led
to heavier use of the back up gas boiler in
March 2013.
From 1 st January 2013 the Trust successfully
secured a new five year contract with SRCL
to operate the incinerator based on the
Hillingdon Hospital site. This arrangement
ensures our clinical waste travels a minimum
distance before entering the incinerator
process; it is also highly sustainable in that
the steam created from burning clinical
waste is used to provide 70% of the energy
needed to heat the radiators and provide hot
water at Hillingdon Hospital.
Waste reduction and minimisation
The Trust’s Waste Group has met on a
regular basis during the year. Part of its role
is to ensure waste is segregated, managed,
recycled and disposed of effectively in line
with the Department of Health publication
‘Safe Management of Healthcare Waste’.
There has been a significant focus on
improving waste signage, ensuring
appropriate waste storage areas are in place,
and the correct segregation is followed.
Of the 1,363 tonnes of waste generated at
Hillingdon and Mount Vernon Hospitals in
2012/13, 351 tonnes (26% of the total) was
recycled. 545 tonnes (40%) of the total was
clinical waste, which was incinerated and
generated steam to provide heating and hot
water at the Hillingdon site. The remaining
467 tonnes (34%) was sent for landfill.
Green travel
The Trust has continued to promote green
travel for staff and service users. Events took
place at both hospital sites giving staff the
opportunity to learn about changing to
greener travel alternatives such as car sharing
and cycling to work. The well attended
events were sponsored by Transport for
London and will be repeated again this year.
The Trust is intending to update its Travel
Survey looking at how people travel to
hospital and will be supporting a wide range
of initiatives in the year ahead including
‘Bikewise’ events and ‘Walk to Work Week’
and will work with Transport for London and
the local authority to promote better public
transport services to the Trust’s hospitals.
Developing our services
Service developments
The Trust has undertaken a number of service
developments over the last year, some of
which are outlined below.
Directors’ report
15

Musculoskeletal (MSK) services
The Trust has been working with
commissioners to implement a redesigned
Orthopaedic, Rheumatology and Pain Service
model from April 2013 with implementation
of jointly agreed pathways. These pathways
will involve the provision of more integrated
care across primary and secondary care
settings with the development of a Clinical
Assessment and Treatment service (CATs) to
triage referrals and streamline patients down
the most appropriate care pathway. This
large scale programme of work will continue
to develop and evolve throughout 2013.
Integrated care pilot
The Trust has participated in the
development of the outer North West
London Integrated Care Pilot (ICP). The
vision is to improve outcomes for patients
by creating access to more integrated
care outside of hospital. The overarching
aim of this ambitious and transformative
programme is to improve health and
social care support for some of our most
vulnerable residents. Patient pathways will
be redesigned by ICP partners, with an initial
focus on care of the elderly (those over 75
years of age) and adults with diabetes.
This integrated approach is expected to
deliver improved outcomes for patients
by averting hospital attendances and
admissions, reducing length of stay for
those patients who are admitted to hospital,
improving patients’ experience of discharge
from hospital, and preventing readmissions.
As a result, a number of pilot schemes have
begun locally in Hillingdon including a falls
prevention management service.
Pathology
The Trust successfully won the tender for
the provision of Hounslow GP pathology
work. This was a significant result for the
organisation given the very competitive
environment that Pathology services operate
in.
A large scale strategic piece of work has
also begun to explore the long term future
strategy for Pathology services. Pathology is a
rapidly evolving field; modalities of diagnosis
are expanding and the necessity to perform
multiple investigations on a sample is ever
increasing.
In response to these changes, in May 2012
the Trust joined with five other Trusts in
North West London to carry out a high
level options analysis that would assist us in
determining the most efficient operating
model for the delivery of Pathology, whilst
improving the quality of the service and
increasing opportunities for training and
research. Whilst the first phase of this project
suggested a model with a single consolidated
NHS hub along with local core laboratories
at each Trust site, the next phase of the
project will look to develop and review this
option further, including a more detailed
operational model covering all aspects of
Pathology. It will also consider variations
to this option as required by the Trusts,
which may have particular needs or areas of
specialist focus. The Trust Board is anticipated
to consider the long term strategic options in
late spring 2013.
Capital developments
As outlined earlier in the report, we
have continued to invest in improving
our hospitals. Three key developments
in particular will improve the patient
experience and the quality of the services
provided by the Trust.
Emergency and urgent care development
A significant amount of work is currently
taking place to redesign both the estate
infrastructure and clinical model of care
for emergency care services. Following
the award of £12.4m of Public Dividend
Capital from the Department of Health, and
approval of the full business case by the Trust
Board in March 2013, the Trust appointed a
contractor to undertake the construction of a
16 Directors’ report

new building. This will accommodate a new
46-bed Acute Medical Unit (AMU) adjacent
to the existing Emergency Department (ED),
a new Rapid Assessment and Triage area to
facilitate a quicker clinical assessment, and a
new Urgent Care Centre (UCC) to integrate
with community, social & mental health
service providers.
The aim is to provide improved high quality,
safe, urgent and emergency care services
for the local population. This will support
achievement of the new A&E indicators,
reduced length of stay, and provide an
environment that will encourage integrated
care with other healthcare providers,
including the 111 telephone service. In
addition to redesigning the A&E department
and ambulatory emergency care pathways,
the Trust plans to develop its workforce to
meet the changing needs of patients that
arrive in the emergency department.
Improvements to the birthing room
environment
The Trust has been awarded over £700,000
of Public Dividend Capital to improve the
birthing room environment, within the
Maternity Unit. This will entail refurbishing
all ten rooms on the labour ward and include
ensuring that all rooms are en-suite.
Development of endoscopy services
The Trust is undertaking an extensive
programme of redevelopment of its
endoscopy services at both Mount Vernon
and Hillingdon sites. This will entail the
reprovision of endoscopy services at Mount
Vernon Hospital from the current location
in the Main Building to the surgical floor in
the Treatment Centre. Endoscopy services
will also be redeveloped as part of the
emergency care changes at the Hillingdon
site. This will require the current unit to be
relocated to the new facility under the new
AMU building. The endoscopy department
will be equipped with two fully developed
endoscopy suites.
The redevelopment will support accreditation
of both units by the Joint Advisory Group
on Gastrointestinal Endoscopy Services.
The relocation will also mean that patients
will enjoy a significant improvement to the
current environment.
Service changes and challenges in
the year ahead
As highlighted in the introduction to the
report, the environment in which the Trust
operates continues to significantly change.
Several of the key strategic issues affecting
the Trust in the coming year are outlined
further below.
Changes in the commissioning of services
From 1st April 2013, NHS Hillingdon Clinical
Commissioning Group is the statutory body
for designing and commissioning local health
services in Hillingdon, and therefore controls
the majority of the Trust’s income. Their
focus will be on securing better health care
outcomes and responding to the needs and
wishes of our patients.
They will do this by commissioning/buying
the health and care services for the local
population including:
• Elective/planned hospital care
• Rehabilitation care
• Urgent and emergency care
• Community health services
• Mental health services.
Other specialist services (for example
neonatal care) will be commissioned by the
National Commissioning Board.
Hillingdon CCG covers the same geographical
area as the London Borough of Hillingdon
and consists of all GP practices in the
borough. The Governing Body consists of
local GPs, a secondary care doctor, a senior
nurse, lay members, a Chief Officer, and a
Chief Financial Officer.
Directors’ report
17

Hillingdon CCG is working with all the CCGs
in North West London to implement the
health care strategy for NW London ‘Shaping
a Healthier Future’. The CCG fully supports
the strategy and they are actively developing
an out of hospital strategy, working
closely with The Hillingdon Hospitals NHS
Foundation Trust.
The key priorities for the CCG in 2013/14 are
to:
• Enable people to die at their preferred
place of death.
• Reduce emergency admissions from
care homes by 10 per cent.
• Reduce by 10 per cent the number of
days of the average length of stay for
people aged 65 or over admitted as a
result of a fall.
North West London reconfiguration
The Trust will continue to input into the
reconfiguration proposals set out in the
‘Shaping a Healthier Future’ programme.
The purpose of this review is to improve the
continued provision of high quality, safe
elective, urgent and emergency care services
to our local population.
The Trust will work with its healthcare
partners and other stakeholders to develop
strategic plans to accommodate anticipated
work flows as a result of proposed service
changes.
Urgent Care Centre (UCC)
The Trust will be submitting a joint bid with
an external partner for the UCC service which
is being tendered by the CCG. As part of this
bid, clinical pathways will be developed to
identify numbers and types of patients to
be treated in the UCC rather than A&E. It is
anticipated that this will hopefully form part
of a fully integrated emergency care model.
Out of hospital care
As healthcare moves out of hospitals
into community settings, the Trust will
continue to work with the commissioners
to develop an integrated model of care for
musculoskeletal (MSK) services. As outlined
earlier in the report, this will include
implementation of a Clinical Assessment and
Triage service (CATs) which ensures provision
of clinically appropriate pathways to the
local population.
The Trust is also working in collaboration
with other health and social care colleagues
on sector wide Integrated Care Pathways.
As part of this programme, £177k has been
awarded for an assisted discharge pilot,
which will be delivered in collaboration
with Central & North West London NHS
Foundation Trust (CNWL). This is expected to
reduce both length of stay and readmissions
for patients in this programme by assisting
them in their transition from acute to
community care. A further £60k has also
been awarded from the ICP innovation fund
for the delivery of a diabetic educational
programme for nursing home staff.
The Trust fully anticipates working on a
number of further out of hospital schemes,
particularly as it relates to planned care, with
new pathways developed in conjunction with
our CCG colleagues.
Development of dermatology services
The Trust plans to provide an integrated skin
centre at Mount Vernon Hospital, which will
include the development of a tertiary service.
The Trust will also be developing bids for
dermatology community services as they are
tendered in a number of localities.
Partnership working
The Trust has continued to develop
and enhance its relationships with local
health and social care partners. The Trust
has formally entered into a number of
regional programmes of work, including
the Integrated Care Pilot for outer North
West London, a joint review of Pathology
modernisation across the sector as well as
formally being a member of the Imperial
18 Directors’ report

College Health Partners Academic Health
Science Partnership. The partnership brings
together health providers in North West
London with Imperial College with the aim
of improving health outcomes by sharing
research.
Locally in Hillingdon we have looked to
redesign pathways of care with the CCG
through the redesign of MSK services which
also includes CNWL as our local community
service provider. The Trust is a member of
the Hillingdon Health Economy Recovery
Board which brings together health and
social care partners in Hillingdon to ensure
there is a financially sustainable local health
economy. The Trust is also a member of the
Hillingdon Health & Wellbeing Board which
comprises a wider range of health and social
care organisations to understand local needs
and agree priorities for improving health and
reducing health inequalities.
Risks and uncertainties
The Board has identified a number of
key risks to the organisation which, if not
managed, will impact on the Trust’s ability
to deliver its mission and objectives. In the
current and forecast operating context the
key risks relate to:
• The unprecedented size of the efficiency
savings required in the next five years and
the Trust not receiving payment for the
activity it undertakes, both of which have
the clear potential to impact on the Trust’s
financial viability and financial capacity to
invest in its services and infrastructure.
• The risk that the strategies to deliver
care out of the hospital setting do not
achieve the necessary goals and thereby
cause an impact on the Trust’s operational
efficiency and quality.
• The risk of uncertainty caused by the
reconfiguration of services in North West
London (‘Shaping a Healthier Future’) not
occurring at the rate anticipated.
The Annual Governance Statement contains
further information on the risks facing the
Trust and the approach to managing these.
Quality reporting
The Quality Report contains a comprehensive
review of the quality of the Trust’s services,
and the priorities for quality improvement.
The following summary outlines some key
points of note.
At the heart of the Trust’s commitment to
quality is a clearly defined clinical quality
strategy, a system of quality performance
management, and as outlined in the
Annual Governance Statement, a clear risk
management process. A key part of the
Board’s assurance on quality and safety is
the Quality & Risk Committee (QRC). The
Committee was formed in October 2012
following the annual review of the Board
and Committees, and brought together the
Integrated Risk Management Committee and
the Clinical Quality & Standards Committee
in order to ensure that quality and risk are
considered in an integrated way. The Board
monitors quality through the monthly quality
and operational performance report and a
more detailed quarterly quality report. The
QRC reviews a further set of quality metrics
and high and medium risks. High risks are
reviewed by the Board, together with Serious
Incidents and the actions taken in response
to the investigation of such incidents.
The Trust has a comprehensive clinical audit
work plan covering both national and local
audits. Information and progress on clinical
audit is reported to the QRC and the Audit &
Assurance Committee.
The Board has reviewed itself against the
Monitor Quality Governance Framework and
considers itself to meet the requirements
in the Framework. In reviewing the
Trust’s position against the Framework in
December 2012, the Board highlighted the
importance of refreshing the Trust’s clinical
strategy in light of the Mid Staffordshire
Directors’ report
19

NHS Foundation Trust Public Inquiry and
the information available to the Board on
the quality of the Trust’s services. The Board
noted the importance of ensuring quality
governance is premised on behaviours,
culture, and processes.
Work is therefore currently underway to
refresh the Board’s quality strategy. Priorities
identified by the Board for this work include
ensuring robust mechanisms are in place to
ensure information flows from the ward to
the Board; ensuring the Board receives both
qualitative and quantitative information;
and an ongoing focus on nursing standards,
mortality levels, and patient safety. Following
issues identified on an unannounced ward
visit by members of the Board, a priority is
to ensure that the Board is assured on the
consistency of care across the Trust’s wards.
The Care Quality Commission (CQC)
undertook an unannounced visit in
December 2012 as part of their planned
review of the Trust. The report issued
from this visit found the Trust to be fully
compliant with the CQC’s Essential Standards
of Quality & Safety. The report made no
recommendations, but highlighted comments
made by patients and staff in relation to
communication, the ward environment, and
staffing levels. An action plan was developed
in response and reported through the Quality
& Risk Committee.
There have been no inconsistencies
between the Annual Governance Statement
(presented later in the report), the annual
and quarterly Board statements submitted
to Monitor as required by the Compliance
Framework, the Quality Report (presented
later in the report) and reports arising from
the Care Quality Commission planned and
responsive reviews of the Trust.
Further information on the quality of the
Trust’s services and the Board’s priorities for
improving clinical quality is presented in the
Quality Report.
Public, patient, and stakeholder
engagement and experience
Improvements following patient
feedback
The Trust continues to remain committed
to using patient feedback to improve
the services provided by the Trust. As
part of this, the Trust has reviewed its
approach to monitoring patient experience
and established a new Experience and
Engagement Group which is chaired by
a Non-Executive Director, and includes
Executive Directors, divisional nursing leads,
Public Governors, and a Staff Governor. The
group meets bi-monthly and oversees the
delivery of ‘Putting People First’ our patient
and staff experience and engagement
strategy. The strategy sets out a variety
of methods that the Trust uses to gather
feedback from patients. During 2012/13
approximately 11,700 patients have given
feedback using our real time survey system.
The comments from these surveys along with
feedback gained from patients who were
asked what matters most to them were used
to help the Trust to identify how we should
prioritise improvements.
In November 2012 the Trust implemented
the Friends and Family Test (FFT); this is a
standardised question that will be used
across the NHS from April 2013. Under the
FFT when patients receive care or treatment
as an inpatient or in an Accident and
Emergency (A&E) department they are given
the opportunity to state whether or not
they would recommend the ward or A&E
department to friends and family if they
needed similar care or treatment. Patients
can respond from one of six options ranging
from ‘extremely likely’ to ‘don’t know’, and
they are also invited to provide comments
relating to the score that they have given.
The comments help staff to gain an insight
on what patients value and the factors that
influence a poor experience of care.
20 Directors’ report

The results from the Friends and Family
Test are analysed to determine if any action
is required. An overall score is calculated
by using the proportion of patients
who ‘strongly recommend’ minus those
who would not recommend, or who are
indifferent; this score will be published
on the NHS Choices website and be made
available publicly by the Trust from July 2013.
This year we have also refreshed the process
for monitoring feedback that patients leave
on the NHS Choices and Patient Opinion
websites. All comments are responded to and
acknowledged by the Trust.
Examples of action undertaken or underway
in response to feedback are outlined below.
• Building on work last year to implement
a Visitors Charter, we are introducing
a visitor’s card. The small card contains
some key points from the Visitors Charter
and ward telephone numbers. The
cards can be modified at a ward level to
include the Matrons’ contact details and
ward visiting times.
• A nurse call bell standard was introduced
in October 2012. The standard sets our
aim to respond to call bells within two
minutes and never any longer than five
minutes. We are able to monitor our
progress in maintaining this standard
through our inpatient survey. Our results
from October 2012 to March 2013 show
that 95% of patients who have used the
nurse call bell reported that their call bell
was answered within the standard, with
79% of patients reporting that it was
answered within two minutes.
• On 1st February 2013 the Phlebotomy
service at the Mount Vernon site brought
forward its opening time to 7.30am in
response to patient feedback.
Complaints
Complaints are an important source of
patient feedback.
In 2012/13 the Trust received 495 complaints,
compared to 386 in 2011/12, a rise of 28%.
The response rate for the year was 76.1%
which means that 383 of the 495 complaints
were answered within the timescale agreed
with the complainant. The chart below
shows the subjects involved. Each complaint
often refers to more than one subject and
therefore the total on the chart adds up to
more than the total number of complaints.
Under the current complaints regulations,
Complaints by subject categories
Clinical Care
Medical Staff
Communication/
Information to
Patients
Clinical Care
Nursing Staff
Appointments
(OPD & A&E)
Attitude
(Medical Staff)
Attitude
(Nursing Staff)
Hotel Services
Number
Subject
Discharge
Transport
Attitude (Other
Support Staff)
Directors’ report
21

the emphasis is on resolving complaints
locally and this has been achieved in 456
(92%) of complaints, with the majority
of these resolved through the Trust’s first
response. 27 (5.5%) of complaints were
resolved through further local resolution,
either by writing again to the complainants,
or by meeting with them.
12 of our complainants (2.4%) were not
happy with our local responses and referred
their complaint to the Parliamentary
and Health Service Ombudsman for an
independent review. The Ombudsman
decided to investigate one complaint and
that is ongoing. Two complaints were
rejected by the Ombudsman as properly
resolved by the Trust. The Trust was asked to
undertake further work locally to resolve the
complaint in four cases, three of which have
now been completed and closed, and one
remains open. In five cases the papers have
been supplied to the Ombudsman and we
are awaiting their decision.
The Trust has continued to work with
complainants and use complaints as drivers
for improvements to the services we
provide. Once again this year changes and
improvements have been embedded in
clinical areas as a result of complaints.
A particular area of focus has been on
ensuring that test results are followed up
appropriately, and new systems have been
put in place in the Clinical Support Services
Division and in the Women’s and Children’s
Division following a complaint in each
Division that results had been overlooked.
In the Division of Surgery, the Urology
Department has been looking at catheter
care, and staff have been working very
closely with a patient who was keen to
be involved in formulating new ideas for
improving the experience and understanding
of patients who have a catheter for a period
of time.
On a simpler level a patient informed us
that after his eye clinic appointments his
eyes were sore and it was uncomfortable
to wait for transport in the Outpatient Hall
because the seats were in a draughty area.
The Matron responsible for the Outpatients
Department met with Facilities staff and the
seating area has been reconfigured; chairs
have been moved away from the draught
and a dedicated waiting area for those
waiting for transport has been arranged,
which is away from draughts. Signage is
being made to identify the area.
Improvements in patient and carer
information
Providing high quality and clear information
is central to the patient experience.
During 2012/13 the Patient Information
Review Group continued to work with staff
across the hospital to develop new patient
and carer information and to refresh existing
information.
Our Readers Panel, service users, and patient
involvement groups support Trust staff to
ensure that the information we produce
is clear, jargon free and user friendly. For
example, our Fighting Infection Together
(FIT) public involvement group worked with
the Trust Infection Control Team to develop
an ‘isolation leaflet’. The leaflet describes
why a patient may be cared for in isolation
and what relatives can expect. Input from
patients and public has been particularly
helpful in developing leaflets on sensitive
issues. For example, our Readers Panel
supported the production of a Post Mortem
leaflet which is given to relatives soon after
the death of a loved one. The panel ensured
that the leaflet presents the relevant legal
and technical information in a sensitive way.
The Trust is developing a poster that will
be used in A&E cubicles to illustrate the
typical pathways through the emergency
department explaining the points at which
there may be waiting periods. The poster
22 Directors’ report

is being developed in response to feedback
from patients who are not always sure what
is happening next, and why they may be kept
waiting. The poster will support the verbal
updates that are given by the staff in the
department.
Other condition/service specific information
produced in 2012/13 included new leaflets in
Radiology; a leaflet to support parents caring
for children with a nasogastric tube; a leaflet
on caring for a surgical wound at home; and
information on the Liverpool Care Pathway.
During 2012/13 the Trust developed a Carers’
Strategy 2012-2015 that outlines the Trust’s
commitment to working in partnership with
all carers and families by listening, learning
and responding to feedback. Our vision is to
provide support and information to all carers
ranging from breastfeeding mothers through
to carers’ needs at the end of people’s lives.
Our objectives are to improve a carer’s
experience by:
• Providing appropriate and timely
information to support the carer and the
person they support.
• Actively involving carers where patient
consent has been granted in decisions
about the care and treatment of the
person they care for.
• Involving carers in the planning or
developing of services and in monitoring
patient and carer experience.
• Providing support for carers who are
caring for people with multiple and
complex needs e.g. learning disabilities,
physical disabilities and dementia.
• Improving staff awareness of the role of a
carer in care delivery.
• Ensuring carers are provided with
sufficient information to enable
safe planning of return to caring
responsibilities.
A Carer’s charter has been developed and is
displayed throughout the Trust. Information
for Carers is available from our Patient
Advice and Liaison Service (PALS) and also on
the Trust and Hillingdon Council websites.
A carer survey is available to monitor carers’
experiences.
Consultation and engagement
The Trust is committed to involving and
consulting with members, patients and the
local community in the planning of service
provision, the development of proposals for
change, and decisions about how services
operate. The Trust will continue to engage
and consult with service users, public and
the wider local community in decisions
about general service delivery to ensure that
services are designed and adapted to better
respond to individual needs.
The Governors and members will clearly
have an important role in any consultation
and engagement on major service changes.
However the Trust will seek to ensure that
such engagement reaches beyond our
membership, particularly where a group that
is under-represented in our membership is
affected.
The Trust’s Head of Patient & Public
Engagement proactively engages with the
community and voluntary organisations
to identify opportunities for the Trust to
engage with their members. For example as
part of this engagement, the Trust invited
representatives from the Alzheimer’s Society,
Age UK, Hillingdon Carers and Disablement
Association Hillingdon (DASH) to attend
a focus group to discuss how to improve
services for patients with dementia.
The Trust encourages and facilitates linkages
between the Council of Governors and
groups and organisations which represent
patients, public and the wider community.
During 2012/13, Public Governors attended
Resident Association meetings across the
Borough, ‘Street Champion’ meetings and
other community events to communicate
with local residents and public members.
Governors are encouraged to attend
meetings in the community and report
Directors’ report
23

ack to the wider Council of Governors,
to help ensure that the Council of
Governors is aware of public comments and
concerns which have been raised in these
meetings. The Membership Development &
Engagement Strategy approved by the Board
outlines the Trust’s policy on the involvement
of members, patients and wider public,
including a statement on the Trust’s approach
to consultation, and addressing the overlap
and interaction between the Governors and
other consultative and representative groups.
The Trust did not undertake any formal
consultations in the past year. NHS North
West London led a public consultation on
proposals for the reconfiguration of health
services in North West London – entitled
‘Shaping a Healthier Future’ which included
consulting with residents living in the London
Borough of Hillingdon.
A selection of examples of public
engagement activities undertaken during the
year are outlined below:
• Members of the Board attended
Hillingdon Council’s External Services
Scrutiny Committee on two occasions in
2012/13. In April 2012 the Medical Director
presented the Trust’s Quality Account and
in September 2012, the Chief Executive
and Medical Director provided an update
on developments at the Trust.
• The Trust continued to hold bi-monthly
meetings of its ‘People in Partnership’
forum. The forum enables the Trust to
listen to the views and opinions of the
communities we serve, share information
about what the Trust is doing and planned
future developments, and provides an
opportunity for members to meet and
communicate with staff, Governors and
fellow members. The People in Partnership
meetings have been refocused to be
meetings between the members and
Governors, and several of the meetings
are now held in the community during the
day, attracting new members and raising a
number of different issues.
• The Trust continued an engagement
project that sought to capture experiences,
manage expectations, and improve the
maternity experience for women from the
Somali community. At a focus group at
the Sahan Centre in Hayes the Trust was
able to provide feedback on action taken
following an earlier session, including
the introduction of awareness sessions on
the maternity department’s mandatory
training programme. The maternity
department has recently commenced
a similar engagement process with an
Afghani women’s group to mirror the
success with the Somali women’s group
engagement.
• As outlined earlier in the report, the Trust
developed ‘Putting People First’ which
sets out the Trust’s vision to be a leader
in terms of the patient experience. The
strategy followed a review of feedback
from patients, staff, and public, and was
widely consulted on with input from
the Local Involvement Network (LINk),
local patient interest groups, Hillingdon
Council, the Council of Governors, and
public and staff members.
• The Trust has continued to work in
close partnership with the Hillingdon
Local Involvement Network (LINk) and
appreciates the valuable contribution that
the LINk provides to the organisation.
Representatives from the LINk have
regularly attended focus groups and
committees and are regular attendees
at our People in Partnership meetings.
This year the Trust has worked closely
with the LINk on the consultation for the
priorities for the Quality Report and the
transfer of catering and cleaning services
back to in-house management. The Trust
looks forward to working with the new
Healthwatch which replaces the LINk from
April 2013.
24 Directors’ report

Developments in nursing care
Nursing care is central to the patient
experience and has been an issue that has
received much attention nationally over the
last year.
The Trust has developed a series of essential
nursing and midwifery standards aligned
with our CARES values that underpin
everyday nursing and midwifery practice.
We are currently introducing an approach
to ensure that care is consistent and reliable
with a focus on responding to fundamental
needs. Our aim is that our patients are
always safe, comfortable, informed, and
involved whilst receiving care on our wards.
This proactive care approach will help us
to embed our essential standards into
practice and steers nursing staff to use every
scheduled contact with patients, for example
when checking blood pressure and at regular
intervals in between, to check on key aspects
of care. These are known as the ‘Ps and Qs’.
These include:
• Pain: Does the patient have any pain?
• Position: Is the patient comfortable and
warm enough, do they need assistance
repositioning?
• Possessions: Does the patient have a
drink and all personal possessions such as
tissues and spectacles within reach?
• Personal: Does the patient need assistance
to visit the toilet?
• Questions: Does the patient have any
questions about their care?
Every contact with the patient should finish
by asking the patient if there is anything else
that is needed at that time.
The Report of the Mid Staffordshire NHS
Foundation Trust Public Inquiry published in
February 2013 and the launch of ‘Compassion
in Practice’, the national Nursing Midwifery
and Care Staff Vision and Strategy reinforce
the need for care to be based on empathy,
respect and dignity. We are confident that
this approach, agreed by our Senior Sisters
and Matrons will encourage consistency in
the fundamentals whilst leaving room to
‘tailor’ care around each patient’s individual
needs.
Proactive care is discussed at nurse induction
by the Deputy Director of Nursing and is
being led at ward level by the Senior Sister
and Matron; it will be supported by posters
and a leaflet that will be given to all nurses
in the Trust.
Nursing Quality and Accreditation
Framework
Measuring the quality of care at a ward level
is not simple or easily quantifiable and so
the Trust utilises a variety of methods. The
Trust has recently developed a new approach
entitled ‘Observations of Care’. This is a
qualitative approach that uses inside and
outside observers and a structured tool,
together with observational prompts that are
used by the Care Quality Commission (CQC)
during their unannounced visits.
Observations of Care are scheduled monthly
and enable the Trust’s most senior nurses
to spend time on wards increasing the level
of scrutiny and vigilance on the quality
of nursing care. The visits assess the ward
environment, attitudes and behaviours of
staff, team working and specific aspects
of safety. There is also a review of nursing
records to ensure that they reflect clear,
accurate and up to date information about
patients’ care and treatment. Patients are
also given the opportunity to discuss any
concerns, whilst the observers check that the
patient has a good understanding of their
care.
Executive and Non-Executive Directors are
also invited to join in the observational
visits. The first observation took place in
February 2013, when 18 wards were visited.
Verbal feedback is given on the day of
the visit; this is followed up by a written
report highlighting areas of good practice
Directors’ report
25

and recommendations for improvement.
Ward staff have stated that they value this
approach and that it helps them prepare for
unannounced CQC visits.
Observations of Care provide important
qualitative information that can be used
as part of the Trust’s overall assessment of
nursing quality; and they are an essential
component of the Nursing Quality and
Accreditation Framework (NQAF) that the
Trust began to develop in February 2013.
The NQAF will be based on our aim of
ensuring that patients on our wards are
always safe, comfortable, informed, and
involved. The NQAF sets out a number of
indicators and other quality factors that
will be used to measure and demonstrate
sustained improvements in quality. It also
describes the assessment process and the
potential rewards for achieving accreditation.
The framework will be shared more widely
and approved by senior nurses in the Trust
prior to its launch later in the first quarter
of 2013/14. Our ambition will be for all our
wards to achieve accreditation.
Dementia
In line with the National Dementia Strategy,
improving care for patients with dementia is
listed as a key priority in the Trust’s Business
Plan for 2013/14. We want to ensure that
older people have timely access to services
that are easy to navigate and fit for purpose.
We are driving improvements in both the
organisation and delivery of services for
patients and carers. These include providing
dementia training to all staff to increase their
knowledge of the condition, ensuring that
care is skilled, compassionate and respectful.
We are increasing access to dementia
screening for patients over 75 years, with
forward referral for further assessment as
indicated. We are developing individualised
care and treatment plans utilising recognised
tools such as the Alzheimer’s Society’s ‘This Is
Me’ to ensure patient and carer involvement.
We are a signatory to the Dementia Action
Alliance’s Declaration and are making
changes to our environment to progress our
aspiration of being dementia-friendly.
We will measure achievement of this
objective through a number of monitoring
tools. The Trust’s Dementia Strategy work
plan includes ‘SMART’ objectives to deliver
improvements in dementia care. We have
also published an action plan on the
Dementia Action Alliance’s website, which
we will review throughout the year. We will
capture patient and carer feedback via direct
questioning and review patient surveys,
compliments, complaints and incidents
to ensure service changes are resulting in
positive patient and carer experience.
Our staff
Staff consultation and engagement
The Trust has a range of mechanisms for
communicating information on matters
of concern to staff including regular
communication from the Chief Executive,
and the Core Brief – an electronic monthly
update. The magazine for staff and public
members of the Foundation Trust, ‘The
Pulse’, is distributed throughout the Trust’s
hospitals.
In 2012/13 a weekly General Information
bulletin was introduced to communicate
other information such as upcoming events
or policy changes as a response to requests
for more managed mechanisms around this
type of information.
Hospital management and Staff in
Partnership representatives meet regularly
at the Joint Negotiating and Consultative
Committee to share information and
discuss a broad range of subjects that may
affect staff. Seven members of the Council
of Governors are elected by staff; and a
further Governor is appointed by the Joint
Negotiating & Consultative Committee in
recognition of the importance of partnership
working between the unions and Trust
management.
26 Directors’ report

Staff members are actively informed and
encouraged to contribute to the Trust’s
performance via the above communication
mechanisms and specific briefing items. In
2012/13 open briefing sessions with the Chief
Executive were introduced and are now
held regularly. At these sessions the Chief
Executive discusses issues relevant to the
Trust, including performance and financial
matters, and responds to questions from
staff. In March 2013 ‘Listening Sessions’ were
held on both the Hillingdon and Mount
Vernon sites to discuss what can be learnt
from the Mid Staffordshire NHS Foundation
Trust Public Inquiry and to ask staff for their
thoughts, views and concerns about how
every patient can be provided with safe,
quality care which encompasses our CARES
values.
Scores were less positive than other Trusts
on team-working, staff working additional
hours, staff receiving job-relevant training,
availability of hand washing materials,
incident reporting measures, staff
experiencing violence and harassment at
work, staff feeling pressure to attend work
when feeling unwell, staff feeling unable to
contribute towards improvements at work,
equal opportunities for career progression,
and staff experiencing discrimination at
work. Tables 2 and 3 identify the Trust’s top
and bottom ranking indicators.
‘Bright ideas’, the Trust’s Staff Suggestion
Scheme was launched in 2013. This scheme
asks for suggestions from staff on a wide
range of ideas they may have including
ways of saving money, time, or making
improvements in our hospitals.
NHS staff survey
Summary of performance
The NHS staff survey provides the Trust
with valuable feedback on the views of our
staff. In 2012, 44% of staff responded to the
national staff survey compared to 43% in
2011, and a national response rate of 50%.
Overall, staff engagement was above (better
than) average when compared to other acute
Trusts and an improvement on 2011.
In the survey, Trust staff members gave
more positive comments compared with
other Trusts on a range of issues. These
included staff feeling satisfied with the
quality of work and patient care they are
able to deliver, appraisals and PDRs (personal
development reviews), good communication,
recommending the Trust as a place to work
or receive treatment, and staff motivation.
Directors’ report
27

Table 1: Trust response rate
2011/2012 2012/13
Trust
improvement/
Deterioration
Trust National average Trust National average
Response rate 43% 54% 44% 50% Increase by 1%
point
Table 2: Trust’s top four ranking scores
2011/2012 2012/13
Trust
Improvement/
Deterioration
Top four ranking scores Trust National average Trust National average
KF7 Staff appraised in 90% 81% 94% 84% Increase by 4%
last 12 months
KF8 Staff having well 44% 34% 46% 36% Increase by 2%
structured appraisals in
last 12 months
KF14 Staff reporting 95% 96% 95% 90% No change
errors, near misses or
incidents witnessed in
the last month
KF9 Support from
immediate line managers
3.58 3.61 3.70 3.61 No change
Table 3: Trust’s bottom four ranking scores
2011/2012
2012/13
Trust
Improvement/
Deterioration
Bottom four ranking
scores
KF17 Staff experiencing
physical violence from
staff in last 12 months
KF6 Staff receiving
job-relevant training,
learning or development
in last 12 months
KF5 Staff working extra
hours
KF10 Staff receiving
health and safety
training in last 12
months
Trust National average Trust National average
1% 1% 4% 3% Increase by 3%
76% 78% 77% 81% Increase by 1%
58% 65% 75% 70% Increase by 17%
81% 81% 65% 74% Decrease by 16%
28 Directors’ report

Action plan
In light of the Francis Report, as well as the
outcomes from our own staff survey and the
various listening events and communication
exercises recently undertaken in the Trust, we
are revisiting a range of current action plans
to ensure that our work in response to what
our staff tell us is co-ordinated and clear.
We will be specifying what our priorities are
and why this is the case, and we will also be
linking our work plans closely to the CARES
values that we have adopted. These actions
may include:
• Publicising the staff survey results for
2012 throughout the Trust utilising
various media. As in previous years,
this will be in the style of ‘You Said’,
‘We Will’.
• Promoting an environment that
encourages the management of workrelated
stress using a risk assessment
approach.
• Promoting the National
Whistleblowing help-line.
• Promoting the availability of statutory
and mandatory training and expand
options for its delivery.
• Promoting the Dignity at Work policy,
exploring options for providing a
mediation service.
We will communicate the outcome of this
work to all staff as soon as possible.
Future priorities
CARES
In 2011, following a number of focus groups
and a period of voting, staff chose CARES
(Communication; Attitude; Responsibility;
Equity; and Safety) as the acronym to reflect
the culture and values of the Trust along with
some underpinning behaviours expected of
all staff.
In 2012/13 the CARES Champions group
focused on raising awareness of our culture
and values and role modelling behaviours
and attitudes that CARES promotes. This
has been done in a range of ways including
the Champions talking about CARES to
colleagues and patients across the Trust. In
2012 the Trust included specific questions on
CARES in the staff survey. This indicated that
84% of staff understood what CARES is.
A CARES rating scale has been included in the
PDR paperwork for this year, standardised
questions have been developed for use
during selection processes, and we have
begun to integrate CARES into key policies
and procedural documents. Future priorities
will include further embedding of CARES and
developing the role of the CARES Champions
into Ambassadors to elevate the status of the
role and provide more structure.
Putting People First (PPF) programme
The Putting People First Programme
was established in 2011 with the aim of
improving both the patient experience and
staff experience and to increase patient and
staff engagement. The programme consists
of work streams to embed and integrate
Putting People First in our key processes.
Progress to embed CARES and the impact
on the Trust will be monitored via the
Putting People First Steering Group using
responses from patients and staff to specific
questions in the patient and staff surveys.
The group will also monitor the number
of complaints received relating to staff
attitude, communication and information
to patients, and discrimination. Progress will
be communicated to staff using a variety of
methods, including ‘The Pulse’ and other
appropriate newsletters.
Policies in relation to disabled
employees and equal opportunities
The Trust has an Equality and Human Rights
Policy and a single equality scheme which
set out very clearly for our staff, patients
and the community that we are committed
to delivering an equality and human rightsbased
approach to healthcare. The policy
Directors’ report
29

outlines how we will provide equality and
fairness for all those in our employment and
not discriminate on grounds of any of the
legally designated protected characteristics
(gender reassignment, marriage and civil
partnership, pregnancy and maternity, race,
religion and belief, sex, sexual orientation,
disability, and age).
The Trust’s policy is implemented in
accordance with all current legislation
relating to The Equality Act 2010. The Trust is
accredited with the ‘two-ticks’ symbol which
is awarded by Job Centre Plus to employers
who have made commitments to employ,
keep, and develop the abilities of disabled
staff.
In 2012 the Trust published its Equality
Objectives Report with specific objectives
around staff culture and values, including fair
and inclusive recruitment processes. Progress
against this objective is monitored by the
Experience and Engagement Group.
Occupational health and sickness
absence data
The Trust has an Occupational Health
department who provide advice on how
to protect individuals from harm, to help
identify all those aspects of health which
affect employees’ capacity to work efficiently,
and improve their quality of life in a safe
working environment. Staff have access to
the Employee Assistance Programme (EAP)
and a free confidential helpline that can
provide advice and support on a range of
issues such as financial difficulties, workplace
difficulties, and health and wellbeing.
Information on sickness absence is contained
in note 6.2 to the accounts.
Equality duty
The Trust as a public health authority is
‘listed’ under Schedule 19 of the Equality
Act 2010 and is therefore required to comply
with the equality duties under Section 149
and Regulations 2011.
This means that when staff are delivering
services and carrying out the Trust’s
functions, they must consciously think about
and pay due regard to the three aims of the
general equality duty as an integral part of
the decision making process. Details of the
equality duty aims and the Trust’s statement,
documenting how the Trust is meeting the
duty, have been published on the Trust’s
website.
The specific duties require public bodies to:
• Publish relevant, proportionate
information demonstrating their
compliance with the general equality
duty by 31st January 2013
• Set and publish specific, measurable
equality objectives by 6th April 2013.
On 31st January 2013, the Trust published
its Service Equality Compliance Report and
Workforce Equality Compliance Report
on the Trust’s public website. Both reports
include actions and initiatives taking place
within the Trust to meet the Public Sector
Equality Duty and that areas that continue
to need addressing are being addressed via
the four year objectives set in April 2012. The
Trust published an update of its objectives
in April 2013 and will do so thereafter on an
annual basis.
Financial disclosures
The financial statements for the year ended
31st March 2013 have been prepared on a
going concern basis. After making enquiries,
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. In making this
declaration the Board is mindful of the
recent financial performance and the
extremely challenging financial context
facing the Trust, including the requirement
for significant year on year efficiency savings
and Hillingdon Clinical Commissioning
30 Directors’ report

Group’s (CCG) intention to reduce the level
of activity at the Trust. To mitigate these
challenges the Board has invested in an
enhanced programme management office
to support the delivery of the savings, and is
also able to draw upon Hillingdon Hospital
being identified as a ‘fixed point’ in the
North West London ‘Shaping a Healthier
Future Strategy’ which the CCG is committed
to supporting.
The NHS Foundation Trust Annual Reporting
Manual states that it is best practice for
NHS Foundation Trusts to disclose ‘other
income’ when such amounts in the notes
to the accounts are significant. There is
no significant ‘other income’ to report.
As outlined earlier in the report, the vast
majority of the Trust’s income is from goods
and services related to the Health Service in
England.
The NHS Foundation Trust Annual Reporting
Manual states that the annual report
and accounts should highlight where any
market values of fixed assets are known
to be significantly different from values
at which those assets are held in the
Trust’s financial statements, where it is the
Directors’ view that any such difference
is of such significance that readers of the
accounts should be alerted to this. There
were no significant differences in market
value compared to holding value to report
for the financial year ending 31 March 2013.
Investment properties were revalued to
current market value as at 31st March 2013
from £13,124k to £14,816k, resulting in a
gain of £1,692k.
The NHS Foundation Trust Annual Reporting
Manual states that it is best practice for NHS
Foundation Trusts to disclose the number of,
and average additional pension liabilities for,
individuals who retired early on ill-health
grounds during the year. Four staff retired on
grounds of ill health at a cost to the Trust of
£165k (in 2011/12 there were nil retirements
on grounds of ill health).
The Trust policy on creditor payment is to
endeavour to adhere to the Better Payment
Practice Code of paying 95% of invoices in
terms of numbers and value within 30 days
of receipt, cash flows permitting. Information
on the Trust’s payment of creditors and
compliance with the Better Payment Practice
Code is included in note 7.1 of the accounts.
In relation to the use of financial
instruments, an indication of the financial
risk management objectives and policies
of the Trust and the exposure to price risk,
credit risk, liquidity risk and cash flow risk
can be found in note 1.38 of the accounts.
Information on the pension arrangements
and other retirement benefits are set out in
note 1.12 of the accounts. Details of senior
employees’ remuneration can be found in
the remuneration report and note 6.9 of the
accounts.
Other disclosures
Research and development
Clinical teams are encouraged to invite their
patients to participate in high quality multicentre
research studies as part of the Trust’s
commitment to improving the quality of
care provided. Participation in research and
development enables patients to access new
treatments that would not have otherwise
been available and supports our clinicians to
stay abreast of the latest treatments.
The majority of the Trust’s research and
development activities are National Institute
for Health Research (NIHR) portfolio adopted
multi-centre studies where the Trust acts
as a recruiting site on behalf of the lead
centre. Our research portfolio is a balance of
observational and treatment studies across
many clinical areas in the Trust including
Cancer, Stroke, Haematology, Paediatrics and
many of the general medicine and surgical
specialities. The Trust also supports a small
number of studies undertaken by our own
staff and students from the local universities
undertaking PhD and Masters courses.
Directors’ report
31

All of our research activity is scrutinised
for quality and compliance to acceptable
standards expected by the Research
Governance Framework. Our research
governance approval metrics comply with the
30 day standards required by the Department
of Health (NIHR).
Charging for information
The Hillingdon Hospitals NHS Foundation
Trust complies with the cost allocation
and charging requirements set out in
HM Treasury and Office of Public Sector
Information guidance. There is no additional
charge for material made available to meet
the needs of particular groups of people, e.g.
in Braille or other languages.
Serious incidents involving data loss or
confidentiality breach
The Trust takes its responsibility to keep
personal data safe very seriously. New
staff receive information governance
training during induction in their first week
at the Trust and it is mandated that all
staff undertake information governance
training annually. The Trust Board is
required to annually certify against the
Trust’s compliance with NHS information
governance standards.
There has been one serious incident relating
to loss of data during 2012/13. In June 2012
the Trust misplaced patient records which
attracted media attention. This incident
was investigated as a serious incident by
the Trust, and reported to the Information
Commissioner’s Office (ICO). The Trust
is currently assisting the ICO with their
investigation.
The table below contains details of other
reported personal data related incidents as
categorised by the Department of Health.
Policies and procedures for countering
fraud and corruption
The Hillingdon Hospitals NHS Foundation
Trust will not tolerate any form of fraud,
bribery or corruption by, or of, its employees,
associates, or any person or body acting on
its behalf.
The Trust is committed to ensure that the
number of offences is kept to a minimum
and that all allegations will be investigated
thoroughly and the strongest sanctions
including criminal sanctions will be taken
against anybody found to be or having
committed a fraud, bribery or corruption
offence.
SUMMARY OF PERSONAL DATA RELATED INCIDENTS IN 2012/13
Category Nature of incident Total
I Loss/theft of inadequately protected electronic equipment, devices or paper 2
documents from secured NHS premises
II Loss/theft of inadequately protected electronic equipment, devices or paper 1
documents from outside secured NHS premises.
III Insecure disposal of inadequately protected electronic equipment, devices 0
or paper documents
IV Unauthorised disclosure 3
V Other 0
32 Directors’ report

The Trust engages Parkhill as its Local
Counter Fraud Specialist (LCFS) in accordance
with Secretary of State Directions to support
its work in this area.
The Trust’s Audit & Assurance Committee
agrees the annual work-plan for the
LCFS and receives six-monthly reports on
progress against its delivery. The Committee
has agreed the Trust’s Counter Fraud Policy,
which is the Trust’s policy for dealing with
suspected fraud, bribery and corruption.
Health & safety performance
The Trust continues to set the highest
standards of health and safety through our
Health and Safety Strategy for all our staff
in the workplace, for members of the public,
patients, and others who come in to our
premises.
Health and safety governance: The Trust has
a management group consisting of clinical
and non clinical senior managers from across
the Trust whose main purpose is health and
safety strategy implementation and planning
that supports the function of the Health and
Safety Committee. The Health and Safety
Committee has met quarterly throughout
2012/13 and the Trust Board has received
quarterly reports on health and safety issues
and performance during the year.
Training: All new members of staff receive
health and safety training during their
corporate induction and are able to access
refresher training via an e-learning package
and face to face courses. The Trust has
achieved over 80% compliance with its
health and safety training.
Trust’s auditors
The Council of Governors has appointed
Deloitte as the Trust’s external auditors.
The audit fee is contained in note 4 of the
accounts.
The Board confirms that for each individual
who was a Director at the time that this
report was approved (28th May 2013):
• so far as the Director is aware, there is
no relevant audit information of which
the NHS Foundation Trust’s auditor is
unaware; and
• the Director has taken all the steps that
they ought to have taken as a Director
in order to make themselves aware of
any relevant audit information and to
establish that the NHS Foundation Trust’s
auditor is aware of that information.
Political and charitable donations
During the year, the Trust has not made any
political or charitable donations.
Important events affecting the
Foundation Trust occurring since the end
of the financial year
The Board confirmed at its meeting on 28th
May 2013 at which this annual report and
accounts were approved, that there were no
events that required disclosure.
Performance: During the reporting period
there were a total of 1,936 incidents
reported. 14 of these incidents were
reportable to the Health & Safety Executive
(HSE) under RIDDOR (Reporting of Injuries,
Diseases and Dangerous Occurrence
Regulations).
Directors’ report
33

GOVERNANCE REPORT
Who does what
The Trust is headed by the Board of Directors
(often referred to as ‘the Board’). The Board’s
key responsibilities are to:
• Provide leadership to the Foundation
Trust within a framework of processes,
procedures and controls which enable risk
to be assessed and managed.
• Ensure the Foundation Trust complies
with its Terms of Authorisation (and
from 1st April 2013 its Licence which
replaces the Terms of Authorisation);
its Constitution; requirements set by
Monitor; and relevant statutory and
contractual obligations.
• Set the Foundation Trust’s vision, values
and standards of conduct.
• Set the Foundation Trust’s strategic aims
and ensure that the necessary human and
financial resources are in place to deliver
these.
• Ensure the quality and safety of the
healthcare services provided by the
Foundation Trust.
• Ensure that the Foundation Trust exercises
its functions effectively, efficiently and
economically.
The Board undertakes these responsibilities
through a set business cycle that includes
approving strategic documents such as the
forward plan (also known as the annual
plan) and other strategies, and receiving
monitoring reports on areas such as key
risks, financial, operational, and quality
performance.
The Board has approved a Scheme of
Reservation and Delegation which outlines
the decisions that must be taken by the
Board and the decisions that are delegated
to the management of the hospital.
For example, contracts or investment
proposals over a certain financial value
must be approved by the Board, whereas
the approval of lower value contracts is
delegated to management.
The Council of Governors is responsible for
representing the interests of the Foundation
Trust members and partner organisations
in the governance of the Foundation Trust.
The Council of Governors is responsible for
providing feedback from the membership
and stakeholders on strategic developments
at the Trust, including for example on
the annual plan, and in turn should keep
members and stakeholders informed about
developments at the Trust.
At the start of the 2012/13 financial year, the
Council of Governors’ statutory powers were
to:
• Appoint, and if appropriate, remove the
Trust Chairman.
• Appoint, and if appropriate, remove the
Non-Executive Directors.
• Decide the remuneration and terms and
conditions of office of the Chairman and
the Non-Executive Directors.
• Approve the appointment of the Chief
Executive.
• Appoint, and if appropriate, remove the
Foundation Trust’s external auditor.
• Receive the Foundation Trust’s annual
accounts, any report of the auditor on
them, and the annual report.
On 1st October 2012, the ‘private patient cap’
was abolished and Foundation Trust Councils
of Governors gained new powers in relation
to non-NHS income as a result of the Health
& Social Care Act 2012. If a Foundation Trust
Board is proposing to generate income from
activities other than for the provision of
goods and services for the Health Service in
England, then the Council of Governors must
vote on whether it is satisfied that these
activities will not significantly interfere with
the Trust’s ability to undertake its principal
purpose (the provision of goods and services
34 Governance report

for the Health Service in England) or its
other functions. Any proposal by the Board
to increase the proportion of total income
earned from non-principal purpose activities
by five percentage points or more (e.g. from
2% to 7% of the Trust’s income) requires
approval by the Council of Governors.
From 1st April 2013 the Board and Council
of Governors gained further new statutory
duties as a result of the Health & Social Care
Act 2012. These made explicit duties which
were previously implicit in their role.
• The Council of Governors gained
duties to (a) to hold the Non-Executive
Directors individually and collectively
to account for the performance of the
Board of Directors; and (b) to represent
the interests of the members of the
corporation as a whole and the interests
of the public.
• Similar to Directors’ duties under the
Companies Act 2006, Board Directors
collectively and individually gained a duty
to promote the success of the Trust so as
to maximise the benefits for members and
for the public; and gained duties to avoid
conflict of interests, not to accept any
benefits from third parties and declare
interests in any transactions that involve
the Trust.
The Council of Governors also gained new
powers to approve ‘significant’ transactions
at the Trust.
Whilst the Council of Governors is responsible
for holding the Board, and in particular
the Non-Executive Directors, to account
and ensuring that it is acting in a way that
means the Trust will meet its obligations, it
continues to remain the Board’s responsibility
to oversee the running of the hospital.
Further information on the Board of
Directors and Council of Governors is
outlined below.
Board of Directors
As at 31st March 2013 the Board comprised
seven Non-Executive Directors, a Non-
Executive Chairman and seven Executive
Directors 12 . Details of Board members as at
31st March 2013 are outlined below.
Mike Robinson: Chair
Prior to joining the Trust in July 2009, Mike
was Chairman of NHS Hillingdon, (formerly
Hillingdon PCT). He has a BA from Queens
University, Belfast and post graduate
qualifications in teaching and planning. He
worked for Bristol City Council as Director of
Housing 1984-1991 then as Chief Executive
1991-1994. In March 1994 he was appointed
Deputy Under Secretary at the Ministry
of Defence until June 1995, and from
September 1995 until September 2003 he
was Chief Executive of South Gloucestershire
Unitary Council. Mike is also an advisor to a
number of local authorities. Mike chairs the
Board of Directors Nominations Committee
and the Transformation Committee. Mike’s
term of office expires on 31st March 2014.
Katey Adderley: Non-Executive Director
Appointed in December 2010, Katey is
a Chartered Management Accountant
with 11 years of investment experience at
Charterhouse Capital Partners where she
was a Director. She has an Economics degree
from Cambridge University and a Masters
degree in Economic Evaluation in Healthcare.
As well as bringing up a young family Katey
is active in local voluntary work. Katey is a
member of the Trust’s Audit & Assurance
Committee. Katey’s term of office expires on
30th November 2014.
12 Claire Gore, Director of People, was appointed to the Board from 1st March 2013, thereby increasing the number of
Executive Directors on the Board to seven (from six). Whilst the Medical Director role has been undertaken as a job-share
from 1st January 2013, only one of the job share partners sits on the Board at any time, thereby counting as one Executive
member of the Board.
Governance report
35

Carol Bode: Non-Executive Director
Appointed in April 2012, Carol is an
Organisational Development Specialist with
30 years in retail, customer services, financial
services, and health & education. Previous
roles have included Non-Executive Chairman
of Southern Health NHS Foundation Trust,
Trustee on the Foundation Trust Network
Board, and a Corporate Board Director with
a General Motors Company. Carol is an
Associate Consultant with both Foresight
Partnership and QGI, and a Senior Advisor
to Newton Europe. Carol is also a Magistrate
in North Hampshire, and a Director of
The Costello School (an Academy Trust) in
Basingstoke. Carol’s term of office expires on
31st March 2015.
Alan McLeod: Non-Executive Director
First appointed in October 2008, Alan
is currently Sales Director of BT UK’s
International Business Unit, and has
extensive experience within the international
telecommunications industry from a sales,
marketing and technical perspective. Previous
roles have included Managing Director of a
UK Telecoms Company and President of an
international joint venture. Alan’s term of
office expires on 30th November 2013.
Anthony Palmer: Non-Executive Director
Appointed in April 2012, Anthony is an
Independent Nursing Consultant and
Expert Witness providing advice to lawyers,
Coroners, and the Crown Prosecution Service.
Anthony was previously Deputy Chief
Executive and Director of Nursing for Luton
& Dunstable Hospital NHS Foundation Trust,
and held Executive Director Board positions
for over 14 years. Anthony has advised
Public Inquiries, has been involved with Care
Quality Commission reviews as a Clinical
Advisor, and was a visiting Professor at the
University of Bedfordshire between 2008 and
2012. Anthony’s term of office expires on
31st March 2015.
Pradip Patel: Non-Executive Director
Appointed in August 2011, Pradip qualified
with a First Class Honours degree in
Pharmacy from the London School of
Pharmacy and has an MBA from Nottingham
University. He has worked for Boots for over
34 years, of which the last 18 years have been
at senior and Board levels. He was Managing
Director for Boots Opticians and Executive
Chairman following its merger with Dolland
and Atchison, and is currently Director of
Healthcare Strategy for Alliance Boots. He
is a Fellow of the Chartered Institute of
Management and a Member of the Royal
Pharmaceutical Society of Great Britain.
Pradip’s term of office expires on 31st July
2014.
Dr James Reid: Non-Executive Director
and Deputy Chair
First appointed in February 2008, James
is a former Chief Executive of a privately
owned oil refining and trading company,
with extensive risk management experience
within the oil and gas industry. He has a PhD
in Mathematics from Edinburgh University,
and worked for Shell for many years holding
senior management positions in Shell’s
trading and shipping organisation. James
chairs the Board’s Quality & Risk Committee
and the Remuneration Committee and
is a member of the Audit & Assurance
Committee. James is also a Non-Executive
Director of West Indies Oil Company and has
advised various oil companies. James’ term of
office expires on 31st March 2015. In March
2012 the Council of Governors reappointed
James as Deputy Chairman for a further one
year period to April 2013.
Craig Rowland: Non-Executive Director
and Senior Independent Director
First appointed in October 2006, Craig
is a qualified accountant and former
Managing Director of BT Group’s UK
Business Division. Prior to his career at BT,
Craig worked for Coopers & Lybrand (now
36 Governance report

PricewaterhouseCoopers - PwC) where he
qualified as a Chartered Accountant. He
then moved to BT where he performed a
number of Finance Director roles before
moving into general management. Before
leaving BT Craig played a lead role in setting
up BT’s Openreach Division. Craig is also
a Board member of the Christian charity
Tearfund. Craig chairs the Trust’s Audit &
Assurance Committee. Craig’s term of office
expires on 30th September 2014. In March
2012 Craig was reappointed as the Trust’s
Senior Independent Director by the Board in
consultation with Council of Governors for a
further one year period to April 2013.
Shane DeGaris: Chief Executive (acting
Chief Executive until 22nd May 2012)
First appointed as the Trust’s Deputy Chief
Executive & Chief Operating Officer, in May
2012 Shane was appointed as the Trust’s
substantive Chief Executive following a
period as Acting Chief Executive. Shane is
an experienced NHS Director having worked
in a number of London Trusts in senior
management roles including as Director of
Operations at Barnet & Chase Farm Hospitals
NHS Trust and as Deputy Chief Executive
at Epsom & St Helier University Hospitals
NHS Trust. Australian by birth, he began his
healthcare career in 1990 after training as a
Physiotherapist in Adelaide, South Australia.
Shane has been appointed by the Board
as the Trust’s Director of Imperial College
Health Partners, and is also a Board member
of the North West London Local Education &
Training Board (a sub committee of Health
Education England), which is a Non-Executive
role.
Claire Gore: Director of People
Claire joined the Trust in 2010 as Director of
People, and was appointed as an Executive
member of the Board by the Board of
Directors Nominations Committee in March
2013. Claire is a Fellow of the Chartered
Institute of Personnel and Development
(FCIPD) and has worked at a senior level
in human resources and training and
development in a number of public sector
organisations including the London Borough
of Brent and the Metropolitan Police Service.
Claire has Board level responsibility for
human resources (including recruitment,
employee relations and temporary staffing),
occupational health, nurse training,
workforce and organisational development.
Dr Richard Grocott-Mason: Medical
Director (job-share)*
Appointed as Medical Director on a jobshare
basis in January 2013, Richard Grocott-
Mason is a Consultant in Cardiology and
General Medicine at THH and Harefield
Hospital. His clinical work at THH covers
general adult Cardiology and acute
medicine cover. At Harefield Richard is
an interventional Cardiologist and is on the
rota covering the heart attack centre. Prior
to taking up the position of Medical Director
he was the Trust’s Clinical Director for the
Division of Medicine and Emergency Care.
Richard has been involved in the Clinical
Expert Panel setting Adult Emergency Care
standards for NHS London and part of the
audit team reviewing acute Trusts in London.
Richard is the Trust’s Responsible Officer for
Revalidation.
* whilst Dr Khakoo and Dr Grocott-Mason undertake the role of Medical Director on a job-share basis, the Board member
responsibilities are held by one of the job-share partners at any given time. Dr Khakoo sits on the Board January to June,
with Dr Grocott-Mason holding these responsibilities July to December.
Governance report
37

Dr Abbas Khakoo: Medical Director (jobshare)*
Appointed as Medical Director on a jobshare
basis in January 2013, Abbas Khakoo
is a Consultant in Paediatrics and the care
of newborn babies. He also runs a children’s
allergy service at Hillingdon Hospital and
at St Mary’s Hospital, part of Imperial
College Healthcare NHS Trust. Since October
2010 Abbas has been the Clinical Director
of Paediatrics (Honorary) at NHS London,
and chairs both the NHS London Paediatric
Emergency Clinical Panel and the North West
London Paediatric Clinical Implementation
Group. Prior to taking up the position of
Medical Director at THH he was the Trust’s
Clinical Director for Quality and Safety.
Karl Munslow Ong: Chief Operating
Officer (Acting COO until 11th October
2012)
After joining the Trust as Director of
Operational Performance, Karl was
appointed as the Trust’s substantive Chief
Operating Officer in October 2012 following
a period as Acting Chief Operating Officer.
Karl is an experienced senior manager
who has worked in a number operational
management roles in Trusts across London,
having also worked at strategic health
authority level and in the private sector
for one of the big four accountancy firms.
Karl holds Board level responsibility for
the management of the clinical divisions,
emergency planning, the QIPP programme
(Quality, Innovation, Productivity and
Prevention) as well as for ensuring the Trust
meets and exceeds all national and local
patient access standards.
David Searle: Corporate Development
Director
Appointed in 2007, David is a Chartered
Director with senior level experience in
the aerospace and defence industries.
David holds Board-level responsibility for
estates and facilities, corporate governance
(including risk management and information
governance), business development,
communications and marketing.
Jacqueline Walker: Acting Executive
Director of the Patient Experience &
Nursing (from 22nd October 2012)
Appointed as the Trust’s Acting Executive
Director of the Patient Experience & Nursing
in October 2012, Jacqueline joined the
Trust in March 2008 as the Trust’s Deputy
Director of Nursing. Jacqueline qualified
as a Registered Nurse in 1990 and has held
a variety of nursing posts, specialising in
urology and renal nursing, and in recent
years specialising in senior nurse manager
roles. As Acting Director of the Patient
Experience & Nursing, Jacqueline holds Board
level responsibility for infection prevention
and control, safeguarding people, the
patient experience and engagement, and
nursing.
Paul Wratten: Finance Director
Appointed in 2000, Paul is a member of
the Chartered Institute of Public Finance
and Accountancy, and has spent almost all
his working life within the NHS, including
working in performance management for
the NHS in London. Paul also holds Boardlevel
responsibility for purchasing and
supplies; and the Trust’s information services
and information technology functions, which
includes the clinical coding team.
38 Governance report

The Constitution states that the Council
of Governors will appoint one of the Non-
Executive Directors as the Deputy Chairman,
whilst the Board, in consultation with the
Council of Governors appoints the Senior
Independent Director. In March 2012, James
Reid and Craig Rowland were reappointed
for a further one year term as the Deputy
Chairman and Senior Independent Director
respectively. In April 2013 James Reid was
appointed as the Senior Independent
Director and Pradip Patel as the Deputy
Chairman; these appointments are not
explicitly time limited and therefore run
until the remainder of their term of office,
unless revised by the Board and Council of
Governors respectively.
Changes to Board membership
during the year
During 2012/13 there were a number of
changes to the Board membership. Patricia
Rushton’s term of office as a Non-Executive
Director expired on 1st April 2012, with Carol
Bode and Anthony Palmer joining the Board
as Non-Executive Directors in April 2012.
Shane DeGaris and Karl MunslowOng were
substantively appointed to the positions of
Chief Executive and Chief Operating Officer
respectively, following a period of acting
up to these positions. Dr Susan LaBrooy
retired as the Trust’s Medical Director on
31st December 2012, with Dr Khakoo and
Dr Grocott-Mason taking up the position
of Medical Director on a job-share basis.
In October 2012 Jacqueline Walker was
appointed as Acting Director of the Patient
Experience & Nursing following Marie Batey’s
secondment to NHS London.
Statement on the balance,
completeness and appropriateness
of the membership of the Board
The Board of Directors Nominations &
Remuneration Committee is responsible for
reviewing the structure, size and composition
of the Board and makes recommendations
to the Council of Governors on the skills
required for any upcoming Non-Executive
Director appointments. As outlined above,
the Board comprises individuals with senior
level experience in the public and private
sectors, across a range of disciplines including
finance, governance, risk management,
human resources, and change management.
Recent Non-Executive appointments with
clinical expertise have further strengthened
the balance of the Board. The Board
therefore confirms that the current
composition is considered to be appropriate.
Taking account of the NHS Foundation
Trust Code of Governance published by
Monitor, the Board considers the Chairman
and all of the Non-Executive Directors to
be ‘independent’. Whilst Craig Rowland
was first appointed to the Board of The
Hillingdon Hospital NHS Trust more than six
years ago (in October 2006), the Board’s view
is that the Director retains an independent
viewpoint and ability to challenge/scrutinise
management.
Board members’ other commitments
and Register of Interests
Company Directorships and other significant
commitments held by Board members
are outlined above. Board members are
required to enter their relevant interests
in the Register of Directors’ Interests which
is formally reviewed by the Board at least
annually. The full register is available from
the Trust Secretary on 01895 279976.
As outlined above, Mike Robinson, the Trust
Chair, is an advisor to a number of local
authorities. During the course of the year,
Mike ceased to be a Non-Executive Director
of FR Morrison Plc.
Appointment and removal of Board
members
In accordance with the requirements of
the NHS Act 2006, the Foundation Trust
Constitution outlines the respective
Governance report
39

esponsibilities of the Directors and
Governors in appointing and removing Board
members.
The Council of Governors is responsible
for appointing, and if necessary, removing
the Chairman and Non-Executive Directors.
The Council of Governors Nominations
& Remuneration Committee has been
established to make recommendations
to the Council of Governors on the
appointment and remuneration of these
positions, including identifying suitably
qualified candidates for appointment. At
the start of the recruitment process the
Board of Directors Nominations Committee
makes recommendations to the Council of
Governors Nominations & Remuneration
Committee on the capabilities required for
these appointments in light of the current
Board composition and the challenges facing
the Trust.
When considering the appointment and
remuneration of Non-Executive Directors,
the Council of Governors Nominations
& Remuneration Committee consists
of the Trust Chairman (who chairs the
Committee), three Public Governors,
one Staff Governor and one Appointed
Governor. When considering the
appointment and remuneration of the
Chairman, the Committee consists of three
Public Governors, one Staff Governor, one
Appointed Governor, and one Non-Executive
Director (who chairs the Committee on
these occasions - this is currently the Senior
Independent Director). The Chief Executive
and Director of People are invited to attend
to provide advice to the Committee.
Should any such circumstances arise, the
Council of Governors Nominations &
Remuneration Committee is responsible for
investigating the grounds for any resolution
to remove the Chairman or a Non-Executive
Director, and preparing a report on this issue
with recommendations for the consideration
of the Council of Governors. Removal of
the Chairman or a Non-Executive Director
requires the approval of three-quarters of
the members of the Council of Governors.
The Chief Executive is appointed by the
Board of Directors Nominations Committee
which comprises the Chairman (Committee
chair) and all of the Non-Executive Directors.
The appointment must be approved by the
Council of Governors. The Board of Directors
Nominations Committee is responsible for
agreeing the removal of the Chief Executive
should this be required – any such decision
does not require the Council of Governors’
approval.
The Board of Directors Nominations
Committee is responsible for appointing and
removing the Executive Directors. The Chief
Executive is also a member of the Committee
when it is considering the appointment
and removal of the Executive Directors. The
Director of People is invited to attend the
Committee to provide advice as required.
Performance evaluation of the
Board, its Committees, and Board
members
The Board reviews its performance annually.
This annual review of the Board draws
upon a self-assessment by each Board
Committee, which includes a review of each
Board Committee’s terms of reference. The
review this year highlighted that there was
a potential for overlap and duplication
between the Integrated Risk Management
Committee and the Clinical Quality &
Standards Committee, with both Committees
considering issues of clinical risk. The Board
therefore merged these Committees into a
single Committee that focuses on all matters
relating to risk and clinical quality, in order
to ensure an alignment of the consideration
of risk and issues relating to clinical quality
and standards. The Board also concluded
as part of this review that greater Board
focus and scrutiny was required on the
transformation that is essential for the Trust
to be able to respond to the challenging
financial and operating context. The Board
40 Governance report

therefore replaced the Finance & Investment
Committee with a new Committee – the
Transformation Committee – which seeks to
replace a backward review of past financial
statements with a more forward look at
change projects. This new Committee is
part of the Board’s recognition that the
traditional approach of incremental savings
will not be sufficient, which also led to the
investment in an enhanced Programme
Management Office.
The Board agreed not to utilise external
support for this Board evaluation in 2012/13
given the significant level of external
review of the Trust’s governance during
the Foundation Trust application, and the
external perspective that could be brought
by recently appointed Board members.
Board members are subject to an annual
individual performance appraisal.
• The Chair’s appraisal is led by the
Senior Independent Director, whilst the
Chairman leads the appraisal of the
Non-Executive Directors. The Council
of Governors, through the Council of
Governors Nominations & Remuneration
Committee, feed in their views to
these appraisals and the full Council of
Governors are formally briefed on the
outcomes. The outcomes of the 2011/12
appraisals were considered at the July
2012 Council of Governors meeting.
• The Chief Executive undertakes the
appraisal of the Executive Directors, and
the Chair undertakes the appraisal of the
Chief Executive. The Board of Directors
Remuneration Committee oversees the
Chairman’s monitoring and evaluation
of the Chief Executive’s performance,
and the Chief Executive’s monitoring and
evaluation of the Executive Directors’
performance. The Committee provides
input into this process midway through
the year and at the year-end.
Nominations Committee meetings in
2012/13
Board of Directors Nominations
Committee
The Committee met nine times in 2012/13.
The Committee appointed Shane DeGaris
to the position of substantive Chief
Executive, Karl Munslow Ong to the
position of substantive Chief Operating
Officer, and Theresa Murphy to the
position of substantive Director of the
Patient Experience & Nursing 13 following
a thorough recruitment exercise involving
the open advertisement of the positions,
involvement of staff and stakeholders,
and external assessors. The Committee
appointed Richard Grocott-Mason and
Abbas Khakoo as Medical Directors on a jobshare
following the advertisement of the
positions internally and formal interviews.
The Committee considered the action to
be taken in respect of the Chair, given that
Mike Robinson’s term of office was due to
expire in July 2013. The Committee agreed
to recommend to the Council of Governors
that Mike be reappointed for a further short
term (to the end of March 2014) in order
to provide continuity and stability during
the introduction of new commissioning
arrangements and in light of the recent
changes of Chief Executive and senior
management.
In line with its terms of reference,
the Committee also reviewed talent
management and succession planning at the
Trust, including proposals for the structure of
the Executive team portfolios.
Council of Governors Nominations &
Remuneration Committee
The Committee met twice during 2012/13.
At its meeting in May 2012, the Committee
provided input on behalf of the Governors
to the Chair’s and Non-Executive Directors’
13 Theresa Murphy is due to start at the Trust in May 2013
Governance report
41

appraisals which were to be undertaken
by the Senior Independent Director and
Chair respectively. At its meeting in October
2012, the Committee considered the
recommendation from the Board of Directors
Nominations Committee on the appointment
of the Chair. The Committee supported
the recommendation that Mike Robinson
be reappointed until the end of March
2014. This recommendation was therefore
presented to, and subsequently approved by,
the Council of Governors. Given that this was
a short term reappointment which sought
to provide continuity, the position was not
subject to competition.
Audit & Assurance Committee
The Trust’s Audit & Assurance Committee
comprises three Non-Executive Directors, one
of whom has recent and relevant financial
experience. The Committee is responsible
for providing an independent and objective
review of the Trust’s systems of internal
control (both financial and non-financial)
and the underlying assurance processes in
place at the Trust. The Committee is also
responsible for ensuring that the Trust has in
place independent and effective internal and
external audit functions. The Committee’s
work in undertaking these responsibilities is
outlined in an annual report to the Board.
Key elements of the Committee’s work
include reviewing the Board Assurance
Framework, and reviewing the findings of
the Trust’s internal and external auditors
and Local Counter Fraud Specialist. The
Committee is responsible for reviewing the
annual financial statements, with particular
focus given to major areas of judgement
and changes in accounting policies, the basis
of the Board’s determination that the Trust
remains a going concern, and the Annual
Governance Statement. The Committee
also reviews the assurance available from
the Trust’s clinical audit function, and has
developed an increasing role in reviewing
the robustness of data quality at the Trust. In
addition to its own annual self-evaluation,
the Committee reviews the performance of
internal audit, external audit, and the Local
Counter Fraud Specialist each year.
The Committee is usually attended by the
internal and external auditors, the Finance
Director and the Executive Director of
Corporate Development. The Local Counter
Fraud Specialist attends at least two
meetings a year, and other Directors and
senior managers attend when invited by
the Committee. The Trust Secretary is the
Committee Secretary.
The Audit & Assurance Committee (AAC) is
responsible for making recommendations to
the Council of Governors on the appointment
and removal of the external auditor. The
Council of Governors has agreed that a full
market testing will be undertaken in time to
enable the Council of Governors to appoint
the external auditor for the 2013/14 audit
cycle, as Deloitte would then have provided
external services to the NHS Trust and
Foundation Trust for five years. This market
testing was in line with the recommendations
of the AAC and is consistent with Monitor
guidance.
The Council of Governors has agreed a
process for undertaking this market-testing,
based on recommendations from the AAC.
A working group comprising the AAC and
representatives of the Council of Governors
will be established to agree the specification
for the tender and make recommendations
to the Council of Governors on the
appointment. This process is expected to
conclude with a recommendation to the
Council of Governors in October 2013 to give
sufficient time for the appointed auditors to
make preparations for the 2013/14 audit.
At their meeting in April 2011 the Council
of Governors approved a policy on the
engagement of the external auditors
to undertake additional services, which
had been reviewed and recommended
by the Audit & Assurance Committee.
Under the policy, the Council of Governors
42 Governance report

has delegated to the Audit & Assurance
Committee the authority for commissioning
additional services from the external auditor.
Any such work will then be reported to the
Council of Governors. No such additional
work was commissioned in 2012/13.
Other Board committees
As noted above, the Board agreed a revised
Committee structure in 2012/13, which
took effect in January 2013. In addition to
the Nominations Committee and Audit &
Assurance Committee, the following Board
Committees are in place. Each of these is
chaired by a Non-Executive Director.
• The Transformation Committee was
established this year to assist the
Board with the shaping, review and
challenge of service transformation,
development and redesign, and to
provide assurance that the strategy
for the management of human,
financial, estate, and IT resources
support such business transformation.
The Committee replaced the Finance
& Investment Committee as the
Board sought to ensure greater Board
scrutiny and challenge on service
transformation and redesign.
• The Board of Directors Remuneration
Committee, which solely comprises
Non-Executive Directors, is responsible
for agreeing the remuneration and
terms of service for the Chief Executive
and Executive Directors. Further
information on the Committee is
outlined in the Remuneration Report.
• The Charitable Funds Committee
assists the Trust in its role as corporate
trustee for The Hillingdon Hospitals
NHS Foundation Trust charity and has
been established to make and monitor
arrangements for the control and
management of the Trust’s charitable
funds.
• The Quality & Risk Committee was
established this year to provide
assurance and make recommendations
in matters relating to clinical quality
and standards, and to ensure that risks
to the delivery of the Trust’s services
are identified and addressed. The
Committee was created out of merger
of the Integrated Risk Management
Committee and Clinical Quality &
Standards Committee to ensure that
risk and safety are considered in a fully
integrated manner.
Governance report
43

Attendance at Board and Board Committee meetings
The following table outlines Board members’ attendance at Board and Committee meetings
during 2012/13 against the total possible number of meetings for which an individual was a
member. Committee attendance is shown in relation to those Committees of which a Director
was formally a member.
Board of
Directors
(13 meetings)
Audit &
Assurance
Committee
(5 meetings)
Board
Nominations
Committee
(9 meetings)
Board
Remuneration
Committee
(6 meetings)
Charitable
Funds
Committee
(3 meetings)
Katey Adderley 13 of 13 5 of 5 8 of 9 6 of 6 3 of 3
Marie Batey 7 of 7 2 of 2
Carol Bode 11 of 13 4 of 4 5 of 9 4 of 6 3 of 3
Shane DeGaris 12 of 13 8 of 8
Claire Gore 1 of 1
Abbas Khakoo 3 of 3
Susan LaBrooy 9 of 10
Alan McLeod 12 of 13 7 of 9 4 of 6
Karl MunslowOng 12 of 13
Anthony Palmer 11 of 13 5 of 9 3 of 6
Pradip Patel 11 of 13 8 of 9 6 of 6
James Reid 12 of 13 5 of 5 8 of 8 6 of 6
Mike Robinson 13 of 13 9 of 9 6 of 6 3 of 3
Craig Rowland 12 of 13 5 of 5 7 of 9 6 of 6
David Searle 13 of 13
Jacqueline Walker 6 of 6 1 of 1
Paul Wratten 13 of 13 3 of 3
Clinical Quality
& Standards
Committee
(3 meetings)
Finance &
Investment
Committee
(4 meetings)
Integrated Risk
Management
Committee
(3 meetings)
Quality & Risk
Committee
(1 meeting)
Transformation
Committee
(3 meetings)
Katey Adderley 4 of 4
Marie Batey 0 of 3 2 of 3
Carol Bode 1 of 1
Shane DeGaris 2 of 3 3 of 3
Claire Gore
Abbas Khakoo 1 of 1 1 of 3
Susan LaBrooy 2 of 3 3 of 3
Alan McLeod 2 of 4 3 of 3 1 of 3
Karl MunslowOng 2 of 3 2 of 3 1 of 1 2 of 3
Anthony Palmer 3 of 3 2 of 3 1 of 1
Pradip Patel 2 of 3 3 of 4 3 of 3
James Reid 3 of 3 3 of 3 1 of 1
Mike Robinson 3 of 3
Craig Rowland 4 of 4 2 of 3
David Searle 4 of 4 3 of 3 1 of 1
Jacqueline Walker 1 of 1 2 of 3
Paul Wratten 4 of 4 3 of 3
44 Governance report

Council of Governors
The role and powers of the Council of Governors are outlined earlier in the report. The
composition of the Council of Governors is outlined in the Trust’s Constitution.
As at 31st March 2013 there were 28 members of the Council of Governors: 17 elected to
represent the public members, seven elected to represent the staff members, and four
appointed by partner organisations (Hillingdon Council, Hillingdon Primary Care Trust, the
London Ambulance Service, and the Trust’s Joint Negotiating & Consultative Committee).
However, as at 1st April 2013, Hillingdon Primary Care Trust ceased to exist as a result of the
changes to the commissioning structure in the NHS brought about by the Health & Social
Care Act 2012. Therefore the number of Appointed Governors reduced to three, with the
overall size of the Council of Governors reducing to 27.
The members of the Council of Governors who served during 2012/13 are outlined below:
Public Governors
North (5)
Name
Date took office
and method (see
key below)
Term of office
expires
David Bishop 01/04/2011 (CE) 31/03/2014
Tony Ellis 01/04/2011 (CE) 31/03/2014
Ahmad Mallick 01/04/2011 (CE) 31/03/2014
Alvan Seth-Smith 12/04/2011 (CE) 31/03/2014*
Pamela Taverner 28/05/2012 (CE) 31/03/2014*
Rachel Owen
(replaced by Pamela Taverner)
01/04/2011 (CE) Resigned 2/05/2012
Donald Dakin 01/04/2011 (CE) 31/03/2014
Martin Elliott 17/05/2012 (CE) 31/03/2014
Central (5)
Neil Fyfe 17/05/2012 (CE) 31/03/2014
Kerstin Rolfe 01/04/2011 (CE) 31/03/2014
Roger Shipton 01/04/2011 (CE) 31/03/2014
John Coleman 01/04/2011 (CE) 31/03/2014
John Davies 01/04/2011 (CE) 31/03/2014
South (6)
Graham Hawkes 17/05/2012 (CE) 31/03/2014
Asma Jalal 01/04/2011 (UE) 31/03/2014
Abid Majeed 01/04/2011 (UE) 31/03/2014
Sharda Mohan 01/04/2011 (UE) 31/03/2014
Rest of England (1) Stuart Marshall 06/08/2012 (UE) 31/03/2014
Staff Governors
Doctors & dentists (1) Alvan Pope 17/05/2012 (CE) 31/03/2014
Bev Hall 01/04/2011 (CE) 31/03/2014
Nurses, midwives,
healthcare assistants (3)
Allied health
professionals (1)
Support staff (2)
Ann Morling
(replaced by Amanda O’Brien)
01/04/2011 (CE)
Resigned
11/05/2012
Amanda O’Brien 11/05/2012 (UE) 31/03/2014
Angela Wilson 01/04/2011 (CE) 31/03/2014
Graham Coombs 01/04/2011 (CE) 31/03/2014
Gay Bineham 01/04/2011 (CE) 31/03/2014
Jennifer Roma 22/11/2011 (CE) 31/03/2014
Governance report
45

Appointed Governors
Post ceased to exist
31/03/2013
Council changed
Cllr Philip Corthorne
01/04/2011 (A)
appointee
6/11/2012
Cllr Mary O’Connor 6/11/2012 (A) 11/05/2014
Hillingdon PCT Sarah Cuthbert 20/07/2011 (A)
London Borough of
Hillingdon (1)
London Ambulance
Service (1)
Joint Negotiating &
Consultative Committee
(1)
Peter McKenna 01/04/2011 (A) 31/03/2014
Lesley Dixon 01/04/2011 (A) 31/03/2014
Key:
CE – contested election
UE – uncontested election
A – appointed by partner organisation
* The Constitution states that where a vacancy arises for an elected Governor other than by the end of a term of office, the
Council of Governors may invite the next highest polling candidate for that seat at the most recent election, who is willing to
take office, to fill the vacant seat until the next election, at which time the seat will fall vacant and be subject to election for
any unexpired period of the term of office. In accordance with these provisions, Alvan Seth-Smith & Pamela Taverner were
invited to take up the positions vacated by Governor resignations. Therefore whilst the term of office is shown as 31st March
2014, should there be an election in the North Public Constituency before this time then the two seats will fall vacant and be
subject to election for the period until 31st March 2014.
During 2012/13 elections for five constituencies were held. The following table outlines the
turnout and number of candidates.
Constituency
Number of
positions
Number of
candidates
Number
of eligible
voters
Turnout
Public: Central 2 6 2,754 24%
Public: South 1 4 2,873 17%
Public: Rest of England 1 1 176 N/A
Staff: Doctors & dentists 1 2 433 20%
Staff: Nurses, midwives & healthcare
assistants
1 1 1,321 N/A
Where an election was contested, voting was undertaken by secret postal ballot, using
the single transferable voting system by which members rank the candidates in order of
preference.
46 Governance report

In 2012/13 the Council of Governors formally
met four times. Governor attendance at
these meetings is outlined below. Where
a Governor was not in office for all four
meetings, the maximum possible attendance
is shown.
Governor
Meetings
attended
David Bishop (Public) 4 of 4
Tony Ellis (Public) 3 of 4
Ahmad Mallick (Public) 2 of 4
Rachel Owen (Public) 0 of 0
Alvan Seth-Smith (Public) 4 of 4
Pamela Taverner (Public) 2 of 3
Donald Dakin (Public) 2 of 4
Martin Elliott (Public) 3 of 3
Neil Fyfe (Public) 1 of 3
Kerstin Rolfe (Public) 2 of 4
Roger Shipton (Public) 4 of 4
John Coleman (Public) 4 of 4
John Davies (Public) 4 of 4
Graham Hawkes (Public) 3 of 3
Asma Jalal (Public) 2 of 4
Abid Majeed (Public) 2 of 4
Sharda Mohan (Public) 2 of 4
Stuart Marshall (Public) 2 of 2
Alvan Pope (Staff) 3 of 3
Bev Hall (Staff) 3 of 4
Ann Morling (Staff) 0 of 0
Amanda O’Brien (Staff) 4 of 4
Angela Wilson (Staff) 4 of 4
Graham Coombs (Staff) 3 of 4
Gay Bineham (Staff) 3 of 4
Jennifer Roma (Staff) 3 of 4
Sarah Cuthbert (Appointed) 0 of 4
Cllr Philip Corthorne (Appointed) 0 of 3
Cllr Mary O’Connor (Appointed) 1 of 1
Peter McKenna (Appointed) 1 of 4
Lesley Dixon (Appointed) 3 of 4
Governors are required to declare any
relevant interests which are then entered
into the publicly available Register of
Governors’ Interests. The Register is formally
reviewed by the Council of Governors
annually and is available from the Trust
Secretary on 01895 279976.
Lead Governor
In line with Monitor’s Code of Governance,
the Council of Governors elects one of the
Public Governors to be the ‘Lead Governor’.
The main duties of the Lead Governor are to:
• Act as a point of contact for Monitor
should the Regulator wish to contact
the Council of Governors on an issue
for which the normal channels of
communication are not appropriate.
• Be the conduit for raising with Monitor
any Governor concerns that the
Foundation Trust is at risk of significantly
breaching the Terms of its Authorisation
(now Licence), having made every attempt
to resolve any such concerns locally.
• Chair such parts of meetings of the
Council of Governors which cannot be
chaired by the Trust Chair or Deputy Chair
due to a conflict of interest in relation to
the business being discussed.
In April 2012 the Council of Governors
appointed Roger Shipton as the Lead
Governor for the 2012/13 financial year.
In April 2013, Roger Shipton did not seek
reappointment for the role and the Council
of Governors elected John Coleman as Lead
Governor to run until 31st March 2014.
The Board’s liaison with Governors
and members
All Board members have a standing invitation
to attend Council of Governors meetings in
order to ensure they understand the views
of Governors and members. The Board and
Council of Governors meet jointly at least
annually as part of enabling the Governors
to input into the Trust’s annual plan and
also to discuss any other matters of joint
concern. In 2012/13 two such meetings were
held: in November 2012 and March 2013.
Board meetings are held in public and there
is an opportunity for members of public and
Governors to ask questions of the Board
members present. Members of the Board
also attend the Trust’s People in Partnership
Governance report
47

meetings and Annual Members’ Meeting to
liaise with members and Governors.
Attendance by Board members at the four
meetings of the Council of Governors and the
two joint meetings between the Board and
Council of Governors in 2012/13 is outlined in
the table below.
No of Council of Governor meetings
Board Member
attended in 2012/13 (including joint
Board/Governor meetings)
Mike Robinson (Chair) 6 of 6
Katey Adderley (Non-Executive Director) 4 of 6
Marie Batey (Executive Director of Patient
Experience & Nursing)
1 of 2
Carol Bode (Non-Executive Director) 4 of 6
Shane DeGaris (Chief Executive) 5 of 6
Abbas Khakoo (Joint Medical Director) 2 of 2
Susan LaBrooy (Medical Director) 0 of 4
Alan McLeod (Non-Executive Director) 4 of 6
Karl Munslow Ong (Chief Operating Officer) 2 of 6
Anthony Palmer (Non-Executive Director) 3 of 6
Pradip Patel (Non-Executive Director) 4 of 6
James Reid (Deputy Chair & Non-Executive Director) 4 of 6
Craig Rowland (Senior Independent Director & Non-
Executive Director)
4 of 6
David Searle (Executive Director of Corporate
Development)
3 of 6
Jacqueline Walker (Acting Executive Director of the
Patient Experience & Nursing)
3 of 4
Paul Wratten (Finance Director) 4 of 6
48 Governance report

Membership
The Foundation Trust membership is divided
into two categories: public membership and
staff membership.
Staff membership
The staff constituency is a single constituency
divided into the following classes:
• Doctors and dentists
• Nurses and midwives (including health
care assistants)
• Allied Health Professionals
• Support staff
Staff membership is open to all those
employed by the Trust on a permanent basis,
those who have a fixed term contract of at
least 12 months, and those who have been
working at the Trust for at least 12 months.
These staff are automatically members of
the Staff Constituency unless they ‘opt-out’
from membership. So far no staff have opted
out from being a member of the Foundation
Trust. In addition, the following individuals
may become staff members providing they
have exercised these ‘functions’ for a period
of 12 months and continue to do so:
Public membership
There are four public constituencies,
which are collectively known as the Public
Constituency. The majority of the public
members are drawn from the three public
constituencies which cover the electoral
wards in Hillingdon Borough together
with several neighbouring electoral wards.
The fourth public constituency covers all
other electoral areas in the rest of England.
Anyone can become a public member of the
Foundation Trust providing they are 16 years
or over, live within the Public Constituency,
and are not eligible to be a staff member of
the Foundation Trust.
• Volunteers working at the Trust (other
than those working for third party
organisations).
• Those working at the Trust through the
temporary staffing ‘bank’.
• Those working at the Trust through an
independent contractor to provide a
service out-sourced by the Trust.
Staff membership will cease at the point that
the member leaves the service of the Trust.
Anyone eligible to be a staff member of the
Foundation Trust cannot be a public member.
Membership Development and
Engagement Strategy 2012-2015
The Board approved a three year
Membership Development and Engagement
Strategy in February 2012. The strategy
describes the Trust’s objectives for the
membership and the approach we will use
to ensure the Trust develops and engages
with a representative membership. It
outlines our plans for raising awareness
about membership and for the recruitment,
Governance report
49

etention and involvement of members. The
strategy was produced with the guidance
and input of the Council of Governors and
builds upon and replaces the Membership
Development and Public Engagement
Strategy that was approved in 2008 and
subsequently updated in 2010. A high level
action plan to deliver the Membership
Development and Engagement Strategy has
been developed with progress periodically
reported to the Council of Governors and the
Board.
The Hillingdon Hospitals NHS Foundation
Trust is committed to recruiting members
from the diverse population served by
the Trust. Membership is open to all those
eligible to be a member regardless of gender,
race, disability, ethnicity, religion or any
other groups covered under the Equality Act
2012.
The membership base is regularly
reviewed to ensure that the membership
is representative of those eligible to be
members. Specific groups that appear
to be under-represented are targeted in
recruitment campaigns in order to seek to
increase membership representation in these
areas, such as people between the ages of 16
and 45.
The Membership Development and
Engagement Strategy set the following
targets for membership growth:
Target Membership
2012/13 2013/14 2014/15
Public constituency 7,500 7,650 7,750
Staff constituency 3,187* 3,187* 3,187*
Total 10,687 10,837 10,937
* These figures were set based on staffing levels as at
February 2012, with the recognition that this would depend
on any future changes in staff numbers.
In order to achieve the above targets there is
a need to recruit approximately an additional
500 public members each year to replace
those who cease to be a member by virtue
of moving or passing away. In agreeing the
strategy it was felt that the above targets
should represent a broad indication of our
objective to increase the membership but
the primary focus would be to maintain
the current level of membership, address
areas of under-representation and focus on
engagement rather than growth.
Key actions to grow membership are to:
• Utilise existing publications (e.g.
Hillingdon People), local groups (e.g.
Street Champion meetings, Resident
Associations and Community Voice) and
local events (May Day Fair and summer
carnivals)
• Attend local community and voluntary
group meetings i.e. AGMs and
conferences
• Attend joint public engagement
meetings with Hillingdon Clinical
Commissioning Group and Central and
North West London NHS Foundation
Trust
• Attend regular ‘speak-easy’ carer events,
hosted by Hillingdon Carers and the
Council
• Promote membership at Trust
engagement events, i.e. armed forces,
BME focus groups and patient support
groups
• Organise membership recruitment
events at Hillingdon and Mount Vernon
Hospitals
• Encourage Governors and members to
sign up family, friends and members of
the public
• Invite ex-staff, their family and friends
to become public members
• Utilise existing networks in promoting
membership with staff and students at
local universities
• Explore the possibility of holding a
careers event for students attending
local schools and colleges
• Make membership forms available in
local libraries and shopping centres.
50 Governance report

Membership as at 31st March 2013
As at 31st March 2013, the Trust had
7,172 public members. The table below
illustrates the number of public members
for each constituency compared to the total
population.
31 st
March
2013
% of
membership
Population
base
% of
area
Central 2,704 37.7 177,608 40
North 1,462 20.4 102,842 23.1
South 2,811 39.2 166,500 36.9
Rest of 194 2.7 0 0
England
Total 7171 100 446,950 0
During 2012/13, the Foundation Trust
recruited 316 new public members and lost
238 public members due to bereavement,
members moving away without providing
a new address or members cancelling their
membership. This has resulted in the Trust
not meeting the target of 7,500 members.
In April 2013 the Board agreed a revised
membership target of 7,400 public members
at its Board meeting on 24th April 2013 to
cover the period April 2013 to March 2014,
in line with the view that the aim is to focus
on engagement rather than recruitment.
The Trust will strive to increase membership
in the coming year to meet this revised
target through a programme of focused
recruitment and engagement using the
actions outlined above.
Contacting Directors and Governors
Directors and Governors can be contacted
through the Foundation Trust Office:
• Email: foundation@thh.nhs.uk
• Telephone: 0800 8766953
• Post: Foundation Trust Office, Hillingdon
Hospital, Pield Heath Road, Uxbridge, UB8
3NN.
Compliance with the Code of
Governance
The Board considers itself compliant with all
provisions of the NHS Foundation Trust Code
of Governance and has made the required
disclosures in this annual report. The Board
has identified areas where the Trust’s
compliance could be strengthened, most
notably in relation to the evolving role of the
Governors, and the assurance as to the extent
the Governors consult with the membership.
Work over the coming year will therefore
seek to strengthen the Trust’s arrangements
in relation to Governors’ engagement
with the members, Governor engagement
with the Board, and Governor training and
induction, in light of the Health & Social
Care Act 2012 and the recommendations of
the Mid Staffordshire NHS Foundation Trust
Public Inquiry.
As at 31st March 2013 the Trust currently had
3,081 staff members. The following table
provides a breakdown by staff group:
Staff Class
Number of members
Doctors and Dentists 395
Nurses, Midwives & Healthcare Assistants (including bank staff) 1,222
Allied Health Professionals (including bank staff) 299
Support staff (including bank staff and volunteers) 1,165
Total 3,081
Governance report
51

REMUNERATION REPORT
Board of Directors Remuneration
Committee
The Board of Directors Remuneration
Committee comprises all of the Non-
Executive Directors and is chaired by the
Deputy Chair. The Chief Executive and
Director of People are invited to attend
to provide professional advice, except
for when the Committee is considering
these individuals’ remuneration and/or
performance. The Trust Secretary attends to
take minutes of the Committee’s meetings.
The Committee’s role and responsibilities
are primarily two-fold: to agree the
remuneration and terms of service for the
Chief Executive and the Executive Directors;
and to oversee the performance monitoring
of the Chief Executive and Executive
Directors. The Committee also reviews at a
high level the remuneration of the Trust’s
most senior employees beneath the Board
(i.e. the first line reports to the Executive
Directors and the Trust’s Consultants) to
ensure this remains appropriate to the
remuneration paid to the Executive Team.
The Committee met six times in 2012/13.
At these meetings the Committee agreed
the remuneration in relation to the
acting and substantive Director of Patient
Experience & Nursing positions, and for
the Medical Director, Chief Executive, and
Chief Operating Officer appointments. The
Committee also reviewed the Trust’s pay
policy for the Executive Team and the case
for any pay awards (see below for further
information), and reviewed the remuneration
for the Trust’s senior management and
Consultants. The Committee also reviewed
the Chair and Chief Executive’s monitoring of
the Chief Executive’s and Executive Directors’
performance at the mid-point of the year
(September 2012) and at the end of the year
(March 2013).
At its meeting in May 2012 the Committee
agreed not to award an increase in Executive
Remuneration for 2012/13. This decision was
based on the fact that Agenda for Change
staff and those on the medical and dentistry
pay scales would not receive a cost of living
increase in 2012/13, and the current focus
on efficiency savings and reductions in the
Trust’s pay spend. The Committee noted
that this meant that no increase had been
awarded for two years, and agreed that
external consultants should be commissioned
to report to the March 2013 meeting on
Executive Remuneration. The Committee
agreed that the report would also assist
the Committee in considering whether its
previous decision not to introduce a formal
performance related element to Executive
Remuneration remains appropriate.
The Committee were mindful of the cost
of commissioning this work and therefore
the Chair of the Committee agreed with
the Director of People to purchase an
existing benchmarking report from Capita
on FT remuneration. Hay Group were also
commissioned by the Director of People to
provide a bespoke report to the Committee
on performance related pay.
At the start of 2012/13 Capita provided
services to the Trust in relation to the
electronic distribution of the Trust’s
membership magazine, but had ceased to
provide these services at the time the report
was provided to the Committee. Hay Group
provided no other services to the Trust in
2012/13.
The Committee considered the reports from
Capita and Hay at its meeting in March 2013.
52 Remuneration report

The Committee confirmed the Trust’s
Executive pay policy is to set remuneration at
the median to upper quartile of comparator
Trusts, with the following conditions to
be taken into account when determining
individual Executives’ pay:
• Performance
• Experience
• Importance to the organisation
• Marketability and likelihood of moving
elsewhere.
The Committee confirmed its previous
decision that Executive Remuneration should
not include provisions for bonus payments
or proportions subject to performance
conditions. The Committee confirmed that
it would continue to consider individual and
overall Trust performance, when determining
Executive remuneration as part of the pay
policy outlined above.
Having considered the pay policy and the
benchmarking information provided by
Capita, the Committee agreed that the Chief
Executive and Executive Directors would not
receive an increase in remuneration at the
present time.
Neither the Chief Executive nor the Executive
Directors are currently appointed for fixed
term contracts. The Board believes that
such contracts would make it harder to
attract and retain high-quality Executives
in a competitive recruitment environment,
and can lead to uncertainty affecting service
delivery towards the end of the contract.
The Trust’s policy on notice periods and
termination payments for Executive Directors
is six months, in line with generally accepted
practice at this level in the NHS. Any decision
to allow an Executive Director to leave the
Trust’s employment without this full notice
period is subject to a risk assessment by the
Board of Directors Nominations Committee,
in line with the Code of Governance.
As outlined earlier in the report, Jacqueline
Walker is currently acting up from her
substantive role as the Trust’s Deputy
Director of Nursing to be the Acting
Executive Director of Patient Experience &
Nursing. This is to cover the period until the
Trust’s new substantive Executive Director of
Patient Experience & Nursing joins the Trust
(expected to be at the end of May 2013).
Attendance at Remuneration Committee
meetings in 2012/13 is outlined earlier in the
‘Governance Report’.
Pay policy for wider staff
The Remuneration Committee annually
reviews the pay of the first layer of
management beneath the Board, to ensure
that there is appropriate differential
between the remuneration of the Executive
team and their direct reports. As part of this,
the Committee also reviews the structure of
Consultant pay.
Staff beneath the Board are paid according
to nationally defined terms and conditions
(i.e. the medical pay-scales or in the case
of non-medical staff, Agenda for Change).
When considering whether to increase
executive remuneration the Remuneration
Committee takes into account whether any
cost of living increases have been awarded
to staff on national terms and conditions.
Non-executive remuneration
The Council of Governors is responsible for
agreeing the remuneration of the Chair and
Non-Executive Directors.
At their meeting in October 2011 the Council
of Governors agreed that the remuneration
for the Chair and Non-Executive Directors
should be increased to £45k pa and £13k
pa respectively to reflect the additional
responsibilities arising from Foundation Trust
status. In making this decision the Governors
drew upon benchmarking information
and independent analysis provided by
Hay Group. In agreeing this increase, the
Council of Governors was mindful of the
wage restraint in the NHS and agreed that
the increase would not take effect until
1st April 2012 (and therefore a year after
Remuneration report
53

authorisation as a Foundation Trust) and
that Non-Executive remuneration would not
be increased for a further two years.
Non-Executive appointments are not within
the jurisdiction of Employment Tribunals and
there is no entitlement for compensation for
loss of office through employment law.
In making decisions on Non-Executive
Remuneration, the Council of Governors
draws on the recommendations of the
Council of Governors Nominations &
Remuneration Committee. Attendance at
the Committee’s two meetings in 2012/13 is
outlined below.
Number of
Name
meetings
attended
Mike Robinson (Trust Chair) 1 14 of 2
John Coleman (Public Governor) 2 of 2
Tony Ellis (Public Governor) 2 of 2
Roger Shipton (Public Governor) 2 of 2
Gay Bineham (Staff Governor) 1 of 2
Peter McKenna (Appointed Governor) 2 of 2
Directors’ remuneration in 2012/13
For the purposes of the remuneration
report, the Chief Executive has confirmed
that the definition of senior manager covers
the members of the Board, in line with the
definition in Monitor’s Annual Reporting
Manual that senior managers are ‘those
persons in senior positions having authority
or responsibility for directing or controlling
the major activities of the Foundation Trust.’
14 One of the meetings was to discuss Mike Robinson’s appointment and therefore this meeting was chaired by Craig
Rowland, the Trust’s Senior Independent Director at that time.
54 Remuneration report

Directors’ remuneration (excluding pension contributions) fell within the following
ranges:
Directors' remuneration (excluding pension contributions) fell within the following ranges:
NOTE
NAME AND TITLE
(Bands of £5000)
Executive Directors £000s £000s £000s £000s £000s £000s £000s £000s £000s
1 Shane DeGaris, Chief Executive 155-160 90-95 2.5-5 5-7.5 20-25 15-20 272 141 91
Marie Batey, Executive
2 Director of Patient Experience 50-55 90-95 - - 30-35 100-105 574 540 24
and Nursing
3 Claire Gore, Director of People 5-10 N/A N/A N/A N/A N/A N/A N/A N/A
4
Richard Grocott-Mason, Joint
Medical Director
40- 45 N/A N/A N/A 40-45 125-130 768 N/A N/A
5
Abbas Khakoo, Joint Medical
Director
40-45 N/A N/A N/A 40-45 120-125 730 N/A N/A
6
Susan LaBrooy, Medical
Director
100-105 175-180 N/A N/A 70-75 215-220 N/A N/A N/A
7
Karl Munslow Ong, Chief
Operating Officer
100-105 5-10 0-2.5 0-2.5 10-15 35-40 130 114 12
David Searle, Executive
Director of Corporate 95-100 95-100 0-2.5 0-2.5 15-20 55-60 380 345 24
Development
Jacqueline Walker, Acting
8 Executive Director of Patient 35-40 N/A N/A N/A 20-25 60-65 N/A N/A N/A
Experience and Nursing
Paul Wratten, Finance Director 115-120 115-120 - - 40-45 120-125 709 664 31
Non Executive Directors
Salary
2012/13
(excluding
social
security
costs)
(Bands of
£5000)
Salary
2011/12
(excluding
social
security
costs)
(Bands of
£5000)
Real
increase in
lump sum
pension at
age 60
(Bands of
£2500)
Real
increase in
pension at
age 60
(Bands of
£2500)
Total accrued
pension at
age 60 at 31
March 2013
(Bands of
£5000)
Lump sum at
age 60 related
to accrued
pension at 31
March 2013
Cash
equivalent
transfer value
at 31 March
2013
Cash
equivalent
transfer value
at 31 March
2012
Michael Robinson, Chair 35-40 30-35 N/A N/A N/A N/A N/A N/A N/A
Katey Adderley, Non-Executive
10-15
Director
5-10 N/A N/A N/A N/A N/A N/A N/A
9
Carol Bode, Non-Executive
Director
10-15 N/A N/A N/A N/A N/A N/A N/A N/A
Alan McLeod, Non-Executive
Director
10-15 5-10 N/A N/A N/A N/A N/A N/A N/A
9
Anthony Palmer, Non-
Executive Director
10-15 N/A N/A N/A N/A N/A N/A N/A N/A
Pradip Patel, Non-Executive
Director
10-15 0-5 N/A N/A N/A N/A N/A N/A N/A
Craig Rowland, Non-Executive
10-15
Director
5-10 N/A N/A N/A N/A N/A N/A N/A
James Reid, Non-Executive
Director
10-15 5-10 N/A N/A N/A N/A N/A N/A N/A
10
Patricia Rushton, Non-
Executive Director
0-5 5-10 N/A N/A N/A N/A N/A N/A N/A
Real increase
in cash
equivalent
transfer value
2012/2013 2011/2012
2012/2013 2011/2012
Band of Band Highest of Highest Paid Paid Director’s Director's Total Total Remuneration Remuneration (£ 000) (£000) 155-160 175-180
Median Total Remuneration
Median Total Remuneration
30,801
30,801
32,237
32,237
Ratio 5.11 5.51
Ratio 5.11 5.51
The HM Treasury Financial Reporting Manual (FReM), requires the Trust to disclose the median remuneration of the
Trust staff and the ratio between this and the mid-point of the banded remuneration of the highest paid director. The
calculation is based on full-time equivalent staff of the Trust at 31st March 2013 on an annualised basis.
The HM Treasury Financial Reporting Manual (FReM), requires the Trust to disclose the
median remuneration of the Trust staff and the ratio between this and the mid-point of
the banded remuneration of the highest paid director. The calculation is based on full-time
equivalent staff of the Trust at 31st March 2013 on an annualised basis.
Remuneration report
55

Notes
1. (A) Acting Chief Executive until 21/5/2012; (B) Chief Executive from 22/5/2012
(A) Gross Pay 1/4/2012 to 21/5/2012 in bands of £5000: £20k - £25k
(B) Gross Pay 22/5/2012 to 31/3/2013 in bands of £5000: £135k - 140k
2. To 29/10/2012
3. In post from 1/3/2013
4. In post from 1/2/2013
5. In post from 1/1/2013. Clinical work in band of £15k - £20k, Director work in band of £25k to £30k. Recharges out to
Imperial College Healthcare NHS Trust and London Health Programme not included in above.
6. To 31/12/2012. Salary was in band of £90k - £95k in respect of executive activities and £10k - £15k in respect of clinical
work. Salary is inclusive of a nationally funded excellence award. Time charged relating to a role at the North West
London Cluster (to December 2012) is excluded.
7. (A) Acting Chief Operating Officer until 10/10/2012; (B) Chief Operating Officer from 11/10/2012.
(A) Gross Pay 1/4/2012 to 10/10/2012 in bands of £5000:£50k - £55k.
During period (A) employed by Homerton NHS Foundation Trust and salary cost fully recharged to Hillingdon Hospitals
NHS Foundation Trust.
(B) Gross Pay 22/5/2012 to 31/5/2013 in bands of £5000: £45k - £50k.
8. In post from 22/10/2012
9. In post from 2/4/2012
10. In post from 1/4/12 to 2/4/2012
During 2012/13, no compensation payments have been made to former senior managers,
and no payments have been made to third parties for the services of a senior manager. No
Executive Director currently serves as a Non-Executive Director of another organisation. The
Directors received no benefits in kind.
56 Remuneration report

Governor and Director expenses
Governors and Directors are entitled to claim for certain expenses incurred whilst
undertaking their role at the Trust. The rates payable to Governors are outlined in guidelines
approved by the Board of Directors, whilst the rates payable to the Chair and Non-Executive
Directors are outlined in guidelines approved by the Council of Governors. These are both
based on the rates payable to the Trust’s staff on Agenda for Change Terms and Conditions.
The Chief Executive and Executive Directors are eligible to claim expenses under the rates
payable to staff employed on the Agenda for Change terms and conditions.
The table below outlines the expenses paid to Board members in 2012/13 (rounded to
nearest £).
Name
Role
Travel (inc
parking)
Other
Katey Adderley Non-Executive Director £130 £0 £130
Total
£94 £30 £124
Marie Batey Executive Director of Patient Experience &
Nursing 15
Carol Bode Non-Executive Director £586 £0 £586
Shane DeGaris Chief Executive £112 £75 £187
Claire Gore Director of People 16 £0 £0 £0
Richard Grocott- Joint Medical Director 17 £0 £0 £0
Mason
Abbas Khakoo Joint Medical Director 18 £0 £0 £0
Susan LaBrooy Medical Director 19 £0 £0 £0
Alan McLeod Non-Executive Director £0 £0 £0
Karl Munslow Ong Chief Operating Officer £61 £0 £61
Anthony Palmer Non-Executive Director £302 £0 £302
Pradip Patel Non-Executive Director £0 £0 £0
James Reid Non-Executive Director £0 £0 £0
Mike Robinson Chair £0 £0 £0
Craig Rowland Non-Executive Director £0 £0 £0
David Searle Executive Director of Corporate Development £140 £0 £140
£106 £330 £436
Jacqueline Walker Acting Executive Director of Patient
Experience & Nursing 20
Paul Wratten Finance Director £543 £0 £543
No expenses claims were made by members of the Council of Governors in 2012/13.
15 To 29th October 2012
16 From 1st March 2013
17 From 1st January 2013
18 From 1st January 2013
19 To 31st December 2012
20 From 22nd October 2012
Remuneration report
57

Reporting related to the review of tax arrangements for public sector appointees
There were three ‘off-payroll engagements’ costing over £58,200 per annum in place as
of 31st January 2012 at the Trust. Of these, one has since come onto the Trust’s payroll.
Following value for money and service considerations, two of the contracts were not
re-engaged or renegotiated to pay via the Trust’s payroll or to seek assurance as to the
individual’s tax obligations. However, these are now being reviewed and, where relevant,
renegotiated in line with the imminent expiry dates of both of these contracts.
There were no new ‘off-payroll’ engagements between 23rd August 2012 and 31st March
2013 that were for more than £220 per day and more than six months in duration.
58 Remuneration report

quality report
Quality Report 2012/2013
Improving your local hospitals
– our report to you
Quality report
59

Quality report: CONTENTS
Page
About this report
61
Introduction
62
Summary of 2012/2013 Quality Report
63
Looking back
65
Looking forward
77
Statement of assurance from the Board
82
Annexe
90
60 Quality report

ABOUT THIS REPORT
This Quality Report confirms the Trust’s
commitment to put the patient and the
quality of care at the heart of everything
that we do. The report is the result
of consultation with a wide group of
stakeholders, including our Governors,
commissioners, People in Partnership, and
our Local Involvement Network (LINk – now
known as Health Watch).
Within North West London the “Shaping
a Healthier Future” programme has been
approved by the Joint Committee of Primary
Care Trusts. This programme places The
Hillingdon Hospitals NHS Foundation Trust as
one of the five major hospitals for providing
a full range of 24/7 emergency care in the
region. The programme also places an
emphasis on the provision of a wider range
of out-of-hours primary and urgent care,
and we are working closely with our GP
commissioners and other providers to ensure
that across the healthcare community patient
care is provided in the right place at the right
time.
The project plans for a new Emergency
Care Department, incorporating a rebuilt
Urgent Care Centre, have been approved,
and building work on the first phase of the
project (due to be completed in 18 months)
has already commenced. This year we have
also been successful with a Department
of Health capital funding bid for a large
maternity refurbishment, the second highest
amount awarded by the NHS in London,
which will improve the birthing environment
for women and their partners. We have
also secured NHS centrally funded money
for dementia which will provide a better
environment for patients with this condition
during their hospital stay.
steps to a seven day hospital. This forms one
of our main priorities in the “Look Forward”
section of the report.
This year has also seen the publication of
the Francis Report which highlights the
failings of a hospital where quality was not
the first priority and which did not listen
to its patients or frontline staff. Our care
priorities, which form one part of a range
of measures of patient care, will continue to
be refined and extended in the coming year.
Along with using Communication, Attitude,
Responsibility, Equity, Safety (CARES) as
our values we will develop a framework
for providing compassionate care, as well
as monitoring the improvements made in
delivering patient care.
I hope you find this report well presented,
and that it gives you useful information
about the Trust. I would be very interested
in your views on the style or content of the
report. If you wish to comment please write
to me via the e-mail address below.
Yours sincerely
Shane Degaris
Chief Executive
shane.degaris@thh.nhs.uk
I confirm that to the best of my knowledge
the information in this document is accurate.
This year has seen the publication of
a London-wide set of emergency care
standards which include more senior decision
making on a seven day a week basis to
reduce weekend mortality and take the first
Quality report
61

INTRODUCTION
This Quality Report, which looks back at our
achievements in 2012/13 and summarises our
key quality objectives for the coming year,
will be available on the NHS Choices website
and our own website – (www.thh.nhs.uk).
Each of the priorities is aligned to the
three domains of quality – safety, clinical
effectiveness and patient experience.
they were treated with dignity and respect,
or whether they found it easy to access the
service.
What is CQUIN?
CQUIN is a scheme to encourage NHS Trusts
to improve quality and patient safety by
setting targets and rewarding achievement
of those targets financially. These targets are
set with local, regional and national bodies.
What do we mean when we talk
about patient safety?
“Treating and caring for people in a safe
environment and protecting them from
avoidable harm”, (National Patient Safety
Agency), for example, ensuring that
medicines are managed safely.
What do we mean when we talk
about clinical effectiveness?
Clinical effectiveness is about whether or not
a patient’s care or treatment was successful.
In other words, did it have the impact that
it was supposed to have? And did it achieve
the best possible result for the patient?
This may include improvement in specific
medical or health conditions, but in the
community we also have a strong focus
on improving quality of life, for example,
independence, mobility, activities of daily
living and social participation.
What do we mean when we talk
about patient experience?
Patient experience is about ensuring
patients, relatives and carers have as
positive experience as possible at every
stage of the care or treatment that is being
provided. Patient experience refers to the
overall experience throughout the course of
treatment, and not just the results that were
achieved at the end.
For example, a patient’s experience could
be strongly influenced by whether they felt
62 Quality report

SUMMARY OF 2012/2013
QUALITY REPORT
Looking back at quality
improvement
Our priorities during 2012/2013
Priority 1 was the further embedding
of the First Contact Project – Improving
the Outpatient Experience where we
fully achieved two of the four targets;
implementing the Call Management
System (CMS), and introducing a document
scanning referral system for all cancer
and symptomatic breast referrals. We
partially achieved our plans to centralise
all appointment bookings; the one target
we did not achieve was introducing the
electronic letters from the hospital clinics to
the GP which is currently being piloted in
four specialties.
Priority 2 was about making Changes in
Maternity where we achieved the majority
of our targets (other than breastfeeding);
improving the patient experience by
2% from 86% to 88%; and reduced our
caesarean section rates from 30.1% in
2011/2012 to 26.9% for 2012/2013. Whilst
breast feeding figures have increased to
82.9%, we did not quite meet the target of
85%. We have recruited women from ethnic
minorities to work in clinical and non-clinical
public facing roles. We have refurbished
public areas which included a new layout in
maternity triage and we were successful in
securing significant funds to modernise the
ten delivery rooms, where work is due to
commence in June 2013.
Priority 3 was Care Priorities where we
achieved the target of 90% at year end for
patients having the correct identification
bands and staff following the correct
process for confirming identification and
for hydration/fluid balance. We did not
achieve the 90% target for record keeping;
achieving 79% at year end; although there
was a significant increase of 7% between Q3
and Q4 result. We are continuing to focus on
improving nursing record keeping across the
Trust.
Priority 4 was The Leaving Hospital
Project where we have achieved some of
the targets to date such as an increased
positive patient experience for when patients
leave hospital; ensuring patients have the
appropriate discharge documentation and
keeping the Visual Management System
(our colour coded system for where a
patient is on their pathway) up to date.
Several of the other standards are close to
their target such as receiving a copy of your
patient journey; 90% of patients are going
home with their medication. We narrowly
missed the 80% target for the proportion
of patients being discharged home before
8pm in the evening. We aim to discharge
patients before 6pm wherever possible,
but they may be discharged later where it
is clinically appropriate and safe to do so,
taking the patient’s home circumstances into
consideration. Although we did not achieve
the target of 85% of GPs receiving a copy of
the patient’s discharge summary within 24
hours, there has been an improvement from
the 2011/2012 baseline figure.
Priority 5 was CQUINs (Commissioning
for Quality and Innovation). Of the nine
CQUIN schemes for 2012/2013 we have fully
achieved four in Q3: preventing blood clots;
collecting the data for the Patient Safety
Thermometer (a local improvement tool
for measuring, monitoring and analysing
patient harm and ‘harm free’ care which
includes assessment for blood clots, urinary
catheter related infections, falls and pressure
ulcers); using the North West London Drug
Formulary and improving the care for
patients with the complications of diabetes.
We partially achieved four remaining CQUINs
in Q3: an improvement of the patient
experience; providing real time information
about our patients for GPs; ensuring we have
Consultant assessments within 12 hours of an
Quality report
63

emergency admission and achieving all the
milestones for end of life care. We predict
that we will not achieve our target for the
dementia screening and risk assessment
process for this year. Confirmed figures for
the full year will be available in mid June.
Looking forward at quality
improvement
Our priorities for 2013/2014
The following five priorities have been
identified for 2013/2014:
1. Continuing with the First Contact
Project which will further embed
the way patients are contacted and
reminded about their appointments
and to further centralise bookings. The
Call Management System needs further
development to ensure we are getting
our messages right for patients. There
will be significant resources allocated to
establish an Electronic Document Record
System which will allow easier clinician
access to full healthcare records and to
relevant referral forms, enhancing clinical
decision making.
2. Continuing with the Leaving Hospital
Project to include work with external
experts regarding Improving Inpatient
Care and Discharge, to enhance early
assessments for elderly people and
reduce any unnecessary lengths of stay in
hospital, as well as reducing readmissions.
We will be improving the discharge
process by better co-ordination of teams
and working closer together with doctors,
nurses, pharmacists and therapists when
reviewing a patient’s needs before they
leave hospital.
on a seven day a week basis to enhance
early senior clinical decision making
and eliminate the difference between
weekday and weekend mortality.
4. Using CARES as our values. These were
launched in May last year and are
supported by a framework that sets out
the standard in terms of attitude and
behaviours we expect from our staff.
5. CQUINs (Commissioning for Quality and
Innovation): we will continue efforts
to prevent blood clots however, we
will be expected to achieve a higher
percentage of patient assessment.
The patient experience CQUIN will be
based on the new “Friends and Family
Test”. The dementia risk assessment will
be continued and the Patient Safety
Thermometer will be based on reductions
in pressure sores and not just on data
submission. Regional CQUINs are not
confirmed but may include supporting
care outside hospital, 12 hour consultant
assessment and GP direct access to
diagnostics and pathology. Local CQUINs
may include the colorectal cancer
pathway and improved communication
between GPs and consultants for effective
patient management.
Our priorities will be monitored by the
individual teams, through their Divisional
Reviews and quarterly through reports to the
Board or Board Committee and the results
will be reported in the 2013/2014 Trust
Annual Report.
3. Improving Emergency Care taking into
account the Acute Emergency Care
Standards that have been set across
London and an analysis of the Hospital
Standardised Mortality Ratio (HSMR).
There will be a focus on early consultant
review of patients requiring admission
64 Quality report

LOOKING BACK…
This section starts by looking at key measurements in a dashboard format. These are derived
from some mandatory requirements, our consultation with our stakeholders, and those of
national importance that patients will want to know about.
Dashboard of key quality measures
Achieved target
Narrowly Missing target
Significantly missing target
Latest data
available to
benchmark
Domain:
Patient Safety (PS)/
Clinical
Effectiveness (CE)/
Patient
Experience (PE)
2011/12
Performance
2012/13
Target
2012/13
Performance
How
London
Trusts
Perform
National
Performance
1a: In Hospital
Standardised
Mortality Ratio
(HSMR)
1b: Standardised
Hospital
Mortality Index
(SHMI)
1c: the
percentage of
patient deaths
with palliative
care coded at
diagnosis
2a:
Readmissions to
hospital within
28 days
2b: Emergency
readmissions
to hospital
within 28 days
of discharge
from hospital:
0-15 years
(Standardised)
Apr-2012 to
Dec-2012
[Dr Foster]
Jul-2011 to
Jun-2012
[Dr Foster]
Jul-2011 to
Jun-2012
[Dr Foster]
Apr-2012 to
Sep-2012
[Dr Foster]
Apr-2011 to
Mar-2012
[HSCIC
Indicator
Portal]
(Local)
PS
PS
PS
CE/PS
107.2
(99.2 - 115.6)
0.8878
(As Expected)
n/a
104.2
(101 - 107.4)

Latest data
available to
benchmark
Domain:
Patient Safety (PS)/
Clinical
Effectiveness (CE)/
Patient
Experience (PE)
2011/12
Performance
2012/13
Target
2012/13
Performance
How
London
Trusts
Perform
National
Performance
2c: Emergency
readmissions
to hospital
within 28 days
of discharge
from hospital:
16+ years
(Standardised)
Apr-2011 to
Mar-2012
[HSCIC
Indicator
Portal]
(Local)
CE/PS 12.09% n/a
[11.86%*]
(7.5%)
[11.95%]
(n/a)
[11.42%]
(n/a)
3: Non clinically
justified
single sex
accommodation
breach, rate per
1,000 finished
consultant
episodes
Apr-2012 to
Dec-2012
[Unify2/DH]
PE 0.11 0 0.06* 0.73 0.21
4: Cancer: Two
week wait from
GP referral
to seeing
a specialist
(suspected
cancer)/(breast
symptoms)
Apr-2012 to
Dec-2012
[OpenExeter/
DH]
CE/PS
Suspected:
98.3%
Breast
Symptom:
96.4%
93%
93%
97.9%”
98.0%”
95.3%
95.1%
95.5%
95.4%
5: Cancer: 31
day maximum
wait from
diagnosis to first
treatment
6: Cancer: 31
day maximum
wait from
diagnosis to
subsequent
treatment, drug
or surgery
7: Cancer: 62-
day maximum
wait from
referral by
GP/screening
service/
consultant
upgrade to
treatment
8: Referral
to treatment
waiting times -
admitted
9: Referral
to treatment
waiting times -
non admitted
Apr-2012 to
Dec-2012
[OpenExeter/
DH]
Apr-2012 to
Dec-2012
[OpenExeter/
DH]
Apr-2012 to
Dec-2012
[OpenExeter/
DH]
Dec-2012
[Unify2/DH]
Dec-2012
[Unify2/DH]
CE/PS 97.9% 96% 99.2%” 98.1% 98.4%
CE/PS
CE/PS
Drug: 100.0%
Surgery:
100.0%
GP/GDP:
92.6%
Screening:
68.6%
Upgrade:
98.3%
98%
94%
85%
90%
85%
100.0%”
100.0%”
93.3%”
93.9%”
98.6%”
99.6%
97.2%
86.1%
92.1%
94.2%
99.7%
97.4%
87.5%
95.1%
93.4%
CE/PS 95.9% 90% 96.7%^ 92.4% 93.1%
CE/PS 98.9% 95% 98.6%^ 97.9% 97.7%
66 Quality report

Latest data
available to
benchmark
Domain:
Patient Safety (PS)/
Clinical
Effectiveness (CE)/
Patient
Experience (PE)
2011/12
Performance
2012/13
Target
2012/13
Performance
How
London
Trusts
Perform
National
Performance
10: Referral
to treatment
waiting times -
Incomplete1
11: Fractured
neck of femur
emergency
patients in
theatre within
36 hours
Dec-2012
[Unify2/DH]
Apr-2011 to
Mar 2012
NHF Database
CE/PS 96.9% 92% 97.6%^ 93.4% 94.5%
CE/PS 79.1% 90% 90.8% n/a n/a
12: Total time
in A&E: 4 hours
or less
Apr-2012 to
Jan-2013
[Unify2/DH]
PE 97.9% 95% 96.7% 96.4% 96.2%
13: Percentage
of patients
not treated
within 28 days
of having
operation
cancelled for
non-clinical
reasons
14: Percentage
of women in
the relevant
PCT population
who have seen
a midwife or
a maternity
healthcare
professional,
for health and
social care
assessment of
needs, risks
and choices
by 12 weeks
and 6 days of
pregnancy
15: Stroke
patients:
Percentage of
patients that
have spent at
least 90% of
their time on
the stroke unit
16: Stroke
patients:
Percentage of
high risk TIA/
mini stroke
patients who
are treated
within 24 hours
Apr-Dec 2012
[Unify2/DH]
Apr-Dec 2012
[Unify2/DH]
Oct-2012 to
Dec-2012
[Unify2/DH]
Oct-2012 to
Dec-2012
[Unify2/DH]
CE/PS 3.4% 0% 6.0% 2.8% 4.6%
PE/CE 90.2% 90%
93.3%
(Excluding
Late Referrals)
80.4% 86.9%
CE 99% 80% 99.6% 93.8% 85.0%
CE 100% 75% 100% 84.6% 75.9%
Quality report
67

17: MRSA
18: Cdiff cases
reported
within the
Trust amongst
patients aged 2
and over during
the reporting
period
19: Percentage
of patients who
were admitted
to hospital
and who were
risk assessed
for Venous
Thrombo
Embolism (VTE)
20a: Patient
Reported
Outcome
Measures
(PROMs) scores
(Health Gain),
Groin Hernia,
EQ-5D Index/
VAS
20b: PROMS
(Health
Gain), Hip
Replacement,
EQ-5D Index/
VAS
20c: PROMS
(Health
Gain), Knee
Replacement,
EQ-5D Index/
VAS
Latest data
available to
benchmark
Apr-2011 to
Mar-2012
[HPA]
Apr-2011 to
Mar-2012
[HPA]
Oct-2012 to
Dec-2012
[Unify2/DH]
Apr-2012 to
Sep-2012
[HES]
Apr-2012 to
Sep-2012
[HES]
Apr-2012 to
Sep-2012
[HES]
Domain:
Patient Safety (PS)/
Clinical
Effectiveness (CE)/
Patient
Experience (PE)
PS
PS
2011/12
Performance
4 Cases
2.9 Cases per
100,000 bed
days
25 Cases
19.3 Cases per
100,000 bed
days
2012/13
Target
3
24
2012/13
Performance
1 Case
0.77 Cases per
100,000 bed
days
23
16.2 Cases per
100,000 bed
days
How
London
Trusts
Perform
114 Cases
2.0 Cases
per
100,000
bed days
1,154
21.1
Cases per
100,000
bed days
PS 87.5% 90% 91.9%+ 93.10%
CE/PS n/a n/a 0.123 / 0.667* n/a
CE/PS n/a n/a 0.4 / 12.105* n/a
National
Performance
471 Cases
1.3 Cases per
100,000 bed
days
7,670
21.8 Cases per
100,000 bed
days
Lowest
Performing
82 Cases,
51.6 Cases
per 100,000
bed days
(Tameside FT)
Highest
Performing
0 Cases
(Birmingham
Women’s)
94.1%
Lowest
Performing
84.6%
(Croydon
Health
Services NHS
Trust)
Highest
Perfoming
100%
(South Essex
Partnership
University FT)
0.091 / -0.603
(i)
0.437 / 10.863
(ii)
CE/PS n/a n/a 0.262 / 18.2* n/a 0.312 / 5 (iii)
21: Inpatient
Experience
Programme
(local survey
results)
88% YTD
[Local Survey]
68 Quality report
PE 87% >87% 88% n/a n/a

Latest data
available to
benchmark
Domain:
Patient Safety (PS)/
Clinical
Effectiveness (CE)/
Patient
Experience (PE)
2011/12
Performance
2012/13
Target
2012/13
Performance
How
London
Trusts
Perform
National
Performance
22: Outpatient
Experience
Programme
(local survey
results)
87% YTD
[Local Survey]
PE 86% >86% 87% n/a n/a
23: Maternity
Experience
Programme
(local survey
results)
86%YTD
[Local Survey]
PE 85% >85% 86% n/a n/a
24: Independent
assessment of
cleanliness of
hospital
88% YTD PE 92% >87% 87% n/a n/a
25: Percentage
of complaints
responded to
within agreed
timescale
n/a PE 84% 90% 74.5% n/a n/a
26: Trust’s
responsiveness
to personal
needs of our
patients
27: Percentage
of staff
who would
recommend
the Trust as a
provider of care
to their family
and friends
28: Patient
safety incidents/
percentage
resulted in
severe harm or
death
Apr 2012 to
March 2013
[National
Patient
Survey]
2012 Survey
[National
Staff Survey]
Apr 2012 to
March 2013
[Datix]
PE 62.9% 72% 65% n/a 67.4%
PE 3.53 n/a 3.66 3.70
PS 1% (45)NRLS n/a
0.75% (41)
(0.75 per 100
admissions)
3.57 average
Lowest
Performing
2.90 (North
Cumbria
University
Hospital)
Highest
Performing
4.08 (Guy’s &
St Thomas’)
1.3 0.9
Notes: 2012/2013 Performance is for Apr-2012 to Mar-2013 unless:
* Same as Benchmark Period
+ Apr -2012 to Jan-2013
“ Apr-2012 to Feb-2013
^ Mar-2013
Quality report
69

(i) Groin
Lowest
performing
Warrington And
Halton Hospitals NHS
Foundation Trust
(-0.062)
EQ-5D Index
Highest
performing
University Hospitals
Bristol NHS
Foundation Trust
(0.227)
Lowest
performing
The Whittington
Hospital NHS Trust
(-10.667)
EQ-5D VAS
Highest
performing
Guy’s And St
Thomas’ NHS
Foundation Trust
(11.4)
(ii) Hip
Replacement
Yeovil District Hospital
NHS Foundation Trust
(0.155)
The Queen Elizabeth
Hospital, King’s Lynn,
NHS Foundation Trust
(0.69)
Brighton And
Sussex University
Hospitals NHS Trust
(-10.571)
Barts And The
London NHS Trust
(30.6)
(iii) Knee
Replacement
Royal National
Orthopaedic Hospital
NHS Trust (0.031)
Mid Cheshire Hospitals
NHS Foundation Trust
(0.527)
Imperial College
Healthcare NHS
Trust (-10.667)
Barnsley Hospital
NHS Foundation
Trust (24.842)
Supporting information about the
indicators required in accordance with
the Quality Account regulations
Indicator 1b
The Hillingdon Hospitals NHS Foundation
Trust considers that this data is as described
for the following reasons - national reporting
shows a stable ratio over the past two years.
The Trust is working on improving the
variation between weekdays and weekends
and will examine any outliers.
Indicator 1c
The Hillingdon Hospitals NHS Foundation
Trust considers that this data is as described
for the following reasons – not all patients
who are receiving palliative care are
on the Liverpool Care Pathway. Clearer
identification of these patients will improve
the palliative care coding.
Indicator 2a, 2b and 2c
The Hillingdon Hospitals NHS Foundation
Trust considers that these percentages are
as described for the following reasons – the
Trust is aware from a variety of data sources
that the figures are higher than expected.
Several initiatives to improve these figures
include strengthening our care pathways and
the Improving Inpatient Care initiative. Refer
to priority 2 for 2013/2014 on page 78.
Indicator 18
The Hillingdon Hospitals NHS Foundation
Trust considers that this rate is described for
the following reasons – the Trust achieved a
target of 23 out of 24 for 2012/2013 and has
shown a year on year improvement. The Trust
will continue with all current initiatives. The
Trust hosted a multidisciplinary workshop in
May chaired by a national expert in infection
control which will inform our measures to
improve our targets for 2013/2014 of 14 for C
Diff and 0 for MRSA.
Indicator 19
The Hillingdon Hospitals NHS Foundation
Trust considers that this percentage is as
described for the following reasons – the
Trust has shown an improvement over the
last two years. This is a CQUIN for 2013/14
and work will be taken forward to bring
about further improvement.
Indicator 20a, 20b and 20c
The Hillingdon Hospitals NHS Foundation
Trust considers that the outcome scores are
as described for the following reasons – Data
shows that the five domains that this score
refers to are hospital outcome measures (EQ
– 5D index VAS). The Trust performs better
70 Quality report

than average for hernias, but worse than
average for hip and knee replacements, and
better than average for all three procedures
from the patient’s perspective (EQ -5 index
VAS).
Indicator 26
The Hillingdon Hospitals NHS Foundation
Trust considers that this data is as described
for the following reasons – there has been
a slow improvement but still below target.
Further work is being undertaken to improve
the situation through our customer care
programme, our CARES values initiative and
the Improving Inpatient Care initiative.
Indicator 27
The Hillingdon Hospitals NHS Foundation
Trust considers that this data is as described
for the following reasons – there has been
a steady improvement but further work is
being undertaken through our CARES values
initiative.
Indicator 28
The Hillingdon Hospitals NHS Foundation
Trust considers that this data is as described
for the following reasons - whilst the Trust
has a lower than average rate of severe
harm / death patient safety incidents, there
is not a nationally established and regulated
approach to reporting and categorising
patient safety incidents. The approach
taken to determine the classification of each
incident, such as those ‘resulting in severe
harm or death’, will often rely on clinical
judgement. In addition, the classification of
the impact of an incident may be subject to a
potentially lengthy investigation which may
result in the classification being changed.
This change may not be reported externally
and the data held by a Trust may not be the
same as that held by the NRLS.
Definitions of the two mandated
indicators
Indicator 7
Percentage of patients receiving first
definitive treatment for cancer within 62
days of an urgent GP referral for suspected
cancer.
Indicator 2a
Percentage of emergency admissions to any
hospital in England within 28 days of the last
previous discharge from hospital.
Priority 1: The First Contact Project –
improving the outpatient experience
We said:
We would centralise all outpatient
appointment bookings to ensure that calls
are answered more quickly; provide more
telephone lines; patients won’t have to wait
so long to be attended to; the system would
also have an interactive element where
patients will receive a phone call and text as
a reminder of their appointment.
We also said we would introduce a document
scanning referral system and introduce the
electronic transfer of outpatient clinic letters
from the hospital clinicians to the GP.
The changes would be measured for
impact by reviewing the data from the Call
Management System (CMS) detailing the
average call waiting time and abandonment
rate, appointment non-attendance (DNA)
rate and the number of complaints.
Quality report
71

We did:
a PARTIALLY ACHIEVED
Booking centralisation
During 2012 staff that make new and follow
up appointments have been centralised to
one location. We recognise that this is the
first step towards centralising all bookings
and that further work to train staff and
equip them with the skills to deal with
queries about any outpatient appointment
related query is necessary.
a ACHIEVED
Call Management System (CMS)
The CMS was implemented in June 2012 with
an appointment reminder function going live
in August 2012.
The CMS has changed the way The
Hillingdon Hospital deals with telephone
calls from patients about their outpatient
appointments. Now patients are given one
telephone number, they then choose from a
list of options which ensures their call is dealt
with by the correct member of staff (agent).
If all agents are busy the patient is held in
a queue and informed that their call will be
answered.
The system provides staff with comprehensive
reports and real time information about call
activity, response times, abandonment rates
and call resolution. Managers are able to
adjust resources to meet the volume of calls.
There has also been a reduction in Patient
Advice and Liaison Services (PALs) concerns
and complaints from 129 in 2011/2012 to 77
in 2012/2013.
The CMS has an optional appointment
reminder functionality (called Remind+)
which contacts patients by telephone seven
days before their appointment to confirm
their attendance. This is then further
supplemented with a text messaging service
which sends a reminder to a mobile number
48 hrs before the appointment.
a ACHIEVED
Introduce a document scanning referral
system
Document scanning has been implemented
for all cancer and symptomatic breast
referrals. The new process allows outpatient
appointment centre staff, Multi Disciplinary
Team (MDT) coordinators and Health
Care Assistants (HCAs) in outpatients to
access the documents electronically which
eliminates the risk of paper letters getting
lost and subsequent delays. GPs are also
increasingly making referrals and outpatient
appointments via an electronic system called
Choose and Book.
r NOT ACHIEVED
Electronic outpatient letters to GPs
From January 2013 the Trust is piloting the
electronic delivery of outpatient letters to
GPs in Hillingdon in the following specialities:
Care of the Elderly, Stroke, Paediatrics and
breast surgery.
There is much more to do particularly in
relation to the centralisation of booking
appointments and implementation of
the electronic document and records
management.
Priority 2: Maternity
We said:
As part of our ongoing maternity strategy
for improving quality of care we said that
we would like to see an improvement in our
patient experience survey by at least 1%
and respond to shortfalls identified by both
staff and comments made within the patient
survey. We look forward to the rich source of
information from the patient diary exercise,
which commenced in November 2012. As a
response to a survey undertaken by the Local
Involvement Network (LINk) survey we have
engaged more with hard to reach groups
including Somali and Afghan support groups.
We also said we would improve the Labour
72 Quality report

Ward environment; reduce caesarean section
rates to 27.6% and increase breastfeeding
rates.
We also aimed to increase the number of
non-obstetric deliveries – including an aim to
increase the number of women having their
babies at home.
We also said that we would reconfigure
our community services to improve the
experience.
We did:
a ACHIEVED
Patient experience in maternity is improving.
The patient experience rate is 86% and by
Q4 the figure is 88%; an increase so far this
year of 2%. We continue to monitor this on a
monthly basis.
a ACHIEVED
We have now managed to recruit women
from a variety of cultural backgrounds
(representative of the population we
serve) to work in the reception area of the
Maternity main foyer and Maternity helpers
(now called maternity mates) on the wards,
depending on language.
Some of these women have a National
Vocational Qualification (NVQ) in health and
social care and are looking to continue their
education into nursing and midwifery.
In June we will be meeting with women
from the Afghan community to identify any
specific needs to improve their experience
of our service and staff. Key learning points
identified from these informative meetings
are shared with staff through relevant
forums and training sessions.
a ACHIEVED
General refurbishment of the maternity unit,
such as painting the stairwell and public
areas, and the layout of the maternity triage
area have been completed.
The “Improving Birth Environments” bid,
a Department of Health funding project
to improve the physical environment of
Maternity units in England, has been
successful and will allow us to modernise 10
delivery rooms which will include en-suite
facilities in each room and restructure the
Labour Ward reception area. This work is due
to commence in June 2013.
a ACHIEVED
The current year to date figure for caesarean
sections is 26.9% for the year compared
with the 2011/2012 full year figure of 30.1%
showing an improvement to date from last
year.
The multifaceted action plan for caesarean
reduction continues to be monitored and
implemented to drive forward appropriate
and safe changes in practice to allow for
reduction in the overall rates of caesarean
section, both elective and emergency.
A three month trial of mixing ante and
postnatal women on both maternity wards
is currently underway to increase Consultant
presence to each area, to enable more
confident decision making with junior staff.
This will shortly end and be audited to
review its impact on care provision.
r NOT ACHIEVED
Breastfeeding initiation rates are improving;
the year to date figure is 82.9% for the
year compared to 81.6% for last year,
however, we did not reach our target of
85%. Breastfeeding initiation stickers have
helped to highlight information sharing and
training. There is still work to be done on
improving these figures.
With the appointment of a Breastfeeding
Health Visitor, working with public health,
we hope that the restructuring of our
community services will strengthen the joint
education and training of all staff with a
view to improving rates further.
Quality report
73

Priority 3: Care priorities
We said we would:
• Ensure every patient is wearing a correctly
labelled identiband
• Improve record keeping
• Improve hydration and fluid balance of
our patients during their stay in hospital.
We did:
a PARTIALLY ACHIEVED
Care priority
Patient
identification
Target
2012/2013
90% 91%
Record keeping 90% 79%
Hydration/ fluid
balance
90% 90%
Result
2012/2013
part of this monthly assessment across all
inpatient wards.
• Matrons and/or senior sisters reviewed the
nursing record of all patients on the ward
as part of the monthly Patient Safety
Thermometer survey. This provided an
opportunity for immediate feedback to
staff with clarification of the standard of
record keeping required.
Priority 4: Leaving hospital –
improving the patient experience
We said we would:
Work to improve the information patients
are given when they leave hospital to
include the purpose and side effects of any
medication that they will be taking when
they get home and who to contact if they are
worried after leaving hospital.
We have achieved the target of 90% in two
of our care priorities, patient identification
and hydration/fluid balance. Record
keeping is short of the target, achieving
79% at year end. We did see a significant
improvement of 8% between Q3 and Q4
and we will continue to focus our attention
on record keeping throughout 2013/2014
to achieve our 90% target even though it is
not included as a priority in the 2013/2014
Quality Account. A number of initiatives to
support improved record keeping were put
into place in 2012/2013, these include:
• A Nursing Documentation Working
Group has been set up. This group is
made up of frontline staff and has been
working to develop core care plans and to
standardise some of the many charts that
are used across the Trust.
• The group will also be developing chart
specific guidance to support accurate and
effective record keeping.
• A new approach to the regular assessment
and assurance of the quality of nursing
care was developed. Peer review of the
nursing documentation is an integral
We did:
Standard
Patient’s experience
of leaving hospital is
positive
Patient receive
a copy of ‘Your
Hospital Journey’
Discharge
documentation is
completed as per
policy
Patients understand
where they are on
their care pathway
The Visual
Management
System (VMS) is kept
updated
Patient goes
home with their
medication
GP receives copy of
discharge summary
within 24 hrs
Patients discharged
in a timely manner:
Before 12pm
Before 4pm
Before 8pm
Target for
2012/2013
Result
2012/2013
72% 82%
100% 93%
80% 93%
90% 88%
90% 95%
90% 89%
85% 73%
25%
60%
80%
15.8%
42.3%
79.5%
74 Quality report

We saw an improvement in the patient
experience of leaving hospital as measured
by our follow up phone call. Additionally,
many patients have commented that the
follow up call is useful to check out any
concerns that they may have. We continue
to revise our processes so going forward
into 2013/2014 our revised and simplified
discharge checklist will be integrated into a
new electronic tool that supports safe and
planned discharges.
Key learning from this project such as the
use of the coloured magnets to display key
steps in the discharge process have now been
incorporated into the electronic whiteboard.
This is part of the Improving Inpatient Care
Project that features in Looking Forward
Priority 2 (see page 78).
Our monthly Observations of Care visits
to wards which began in February include
asking patients key questions about their
understanding of their care, current
treatment and ongoing plans towards
discharge.
We are now looking at integrating
information about who to contact if worried
following discharge with an existing patient
information leaflet.
Quality report
75

Priority 5: CQUINs – Commissioning for quality & innovation (subject to
confirmation)
Looking back:
CQUIN targets for 2012/2013
National
Preventing blood clots
Patient experience (patient survey)
Dementia risk assessment (scoring tool to identify clinical risks)
Collection of data for the Patient Safety Thermometer (see page 63
for definition)
Regional schemes
Real time GP information (information for GPs about admission
treatment and discharge of patients)
Use of the North West London Formulary (a list of all medicines
that are agreed for use across North West London between hospital
and primary care services)
Local schemes
Consultant Assessments within 12 hours of emergency admission
Patients with complications of diabetes
End of life care (a structured pathway to ensure patients receive
high quality patient focused care)
What we did
100% full year result
20% predicted full year result
Not achieved
100% full year result
84% predicted full year result
100% full year result
50% predicted full year result
100% predicted full year result
92% predicted full year result
Exact percentages to be confirmed in mid
June.
Patient experience – The Trust achieved
20% of the targets which was a steady
improvement over 2 years.
Dementia risk assessment – This depends
on electronic recording of assessments, the
system required to do this was not available
at the time.
Real time GP information – The IT
system required to achieve this has been
implemented for patients who attend
A&E, and patients who are admitted as
an emergency and inpatient discharge
summaries. However, an electronic solution
for sending outpatients letters was not
available.
Consultant assessments within 12 hours
of emergency admission – The Trust has
successfully achieved 55% of emergency
admitted patients having a consultant
assessment within 12 hours. It will continue
to strive to achieve a higher percentage
during 2013/14.
End of life care – The drop in percentage
points is due to a very high level of staff
needing to be trained.
76 Quality report

LOOKING FORWARD…
Our priorities for 2013/2014
No. Priority Safety Clinical Patient
effectiveness experience
1
First contact – Continuing to improve the
outpatient experience
ü
ü
2
Continuing with the leaving hospital Project to
include work regarding Improving inpatient care ü ü ü
and discharge
3 Emergency care ü ü ü
4 CARES ü
5 CQUINs ü ü ü
In arriving at these priorities, agreed by the
Trust Board, we had a systematic process
of stakeholder involvement, as in previous
years. This included our public, in the form
of our People in Partnership (PiP) which
included a series of focus groups, our
Governors, LINKs (which included difficult to
reach groups) and our Commissioners. There
was a strong opinion from our stakeholders
that we should continue with projects started
in previous years where further outcomes
needed to be set and achieved to fulfil
their potential. Hence the projects relating
to an effective outpatient experience and
high quality inpatient care with efficient
discharge planning have been retained.
During 2012/2013 a review of inpatient care
on one ward showed that the balance of
nurses to healthcare assistants on the ward
was not always at the planned level; multiprofessional
communication was sometimes
fragmented and nursing leadership on the
ward needed to improve. We undertook a
number of actions to address these issues
and this work continues to inform our
quality priorities, notably through the CARES
and Improving Inpatient Care priorities
outlined below. We will also be performing
a detailed review of our ward staffing levels.
During the later stages of the consultation,
the Francis Report was released and we
have incorporated a number of its key
recommendations in this document. The
“Emergency Care” priority will have targets
related to improving mortality, and a full
participation in the “Friends and Family” test
which preliminary data from most Hospitals
has found to be difficult to implement in
A&E. The priority related to implementing
our CARES framework of staff values goes to
the heart of the Francis report by acting as
the framework for providing patient-focused
high quality, responsive and compassionate
care.
PRIORITY 1: First Contact –
continuing to improve the
outpatient experience
Why is this one of our priorities?
We recognise that we have made some
changes to the way patients are contacted
and are reminded about their outpatient
appointments and these changes have now
been made. Furthermore we have more work
to do to centralise bookings and implement
a new electronic document records
management system; this work remains a
priority because the changes have a clear
impact on quality and patients’ experience.
Quality report
77

Our aims for 2013/2014:
Call Management System (CMS)
Implementation of the CMS has significantly
changed the way we handle calls and remind
people about their outpatient appointments.
This year we will set up a focus group to
gain feedback from our patients and users
about their experience in navigating the
system so we can establish what further work
is needed and take the appropriate action.
Some of the things we will be discussing at
the focus group are the opening times of
the outpatient appointments centre and
communication with patients about times
when we know the call volume will be high.
We continue to provide staff training on
customer care including telephone handling
skills which reflects the CARES strategy
(see Priority 4 on page 80). We use random
call listening to support staff training and
development. Furthermore staff are being
trained to deal with a variety of patients’
queries with the aim to improve first call
resolution.
Electronic document records management
This year the Trust is undertaking a
major change to the way medical records
are accessed and stored. The Electronic
Document Records System is being proposed
as a key infrastructure for the Trust in
order to enhance the quality and efficiency
of healthcare provided to our patients.
The underlying vision for this case is to
ensure that the best and most up to date
information should be readily available to
enable professional staff to offer appropriate
care and treatment.
It will also increase productivity and
improve quality of care provided through
the facilitation of electronic forms and
workflows. Scanned documents e.g. referral
letters will be used in workflow processes,
allowing the conversion of paper formcentric
processes into paperless ones with
electronic forms being stored directly into
patient records to support clinical decision
making and administrative functions.
Booking centralisation
During 2013/2014 further work will take
place to centralise the booking of new
and follow up outpatient appointments
across the Trust. We have already achieved
the first stage of centralising where the
Outpatient Appointments Centre now takes
all telephone queries for Mount Vernon
Hospital outpatient appointments.
The performance targets we will use to
measure the impact of the changes and new
initiatives are:
• Call abandonment rate - we aim to
keep this below 10% (currently 28% for
January-March 2013)
• 95% of calls to be answered within 60
seconds
• First contact resolution – aim to resolve
more than 90% of the queries in the first
contact (less than 10% of calls transferred
to other departments)
• Reduction in ‘did not attend’ rates (DNA)
for outpatient appointments (to be
agreed in quarter 1).
PRIORITY 2: Continuing to improve
the Leaving Hospital Project –
improving inpatient care
Why is this one of our priorities?
Following the success of implementing our
leaving hospital principles across all of our
wards, we reviewed our goals and priorities
and re-launched the project as “Improving
Inpatient Care”. The overall objective of
this programme of work is to ensure we
provide high quality of care to all inpatients
by improving the patient journey and
thereby decreasing length of stay.
78 Quality report

How are we doing so far?
Length of stay for inpatients at Hillingdon
Hospital has been a priority service
improvement goal for a number of years. We
know that the longer patients are in hospital,
the more risks there are to the patient, and
fundamentally, we know people do not
want to be in hospital. We want to support
our patients to return to their homes and
be supported in the community as soon as
clinically appropriate. We want to remove all
unnecessary waits in hospital, and provide a
better service, particularly for those patients
with greater need, such as those who may
need social care support or ongoing care in
the community.
Successful changes have been made gradually
through individual teams and Trust wide
initiatives which have enabled more effective
working and as a result, more efficient, high
quality care. Almost 50% of our emergency
patients are discharged within 72 hours.
The average length of stay for the Trust has
reduced by 0.8 days over the past 12 months;
we are heading in the right direction.
Our aims for 2013/2014 are:
The Improving Inpatient Care programme,
initiated in December 2012, is putting in
place a series of changes across the Trust to
continue to reduce the length of stay, by
eliminating delays and improving the overall
experience patients receive whilst in hospital.
Examples of this work include:
• Developing an enhanced service for frail
and elderly patients who are admitted as
an emergency. The full details are being
developed and tested during the early
part of 2013, but will aim to involve an
enhanced comprehensive assessment
completed by a specialist Care of the
Elderly Consultant and a team of specialist
occupational and physiotherapists on
day one of admission. This will then
mean the hospital can start putting in
place everything the patient will need
to get home, as soon as they are better.
For example, for patients who might be
unsteady on their feet, fitting rails in their
home so they can manage stairs without
coming to harm.
• Improving how we set discharge dates,
with better co-ordination of teams
through doctors’ rounds, and supporting
nurses, doctors, pharmacists and
therapists to work together better when
reviewing a patient’s needs.
• Implementing new electronic whiteboards
to provide reminders of all patients’
next steps for all teams who work on the
wards.
• Improving the clarity of information we
provide to nursing and residential homes,
in order to support them in looking
after patients when they are discharged
from hospital. This aims to reduce the
likelihood of that person needing to come
back into hospital, as their care teams
will know how to manage their needs
appropriately.
Specific goals for this project are:
• Reduce length of stay to become one of
the top 25% of Trusts nationally
• Achieve 40% of all discharges leaving
before 12pm
• Earlier therapy and specialist review for
complex elderly patients, supporting up
to an additional 400 patients per year
• Reduce the rate of readmissions aiming to
prevent up to 230 avoidable readmissions
per year
PRIORITY 3: Improving emergency
care
Why is this one of our priorities?
There is national and London evidence to
show that there are significant differences
in the mortality rates for patients admitted
as an emergency during the week compared
with patients admitted as an emergency
at the weekend. Reduced service provision
Quality report
79

at weekends has been associated with this
higher mortality rate.
In response to the data, NHS London have
developed commissioning standards for
emergency care with the aim of ensuring
that consultants have early and continued
involvement in the care of all patients
admitted as an emergency.
How are we doing so far?
As a Trust we are committed to achieving the
emergency care standards and have invested
in additional senior doctor time, out of hours
Monday to Friday and also at the weekends.
Notably we have provided Consultant
ward rounds twice a day on our medical
Emergency Assessment Unit. This has ensured
that our patients continue to receive care
from our most senior doctors irrespective of
the day of the week.
We have also ensured that in Medicine,
Surgery and Paediatrics, all Consultants
covering A&E are freed from all other clinical
commitments.
Further investment has allowed for an
increase in therapy provision at weekends
which has facilitated patients with complex
needs having access to a multi-disciplinary
team assessment.
In 2012 a detailed review of our hospital
mortality data was carried out, specifically
the measure of mortality known as the
Hospital Standardised Mortality Ratio
(HSMR).
This review concluded that the Trust had a
lower than average palliative care and comorbidity
coding which may falsely elevate
the HSMR, but that some specialties had a
higher than expected HSMR.
In response to the findings of the report a
great deal of work has been undertaken to
improve coding for palliative care and comorbidity
which are at a national average
and now monitored monthly. Specialties
that were identified to have a higher
than expected HSMR have been or are in
the process of being reviewed through
clinical workshops. These workshops have
provided the opportunity for clinical staff
to come together to identify areas of care
for improvement and also to ascertain the
suitability of utilising a care bundle approach
(a group of several clinical interventions).
These approaches together have reduced the
HSMR to 89.8 (up to and including January
2013) but there is still some weekday versus
weekend variability.
Our aims for 2013/2014 are
• To invest in evening and weekend
Consultant emergency presence in
Medicine, Surgery, A&E and Paediatrics.
• Implement NHS London emergency care
standards in relation to Consultant review
within 12 hours of decision to admit:
number of patients being seen within
target time 2013/2014 is 90%, and to
ensure that there is no weekday versus
weekend variability.
• To reduce HSMR to London average in
2013/2014 and ensure no difference in
weekday vs. weekend mortality.
• Seven day access to pharmacy and all
therapies (physiotherapy, respiratory, and
occupational therapy).
• Full participation in the Friends
and Family test (more than 15% of
all attending patients) in the A&E
Department where participation so
far has been disappointing, running at
around 5.7% for 2011/2012.
PRIORITY 4: CARES
Why is this one of our priorities?
There continues to be an increased focus
nationally on the patient/staff experience
and engagement of these groups. It is
essential that we see more significant
changes in attitude and behaviour from
our staff to improve the experience of our
patients. Through analysing information
captured from key sources such as the
80 Quality report

National Patient Survey, Inpatient Survey,
National Staff Survey and incidents and
complaints locally, we recognise that we can
make improvements to the experience of our
patients and staff.
Our goal is to deliver the best possible
experience to our patients and to our
staff. In May 2012 we formally launched
Communication Attitude Responsibility
Equity Safety (CARES), which is our set of
values supported by a framework that sets
out the standard, in terms of attitude and
behaviours we expect from our staff. This
will support our staff to deliver care with
compassion as well as ensuring it is also safe
and effective.
Our aims for 2013/2014 are:
• Complaints – We will ensure that all
complaints are addressed using the CARES
framework. We will make the framework
an integral part of the investigation
process to identify behavioural and
attitudinal issues as well as the technical
aspects so that we can learn from them.
• Performance and Personal Development
Reviews (PDR) – All staff are expected to
undertake a PDR annually with their line
manager so they can ensure individual
performance is linked to the achievement
of Trust and departmental objectives.
It is also essential to see how they are
progressing in terms of their performance
and provides an opportunity to discuss
personal and professional development.
We have introduced a CARES behavioural
scale into the PDR paperwork to help
initiate discussions around staff attitude
and behaviours so that agreements can be
reached on any developmental areas in an
open manner.
• Customer Care Training – We want all
staff to recognise how their behaviours
and attitudes can have a negative or
positive impact on the experience of
patients and colleagues. Through the
delivery of a tailored Customer Care
training programme we will support
staff to understand how by adopting the
CARES behaviours they can enhance that
experience.
• CARES plays a large part in the work
programme we are developing in relation
to the Engagement and Experience
Strategy.
• Some Key Performance indicators for
2013/2014 are presented in the table
above; others are being developed in
quarter 1.
Performance indicator
Communication, involvement and
information – using the cluster of
questions in the patient survey
Compassionate Care – using
the cluster of questions in the
questionnaire from the Improving
Patient Care initiative.
PRIORITY 5: CQUINs
Target
2012/13
Improve result
by 2%
Achieve 85%
The National CQUINs for the next financial
year will still include the prevention of blood
clots, but we will be expected to achieve a
higher percentage of patient assessment. The
patient experience CQUIN will be based on
the new “Friends and Family Test” and the
dementia risk assessment will be continued.
The Patient Safety Thermometer will be
based on reductions in pressure sores and not
just on data submission.
Regional and local CQUINs are still to be
agreed.
Quality report
81

Statements of assurance
from the Board
Information for our regulators
Our regulators need to understand how
we are working to improve quality so the
following pages are specific messages they
have asked us to provide:
Services
During 2012/2013 The Hillingdon Hospitals
NHS Foundation Trust provided medicine,
surgery, clinical support services and
women’s and children’s NHS services. The
Hillingdon 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 2012/2013 represents
100% of the total income generated
from the provision of NHS services by the
Hillingdon Hospitals NHS Foundation Trust
for 2012/2013.
Audit
National audits
During 2012/2013, 38 national clinical audits
and two national confidential enquiries
covered NHS services that The Hillingdon
Hospitals NHS Foundation Trust provides.
During that period The Hillingdon Hospitals
NHS Foundation Trust participated in 82% of
national clinical audits and 100% of national
confidential enquiries for which it was
eligible to participate in. The national clinical
audits and national confidential enquiries
that The Hillingdon Hospital NHS Foundation
Trust was eligible to participate in during
2012/2013 are listed below alongside 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.
82 Quality report

Audit Participated Cases submitted
WOMENS AND CHILDRENS HEALTH
Child Health Programme (CHR-UK) Yes 0% (only 1 patient applicable)
Perinatal Mortality (MBRRACE-UK) Yes 100%
Neonatal Intensive and Special Care (NNAP) Yes 100%
Paediatric Pneumonia (British Thoracic Society) Yes 100%
Paediatric Asthma (British Thoracic Society) Yes 100%
Paediatric Fever (College of Emergency Medicine) No N/A
Epilepsy 12 Audit (RCPH National Childhood Epilepsy Audit) Yes
Data entry commenced 1 st March 2013
and continues throughout 2013/14 –
Trust participating
ACUTE CARE
Emergency Use of Oxygen (British Thoracic Society BTS) Yes 100%
Adult Community Acquired Pneumonia (BTS) Yes 100%
Non-invasive Ventilation (BTS) Yes 85%
Renal Colic (College Emergency Medicine) Yes 100%
Hip, Knee and Ankle Replacements (National Joint Registry) Yes
Hillingdon 71%
Mount Vernon Treatment Centre 93%
Adult Critical Care (ICNARC CMPD) No N/A
Alcohol Related Liver Disease (National Confidential Enquiry
NCEPOD)
Yes 100%
Subarachnoid Haemorrhage (NCEPOD) Yes Data submission ongoing
Severe Trauma (Trauma Audit & Research Network, TARN) Yes 81%
LONG TERM CONDITIONS
Diabetes (National Audit Diabetes Audit) No N/A
Diabetes (RCPH National Paediatric Diabetes Audit) Yes 100%
National Review of Asthma Deaths Yes No applicable cases
Chronic Pain (National Pain Audit) Yes 34.7%
Inflammatory Bowel Disease (IBD)
Yes
Data submission commenced Jan
2013, 100% patients included to date
Adult Asthma (BTS) Yes 88%
Adult Bronchiectasis (BTS) No N/A
Paediatric Bronchiectasis (BTS) No N/A
OTHER
Elective Surgery (National PROMS programme)
Yes
Percentages unavailable, numbers are:
Hip replacements: 249; knee
replacements: 312; groin hernia: 167;
varicose veins: 7.
CARDIOVASCULAR DISEASE
Acute Myocardial Infarction & other ACS (MINAP) Yes 100%
Heart Failure (Heart Failure Audit)
Yes
59% due to staff changeover our
participation is lower than previous
years - this has now been resolved
Cardiac Arrest (National Cardiac Arrest Audit)
No
N/A, Trust will be submitting data
from July 2013
CANCER
Head and Neck Oncology (DAHNO) Yes 100%
Lung Cancer (National Lung Cancer Audit) Yes Expected 100%
Bowel Cancer (National Bowel Cancer Audit Programme) Yes 100%
Oesophago-gastric Cancer (National O-G Cancer Audit) Yes
Deadline for submission October 2013
- expected 100%
OLDER PEOPLE
Fractured Neck of Femur (College of Emergency Medicine) Yes 70%
National Audit of Dementia (NAD) Yes 100%
Parkinson’s Disease (National Parkinson’s Audit) No N/A
Sentinel Stroke National Audit Programme (SSNAP) Yes 100%
Hip Fracture (National Hip Fracture Database) Yes 100%
BLOOD and TRANSPLANT
Blood Sample Labelling (National Comparative Audit of
Blood Transfusion)
Yes 100%
Potential Donor Audit (NHS Blood and Transplant) Yes 100%
Medical use of Blood (National Comparative Audit of Blood
Transfusion)
Yes 100% Quality report 83

Taking actions
The reports of 13 national clinical audits were reviewed by the provider in 2012/2013 and The
Hillingdon Hospitals NHS Foundation Trust intends to take the following actions to improve
the quality of healthcare provided.
Audit
Neonatal intensive and special care (NNAP)
Diabetes (RCPH) national paediatric
diabetes audit
Pain management in children (College of
Emergency Medicine)
Epilepsy 12 audit (rcph national childhood
epilepsy audit)
Paediatric asthma (British Thoracic Society)
Emergency use of oxygen (British Thoracic
Society)
Non-invasive ventilation (British Thoracic
Society)
Severe sepsis & septic shock (College Of
Emergency Medicine)
Cardiac arrest procedures – time to
intervene (NCEPOD)
Inflammatory bowel disease (IBD)
Lung cancer (National Lung Cancer Audit)
Oesophago-gastric cancer (National O-G
Cancer Audit)
Hip fracture (National Hip Fracture
Database)
Actions
The Trust performs well in the majority of the standards for this audit. We
have not been submitting data for whether babies have an encephalopathy
(neurological assessment) to allow us to review clinical practice, this has
now been addressed and data will be available within future reports.
The Trust now uses the Twinkle database which records all of the
requirements for the national paediatric diabetes audit. Use of this
database prompts awareness of diabetes clinical indicators to team
members, improves the quality of data collection and will allow for a more
automated submission to this national audit.
To reduce admissions for diabetic ketoacidosis and to raise awareness for
early diagnosis of diabetes, we are using the diabetes UK 4Ts campaign
(toilet, thirsty, tired, thinner) in all our clinic letters sent to GPs and schools.
A pain rating scale document is in development. This document can help us
to assess pain severity quickly so we will be able to manage a child’s pain as
soon as possible.
A ‘transitional clinic’ to transfer from paediatric to adult epilepsy care has
been set up. The first clinic ran in July 2012 and we plan to run 3 to 4 clinics
per year.
A Trust paediatric asthma guideline has been produced and was published
for use in the hospital in December 2012. Two new A&E Paediatric
Consultants started in December 2012, which will support implementation
of this guideline and improve paediatric asthma standards.
Improvements will be made, relating to documentation of prescribing of
oxygen, as a result of an oxygen prescribing policy being published within
the Trust. A new prescription chart is in development for the hospital,
which includes a section on oxygen prescribing.
The lead respiratory Consultants are using existing training sessions to reiterate
the need to document a clear non invasive ventilation (NIV) plan.
A clinical guideline specific to the emergency department is being agreed,
this will be used in conjunction with the sepsis care bundle.
The Trust has signed up to join the national cardiac arrest audit and will
start submitting data from July 2013.
Written information leaflets for surgical inflammatory bowel disease (IBD)
patients now provided. Meetings with x-ray and gastroenterology have
been restructured to discuss IBD patients, surgeons are present to discuss to
relevant patients.
The national lung cancer audit has been improved for the 2012 submissions.
The development of closer links with the Royal Brompton and Harefield
NHS Foundation Trust and locally between our clinical nurse specialist and
lung team co-ordinator has greatly facilitated a more streamlined reporting
process.
Patients within this audit are included as part of a review of emergency
admission & re-admission rates of palliative care patients captured at
local level. All patients are identified with a pall alert tag on the patient
administration system. The Co-Ordinate My Care (CMC) system is a recent
strategy to identify patients with their consent to reduce emergency
admissions and re-admissions into hospital and guide community resources
to them with appropriate care identified in the community.
Following the introduction of the “assessment and protocol document
for hip fragility fractures” compliance with hip fracture standards has
improved, including falls assessment and both abbreviated mental tests.
A separate audit of this document is now taking place and any identified
improvements will be made.
84 Quality report

Local audits
The reports of 84 local clinical audits were reviewed by the provider in 2012/13 and
examples of The Hillingdon Hospitals NHS Foundation Trust actions to improve the quality of
healthcare provided are detailed below.
Audit of inpatient pathways and day of
discharge processes
Quality of inpatient care (treatment) plans
Audit of Deep Vein Thrombosis pathway
Re-audit - Staff survey of caring for
vulnerable patients including those with a
learning difficulty
Survey of staff to evaluate the
implementation of the mental capacity act
2005 and DOLS - re-audit
Staff taking blood cultures using best practice
Measures of care nursing audits: Falls,
hydration and fluid balance, medicines
management, record keeping, privacy and
dignity, pressure ulcer prevention, food
and nutrition, failure to rescue & patient
identification
Audit of children who Do Not Attend (DNA)
Children’s Outpatients (Wendy Ward)
Audit of records of women with safeguarding
concerns in Maternity Department
This audit was part of the improving inpatient care project and will
roll out the new PAS+ system which will help streamline processes
on the ward to the introduction of electronic white boards and real
time bed management. This should support better discharge planning
and recording of estimated dates of discharge.
To improve quality of care plans we are working with each Division
to devise ward round standards, which will include increased multidisciplinary
input into care planning. We are also looking at ways to set
and record estimated discharge dates consistently e.g. prompt stickers on
ward rounds.
Revised Deep Vein Thrombosis Pathway is under development in
consultation with the Clinical Commissioning Group.
This re-audit identified a general positive increase in awareness of caring
for vulnerable patients. The use of the vulnerable adults action card
and patient passport is continually re-inforced to staff, for example, at
mandatory training and induction. The documents are available on the
Trust Intranet.
The re-audit identified the need for further training for staff on the
Mental Capacity Act. Local training sessions have been provided within
the Trust. In March 2013 a training session was delivered by Central
North West London NHS Foundation Trust.
The blood culture audit has demonstrated a significant increase in
blood culture training provided by the Trust from 16% in 2009 to 83%
in 2012. We have standardised blood culture equipment and all new
medical staff receive blood culture theoretical training including a copy
of the blood culture guidelines on induction. The Foundation Year 1 &
2 doctors receive clinical skills & competency checks within 6 weeks of
commencement in the Trust.
During 2012/13 there has been an overall improvement with some
areas sustaining well above target scores. To achieve this, the Nursing
Performance Unit undertook bespoke teaching, one to one working,
role modelling and observation feedback. This together with staff
motivation, commitment, and engagement in undertaking audits and
hard work resulted in improvement.
All clinic staff have been reminded of the need to document, in the
patient notes, the process followed when a child does not attend their
appointment. Each consulting room has a copy of the DNA process
flowchart on the desk for staff to refer to.
A postnatal communication sheet, to aid information sharing, has been
developed and introduced. This document identifies the lead midwife,
confirms the health visitor has been contacted and specifies the plan of
action for individual safeguarding cases.
Quality report
85

Research
Commitment to research as a driver for
improving the quality of care and patient
experience
The number of patients receiving NHS
services provided by The Hillingdon Hospitals
NHS Foundation Trust, that were recruited
during the period to participate in research
approved by a research ethics committee was
547.
The Hillingdon Hospitals NHS Foundation
Trust has a good research track record for
a hospital of its size. We are continuing
with our strategy to broaden our research
portfolio and this has enabled us to offer a
greater number of patients, from different
clinical areas the opportunity to participate
in research. This year we invested in a
research nurse to support our Cardiologists
and Diabetes Consultants as a means of
increasing commercially funded and portfolio
adopted research activity in these areas.
It is projected that within two years the
commercial income generated should sustain
this post thereafter.
Participation in clinical research demonstrates
The Hillingdon Hospitals NHS Foundation
Trust‘s commitment to improving the
quality of care we offer and to making our
contribution to wider health improvement.
This allows our clinical staff to stay abreast
of the latest treatment possibilities and
active participation in research allows our
patient’s access to new treatments that
they otherwise would not have. With this
in mind we aim to offer our patients the
opportunity to participate in a wide range of
clinical research projects. These studies are
both funded by the pharmaceutical industry
and by the Department of Health via the
North West London Comprehensive Research
Network (CLRN); for this work we received
£524,911 from the CLRN.
The money generated from this research
activity funds research nurses and data
managers to support the clinicians in this
work. The majority of our studies are
National Institute for Health Research (NIHR)
portfolio adopted multi-centre studies where
we are acting as a recruiting site on behalf
of the lead centre. Our research portfolio is
a balance of observational and treatment
studies across many clinical areas in the Trust
including cancer, stroke, and haematology,
many of the general medicine and surgical
specialities and paediatrics. We also support
PhD and Masters students from the local
universities giving them access to our
patients for their projects.
During 2012/2013 we had 66 open or followup
studies. We recruited 505 patients into
30 NIHR Portfolio Studies, supported the
repatriation of 20 patients recruited into
treatment studies at other hospitals and
supported four Masters or PhD student
studies.
Our research management processes reflect
the Research Support Services nationally
and have a setup time that meets the NIHR
national targets. On average our research
governance review is undertaken in less than
10 days which is well below the national
target of 30 days.
Summary of lessons learned from serious
incidents
During 2012/2013, the Trust reported
nine Serious Incidents where panel
investigations were conducted. There were
two Serious Incidents reported as ‘Never
Events’; one of these was investigated by
a panel. Never Events are serious grade
2, largely preventable patient safety
incidents that should never occur if the
available preventable measures have been
implemented by healthcare providers (NPSA
2010). It is a legal requirement under CQC
regulations to report them. Protecting
patients from avoidable harm is something
to which there is universal agreement and
the Trust has clearly defined processes and
procedures to follow to help avoid these
events occurring.
86 Quality report

Lessons learnt as a result of the serious incidents include:
Area Division Summary
CT scans
Deteriorating patients
Cancer and Clinical
Support Services
(CCSS)
All divisions
The investigation led to the requirement for more radiology
staff.
Training and use of an established structured communication
tool (SBAR) for the deteriorating patient.
Record keeping All divisions Training and audit programme in place.
Administration of medicine for
patients that are nil by mouth
Review the Deep Vein
Thrombosis (DVT) clinical
pathway
Refresher training for DVT and
Venous Thrombo Embolysis
(VTE)
Translation for non-English
speaking patients
Maternal sepsis
Recognition and management
of diabetes in the sick patient
Sharing the learning from
serious incidents
Skills and drills training in the
maternity triage area
Neonatal resuscitation training
Maternity escalation policy
Supernumerary status for the
maternity bleep holder
CTG training and CTG ‘buddy’
system
Medicine
Medicine
All medical staff
Maternity
Maternity
Medical staff
Medical staff
Maternity
Paediatrics
Maternity
Maternity
Maternity
Reminder to staff regarding using alternative routes of
medicine administration.
Review undertaken and new pathway being implemented.
Refresher training provided and access for doctors to the e
learning module for DVT.
Memo sent out to remind all staff to provide the Trust
translation service when required.
Reminder sent to all staff regarding the use of the centre for
maternal and child enquiries (cmace) guidelines and inclusion
of giving antibiotics to cover listeria.
Clinical training reviewed and updated.
Conducted at the divisional clinical governance forums
Now included in the regular skills and drills programme.
(Skills and drills are practice clinical scenarios undertaken
both formally, through mandatory training and informally
through mock assessments (spontaneous and unexpected
scenarios, practicing specific emergency situations, usually
led by the practice development team and a Consultant).
These are undertaken to ensure that staff are prepared for
all emergency situations, and where shortfalls are identified,
then further training implemented).
Refresher training in place using the regular skills and drills
programme (as above).
Policy reinforced, ongoing monitoring of compliance being
undertaken.
Under review, all co-ordinators reminded about their
supernumerary status.
Reviewed and competencies being monitored, spot audits in
place.
Security of documents in transit Corporate Use of security envelopes across the Trust.
Escalation of missing patient
communication
Corporate
Monitored on the incident reporting system.
Scanning cancer referral
documents
CCSS
Scanning now in place.
WHO surgical patient safety
checklist
Safe sedation
Pain procedure lists and shifts
Surgical
Surgical
Surgical
Implemented and audit being undertaken. Reminder to use
checklist sent out to staff.
Reminder of safe sedation practice sent out to staff and audit
being undertaken to ensure compliance.
Review of workload undertaken, number, skill mix and
duration of lists.
Quality report
87

Goals agreed with commissioners
(CQUINs)
A proportion, 2.5%, of out turn value of
The Hillingdon Hospitals NHS Foundation
Trust’s income in 2012/2013 was conditional
on achieving quality improvement and
innovation goals agreed between The
Hillingdon Hospitals NHS Foundation Trust
and any body they entered into a contract,
agreement or arrangement with for the
provision of NHS services, through the
Commissioning for Quality and Innovation
payment framework. The monetary total for
the associated payments was £3.3 million.
Further details of the agreed goals for
2012/2013 and for the following 12 month
period are available on request from the
Financial Planning Department, The Furze,
The Hillingdon Hospitals NHS Foundation
Trust, Pield Heath Road, Uxbridge, Middlesex.
UB8 3NN or from the Trust website www.thh.
nhs.uk.
Care Quality Commission
The Trust is required to register with the Care
Quality Commission and is registered without
conditions. The CQC paid an unannounced
visit in December 2012 as part of their
planned review of the Trust. The report
issued from this visit stated the Trust is fully
compliant with the Essential Standards of
Quality and Safety.
The Trust received notification on 15 th
February 2013 that it was an outlier for
puerperal sepsis (maternal infection)
following delivery and an update was
also requested on maternal emergency
readmission rates. Coding issues and clinical
issues mostly relating to urinary catheters
and infections were identified and a
comprehensive action plan was put in place
which enabled the readmission rate to
reduce to less than 1% bringing us within the
expected range and well below the national
average.
Data quality
The Hillingdon Hospitals NHS Foundation
Trust submitted records during April –
January for 2012/2013 to the Secondary
User’s Service (SUS) for inclusion in the
Hospital Episode Statistics (HES) which
included the patient’s valid NHS number (to
month 10:)
• 98.5% for admitted patient care
• 99.8% for outpatients care
• 96.4% for accident and emergency care.
The percentage records in the published data
which included the patient’s valid General
Medical Practitioner Code was:
• 100% for admitted patient care
• 100% for outpatient care
• 100% for accident and emergency care.
The Hillingdon Hospitals NHS Foundation
Trust will be taking forward the following
actions to improve data quality:
• continue to review and action data
quality issues at the Trust’s data quality
meetings
• daily data quality reports are published
on the Trust’s web based management
information system for action and
rectification.
Information Governance Toolkit
The Hillingdon Hospitals NHS Foundation
Trust’s Information Governance Assessment
report overall score for 2012/2013 was 81%
and termed as unsatisfactory as one of 44
requirements remains at level 1; all the other
scores are at level 2 or 3.
Clinical coding error rate
The Hillingdon Hospitals NHS Foundation
Trust was subject to the Payment by Results
Clinical Coding Audit during the reporting
period by the Audit Commission. However,
the final 2012/2013 report is yet to be
published and so the latest published report
is from 2011/2012.
88 Quality report

The Audit Commission sampled Finished
Consultant Episodes (FCEs) and the overall
average Health Resource Group (HRG) error
rate was 6.5% at episode level compared to
a National average of 9.1% in 2009/2010.
The error rates reported in that audit for
diagnoses and treatment coding (clinical
coding) was:
• Primary diagnosis incorrect 4.0%
• Secondary diagnosis incorrect 5.1%
• Primary procedure incorrect 3.6%
• Secondary procedure incorrect 16.2%.
The results were not extrapolated further
than the actual sample audited. The sample
covered 100 case notes from Respiratory
Medicine and 100 randomly selected case
notes across all specialties.
Quality report
89

ANNEXE
Commissioner statement from
Hillingdon Clinical Commissioning
Group (CCG)
Hillingdon CCG is pleased to receive The
Hillingdon Hospitals Foundation Trust
2012/13 Quality Account. We note that the
involvement of your patients in identification
of priorities for 2013/14 and that you have
included reference to the Francis Report.
2012/13 priorities
We share the Trust’s disappointment that
not all the 2012/13 priorities were achieved;
in particular those relating to information
to GPs following discharge and discharging
patients early in the day as these support
effective and safe discharge from hospital
for patients and reduces the likelihood
of readmission. We would hope to see
a strong patient voice in future work to
improve discharge processes. We note
the very positive steps taken as part of
priority 4 Leaving Hospital – Improving the
Patient Experience; especially the follow up
telephone call and monthly observations of
care visits. Priority 2 – Changes in Maternity
also demonstrated well if not 100%
achievement of targets set. It would be
helpful to see more detail on the steps that
will be taken to increase breast feeding rates.
Quality measures
Quality Measure 4: Independent measure of
cleanliness was 88% and rated green. The
National Inpatient Survey (CQC) indicated
that the Trust scored below the national
average for cleanliness of the toilets and
bathrooms as well as the hospital ward.
There is some discrepancy between the
scores.
We notice that many of the performance
achievements have been achieved by the
Trust.
2013/14 priorities
Broadly speaking the CCG supports the
priorities identified for 2013/14. It is
reassuring to see a continued focus on
patient experience through continuation
of the CARES priority. We recognise it is
important enough to be a stand-alone
priority but would anticipate that these
values underpin all other priorities.
We were surprised that reference to the
Emergency Care Intensive Support Team
(ECIST) was not made in relation to the
emergency care priority but pleased to see it
identified as an area of focus in 2013/14.
Information for regulators
It would be useful in future reports to
have a better understanding of the impact
of actions where the action has been for
example “reviews” or “memos”.
The overall score for the Information
Governance Toolkit was 81% and termed
“unsatisfactory”. It would have been helpful
if actions planned to improve the score had
been included in the Quality Account.
Hillingdon CCG can confirm that the review
of the 2012/13 performance is consistent
with the SLA monitoring information it has
received in 2012/13.
Linking to our previous comment on
discharge processes, there is a need to
continue focus on reducing admissions.
90 Quality report

Hillingdon Health Watch response
to The Hillingdon Hospitals NHS
Foundation Trust Annual Quality
Report
Introduction
Although Health Watch Hillingdon was only
established under The Health and Social Care
Act 2012 on 1st April 2013, it feels qualified
to respond to The Hillingdon Hospitals
NHS Foundation Trust (THH) Quality Report
2012-2013, due to the transfer of staff and
volunteers from Hillingdon Link who have
been involved in working with THH in this
and the previous year’s quality accounts
programme.
Health Watch Hillingdon wishes to thank
THH for the opportunity to comment on the
Trust’s Quality Report for the year 2012-2013.
We would also like to acknowledge the
Trust’s continued commitment to engage
with Hillingdon LINk during the last year. This
has seen an open working relationship, in
which the Trust has embraced the LINk as a
critical friend, encouraging positive challenge
for the improvement of service quality.
The Chief Executive Officer, Chair and
Director of Nursing of the Trust met regularly
with LINk representatives and LINk were
invited to sit on a number of important
groups to monitor patient experience
and quality, such as the Experience and
Engagement Group, the Maternity Liaison
Group, and The Leaving Hospital Project
Group.
Quality report
Health Watch Hillingdon found this year’s
Quality Report easy to read, with clear
explanation throughout the document,
making it accessible to the general public.
Written in a similar style to the 2011/12
report, this year’s report is more focused
on quantitative outcomes, and although
subjective, we have a preference for the
qualitative touches from last year which
quoted patients feedback.
From the Quality Report and the work
LINk has been doing with the Trust it is
self-evident that the Trust is committed to
improving the quality of the services they
provide.
Health Watch Hillingdon found the Quality
Report to be an honest assessment of the
Trust’s performance and provided a balanced
report on the quality of their services.
The Trust should be congratulated on
achieving many of its targets and in making
significant progress in many other areas. It
was especially good to see the recruiting
of women in Maternity reception and as
Maternity Mates to meet the diverse cultural
needs of the women in Hillingdon.
We are pleased that the Trust has been
candid in acknowledging the areas which
require improvement and in recognising
shortfalls that the Trust has made
commitments to improve in these areas. We
particularly feel that for patients, further
improvements around record keeping, and
discharge information given to GP’s and
community health services within 24 hours,
will be specifically beneficial.
We are in agreement with and support THH
in their choice of 2013/14 quality priorities
which has taken into account the views of
LINk and the wider public.
The First Contact Project has now been a
Trust priority for four years and CARES is a
long term programme. It would be helpful
for the general public, where completion of
a project is planned over a long period of
time, for this to be indicated in the report,
setting out the long term goals in addition
to the short term. If this is not the case and a
priority extends due to complexities, it would
be useful if the reasons for this are reported.
The Trust has also indicated in its future
priorities for 2013/14 that it intends to
Quality report
91

increase those people discharged before
12pm from 15.8% to 40% and that the
number of patients being seen by a
consultant within 12 hours of the decision
to admit them will increase from 55% to
90%. We very much welcome these areas as
priorities, with improvements of this scale
and the positive affect this will have on the
patient experience. We are cautious of the
effect these targets may have on patient
expectation, especially around discharge.
Health Watch Hillingdon look forward to
continuing the relationship THH has had
with LINk and working with THH in a joint
commitment to monitor and improve quality.
External Services Scrutiny
Committee Statement
Response on behalf of the External Services
Scrutiny Committee at the London Borough
of Hillingdon
The External Services Scrutiny Committee
welcomes the opportunity to comment on
the Trust’s 2012/2013 Quality Report and
acknowledges the Trust’s commitment to
attend its meetings when requested.
The Committee is pleased to note that the
mortality rate is lower than the national
average expected in hospitals. The Trust has
met the year’s targets for infection control.
The Committee has noted that the Trust has
had only one incident of MRSA in the last
year; and notes the target for next year is
zero. The patient bed days are also below
the national average and London average.
The Trust has also met the 4 hour average
waiting time at A&E.
The Committee is mindful of the imminent
closure of Ealing Hospital’s A & E department
and whether this will have a big impact on
Hillingdon Hospital. The Committee has
noted that in theory rather than the numbers
increasing at Hillingdon, people should
be directed to the appropriate care. The
Committee has noted the challenging times
within the NHS and the planning involved in
this. The Trust will be spending £12million
in the next few years to start to gear up for
this change. The Committee would like to be
kept up to date on these changes and how
they will affect the residents of Hillingdon
for better or worse.
The Committee is aware that improving
patient care and discharge continues to be
a priority for the Trust. Complaints with
regard to discharge have been identified
as a problem that needs to be addressed;
in particular with regard to when patients
receive their medication. It has been
recognised that this is a problem and the
aim is to have patient’s papers ready on
discharge. The Committee has noted that
the targets for complaints response had
not been met and suggested improvement
in this area. There are some issues with
the turnaround time for complaints which
needed addressing. The Committee has
noted that the Trust is still using a paper
based system but there are plans for
improvements to this.
It is noted that the Trust has formulated 5
priorities for the forthcoming year which are
broadly similar to last years. These priorities
are: First Contact Project; Improving Inpatient
Care and Discharge; Improving Emergency
Care; CARES and CQUINs.
Overall, the Committee is pleased with
the continued progress that the Trust has
made over the last year but notes that
there are a number of areas where further
improvements still need to be made. We
look forward to being informed of how the
priorities outlined in the Quality Report are
implemented over the course of 2013/14.
92 Quality report

The Hillingdon Hospitals NHS
Foundation Trust response to the
consultation
The Hillingdon Hospitals NHS Foundation
Trust thanks all its stakeholders for their
comments about the 2012-13 Quality Report.
The Trust would like to reassure our
Commissioners that there is a clear action
plan to improve Information Governance
training to achieve Level 2. This plan includes
full training to all new staff on induction,
more regular refresher sessions, bespoke
training where needed, an up to date
training record, and clear escalation for nonattendance.
There is also a more detailed
action plan to increase breastfeeding rates.
to be articulated rather than just a one year
strategy, and we will share these plans in the
coming year.
The External Services Scrutiny Committee
comment on the potential impact of the
implementation of Shaping a Healthier
Future, and the Trust will involve all
stakeholders, including the residents of
Hillingdon, to ensure that a high quality
service will be provided. A merging of the
PALS and complaints teams, as well as our
plan to deal with issues as they arise at
the bedside, should lead to a reduction in
complaints and a prompter turnaround.
Our Commissioners are right in noting the
importance of the 2012 Emergency Care
Intensive Support Team (ECIST) report
and the NHS England: Improving A&E
Performance report (Gateway reference
00062, released April 2013), which both
support our stated aims for improving
emergency care. They also offer other best
practice and operational recommendations
many of which have been, or are being,
implemented.
Our Commissioners have rightly pointed out
the difference between our independent
measure of cleanliness (an audit of
cleanliness standards) being higher than the
National Inpatient Survey for the cleanliness
of toilets and bathrooms as well as the
hospital ward (a measure of the patients
perception of cleanliness). The results of the
National Inpatient Survey has historically
been lower and is difficult to reconcile
because they are asking different questions
and measuring different things.
Health Watch note the need for the Trust to
continue to be candid, balanced, and honest,
qualities we agree are essential. We agree
that a clear plan for long term project needs
Quality report
93

Independent Auditor’s Report to
the Council of Governors of The
Hillingdon Hospitals NHS Foundation
Trust on the Quality Report
We have been engaged by the Council of
Governors of The Hillingdon Hospitals NHS
Foundation Trust to perform an independent
assurance engagement in respect of The
Hillingdon Hospitals NHS Foundation Trust’s
Quality Report for the year ended 31 March
2013 (the “Quality Report”) and certain
performance indicators contained therein.
This report, including the conclusion, has
been prepared solely for the Council of
Governors of The Hillingdon Hospitals
NHS Foundation Trust as a body, to assist
the Council of Governors in reporting
The Hillingdon Hospitals NHS Foundation
Trust’s quality agenda, performance and
activities. We permit the disclosure of this
report within the Annual Report for the year
ended 31 March 2013, to enable the Council
of Governors to demonstrate they have
discharged their governance responsibilities
by commissioning an independent assurance
report in connection with the indicators.
To the fullest extent permitted by law, we
do not accept or assume responsibility to
anyone other than the Council of Governors
as a body and The Hillingdon Hospitals NHS
Foundation Trust for our work or this report
save where terms are expressly agreed and
with our prior consent in writing.
Scope and subject matter
The indicators for the year ended 31 March
2013 subject to limited assurance consist of
the national priority indicators as mandated
by Monitor:
• Maximum 62 day waiting time from
urgent GP referral to treatment for all
cancers;
• Emergency readmissions within 28
days of discharge from hospital.
We refer to these national priority indicators
collectively as the “indicators”.
Respective responsibilities of the
Directors and auditors
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 issued by Monitor. Our responsibility
is to form a conclusion, based on limited
assurance procedures, on whether anything
has come to our attention that causes us to
believe that:
• the Quality Report is not prepared in
all material respects in line with the
criteria set out in the NHS Foundation
Trust Annual Reporting Manual;
• the Quality Report is not consistent in
all material respects with the sources
specified in the guidance; and
• the indicators in the Quality Report
identified as having been the subject
of limited assurance in the Quality
Report are not reasonably stated in
all material respects in accordance
with the NHS Foundation Trust
Annual Reporting Manual and the six
dimensions of data quality set out in
the Detailed Guidance for External
Assurance on Quality Reports.
We read the Quality Report and consider
whether it addresses the content
requirements of the NHS Foundation Trust
Annual Reporting Manual, and consider the
implications for our report if we become
aware of any material omissions.
We read the other information contained in
the Quality Report and consider whether it is
materially inconsistent with the documents
specified within the detailed guidance. We
consider the implications for our report
if we become aware of any apparent
misstatements or material inconsistencies
with those documents (collectively the
94 Quality report

“documents”). Our responsibilities do not
extend to any other information.
We are in compliance with the applicable
independence and competency requirements
of the Institute of Chartered Accountants in
England and Wales (ICAEW) Code of Ethics.
Our team comprised assurance practitioners
and relevant subject matter experts.
Assurance work performed
We 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”). Our limited
assurance procedures included:
• Evaluating the design and
implementation of the key processes
and controls for managing and
reporting the indicators.
• Making enquiries of management.
• Testing key management controls.
• Limited testing, on a selective basis, of
the data used to calculate the indicator
back to supporting documentation.
• Comparing the content requirements
of the NHS Foundation Trust Annual
Reporting Manual to the categories
reported in the Quality Report.
• Reading the documents.
A limited assurance engagement is smaller
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
Non-financial performance information
is subject to more inherent limitations
than financial information, given the
characteristics of the subject matter and
the methods used for determining such
information. The absence of a significant
body of established practice on which to
draw allows for the selection of different
but acceptable measurement techniques
which can result in materially different
measurements and can impact comparability.
The precision of different measurement
techniques may also vary. Furthermore, the
nature and methods used to determine such
information, as well as the measurement
criteria and the precision thereof, may
change over time. It is important to read the
Quality Report in the context of the criteria
set out in the NHS Foundation Trust Annual
Reporting Manual.
The scope of our assurance work has not
included governance over quality or nonmandated
indicators which have been
determined locally by The Hillingdon
Hospitals NHS Foundation Trust.
Conclusion
Based on the results of our procedures,
nothing has come to our attention that
causes us to believe that, for the year ended
31 March 2013:
• the Quality Report is not prepared in
all material respects in line with the
criteria set out in the NHS Foundation
Trust Annual Reporting Manual;
• the Quality Report is not consistent in
all material respects with the sources
specified in the guidance; and
• the indicators in the Quality Report
subject to limited assurance have not
been reasonably stated in all material
respects in accordance with the NHS
Foundation Trust Annual Reporting
Manual.
Deloitte LLP
Chartered Accountants
St Albans
29 May 2013
Quality report
95

Statement of Directors’
responsibilities in respect of the
Quality Report
The Directors are required under the Health
Act 2009 and the National Health Service
(Quality Accounts) Regulations 2010 as
amended to prepare Quality Accounts for
each financial year. Monitor has issued
guidance to NHS Foundation Trust Boards
on the form and content of Annual Quality
Reports (which incorporate the above legal
requirements) and on the arrangements
that Foundation Trust Boards should put
in place to support the data quality for the
preparation of the Quality Report.
In preparing the Quality Report, Directors are
required to take steps to satisfy themselves
that:
• the content of the Quality Report meets
the requirements set out in the NHS
Foundation Trust Annual Reporting
Manual 2012/2013;
• the content of the Quality Report is not
inconsistent with internal and external
sources of information including:
° Board minutes and papers for the
period April 2012 to May 2013
° Papers relating to quality reported to
the Board over the period April 2012 to
May 2013
° Feedback from the Commissioners
dated 22/5/2013
° Feedback from the Governors dated
25/4/2013
° Feedback from LINks dated 7/5/2013
° The Trust’s Complaints Report
published under Regulation 18 of the
Local Authority Social Services and
NHS Complaints Regulations 2009,
17/5/2013;
° The latest national patient survey
published 16/4/2013
° The latest national staff survey
28/2/2013
° The Head of Internal Audit’s annual
opinion over the Trust’s control
environment dated 8/5/2013
° CQC Quality and Risk Profiles dated
from 1 April 2012 to 31 March 2013
• The Quality Report presents a balanced
picture of the NHS Foundation Trust’s
performance over the period covered;
• The performance information reported in
the Quality Report is reliable and accurate;
• There are proper internal controls over the
collection and reporting of the measures
of performance included in the Quality
Report, 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
Report is robust and reliable, conforms
to specified data quality standards and
prescribed definitions, is subject to
appropriate scrutiny and review; and
the Quality Report has been prepared
in accordance with Monitor’s annual
reporting guidance (which incorporates
the Quality Accounts Regulations)
(published at www.monitor-NHSft.gov.
uk/annualreportingmanual) as well as
the standards to support data quality for
the preparation of the Quality Report
(available at www.monitor-NHSft.gov.uk/
annualreportingmanual).
The Directors confirm to the best of their
knowledge and belief they have complied
with the above requirement in preparing the
Quality Report.
96 Quality report

STATEMENT OF THE CHIEF EXECUTIVE’S RESPONSIBILITIES AS
THE ACCOUNTING OFFICER OF THE HILLINGDON HOSPITALS
NHS FOUNDATION TRUST
The NHS Act 2006 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 public finances for which they are
answerable, and for the keeping of proper accounts, are set out in the NHS Foundation Trust
Accounting Officer Memorandum issued by Monitor.
Under the NHS Act 2006, Monitor has directed The Hillingdon 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 Hillingdon 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 NHS Foundation Trust and
to enable him/her to ensure that the accounts comply with requirements outlined in the
above mentioned Act. The Accounting Officer is also responsible for safeguarding the assets
of the NHS 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.
Statement
97

STATEMENT OF DIRECTORS’ RESPONSIBILITIES IN RESPECT OF
THE ACCOUNTS
The Directors are required under the National Health Service Act 2006 to prepare accounts
for each financial year. Monitor, with the approval of the Secretary of State, directs that
these accounts give a true and fair view of the state of affairs of the Trust and of the
Statements of Comprehensive Income, Financial Position, Tax Payers Equity, Cash Flow and all
disclosure notes in the Annual Accounts.
In preparing those accounts, Directors are required to:
• apply on a consistent basis accounting policies according to the NHS Foundation Trust
Annual Reporting Manual 2012/13 with the approval of the Secretary of State;
• Make judgements and estimates which are reasonable and prudent;
• State whether applicable accounting standards have been followed, subject to any
material departures disclosed and explained in the accounts;
• Comply with International Financial Reporting Standards.
The Directors are responsible for keeping proper accounting records which disclose with
reasonable accuracy at any time the financial position of the Trust and to enable them
to ensure that the accounts comply with requirements outlined in the above mentioned
direction of the Secretary of State. They are also responsible for safeguarding the assets of
the Trust and hence for taking reasonable steps for the prevention and detection of fraud
and other irregularities.
The Directors confirm to the best of their knowledge and belief they have complied with the
above requirements in preparing the accounts.
98

ANNUAL GOVERNANCE STATEMENT 2012/13
1. 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.
2. 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 on-going
process designed to identify and prioritise
the risks to the achievement of the policies,
aims and objectives of The Hillingdon
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 The Hillingdon Hospitals
NHS Foundation Trust for the year ended 31
March 2013 and up to the date of approval
of the annual report and accounts.
3. Capacity to handle risk
The Board is responsible for reviewing
the effectiveness of the system of internal
control, including systems and resources
for managing all types of risk. The Trust
Board approved Risk Management
Strategy and Policy (including Board
Assurance Framework) ensures that the
Trust approaches the control of risk in a
strategic and organised manner. It sets out
the responsibilities of Executive Directors
and Senior Managers in relation to their
leadership in risk management and makes it
clear that all employees have a role to play
in risk management appropriate to their
level within the organisation. The Board has
established a Committee structure to provide
assurance on and challenge to the Trust’s
risk management process. Each of these
Committees are chaired by a Non-Executive
Director to enhance this challenge, and the
Committee chairs report formally to the
Board to escalate issues that require further
Board discussion. An example of this is the
attendance at the Quality & Risk Committee
(QRC) of both the Clinical Director and the
Matron for Children’s services to explain
to the committee the complexities of
staffing level risks in A&E and a lack of
high dependency unit (HDU) facilities. This
enabled the QRC to recommend to the Board
that both of these risks are high on the risk
register.
The two main Board committees for risk
management are the Audit & Assurance
Committee (AAC) and the QRC. The QRC
was formed in-year from an amalgamation
of the former Integrated Risk Management
Committee (IRMC) and the Clinical Quality
& Standards Committee (CQSC). The AAC
provides assurance that there is a sound
system of internal control and governance.
The QRC ensures that risks to the delivery
of the Trust’s services are identified and
Annual governance statement
99

addressed. Corporate risks are reported
from ward to Board/QRC via Divisional
Governance Boards using the online risk
register managed by the Trust’s Corporate
Governance department. The QRC also
provides assurance in matters relating to
clinical quality and standards. The Medical
Director and Director of Patient Experience
& Nursing together provide leadership
in Clinical Governance, supported by the
Assistant Director of Clinical Governance &
Quality.
The Board Assurance Framework (BAF) is
the key proactive risk identification tool
for the Trust. The Trust’s Strategy on a
Page which includes critical success factors,
reviewed annually, is mapped into the
BAF. The BAF aims to provide the Board
with assurance that significant threats to
achieving the principal Trust objectives have
been identified and are being appropriately
controlled, and that there is timely and
reliable assurance in place to evidence
this. Action plans within the BAF address
how assurances will be provided; or, where
assurances have identified inadequate
controls, how controls will be improved.
The BAF provides a structure for the
evidence to support the Annual Governance
Statement. Any unacceptable residual levels
of risk remaining are further risk assessed
and added to the corporate risk register to
ensure the gaps in control are reduced or
closed as soon as reasonably practicable. The
BAF has cross references from the delivery
of strategic objectives to the corporate
risk register; to regulatory standards e.g.
NHSLA, CQC in order to demonstrate where
a strategic objective links with a regulatory
standard and the risks currently associated
with the delivery of the objective; and to the
monthly performance targets where trends
in poor performance are picked up, noted
in the BAF and the actions taken to mitigate
the poor performance stated.
The AAC and QRC have the opportunity to
review and shape the BAF at their quarterly
meetings. The Trust Board reviews the BAF
twice a year and there is an annual Board
Strategy Session which focuses on refreshing
the BAF to ensure the principal risks have
been identified. No significant gaps in
control have been identified by the Board/
Board Committees this year.
There are structured processes in place
for incident reporting, the investigation
of Serious Incidents and following up
outcomes from Board commissioned external
reports. The Trust Board, through the Risk
Management Strategy & Policy (including
Board Assurance Framework) and the
Incident Policy (including Serious Incident),
promotes open and honest reporting of
incidents, risks and hazards.
The Trust has a positive culture of reporting
incidents enhanced by accessible online
reporting systems available across the Trust.
The latest National Reporting Learning
System (NRLS) report (March 2013) has shown
the Trust to be in the 50th percentile for
incident reporting. Clinical and non-clinical
events that are assessed using the Trust
Incident (including Serious Incident) policy
to be a Serious Incident (SI) are forwarded to
the Chief Executive or designated Executive
to confirm if the incident is an SI.
Once declared, SIs are reported on the
Department of Health Strategic Executive
Information System (STEIS); to Monitor on
a quarterly basis and a monthly update
to the Trust Board on the progress of
investigation/action progress and lessons
learnt. Lessons learnt are shared within and
where appropriate across Divisions. Further
information on the SIs at the Trust, and
the actions taken by the Trust as a result of
the learning from these, is included in the
Quality Report.
100 Annual governance statement

The Board has proactively commissioned
external assurance when the information
reviewed by the Board, such as from Serious
Incidents, mortality data, and ward visits
has indicated that there is scope for further
investigation and improvement.
Risk management training and awareness is
included in the mandatory New Employees
Week (NEW) programme for all new
employees. The Trust’s Health and Safety
team deliver risk management training
appropriate to all levels across the Trust
including the Trust Board. The Nursing
Education Skills Programmes are reviewed
three monthly, and updated to ensure the
latest evidence-based/best practices are
incorporated; this would include learning
from for example NPSA alerts.
The Board is committed to a culture of
continual learning and quality improvement.
Learning from risk management activities
such as trends in incidents, complaints and
claims are monitored and acted upon at
Divisional level. Where appropriate, Internal
Audit and Clinical Audit is used to provide
assurance that changes to practice have
become embedded e.g. the programme of
Infection Prevention and Control audit and
monitoring provides assurance to the Board
and has played a pivotal role in the reduction
in Healthcare Associated Infections. Major
reports from Healthcare Regulators are
used to assess what lessons the Trust can
learn from significant incidents and events
in other healthcare organisations in order
to evaluate and improve our practice the
most recent being the Independent Inquiry
into care provided by Mid Staffordshire
NHS Foundation Trust January 2005 – March
2009 Volume II Robert Francis QC (Francis),
published February 2013. Here a public
Board paper was produced in February
2013 highlighting the key findings and
immediate actions to be taken by the Trust.
Listening events have been held with staff
in March 2013 on both hospital sites as
recommended by Health Secretary Jeremy
Hunt. In addition, a presentation to the
People in Partnership meeting was delivered;
this provided an outline of the findings of
the Francis Inquiry and its recommendations
and allowed the Trust an opportunity to
engage with its public and patients to hear
their concerns and views in relation to
the report. Recognising that the CQC will
publish guidance for Governors to make
their role more accountable, a presentation
and discussion at a Council of Governors
meeting was also undertaken. The Board
will also consider the implications at a future
Board Strategy session to ensure work that
is to be taken forward is aligned with the
conversations that have already taken place
in relation to a new and refreshed clinical
quality strategy.
4. The risk and control framework
The system of internal control is based on an
on-going risk management process that is
embedded in the organisation and combines
many elements. The aforementioned
comprehensive Risk Management Strategy
& Policy (including BAF) is available to all
staff on the Trust’s intranet site. All staff
are responsible for managing risks within
the scope of their role and responsibilities
as employees of the Trust. The purpose of
this risk management policy is to ensure
that the Trust manages risks in all areas
using a systematic and consistent approach.
The document describes the Trust’s overall
risk management process and the Trust’s
risk identification, evaluation and control
system, which includes the risk matrix used to
evaluate risks. Risks are identified reactively
and proactively.
All risks are assessed against one standard
tool this ensures that a consistent approach
is taken to the evaluation and monitoring of
risk in terms of the assessment of likelihood
and impact. Risks are monitored through a
formal reporting process where the assessed
level of risk and its strategic significance
determines where it will be reviewed and
Annual governance statement
101

monitored. The monitoring of risks and
action plans have been undertaken by the
Trust Board/Trust Board committees during
2012/13.
These committees are supported by
Executive chaired committees/groups and
Divisional governance structures that channel
information up to and down from the Board/
Board committees via the online risk register.
Risk appetite as well as risk tolerance is
covered in the risk strategy. The Board has
not set specific limits for this, but will view
risks and the progress of actions designed
to mitigate risk, on an individual risk basis.
The accepted risks are reviewed at least
annually by IRMC/QRC/Divisional Governance
Boards to check that the controls for these
accepted risks still stand. The Board’s IRMC/
QRC recommends which corporate risks
may be accepted based on the level of
the required resource; assurance that all
reasonable measures have been put in
place to mitigate any risks; and that there is
assurance that these are monitored regularly.
Risk consequences are considered as part
of cost improvement plans, business cases,
capital expenditure projects and staffing
and workforce priorities regarding vacancy
authorisation. This ensures that the Trust
is taking account of the key inter-linking
priorities and dependencies of finance,
operation and service quality risk in order to
deliver the best quality service to patients.
The Trust Board reviews all of the high
corporate risks quarterly; the IRMC/QRC
reviews all the medium and high corporate
risks quarterly and the Divisional Boards
review all relevant risks at all levels quarterly.
The main risks facing the Trust are
summarised:
• Significant clinical risks in-year:
shortage of paediatric A&E nurses
and lack of commissioned High
Dependency Unit (HDU) facilities
for children (the latter being a pan
London issue). This is mitigated by
adult trained nurses from other
areas of A&E being deployed to the
paediatric A&E as required; a senior
staff nurse has been appointed as
Head of Paediatric nursing to assist
with staff cover including redeploying
paediatric nurses from the ward to
A&E as required. Paediatric HDU cover
is provided by using bank/agency
nursing staff; a dedicated paediatric
clinical transfer bag is available and
in use and a paediatric ventilator
has been procured and used prior to
transferring children out of the Trust
as required this is monitored through
internal incident reporting.
• Financial – financial performance
and liquidity. This risk is mitigated
by a revised monthly and quarterly
performance management framework,
monthly QIPP Board and monthly
Trust Board reporting. The Trust has a
committed working capital facility and
written agreements from NW London
Commissioners to support with cash in
2012/13 to maintain current financial
risk rating and written agreement
from NW London Commissioners to
pay for valid over performance in
2012/13.
• Age and condition of the Estate poses
both a clinical and financial risk with
its extensive and old building stock
on both sites; resulting in increasing
frequency and severity of fabric failure
and interruption of service delivery.
This is managed by a prioritised
five year forward view of high and
significant backlog maintenance
requirements, risk assessed and rated
against available capital.
102 Annual governance statement

The main future risks facing the Trust are
summarised:
Future clinical risks:
‣ NW London Shaping a Healthier
Future does not develop at the
anticipated rate affecting acute
activity;
‣ the large emergency care project
(ECP) is not managed or delivered as
planned to specific timescales/cost;
and during the build the reduction in
A&E treatment space is not efficiently
managed; and
‣ potential staffing pressure and costs
post Francis.
These risks are mitigated by:
‣ working closely with GPs and CCG
leads to ensure that the right
incentives and contract levers are in
place to influence social care provision
to facilitate timely discharge and an
appreciation that shifting work from
the acute hospital is only possible once
the out of hospital strategy is worked
up in the community;
‣ for the ECP early clinical engagement
to improve patient pathway
efficiencies, reduce length of stay and
ensure adequate communication for
staff, patients and visitors; and
‣ for staffing issues post Francis – the
Trust has recently participated in a
pan-London nursing and midwifery
productivity benchmarking exercise
which, along with other best practice
guidance will inform our future
staffing requirements; from April 2013
the Trust is implementing mandatory
customer care training for all staff; a
leadership strategy has been agreed
by the Board and work has begun
in a number of areas; over 30 of the
Trust’s nursing leaders have undergone
a three day leadership development
course, in April the Trust will extend
its Talent Management Programme to
nearly 500 staff including consultants
which will help identify any gaps in
leadership skills amongst our leaders
as well as identify those with potential
whilst supporting our succession
planning and training commissioning;
a review of band 1-4 roles and
development has also commenced.
Future financial risk:
‣ commissioning risk if activity is not
paid for, potentially leading to clinical
and financial viability concerns;
‣ operational and investment cash gets
extremely tight and starts to impede
on service delivery; and
‣ unprecedented size of efficiency
savings required in 2013/14 and for
the next five years and its impact on
quality of care provided.
These risks are mitigated by:
‣ regular meetings with the Hillingdon
Clinical Commissioning Group and
the North West (NW) London sector
commissioners to identify issues early;
‣ regular internal meetings in relation
to contract management performance
with responsible managers;
‣ agreed robust mitigation plans are
in place to manage the financial
consequences of a reasonable
reduction in revenue as a consequence
of services being decommissioned.
The Trust will remain focused on the tension
between quality, safety, financial efficiency,
and risk to ensure that patient care remains
uncompromised. The Trust will do this by
having regular Board and Executive reviews
of progress and delivery of agreed plans and
checking that all schemes are quality impact
assessed.
For data security, the Trust has an established
Information Security Management System
(ISMS) similar to that defined within the
Annual governance statement
103

International Standard (ISO) 27001. This
entails the identification and classification of
information assets, risk assessing those assets
and then establishing control frameworks
to keep those assets secure. The Trust has
committed to establishing ISMS through its
compliance with the Information Governance
(IG) Toolkit. One key element of our
compliance is having a current Information
Risk Policy. The policy is supported by an
Information Risk Strategy and accompanying
procedures. These set out the arrangements
for governing information risk processes,
i.e. the framework of accountability and
the roles and responsibilities of staff,
management and committees. Together
these contribute to the organisation meeting
its legislative and regulatory requirements,
as well as meeting requirements from the
Department of Health for organisations to
manage the security of their information,
defined within the Connecting for Health
Information Governance Toolkit. Compliance
evidence for version 10 of the Information
Governance Toolkit has been uploaded
to NHS Connecting for Health and all
requirements are at a level 2 or 3 except for
the requirement to have 95% of staff trained
annually in Information Governance which
is at level 1. IG training compliance will be
driven by a change in Trust Statutory and
Mandatory Training Policy which provides
monthly reporting of staff compliance to
managers, and by the delivery of bespoke
training to specific staff groups.
The key quality performance information is
assessed monthly by the Trust Board which
reviews the performance report – both the
targets table and the prose which interprets
the numbers, discrepancies and any required
actions. The data is further assured by the use
of Data Quality Badges which are described
in each monthly performance report.
Internal Audit reviewed IG arrangements in
the Trust and gave substantial assurance. This
took into account the one serious incident
regarding data loss which was duly reported
to the Information Commissioner, Monitor
and fully investigated and managed by
the Trust. Lessons learnt have now become
established practice for example internal mail
is now transported in sealed Envopaks rather
than individual envelopes.
Control measures are in place to ensure
that all the organisation’s obligations
under equality, diversity and human rights
legislation are complied with.
Equality impact assessments (EIA) are
integrated into core Trust business e.g. they
are carried out as standard procedure for
all Trust’s policies. In addition the Trust has
published its Service and Workforce Equality
Compliance Reports on 31st January 2013
and reported on year one of its Equality
Objectives on 6th April 2013 providing
assurance that the Trust is compliant with
Equality legislation.
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, employer’s contributions and
payments to 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.
Care Quality Commission (CQC)
Compliance
Compliance with the CQC essential standards
of quality and safety are one of the elements
of the organisation’s risk management
process.
The Trust is registered with the CQC without
conditions. The Trust is fully compliant with
the registration requirements of the Care
Quality Commission.
104 Annual governance statement

To ensure the Trust remains compliant with
the CQC essential standards of quality and
safety the following assurance processes are
in place:
• Corporate Governance examines the
Quality & Risk profile and produces a
tracker risk profile for review by the
Executive team and senior managers
in the Trust. This enables any issues to
be raised and challenged and opens
dialogue with the CQC inspectors
as required. The highest rated risk
this year has been high amber for
complaints; this has now dropped to
low amber. Complaints have been
picked up in the Board performance
reports and systems are in place to
increase efficiency with dealing with
complaints.
• CQSC/QRC receives a CQC compliance
report twice yearly and AAC
annually. This report is produced
by Corporate Governance and is an
outcome review of all the regulated
outcomes. The provider compliance
assessments (PCA) are used to ensure
the Trust has due processes in place
to enable compliance. However, the
current Trust approach does not
facilitate a granular approach to
compliance monitoring and Corporate
Governance are putting forward a
case to install a software package that
enables input of data from varied
sources in order to gauge CQC (and
NHSLA) compliance across each area
of the Trust. This will form part of the
evolving Informatics Strategy.
Internal audit reviewed a sample of our
PCA and methodology of CQC compliance
monitoring and gave substantial assurance in
September 2012.
The CQC paid an unannounced visit to the
Hillingdon Hospital site in December 2012.
The resulting report from the CQC stated full
compliance with the essential standards of
quality and safety. These two recent external
reports, as well as the internal monitoring
of CQC compliance, provide me with good
assurance that the Trust continues to be fully
compliant with the CQC essential standards
of quality and safety.
There has been one Internal Audit report
giving Limited Assurance this year and this
related to Oversees Visitors and the Trust not
having robust systems in place to ensure that
appropriate identification, billing, payment
and debt collection procedures were in place
and operating effectively. Since this report
several improvements have been put in place
at the frontline to ensure higher efficiency.
The Trust involves its key public stakeholders
with managing the risks that affect them
through the following mechanisms:
• Engagement with the local Health
Overview and Scrutiny Committee
• Engagement with the Local Involvement
Network (Healthwatch from 1st April
2013)The Council of Governors are
consulted on key issues and risks as part
of the annual plan
• Board approved Membership
Development and Engagement
Strategy 2012-15, which was consulted
on extensively with the Council of
Governors
• Regular People in Partnership Forums
which aim to involve patients and the
local community in decision-making on
the acute health services offered
• Annual Members Meeting
• Foundation Trust Office where members
can raise specific issues with the Trust
and/or relevant Governor
• Engagement with User Groups and
Support Groups e.g. People Improving
Cancer Services, Fighting Infection
Together, Somalian Maternity focus
group, Disability Action Group, Readers
Panel.
Annual governance statement
105

The Hillingdon Hospitals NHS 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.
Adaption reporting uses a risk assessment
approach; coupled with regular detailed
buildings condition survey, in conjunction
with resilience planning, founded on
weather-based risks e.g. heat wave, extreme
cold, drought, and flood.
Compliance with the Code of Governance -
The Board considers itself compliant with all
provisions of the NHS Foundation Trust Code
of Governance. This is following discussion
and review at the AAC and Trust Board. The
Board has made the disclosures required by
the Code in the Governance Report section
of this annual report, including attendance
records and coverage of work for each Board
committee.
5. Review of economy, efficiency
and effectiveness of the use of
resources
The following key processes are in place to
ensure that resources are used economically,
efficiently and effectively:
• Scheme of Delegation and Reservation
of Powers approved by the Board sets
out the decisions, authorities and duties
delegated to officers of the Trust.
• Standing Financial Instructions detail
the financial responsibilities, policies
and procedures adopted by the Trust.
They are designed to ensure that an
organisation’s financial transactions
are carried out in accordance with the
law and Government policy in order
to achieve probity, accuracy, economy,
efficiency and effectiveness.
• Robust competitive processes used for
procuring non-staff expenditure items.
Above £25k, procurement involves
competitive tendering.
• Cost improvement programmes (CIPs),
which are assessed for their impact on
quality with local clinical ownership and
accountability
• Use of National and London
benchmarking for non-clinical support
functions.
The Trust Board has gained assurance
from the former Finance and Investment
(F&I) Committee in respect of financial
and budgetary management across the
organisation and the AAC, which receives
quarterly reports regarding Losses and
Compensations (with high value approved
by the Board), Write-Off of Bad Debts, Going
Concern and Contingent Liabilities. The AAC
has agreed levels of charges for overseas
visitors based on write offs to ensure that
the charges take account of the risk of nonpayment.
For information the F&I Committee has
been disbanded. The newly formed
Transformation Committee (January 2013)
was established to assist the Board with the
shaping, review and challenge of service
transformation, development and redesign,
increasing governance of the CIPs (supported
by a strengthened project management
office established in the light of a Monitor
Annual Plan Review recommendation);
and to provide assurance that the strategy
for the management of human, financial,
estate, and IT resources support such business
transformation. The Committee replaced
the Finance & Investment Committee
as the Board sought to ensure greater
Board scrutiny and challenge on service
transformation and redesign.
Value for money discussions take place at
Board strategy sessions based on service line
reporting reviewing how much a service
106 Annual governance statement

costs to run versus the income it generates
and how it is performing both clinically
and operationally. This is particularly the
approach used around services where
competition is greatest and/or where a
service is out to tender.
Further information with reference to the
Trust’s financial future regarding the Going
Concern assessment, is included in the
‘Financial Disclosures’ section in the Directors
Report of this Annual Report. This draws
specific attention to the recent financial
performance, the challenging financial
context facing the Trust and the programme
the Board is investing in to support the
delivery of the savings identified going
forward.
There are a range of internal and external
audits (e.g. Audit Commission external
reviews on payment by results) that provide
further assurance on quality of financial
data, economy, efficiency and effectiveness,
including internal audit reports on creditors,
financial reporting and budgetary control,
healthcare contracting & payment by results,
cash management, cost improvement
programmes and financial and activity data
and how it is linked including clinical coding.
These are all reported to AAC. All Internal
Audit reports into finance functions have
reported substantial assurance for the past
three financial years.
6. Annual Quality Report
The Directors are required under the Health
Act 2009 and the National Health Service
(Quality Accounts) Regulations 2010 (as
amended) to prepare Quality Accounts
for each financial year. Monitor has issued
guidance to NHS Foundation Trust Boards
on the form and content of Annual Quality
Reports which incorporate the above legal
requirements in the NHS Foundation Trust
Annual Reporting Manual.
The Trust’s commitment to quality and
quality governance is based on a clearly
defined clinical quality strategy, a system
of quality performance management, and
a clear risk management process. There is a
performance and quality report presented
to the Board which allows key threats and
risks to quality to be identified with more
quality detail including review of incident,
complaints data and the like being reviewed
by the Board’s committee, the Clinical Quality
and Standards Committee (CQSC)/now the
Quality & Risk Committee (QRC).
The supply of information to the Board,
and the management team, and oversight
of this, is undertaken by a specialist team in
clinical governance. This is led by a senior
clinical manager and supported by specialist
risk facilitators and a clinical audit and
effectiveness manager and audit team.
The Board monitors quality through the
following processes:
1) the monthly quality operational report
and a quarterly quality report;
2) the reporting of serious incidents and
learning from them to the monthly
Board meetings;
3) a more in-depth review of quality and
parameters by the CQSC/QRC.
4) Observations of care – undertaken on
a monthly basis where Board members
accompany senior nurses and visit
wards on a rotational basis to review
the quality of care. During the visit, the
environment, attitudes and behaviours
of staff, team working and specific
aspects of patient experience and
safety are assessed.
The Trust has a comprehensive clinical audit
work plan covering both national and
local audits. Regular updates on clinical
audit are reported to the CQSC/QRC. Issues
raised via Clinical Audit result in changes in
practice within the Trust e.g. as a result of
the National Audit of Dementia the Trust
has implemented the following: A dementia
Annual governance statement
107

training programme that ensures the correct
level of training for staff e.g. specialised
training for staff working closely with
dementia patients and ‘This is me’ document,
which helps to find out better information
about dementia patients to help care better
for them and meet their individual needs.
A Clinical Assurance Panel (CAP) has been
set up to assess the quality impact of any
changing service brought about for QIPP. This
is a multi-professional clinical panel, chaired
by the Medical Director, which formally
reviews all cross-divisional service changes.
A nursing quality dashboard has been
developed to allow ward to Board reporting;
this includes headline nursing metrics under
the domains of clinical effectiveness, patient
safety and patient quality experience.
The dashboard is presented to the QRC
on a quarterly basis and reviewed by the
Director of Nursing at divisional performance
meetings with senior nursing staff on a
monthly basis.
A framework exists for the management and
accountability of data quality, supported
by a comprehensive audit programme and
the Data Quality Policy, which consist of a
set of quality data groups that run across
the organisation. These groups report to
an Executive Director-led steering group
which feeds quarterly into the AAC. These
quarterly data quality reports to AAC cover
the Monitor compliance data reported to
the Board and other key data quality issues
like NHS number and duplicate records. This,
together with the data audit results, provides
assurance to the Board on data quality
issues and strength of internal control.
Three key data areas have been identified
this year where further actions are being
implemented:
1) Duplicate patient records – this involves
the last few remaining Trust systems
that have a relatively high number of
duplicate records (above 3%).
2) 18 week patient pathways - to
strengthen controls to ensure these are
always accurately recorded.
3) VTE assessment sheets – to ensure
these are always attached to patient
notes.
The priorities for the Annual Quality
Report are drawn together and shaped
via a structured timeline which engages
our key stakeholders, such as Patients
in Partnership, Governors, Healthwatch;
the Clinical Divisions, Clinical Governance
Committee and QRC. These processes and
the leadership involved ensure the Quality
Report represents a balanced view.
7 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. I have been advised
on the implications of the result of my
review of the effectiveness of the system
of internal control by the Board, the Audit
and Assurance Committee, Integrated
Risk Management Committee/Quality
& Risk Committee and Clinical Quality
and Standards committee, and a plan to
address weaknesses and ensure continuous
improvement of the system is in place.
108 Annual governance statement

The process that has been used to maintain
and review the effectiveness of the system of
internal control centres on
• the effectiveness of the Board has
been reviewed during the year and
as a result the Board changed its
committee arrangements to enable
it to work in a more structured way
with regards to service development
and transformation, including the role
of the Trust’s workforce, estate and IT
services
• the Board’s annual review of the
Board Committee structure, their
effectiveness and terms of reference
which are reviewed by the Board and
by each Committee; of note this year
the changes in amalgamating IRMC
and CQSC to form the QRC, dissolving
the F&I committee and forming the
Transformation Committee;
• development, review and challenge
of the BAF which is compiled by
Corporate Governance in conjunction
with the relevant Executive Directors
and their senior managers; the BAF
is then scrutinised quarterly at both
the former IRMC/QRC and AAC prior
to being reviewed by the Board twice
yearly.
Internal audit have reviewed the BAF and the
methodology involved in forming the tool
and have given substantial assurance that the
Trust has in place adequate and appropriate
arrangements for gaining assurances about
the effectiveness of the organisation’s system
of internal control.
Some of the more challenging areas this year
have been the closeness to the Clostridium
difficile target, A&E 4 hour target issues in
the later part of quarters 3 and 4 and the
cost improvement plan. However, despite
these challenges the Trust has managed to
maintain a financial risk rating of 3 and a
green governance rating.
On balance, I therefore conclude that that
the Board has conducted a review of the
effectiveness of the Trust’s system on internal
controls and found them to be sufficient.
Conclusion
My review confirms that The Hillingdon
Hospitals NHS Foundation Trust has no
significant internal control issues and a
generally sound system of internal control
that supports the achievement of its policies,
aims and objectives.
The BAF is reviewed and challenged as
described in section 3 above. There is then
an annual examination and refreshing of the
principal objectives cited in the BAF, new risks
added if required or risks amended to suit
the current climate.
Annual governance statement
109

INDEPENDENT AUDITOR’S REPORT TO THE BOARD OF
GOVERNORS AND BOARD OF DIRECTORS OF THE HILLINGDON
HOSPITALS NHS FOUNDATION TRUST
We have audited the financial statements of The Hillingdon Hospitals NHS Foundation
for the year ended 31 March 2013 which comprise the Income Statement, the Statement
of Comprehensive Income, the Balance Sheet, the Cash Flow Statement, the Statement
of Changes in Taxpayers Equity and the related notes 1 to 31. The financial reporting
framework that has been applied in their preparation is applicable law and the accounting
policies directed by Monitor – Independent Regulator of NHS Foundation Trusts.
This report is made solely to the Board of Governors and Board of Directors (“the Boards”) of
The Hillingdon Hospitals NHS Foundation Trust, as a body, in accordance with paragraph 4 of
Schedule 10 of the National Health Service Act 2006. Our audit work has been undertaken
so that we might state to the Boards those matters we are required to state to them in an
auditor’s report and for no other purpose. To the fullest extent permitted by law, we do not
accept or assume responsibility to anyone other than the trust and the Boards as a body, for
our audit work, for this report, or for the opinions we have formed.
Respective responsibilities of the accounting officer and auditor
As explained more fully in the Accounting Officer’s Responsibilities Statement, the
Accounting Officer is responsible for the preparation of the financial statements and for
being satisfied that they give a true and fair view. Our responsibility is to audit and express
an opinion on the financial statements in accordance with applicable law, the Audit Code
of NHS Foundation Trusts and International Standards on Auditing (UK and Ireland). Those
standards require us to comply with the Auditing Practices 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 Accounting Officer; and the overall presentation of the financial
statements. In addition, we read all the financial and non-financial information in the
annual report to identify material inconsistencies with the audited financial statements and
to identify any information that is apparently materially incorrect based on, or materially
inconsistent with, the knowledge acquired by us in the course of performing the audit. If we
become aware of any apparent material misstatements or inconsistencies we consider the
implications for our report.
110 Auditor’s report

Opinion on financial statements
In our opinion the financial statements:
• give a true and fair view of the state of the trust’s affairs as at 31 March 2013 and of its
income and expenditure for the year then ended;
• have been properly prepared in accordance with the accounting policies directed by
Monitor – Independent Regulator of NHS Foundation Trusts; and
• have been prepared in accordance with the requirements of the National Health Service
Act 2006.
Opinion on other matter[s] prescribed by the National Health Service Act
2006
In our opinion:
• the part of the Directors’ Remuneration Report to be audited has been properly prepared
in accordance with the National Health Service Act 2006; and
• the information given in the Directors’ Report for the financial year for which the
financial statements are prepared is consistent with the financial statements.
Matters on which we are required to report by exception
We have nothing to report in respect of the following matters where the Audit Code for NHS
Foundation Trusts requires us to report to you if, in our opinion:
• the Annual Governance Statement does not meet the disclosure requirements set out in
the NHS Foundation Trust Annual Reporting Manual, is misleading or inconsistent with
information of which we are aware from our audit. We are not required to consider, nor
have we considered, whether the Annual Governance Statement addresses all risks and
controls or that risks are satisfactorily addressed by internal controls;
• proper practices have not been observed in the compilation of the financial statements;
or
• the NHS foundation trust has not made proper arrangements for securing economy,
efficiency and effectiveness in its use of resources.
Certificate
We certify that we have completed the audit of the accounts in accordance with the
requirements of Chapter 5 of Part 2 of the National Health Service Act 2006 and the Audit
Code for NHS Foundation Trusts.
Craig Wisdom (Senior Statutory Auditor)
for and on behalf of Deloitte LLP
Chartered Accountants and Statutory Auditor
St Albans, United Kingdom
29 May 2013
Auditor’s report
111

ANNUAL ACCOUNTS 2012/13
Foreword to the accounts
The accounts for the year ended 31st March 2013 have been prepared by the Hillingdon
Hospitals NHS Foundation Trust in accordance with paragraphs 24 and 25 of Schedule 7 of
the National Health Services Act 2006 in the form which the Independent Regulator of NHS
Foundation Trusts (Monitor) has, with the approval of the Secretary of State, directed.
112 Annual accounts

The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
STATEMENT OF COMPREHENSIVE INCOME NOTE 31 March 2013 31 March 2012
£000 £000
Operating Income 3 194,541 190,291
Operating expenses 4 (192,732) (191,129)
OPERATING SURPLUS / (DEFICIT) 1,810 (838)
NON-OPERATING INCOME
Finance income 8 14 14
Other non-operating Income 9 1,692 2,347
TOTAL NON-OPERATING INCOME 1,706 2,361
NON-OPERATING COSTS
Finance expense - financial liabilities 10 (1,778) (1,688)
Finance expense - unwinding of discount on provisions 25 (63) (47)
PDC Dividends payable (3,533) (3,723)
TOTAL NON-OPERATING COSTS (5,374) (5,458)
SURPLUS/(DEFICIT) FOR THE YEAR (1,858) (3,935)
Other comprehensive income
Impairments 12 (16) (5,062)
Revaluations 12 420 6,212
TOTAL COMPREHENSIVE INCOME / (EXPENSE) FOR THE YEAR (1,454) (2,785)
All income and expenditure is derived from continuing operations.
The notes on pages 117 135 to 156 174 form part of these accounts.
Annual accounts
113

The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
STATEMENT OF FINANCIAL POSITION NOTE 31 March 2013 31 March 2012
£000 £000
Non-current assets
Intangible Assets 11 1,948 0
Property, plant and equipment 12 114,917 115,771
Investment property 14 14,816 13,124
Trade and other receivables 18 1,473 1,344
Total non-current assets 133,154 130,239
Current assets
Inventories 17 3,042 2,916
Trade and other receivables 18 13,319 14,509
Cash and cash equivalents 19 3,906 1,897
Total current assets 20,267 19,322
Total assets 153,421 149,561
Current liabilities
Trade and other payables 20 (20,446) (18,348)
Borrowings 21 (1,353) (1,351)
Provisions 25 (165) (162)
Total Current Liabilities (21,964) (19,861)
Net current assets/(liabilities) (1,697) (539)
Total assets less current liabilities 131,457 129,700
Non-current liabilities
Borrowings 21 (21,942) (21,186)
Provisions 25 (1,948) (1,930)
Total assets employed 107,567 106,584
Financed by taxpayers' equity:
Public dividend capital 60,251 57,814
Revaluation reserve 23,090 23,436
Retained earnings 24,226 25,334
Total taxpayers' equity 107,567 106,584
The financial statements on pages 131 to 134 were approved by the Board on 28th May 2013 and signed on
its behalf by:
The financial statements on pages 113 to 116 were approved by the Board on 28th May 2013 and
signed on its behalf by:
Signed: …………………………(Chief Executive)
Date: ……………………
114 Annual accounts

The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
STATEMENT OF CHANGES IN TAXPAYERS' EQUITY
Income and
STATEMENT OF CHANGES IN TAXPAYERS' EQUITY
Public Dividend Revaluation Income and Expenditure
Public Total Dividend Capital Revaluation Reserve Expenditure Reserve
Total
£000
£000 Capital
£000
£000 Reserve
£000
£000 Reserve
£000
£000
Taxpayers' Equity at 1 April 2012 106,584 57,814 23,436 25,334
Taxpayers'
Surplus/(deficit)
Equity at 1 April
for
2012
the year
106,584 57,814 23,436 25,334
(1,858) 0 0 (1,858)
Surplus/(deficit)
Transfers
for
between
the year
reserves
(1,858) 0 0 (1,858)
0 0 (750) 750
Transfers
Impairments
between reserves 0
(16)
0
0
(750)
(16)
750
0
Impairments
Revaluations - property, plant and equipment
(16)
420
0
0
(16)
420
0
0
Revaluations
Public
- property,
Dividend
plant
Capital
and
received
equipment 420
2,437
0
2,437
420
0
0
0
Public Dividend
Taxpayers'
Capital
Equity
received
at 31 March 2013
2,437
107,567
2,437
60,251
0
23,090
0
24,226
Taxpayers' Equity at 31 March 2013 107,567 60,251 23,090 24,226
Taxpayers' Equity at 1 April 2011 108,569 57,014 23,262 28,293
Taxpayers' Equity at 1 April 2011 108,569 57,014 23,262 28,293
Surplus/(deficit) for the year (3,935) 0 0 (3,935)
Surplus/(deficit) for the year
Transfers between reserves (3,935) 0 0 (3,935)
0 0 (976) 976
Transfers between reserves
Impairments 0 0 (976) 976
(5,062) 0 (5,062) 0
Impairments
Revaluations - property, plant and equipment (5,062) 0 (5,062) 0
6,212 0 6,212 0
Revaluations - property, plant and equipment
Public Dividend Capital received 6,212 0 6,212 0
800 800 0 0
Public Dividend Capital received
Taxpayers' Equity at 31 March 2012 800 106,584 800 57,814 0 23,436 0 25,334
Taxpayers' Equity at 31 March 2012 106,584 57,814 23,436 25,334
Annual accounts
115

The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
STATEMENT OF CASH FLOWS NOTE 31 March 2013 31 March 2012
£000 £000
Cash flows from operating activities
Operating surplus/(deficit) 1,810 (838)
Non-cash income and expense:
Depreciation and amortisation 7,619 7,482
Impairments 36 4,197
(Gain)/Loss on disposal 441 0
Receipt of Donated Assets (194) (1,281)
(Increase)/Decrease in Trade and Other Receivables 1,126 (1,908)
(Increase)/Decrease in Inventories (126) 78
Increase/(Decrease) in Trade and Other Payables 2,159 5,116
Increase/(Decrease) in Trade and Other Liabilities (63) 0
Increase/(Decrease) in Provisions 21 (75)
Other Movements in Cash Flow 1 0
Net cash generated from/(used in) Operations 12,830 12,771
Cash flows from investing activities
Interest received 14 14
Sales of property plant and equipment 5 0
Purchase of intangible assets (20) 0
Purchase of Property, Plant and Equipment (8,578) (5,425)
Net cash generated from/(used in) investing activities (8,579) (5,411)
Cash flows from financing activities
Public dividend capital received 2,437 800
Loans repaid to the Department of Health (390) (390)
Capital element of finance lease rental payments (851) (721)
Capital element of LIFT (257) (241)
Capital Finance through Finance Leases 2,256 0
Interest paid (284) (297)
Late payment of Commercial Debts Interest (8) (3)
Interest Element on Finance Lease (142) (128)
Interest element of LIFT (1,344) (1,260)
PDC Dividend paid (3,659) (3,723)
Net cash generated from/(used in) financing activities (2,242) (5,963)
Increase/(decrease) in cash and cash equivalents 2,009 1,397
Cash and Cash equivalents at start of period 1,897 500
Cash and Cash equivalents at end of period 19 3,906 1,897
116 Annual accounts

Note 1 Accounting Policies
1.1. Basis of Preparation
Monitor, the Independent Regulator
of NHS Foundation Trusts has directed
that the financial statements of NHS
Foundation Trusts shall meet the
accounting requirements of the NHS
Foundation Trusts Annual Reporting
Manual (FT ARM), as agreed with HM
Treasury. Consequently, the following
financial statements have been
prepared in accordance with the 2012-
13 FT ARM. The accounting policies
contained in that manual follow
International Financial Reporting
Standards (IFRS) and the HM
Treasury's Financial Reporting Manual
(FReM) to the extent that they are
meaningful and appropriate to NHS
Foundation Trusts. The particular
policies adopted by the Trust are
described below. They have been
applied consistently in dealing with
items considered material in relation
to the accounts.
1.2. Accounting judgments and
key sources of estimation and
uncertainty
In the application of the Trust’s
accounting policies management
is required to make judgments,
estimates, and assumptions about
the carrying amount of assets
and liabilities that are not readily
apparent from other sources.
The estimates and associated
assumptions are based on historical
experience and other factors
considered of relevance. Actual results
may differ from those estimates
and underlying assumptions are
continually reviewed. Revisions to
estimates are recognised in the period
in which the estimate is revised, if the
revision affects only that period, or
in the period of revision and future
periods if the revision affects both
current and future periods.
The following are the areas that
critical judgments have been made
in the process of applying accounting
policies at the end of the reporting
period that have a risk of causing a
material adjustment to the carrying
amount of assets and liabilities within
the next financial year
• Going Concern
• Asset valuation and lives
• Impairments of receivables
• Provisions
• Accruals.
The critical judgements are addressed
in the accounting policies that follow.
1.3. Going concern
After making enquiries, the directors
have a reasonable expectation that
the Foundation 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 these financial statements.
1.4. 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.
1.5. Current / non-current
classification
Assets and liabilities are classified as
current if they are expected to be
realised within twelve months from
the Statement of Financial Position
date, the primary purpose of the asset
and liability is to be traded, or of
Annual accounts
117

loans and receivables where they have
a maturity of less than twelve months
from the Statement of Financial
Position date. All other assets and
liabilities are classified as non-current.
1.6. Consolidation
The Trust’s charitable funds would
be considered as a subsidiary entity
in that the Hillingdon Hospitals
NHS Foundation Trust are corporate
trustees and as such exert control over
the uses of these funds. The Trust also
governs the financial and operational
policies as homogeneous with those
of the main body. However HM
Treasury has granted a dispensation
from applying IAS 27 for 2012/13.
1.7. Income recognition
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 revenue for the Trust is from
NHS commissioners for healthcare
services.
Where income is received for a
specific activity that is to be delivered
in the following year, that income is
deferred.
Income from the sales 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.
1.8. Partially Completed Spells
The Partial Spells accrual relates to
patients who remain undischarged at
31/03/2013 in relation to income. The
Trust reflect income at the point of
discharge in line with the matching
concept. The Trust have accrued
income on a per patient basis to
31/03/2013 based on average tariff
rates for the speciality. Ordinarily
this activity is coded once the patient
has been discharged and generated
a Health Resource Grouper code to
which National Tariff rates are applied
to calculate the income. Hence an
average tariff is applied based on
point of delivery and length of stay by
speciality.
1.9. Expenditure on employee
benefits
Short-term employee benefits
Salaries, wages and employmentrelated
payments are recognised in
the period in which the service is
received from employees.
1.10. Pension costs
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 the Secretary
of State, in England and Wales. The
scheme is not designed to be run in
a way that would enable the NHS
Foundation Trust to identify its share
of the underlying scheme assets and
liabilities. Therefore, the scheme is
accounted for as if it were a defined
contribution scheme: the cost to
the NHS body of participating in
the scheme is taken as equal to the
contributions payable to the scheme
for the accounting period.
For early retirements other than
those due to ill health the additional
pension liabilities are not funded
by the scheme. The full amount of
the liability for the additional costs
is charged to expenditure at the
time the Trust commits itself to the
retirement, regardless of the method
of payment.
118 Annual accounts

Further details of NHS Pensions
payable under these provisions
can be found on the NHS Pensions
website at www.nhsba.nhs.uk/
pensions.
1.11. Other expenses
Other operating expenses are
recognised when, and to the extent
that, the goods or services have
been received. They are measured at
the fair value of the consideration
payable. Expenditure is recognised
in operating expenses except where
it results in the creation of a non
current asset such as property, plant
and equipment.
1.12. NHS pension scheme
The scheme is subject to a full
actuarial valuation every four years
(until 2004, every five years) and an
accounting valuation every year. An
outline of these follows:
a. Full actuarial (funding) valuation
The 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 scheme is subject to full
actuarial valuations. The last such
valuation, which determined
current contribution rates was
undertaken as at 31 March 2004
and covered the period from 1
April 1999 to that date.
The conclusion from the 2004
valuation was that the scheme
had accumulated a notional
deficit of £3.3 billion against
the notional assets as at 31
March 2004. In order to defray
the costs of benefits, employers
pay contributions at 14% of
pensionable pay and most
employees had up to April 2008
paid 6%, with manual staff
paying 5%.
Following the full actuarial review
by the Government Actuary
undertaken as at 31 March
2004, and after consideration
of changes to the NHS Pension
Scheme taking effect from 1
April 2008, his Valuation report
recommended that employer
contributions could continue
at the existing rate of 14% of
pensionable pay, from 1 April
2008, following the introduction
of employee contributions on
a tiered scale from 5% up to
8.5% of their pensionable pay
depending on total earnings.
On advice from the scheme
actuary, scheme contributions
may be varied from time to time
to reflect changes in the scheme’s
liabilities.
b. Accounting valuation
A valuation of the scheme liability
is carried out annually by the
scheme actuary as at the end of
the reporting period by updating
the results of the full actuarial
valuation.
Between the full actuarial
valuations at a two-year
midpoint, a full and detailed
member data-set is provided
to the scheme actuary. At this
point the assumptions regarding
the composition of the scheme
membership are updated to allow
the scheme liability to be valued.
The valuation of the scheme
liability as at 31 March 2013, is
Annual accounts
119

ased on detailed membership
data as at 31 March 2008 (the
latest midpoint) updated to 31
March 2013 with summary global
member and accounting data.
The latest assessment of the
liabilities of the scheme is
contained in the scheme actuary
report, which forms part of the
annual NHS Pension Scheme
(England and Wales) Resource
Account, published annually.
These accounts can be viewed on
the NHS Pensions website. Copies
can also be obtained from The
Stationery Office.
c. Scheme provisions
The NHS Pension Scheme provided
defined benefits, which are
summarised below. This list is an
illustrative guide only, and is not
intended to detail all the benefits
provided by the Scheme or the
specific conditions that must be
met before these benefits can be
obtained:
The Scheme is a “final salary”
scheme. Annual pensions are
normally based on 1/80th for the
1995 section and of the best of
the last three years pensionable
pay for each year of service,
and 1/60th for the 2008 section
of reckonable pay per year of
membership.
Members who are practitioners
as defined by the Scheme
Regulations have their annual
pensions based upon total
pensionable earnings over the
relevant pensionable service.
With effect from 1 April 2008
members can choose to give up
some of their annual pension
for an additional tax free lump
sum, up to a maximum amount
permitted under HMRC rules.
This new provision is known as
“pension commutation”.
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.
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 five times their
annual pension for death after
retirement is payable.
For early retirements other
than those due to ill health the
additional pension liabilities are
not funded by the scheme. The
full amount of the liability for
the additional costs is charged to
the statement of comprehensive
income at the time the Trust
commits itself to the retirement,
regardless of the method of
payment. These costs exclude
voluntary early retirement, as
these costs are borne by the
employee.
Members can purchase additional
service in the NHS Scheme and
contribute to money purchase
AVC’s run by the Scheme’s
approved providers or by
other Free Standing Additional
Voluntary Contributions (FSAVC)
providers.
120 Annual accounts

1.13 Property, plant and equipment
recognition
Property, plant and equipment is
capitalised if:
• 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 will be supplied to, the
Trust;
• the cost of the item can be
measured reliably; and
• the item has cost of at least £5,000;
or
• collectively, a number of items
have a cost of at least £5,000 and
individually have a cost of more
than £250, 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
• items form part of the initial
equipping and setting-up cost
of a new building, ward or unit,
irrespective of their individual or
collective cost.
The Trust is permitted to borrow funds
to the extent that it complies with the
Prudential Borrowing Code for NHS
Foundation Trusts. The capital sum is
recognised as a liability and interest
incurred is charged to finance expenses
in the Statement of Comprehensive
Income. Total borrowings of the
Trust and performance against the
Prudential Borrowing Limit is disclosed
in note 29.
Componentisation
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.
Valuation
All property, plant and equipment are
measured initially at cost, representing
the cost 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.
Land and buildings used for the
Trust’s services or for administrative
purposes are stated in the Statement
of Financial Position at their revalued
amounts, being the fair value at the
date of revaluation less any subsequent
accumulated depreciation and
impairment losses. Revaluations are
performed with sufficient regularity to
ensure that carrying amounts are not
materially different from those that
would be determined at the end of
the reporting period. Fair values are
determined as follows:
• Land and non-specialised buildings –
market value for existing use
• Investment Properties - market value
and or net rental income stream
• Specialised buildings – depreciated
replacement cost.
HM Treasury has adopted a standard
approach to depreciated replacement
cost valuations based on modern
equivalent assets and, where it would
meet the location requirements of the
service being provided, an alternative
site can be valued.
Properties in the course of construction
for service or administration purposes
are carried at cost, less any impairment
loss. Cost includes professional fees
but not borrowing costs, which are
recognised as expenses immediately, as
allowed by IAS 23 for assets held at fair
Annual accounts
121

value. Assets depreciation commences
when they are brought into use.
A full revaluation exercise took place in
the 20011/12 financial year. In line with
Treasury guidance, where appropriate
the revaluation was based on a
Modern Equivalent Assets replacement
basis. The valuation was carried out in
accordance with the Royal Institute of
Chartered Surveyors (RICS) Appraisal
and Valuation Manual insofar as these
terms are consistent with the agreed
requirements of the Department of
Health and HM Treasury. The Surveyors
were Gerald Eve.
The Trust carries out a full revaluation
exercise at least every five years
unless the Trust considers there has
been significant market movement In
the intervening years. The Trust has
taken advice from Gerald Eve who
have advised that there have been no
significant market movements relating
to the Trust's land and buildings for
2012/13 financial year.
New fixtures and equipment are
carried at depreciated historic cost as
this is not considered to be materially
different from 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 the cost incurred to
replace a component of 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, amortisation and
impairments
Freehold land, properties under
construction, and assets held for
sale are not depreciated. Otherwise,
depreciation and amortisation are
charged to write off the costs or
valuation of property, plant and
equipment and intangible noncurrent
assets, less any residual
value, over their estimated useful
lives, in a manner that reflects the
consumption of economic benefits
or service potential of the assets.
The estimated useful life of an asset
is the period over which the Trust
expects to obtain economic benefits
or service potential from the asset.
This is specific to the Trust and may be
shorter than the physical life of the
asset itself. Estimated useful lives and
residual values are reviewed each year
end, with the effect of any changes
recognised on a prospective basis.
Assets held under finance leases are
depreciated over the lease period.
In accordance with the Foundation
Trust Annual Reporting Manual (FT
ARM), impairments that are due to a
loss 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.
122 Annual accounts

Other impairments are treated as
revaluation losses. Reversals of other
impairments are treated as revaluation
gains.
An impairment arising from a loss of
economic benefit or service potential
is reversed when, and to the extent
that, the circumstances that gave rise
to the loss is reversed. Reversals are
recognised in operating income to
the extent that the asset is restored
to the carrying amount it would have
had if the impairment had never been
recognised. Any remaining reversal is
recognised in the revaluation reserve.
Where, at the time of the original
impairment, a transfer was made from
the revaluation reserve to the income
and expenditure reserve, an amount
is transferred back to the revaluation
reserve when the impairment reversal
is recognised.
Revaluation gains, losses and
de-recognition
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’.
De-recognition
Assets intended for disposal are
reclassified as ‘Held for Sale’ once all
of the following criteria are met: 1) the
asset is available for immediate sale
in its present condition subject only to
terms which are usual and customary
for such sales; 2) the sale must be
highly probable i.e. management are
committed to a plan to sell the asset;
or an active programme has begun to
find a buyer and complete the sale; 3)
the asset is being actively marketed
at a reasonable price; 4) 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. Assets are derecognised
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.
1.14. Investment property
Investment property is property
held to earn rentals or for capital
appreciation or both. A key factor
in determining classification would
be whether property was saleable
separately. In considering whether
land meets this criteria the Trust would
consider whether property had direct
public access.
Annual accounts
123

Investment property is accounted for
under the fair value model. A gain
or loss arising from a change in the
fair value of investment property is
recognised in profit or loss for the
period in which it arises.
1.15. Donated assets
Donated property, plant and
equipment assets are capitalised
at their fair value on receipt. The
donation is credited to income at
the same time, unless the donor has
imposed a condition that the future
economic benefits embodied in the
donation are to be consumed in a
manner specified by the donor, in
which case, the donation is deferred
within liabilities and is carried forward
to future financial years to the extent
that the condition has not yet been
met.
The donated assets are subsequently
accounted for in the same manner
as other items of property, plant and
equipment.
1.16. Intangible assets
Recognition
Intangible assets are non-monetary
assets without physical substance which
are capable of being sold separately
from the rest of the Trusts 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
Foundation Trust and where the cost of
the asset can be measured reliably.
• The project is technically feasible
to the point of completion and will
result in an intangible asset for sale
or use;
• The Foundation Trust (FT) intends to
complete the asset and sell or use it;
• The FT has the ability to sell or use
the asset;
• How the asset will generate
probable future economic benefits
e.g. the presence of a market for 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
FT to complete the development
and sell or use the asset during
development.
Internally generated intangible
assets
Internally generated goodwill,
brands, mastheads, publishing titles,
customer lists, and similar items are not
capitalised as intangible assets, neither
is expenditure on research.
Impairments
Assets that are subject to amortisation
are reviewed for impairment whenever
events or changes in circumstances
indicate that the carrying amount may
not be recoverable. Any impairment
loss is recognised in the Statement of
Comprehensive Income to reduce the
carrying amount to the recoverable
amount.
Expenditure on research is not
capitalised.
The Trust is permitted to borrow funds
to the extent that it complies with the
Prudential Borrowing Code for NHS
Foundation Trusts. The capital sum is
recognised as a liability and interest
incurred is charged to finance expenses
in the Statement of Comprehensive
Income. Total borrowings of the
Trust and performance against the
Prudential Borrowing Limit is disclosed
in note.
124 Annual accounts

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.
Measurement
Intangible assets are recognised
initially at cost, comprising of 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. comprising of 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.
Intangible assets held for sale are
measured at the lower of their carrying
amount or ‘fair value less costs to sell.
Amortisation
Intangible assets are amortised over
their expected useful economic lives
in a manner consistent with the
consumption of economic or service
delivery benefits.
• Development expenditure up to 5
years
• Software up to 5 years.
1.17. Leases
The Trust as lessee
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. The value at which
both 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 implicit
interest rate is that which produces a
constant periodic rate of interest on
the outstanding liability.
The asset and liability are recognised
at the commencement of the lease.
Thereafter, the asset is accounted
for as 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 de-recognised when the
liability is discharged, cancelled or
expires.
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.
Leases of land and buildings
Where a lease is for land and buildings,
the land component is separated
from the building component and
Annual accounts
125

the classification for each is assessed
separately.
The Trust as Lessor
Rental income from operating leases is
recognised on a straight-line basis over
the term of the lease. Initial direct costs
incurred in negotiating and arranging
an operating lease are added to the
carrying amount of the leased asset
and recognised on a straight-line basis
over the lease term.
1.18. Local Improvement Finance
Trust (LIFT) transactions
HM Treasury has determined that
government bodies shall account for
infrastructure LIFT schemes where the
government body controls the use of
the infrastructure and the residual
interest in the infrastructure at the
end of the arrangement as service
concession arrangements, following
the principles of the requirements of
IFRIC 12. The Trust therefore recognises
the LIFT asset as an item of property,
plant and equipment together with
a liability to pay for it. The services
received under the contract are
recorded as operating expenses.
The annual lease plus payment
is separated into the following
component parts, using appropriate
estimation techniques where necessary:
a. Payment for the fair value of
services received;
b. Payment for the LIFT asset, including
finance costs;
The Trust is currently party to a 25-year
LIFT lease plus contract.
Services received
The fair value of services received
in the year is recorded under the
relevant expenditure headings within
‘operating expenses’.
LIFT Asset
The LIFT assets are recognised as
property, plant and equipment,
when they come into use. The assets
are measured initially at fair value
in accordance with the principles of
IAS 17. Subsequently, the assets are
measured at fair value, which is kept
up to date in accordance with the
Trust’s approach for each relevant
class of asset in accordance with the
principles of IAS 16.
LIFT liability
A LIFT liability is recognised at the
same time as the LIFT assets are
recognised. It is measured initially at
the same amount as the fair value of
the LIFT assets and is subsequently
measured as a finance lease liability in
accordance with IAS 17.
An annual finance cost is calculated by
applying the implicit interest rate in
the lease to the opening lease liability
for the period, and is charged to
‘Finance Costs’ within the Statement of
Comprehensive Income.
The element of the lease plus payment
that is allocated as a finance lease
rental is applied to meet the annual
finance cost and to repay the lease
liability over the contract term.
An element of the lease plus payment
increase due to cumulative indexation
is allocated to the finance lease. In
accordance with IAS 17, this amount
is not included in the minimum lease
payments, but is instead treated as
contingent rent and is expensed as
incurred. In substance, this amount
is a finance cost in respect of the
liability and the expense is presented
as a contingent finance cost in the
Statement of Comprehensive Income.
126 Annual accounts

1.19. Inventories
Inventories are valued on a FIFO basis
(First In First Out).
1.20. Cash and cash equivalents
Cash is cash in hand and deposits with
any financial institution repayable
without penalty on notice of not more
than 24 hours. Cash equivalents are
investments that mature in 3 months
or less from the date of acquisition and
that are readily convertible to known
amounts of cash with insignificant risk
of change in value.
In the Statement of Cash Flows, cash
and cash equivalents are shown net of
bank overdrafts that are repayable on
demand and that form an integral part
of the Trust’s cash management.
1.21. Provisions
The amount recognised as a provision
is the best estimate of the expenditure
required to settle the obligation
at the end of the reporting period,
taking into account the risks and
uncertainties. Injury Benefits and
Early Retirement: Where a provision
is measured using the cash flows
estimated to settle the obligation, its
carrying amount is the present value of
those cash flows using HM Treasury’s
discount rates.
From 2012/13 The Treasury publishes
three discount rates that are to be
employed. These are short term less
than 5 years. Medium term 5 to 10
years and long term over 10 years.
Where cash flows are expected to fall
into into more than one on these time
frames, then multiple discount rates
will need to be used when calculating
the carrying value of the provision.
In discussion with the Trust Auditors,
it has been agreed that the Trust will
continue using its long term rate of
3% as there is no material effect in
changing the rate used.
The period over which future cash
flows will be paid is estimated using
the England life expense tables as
published by the Office of National
Statistics.
1.22. Clinical negligence costs
The NHS Litigation Authority (NHSLA)
operates a risk pooling scheme under
which the Trust pays an annual
contribution to the NHSLA which in
return settles all clinical negligence
claims. The contribution is charged
to expenditure. Although the NHSLA
is administratively responsible for
all clinical negligence cases the legal
liability remains with the Trust.
1.23. Non-clinical risk pooling
The 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 as
and when they become due.
1.24. Contingencies
A contingent liability is a possible
obligation that arises from past
events and whose existence will be
confirmed only by the occurrence
or non-occurrence of one or more
uncertain future events not wholly
within the control of the Trust, or
a present obligation that is not
recognised because it is not probable
that a payment will be required to
settle the obligation or the amount
of the obligation cannot be measured
sufficiently reliably. A contingent
liability is not recognised but is
Annual accounts
127

disclosed unless the possibility of a
payment is remote.
A contingent asset is a possible asset
that arises from past events and whose
existence will be confirmed by the
occurrence or non-occurrence of one
or more uncertain future events not
wholly within the control of the Trust.
A contingent asset is not recognised
but is disclosed where an inflow of
economic benefits is probable.
Where the time value of money is
material, contingencies are disclosed at
their present value.
1.25. Public Dividend Capital (PDC)
and PDC dividend
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 public dividend capital
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 (i) donated assets (including
lottery funded assets), (ii) net cash
balances held with the Government
Banking Services (GBS), excluding cash
balances held in GBS accounts that
relate to a short-term working capital
facility, and (iii) any PDC dividend
balance receivable or payable. In
accordance with the requirements laid
down by the Department of Health
(as the issuer of PDC), the dividend for
the year is calculated on the actual
average relevant net assets as set out
in the ‘pre-audit’ version of the annual
accounts. The dividend thus calculated
is not revised should any adjustment to
net assets occur as a result of the audit
of the annual accounts.
1.26. Value Added Tax
Most of the activities of the 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 fixed assets. Where
output tax is charged or input VAT is
recoverable, the amounts are stated
net of VAT.
The Trust makes both taxable and
exempt supplies and incurs input tax
that relates to both kinds of supply.
The Trust is therefore classified
as 'partly exempt'. Partly exempt
businesses must undertake calculations
which work out how much input tax
they may recover. The percentage
relating to partially exempt supplies
is currently 1.25% which reduces the
Trust's VAT recovery. This percentage is
reviewed annually.
1.27. Corporation tax
The Trust is a Health Service body
within the meaning of s519A ICTA 1988
and accordingly in relation to specified
activities of a Foundation Trust (s519A
(3) to (8) ICTA 1988).
None of the Trust's activities in the
period are subject to a corporation tax
liability.
1.28. Third party assets
Assets belonging to third parties (such
as money held on behalf of patients)
are not recognised in the accounts
since the Trust has no beneficial
interest in them.
128 Annual accounts

1.29. 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.
1.30. Financial instruments and
financial liabilities
Recognition
Financial assets and financial liabilities
which arise from contracts to the
purchase or sale of non-financial items
(such as goods or services), which are
entered into in accordance with the
Foundation 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 required or
disposed of through finance leases
are recognised and measured in
accordance with the accounting policy
for leases described below.
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.
Classification and Measurement
Financial assets are categorised as loans
and receivables or available for sale as
financial assets. Financial liabilities are
classified as other financial liabilities.
1.31. Loans and receivables
Loans and receivables are nonderivative
financial assets with fixed or
determinable payments which are not
quoted in an active market. They are
included in current assets if receivable
in the current reporting period, or
in non current assets if outside the
current reporting period.
The Trust's loans and receivables
comprise cash and cash equivalents,
NHS debtors, accrued income and
other debtors.
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 exactly
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.
1.32. Other financial liabilities
All other 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,
Annual accounts
129

a shorter period, to the net carrying
amount of the financial liability.
They are included in current liabilities
except for amounts payable more
than 12 months after the reporting
period, which reclassified 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.
1.33. Impairment of financial assets
At the end of the reporting period, the
Trust assesses whether any financial
assets, other than those held at ‘fair
value through profit and loss’ are
impaired. Financial assets are impaired
and impairment losses recognised
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
directly or through the use of a bad
debt provision.
1.34. Foreign currencies
The Trust's functional currency and
presentational currency is sterling.
Transactions denominated in a foreign
currency are translated into sterling at
the exchange rate ruling on the dates
of the transactions. Resulting exchange
gains and losses are recognised in the
Trust’s surplus/deficit in the period in
which they arise.
1.35. Prudential borrowing regime
The Trust is permitted to borrow funds
to the extent that it complies with the
Prudential Borrowing Code for NHS
Foundation Trusts. The capital sum is
recognised as a liability and interest
incurred is charged to finance expenses
in the Statement of Comprehensive
Income.
1.36. Government grants
Government grants are grants from
Government bodies other than income
from primary care trusts or NHS trusts
for the provision of services. Where
a grant is used to fund revenue or
capital expenditure it is taken to
the Statement of Comprehensive
Income to match that expenditure.
The exception to this is where specific
grant conditions apply regarding the
recognition of income.
1.37. Private patient income
The statutory limitation on private
patient income in section 44 of the
2006 Act was repealed on 1 October
2012 by the Health and Social Care
Act 2012. The financial statements
disclosures that were provided
previously are no longer required.
1.38. Financial risk management
International Financial reporting
standard IFRS 7 requires disclosure
of the role that financial instruments
have had during the period in creating
or changing the risks a body faces
in undertaking its activities. Because
of the continuing service provider
relationship that the NHS Foundation
Trust has with primary care trusts and
the way those primary care trusts are
financed, the NHS Foundation Trust is
130 Annual accounts

not exposed to the degree of financial
risk faced by business entities. Also
financial instruments play a much
more limited role in creating or
changing risk than would be typical
of listed companies, to which the
financial reporting standards mainly
apply. The NHS Foundation Trust has
limited powers to borrow or invest
surplus funds and financial assets and
liabilities are generated by day-to-day
operational activities rather than being
held to change the risks facing the NHS
Foundation Trust in undertaking its
activities.
The Trust’s treasury management
operations are carried out by the
finance department, within parameters
defined formally within the Trust’s
standing financial instructions and
policies agreed by the board of
directors. Trust treasury activity is
subject to review by the Trust’s internal
auditors.
Currency risk
The Trust is principally a domestic
organisation with the great majority of
transactions, assets and liabilities being
in the UK and sterling based. The Trust
has no overseas operations. The Trust
therefore has low exposure to currency
rate fluctuations.
Interest rate risk
To date, the Trust has only borrowed
from UK Government for capital
expenditure. The borrowings were for
1 - 25 years, in line with the life of the
associated assets, and interest charged
at the National Loans Fund rate, fixed
for the life of the loan. The Trust
therefore has low exposure to interest
rate fluctuations.
Credit risk
Because the majority of the Trust’s
income comes from contracts with
other public sector bodies, the Trust
has low exposure to credit risk. The
maximum exposures as at 31 March
2013 are in receivables from customers,
as disclosed in the trade and other
receivables note.
Liquidity risk
The majority of the Trust’s operating
costs are incurred under contracts with
Primary Care Trusts, which are financed
from resources voted annually by
Parliament. The Trust funds its capital
expenditure from funds obtained
within its prudential borrowing limit.
The Trust is not, therefore, exposed to
significant liquidity risks.
1.39. Events after the reporting
period
There are no post balance sheet events
to report.
1.40. Research and development
Research and development expenditure
is charged against income in the year
in which it is incurred, except insofar as
development expenditure relates to a
clearly defined project and the benefits
of it can reasonably be regarded as
assured. Expenditure so deferred is
limited to the value of future benefits
expected and is amortised through
the Operating Cost Statement on
a systematic basis over the period
expected to benefit from the project.
It should be revalued on the basis
of current cost. The amortisation
is calculated on the same basis as
depreciation, on a quarterly basis.
1.41. Significant accounting
assumptions
The Trust view is there is no material
credit risk within its financial assets
and liabilities. All significant potential
suppliers are credit risk assessed before
the Trust enters into a contract.
The Trust is permitted to borrow funds
Annual accounts
131

to the extent that it complies with the
Prudential Borrowing Code for NHS
Foundation Trusts. The capital sum is
recognised as a liability and interest
incurred is charged to fiannce expenses
in the Statement of Comprehensive
Income. Total borrowings of the
Trust and performance against the
Prudential Borrowing Limit is disclosed
in note 29.
1.42. New standards and
interpretations
IAS 1 Presentation of financial
statements (Other Comprehensive
Income) - subject to consultation
IAS 12 Income Taxes amendment -
subject to consultation
IAS 19 Post - employment benefits
(pensions) - subject to consultation
IAS 27 Separate Financial
Statements - subject to consultation
IAS 28 Investments in Associates
and Joint Ventures - subject to
consultation
IFRS 7 - Financial Instruments:
Disclosures -amendments - subject to
consultation
IFRS 9 Financial Instruments - subject
to consultation
IFRS 10 Consolidated Financial
Statements - subject to consultation
IFRS 11 Joint Arrangements - subject
to consultation
IFRS 12 Disclosure of Interests
in Other Entities - subject to
consultation
IFRS 13 Fair Value Measurement -
subject to consultation
IPSAS 32 - Service Concession
Arrangement - subject to consultation
132 Annual accounts

The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
Note 2
Operating segments
Note 2
Surgical
Medical Operating Women & segments Clinical Support Corporate
Total
Division
Division Children's
Services
Division
Surgical
Medical Women & Clinical Support Corporate
Total
Division
Division
Division Children's
Services
Division
31st March 2013 ### 31st March 2013 ### 31st March 2013 ### 31st March 2013 ### 31st March 2013 ### 31st March 2013
Division
###
(£'000)
###
(£'000)
###
(£'000)
###
(£'000)
###
(£'000)
###
(£'000)
###
NHS Clinical Income
(£'000)
58,535
(£'000)
64,436
(£'000)
31,556
(£'000)
14,791
(£'000)
-
(£'000)
169,317
Non
NHS
NHS
Clinical
Clinical
Income
Income
58,535
306
64,436
256
31,556
236
14,791
118 1,341
- 169,317
2,256
Other
Non NHS
Income
Clinical Income
2,306
306
1,911
256
1,217
236
2,389
118
10,421
1,341
18,244
2,256
Unallocated
Other Income
Income
2,306
-
1,911
-
1,217
-
2,389
-
10,421
-
18,244
4,724
Total
Unallocated
Operating
Income
Revenue 61,147
-
66,603
-
33,009
-
17,298
-
11,762
-
194,541
4,724
Total Operating Revenue
Pay
61,147
(29,730)
66,603
(31,144)
33,009
(17,893)
17,298
(23,773)
11,762
(19,572)
194,541
(122,113)
Non
Pay
Pay (14,036)
(29,730)
(10,942)
(31,144) (17,893)
(2,292) (10,089)
(23,773)
(24,570)
(19,572) (122,113)
(61,929)
Internal
Non Pay
Recharges
(14,036)
(2,351)
(10,942)
(2,045)
(2,292)
(844)
(10,089)
5,249
(24,570)
(10)
(61,929)
0
Unallocated
Internal Recharges
Expenses
(2,351)
-
(2,045)
-
(844)
-
5,249
-
(10)
- (593)
0
Total Unallocated Operating Expenses Expenditure
- - - - - (593)
before Depreciation,Impairments
Total Operating Expenditure
and Interest
before Depreciation,Impairments
(46,117) (44,131) (21,029) (28,613) (44,152) (184,635)
and Interest
(46,117) (44,131) (21,029) (28,613) (44,152) (184,635)
Earnings before Interest, Taxation,
Depreciation, and Amortisation
Earnings before Interest, Taxation,
15,030 22,472 11,980 (11,315) (32,390) 9,906
Depreciation, and Amortisation
15,030 22,472 11,980 (11,315) (32,390) 9,906
Unallocated Depreciation &
Amortisation
(7,619)
Unallocated Depreciation &
Unallocated
Amortisation
Impairments
(7,619) (477)
Operating
Unallocated
Surplus/(Deficit)
Impairments
15,030 22,472 11,980 (11,315) (32,390) 1,810
(477)
Operating Surplus/(Deficit) 15,030 22,472 11,980 (11,315) (32,390) 1,810
Surgical Division
Medical Women & Clinical Support Corporate
Total
Division Children's
Services
Division
Surgical Division
Medical Women & Clinical Support Corporate
Total
Division
31st March 2012 ### 31st March Division 2012 ### 31st March Children's 2012 ### 31st March Services 2012 ### 31st March Division 2012 ### 31st March 2012 ###
Division
(£'000)
###
(£'000)
###
(£'000)
###
(£'000)
###
(£'000)
###
(£'000)
###
NHS Clinical Income
(£'000)
58,067
(£'000)
61,301
(£'000)
32,138
(£'000)
13,494
(£'000)
-
(£'000)
165,000
Non
NHS
NHS
Clinical
Clinical
Income
Income
58,067
263
61,301
310
32,138
106
13,494
139 1,151
- 165,000
1,969
Other
Non NHS
Income
Clinical Income
2,270
263
1,947
310
1,334
106
2,415
139
7,720
1,151
15,686
1,969
Unallocated
Other Income
Income
2,270 1,947
-
1,334
-
2,415
-
7,720
-
15,686
7,636
Total
Unallocated
Operating
Income
Revenue 60,600 63,558
-
33,578
-
16,048
-
8,871
-
190,291
7,636
Total Operating Revenue
Pay
60,600
(29,663)
63,558
(30,298)
33,578
(17,879)
16,048
(23,406)
8,871
(17,511)
190,291
(118,757)
Non
Pay
Pay (14,670)
(29,663) (30,298)
(9,321)
(17,879)
(2,256) (10,060)
(23,406)
(23,773)
(17,511) (118,757)
(60,080)
Internal
Non Pay
Recharges
(14,670)
(2,302) (2,028)
(9,321) (2,256)
(865)
(10,060)
5,200
(23,773)
(5)
(60,080)
0
Unallocated
Internal Recharges
Expenses
(2,302)
-
(2,028)
-
(865)
-
5,200
-
(5)
(613)
0
Total Operating Expenditure before
Unallocated Expenses - - - - (613)
Depreciation,Impairments and
Total Operating Expenditure before
Interest
(46,635) (41,647) (21,000) (28,266) (41,289) (179,450)
Depreciation,Impairments and
Interest
(46,635) (41,647) (21,000) (28,266) (41,289) (179,450)
Earnings before Interest, Taxation,
Depreciation, and Amortisation
Earnings before Interest, Taxation,
13,965 21,911 12,578 (12,218) (32,418) 10,841
Depreciation, and Amortisation
13,965 21,911 12,578 (12,218) (32,418) 10,841
Unallocated Depreciation &
Amortisation
Unallocated Depreciation &
(7,482)
Unallocated AmortisationImpairments (4,197) (7,482)
Operating
Unallocated
Surplus/(Deficit)
Impairments
13,965 21,911 12,578 (12,218) (32,418) (838)
(4,197)
Operating Surplus/(Deficit) 13,965 21,911 12,578 (12,218) (32,418) (838)
The only activity of the NHS Foundation Trust is Healthcare and its primary customers are
Primary Care Trusts (PCTs). However, segmental information has been included on the basis
The only The
the
activity only activity
following
of of
information the NHS Foundation
is reported Trust is Healthcare
regularly to
Trust
the Chief
is and Healthcare, its primary customers
Executive for the purpose
and its are
of
primary customers are Primary Care Trust
Primary Care Trusts (PCTs). However, segmental information has been included on the basis
(PCTs). However, allocating resources to that segment and assessing its performance. Transactions between
the following segmental information is reported information regularly to has the Chief been Executive included for the purpose of basis the following information is reported
divisions would reflect the re-allocation of shared costs. All services relating to transactions
regularly
allocating
shown to the
resources
below Chief
to
were provided Executive
that segment
to external for
and assessing
customers the purpose
its performance.
of the Trust. of allocating
Transactions
resources
between
to that segment and assessing its
divisions would reflect the re-allocation of shared costs. All services relating to transactions
performance. Segmental shown below Transactions net were assets provided are not between recorded to external as customers part divisions of the of internal the would Trust. reporting reflect process the and re-allocation as such are not disclosed. of shared costs. All services relating
to transactions The Segmental reportable net shown assets segments are below not are recorded different were as operational provided part of the divisions internal to external within reporting the Trust, process customers which and as provide such of are the not Trust. disclosed.
different groups of service. They are managed separately as they involve different medical
The reportable segments are different operational divisions within the Trust, which provide
Segmental
disciplines
net
and
assets
patient
are
groups.
not
Segments
recorded
have
as
not
part
been aggregated
different groups of service. They are managed separately of as they involve internal different reporting medical process and as such are not disclosed.
disciplines and patient groups. Segments have not been aggregated
The major external customer is NHS Hillingdon which accounted for revenue of £131,997k and features in all segments.
The reportable segments are different operational divisions within the Trust, which provide different groups of
No other
major
customer
external
accounted
customer is
for
NHS
more
Hillingdon
than 10%
which
of revenue.
accounted for revenue of £131,997k and features in all segments.
service.
No
They
other
are
customer
managed
accounted
separately
for more than 10%
as they
of revenue.
involve different medical disciplines and patient groups. Segments
have not been aggregated.
The major external customer is NHS Hillingdon which accounted for revenue of £131,997k and features in all
segments. No other customer accounted for more than 10% of revenue.
Annual accounts
133

Page 22
Note 3.1 Operating income (by classification) 31 March 2013 31 March 2013 31 March 2013
Total Total Total
£000 £000 £000
NHS Clinical Income
Elective income 31,434 31,434
Mandatory Non Mandatory
Income
Income
Non elective income 53,837 53,837
Outpatient income 41,216 41,216
A & E income 11,397 11,397
Other NHS clinical income 31,433 31,433
Non-NHS Clinical Income
Private patient income 253 253
Other non-protected clinical income 2,031 2,031
Total income from activities 171,601 169,317 2,284
Other operating income
Research and development 998 998
Education and training 7,323 7,018 305
Receipts from donated assets 194 194
Non-patient care services to other bodies 8,176 8,176
Other 4,204 4,204
Rental revenue from operating leases 1,981 1,981
Income in respect of staff costs where accounted on gross basis
64 64
Total other operating income 22,940 7,018 15,922
Total Operating Income 194,541 176,335 18,206
31 March 2012 31 March 2012 31 March 2012
Total Total Total
£000 £000 £000
NHS Clinical Income
Elective income 30,110 30,110
Mandatory Non Mandatory
Income
Income
Non elective income 52,444 52,444
Outpatient income 39,755 39,755
A & E income 10,831 10,831
Other NHS clinical income 31,860 31,860
Non-NHS Clinical Income
Private patient income 243 243
Other non-protected clinical income 1,902 1,902
Total income from activities 167,145 165,000 2,145
Other operating income
Research and development 954 954
Education and training 7,470 7,077 393
Charitable and other contributions to expenditure 1,281 1,281
Non-patient care services to other bodies 8,304 8,304
Other 3,467 3,467
Rental revenue from operating leases 1,626 1,626
Income in respect of staff costs where accounted on gross basis
44 44
Total other operating income 23,146 7,077 16,069
Total Operating Income 190,291 172,077 18,214
Mandatory income relates to the treatment of NHS patients and for the training and education for clinical
healthcare Mandatory Income staff. relates to the treatment of NHS patients and for the training and education for
clinical healthcare staff.
134 Annual accounts

The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
Note 3.2 Operating income by entity 31 March 2013 31 March 2012
£000 £000
NHS Foundation Trusts 1,926 524
NHS Trusts 7,228 7,726
Department of Health 189 0
Strategic Health Authorities 6,975 7,063
Primary Care Trusts 172,586 167,028
Local Authorities 41 54
Non Government Bodies 5,596 7,896
Total operating income 194,541 190,291
Non Operating income 31 March 2013 31 March 2012
£000 £000
Finance Income (Interest on Bank Accounts) 14 14
Valuation Gain on Investment Properties 1,692 2,347
Total non operating income 1,706 2,361
Note 3.3 Operating lease income 31 March 2013 31 March 2012
£000 £000
Operating Lease Income
Rents recognised as income in the period 1,519 1,017
Contingent rents recognised as income in the period 462 609
TOTAL 1,981 1,626
Future minimum lease payments due
on leases of Land expiring
- not later than one year; 1,150 659
- later than one year and not later than five years; 4,600 2,637
- later than five years. 82,800 48,075
sub total 88,550 51,371
on leases of Buildings expiring
- not later than one year; 200 322
- later than one year and not later than five years; 776 846
- later than five years. 356 1,742
sub total 1,332 2,910
TOTAL 89,882 54,281
Leasing arrangements relate significantly to land rental on both the Hillingdon and Mount Vernon site.
Most substantially, the Trust is party to a lease with BMI for land rental on the Mount Vernon site. This is a
99 year lease which commenced in March 1991. At the beginning of 2012/13 a revision of the lease
agreement was signed by both parties, the end period for the lease remained the same, but one change
was to update the contracted rental value written within the contract to 2011/12 price levels. As a result,
rent previously reported as contingent rent, is now reflected within rents recognised as income. In
addition, the future minimum lease payments, based upon the length of the lease and the rental value
written within the lease, have increased substantially.
Annual accounts
135

The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
Note 4. Operating expenses (by type) 31 March 2013 31 March 2012
£000 £000
Services from NHS Foundation Trusts 983 835
Services from NHS Trusts 30 256
Services from PCTs
0 31
Employee Expenses - Executive directors 889 918
Employee Expenses - Non-executive directors 139 71
Employee Expenses - Staff 121,231 117,774
Supplies and services - clinical (excluding drug costs) 20,898 20,430
Supplies and services - general 5,977 7,963
Establishment 3,917 3,776
Transport 1,335 1,270
Premises 7,487 6,246
Increase/(decrease) in provision for impairment of receivables 524 335
Increase in other provisions 122 88
Drugs 12,028 11,546
Other impairment of financial assets 0 0
Rentals under operating leases - minimum lease receipts 547 540
Rentals under operating leases - contingent rent 63 38
Depreciation on property, plant and equipment 7,108 7,482
Amortisation on intangible assets 511 0
Impairments of property, plant and equipment 36 4,197
Audit services- statutory audit* 115 100
Clinical negligence 5,155 4,574
Loss on disposal of other property, plant and equipment 441 0
Legal fees 98 137
Consultancy costs 40 8
Training, courses and conferences 465 367
Patient travel 5 6
Car parking & Security 109 136
Redundancy - (Included in employee expenses) 51 112
Hospitality 16 25
Insurance 231 267
Other services, e.g. external payroll 2,030 1,168
Losses, ex gratia & special payments- (Not included in employee expenses)
53 49
Other 98 384
TOTAL OPERATING EXPENSES 192,732 191,129
*The Trusts auditors Deloitte LLP have not limited their auditor's liability under their contract with the Trust.
* The Trust’s auditors Deloitte LLP have not limited their auditor’s liability under their contract with the Trust.
136 Annual accounts

The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
5. Operating lease Expenditure
Payments recognised as an expense 31 March 2013 31 March 2012
£000 £000
Minimum lease payments 547 540
Contingent rents 63 38
610 578
Total future minimum lease payments 31 March 2013 31 March 2012
£000 £000
Payable:
Not later than one year 362 603
Between one and five years 0 352
Total 362 955
The Trust is is party to to a a five five year year lease lease agreement for for a Module a Module Healthcare Healthcare Complex Complex building building on the on the
Hillingdon Hospital site.
All future minimum lease payments relate to a single lease with a cessation date end October 2013.
All future minimum lease payments relate to a single lease with a cassation date end October 2013
Annual accounts
137

The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
6. Employee costs and numbers
6.1 Directors aggregate remuneration 31 March 2013 31 March 2013 31 March 2012 31 March 2012
Remuneration Number of Remuneration Number of
£000 Directors ** £000 Directors
Executive Directors (Details of Directors can be found in
Annual Report)
889 10 918 8
Non Executive Directors* 139 9 71 7
Total** 1,028 19 989 15
**Analysis of Directors Remuneration (£000)
Gross pay 849 799
Employer Pension Contributions 96 97
Employer National Insurance Contributions 83 93
Total 1,028 989
*Non Executive Directors are not members of the NHS
pension scheme.
** The number of directors denotes the number of
individuals employed in a director position at some point
during the financial year, not the number of directors
simultaneously employed.
6.2 Staff sickness absence 31 March 2013 31 March 2012
Number Number
Days lost (long term) 18,020 17,176
Days lost (short term) 12,327 11,815
Total days lost 30,347 28,991
Total staff years* 2,610 2,413
Average working days lost 12 12
Total staff employed in period (headcount) 2,904 2,701
Total staff employed in period with no absence (headcount) 1,037 997
Percentage staff with no sick leave 35.71% 36.91%
*Staff years is a calculation based on the number of
working days of full time and part time staff employed by
the Trust converted into composite staff years.
6.3 Early Retirements due to ill health 31 March 2013 31 March 2012
Number Number
No of early retirements on the grounds of ill-health 4 0
31 March 2013 31 March 2012
£000 £000
Value of early retirements on the grounds of ill-health 165 0
138 Annual accounts
Page 26

The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
The
6. Employee
Hillingdon
costs
Hospitals
and numbers
NHS Foundation
(continued)
Trust - Annual Accounts 2012-13
6.
6.4
Employee
Employee costs
costs and numbers (continued)
31 March 2013 31 March 2012
Total Permanently Other Total Permanently Other
6.4 Employee costs 31 March employed 2013 31 March employed 2012
Total Permanently Other Total Permanently Other
£000 employed £000 £000 £000 employed £000 £000
Salaries and wages 102,261 £000 97,661 £000 4,600 £000 99,612 £000 94,850 £000 4,762 £000
Social security costs 9,079 8,777 302 8,919 8,583 336
Salaries
Employer
and
contributions
wages
to NHS Pension scheme
102,261 11,046 97,661 10,874 4,600 171 99,612 10,865 94,850 10,707 4,762 158
Social Termination security benefits costs 9,079 51 8,777 51 3020 8,919 124 8,583 124 3360
Employer Agency/contract contributions staff to NHS Pension scheme 11,046 2,140 10,8740 2,140 171 10,865 1,446 10,7070 1,446 158
Termination Less Salary Costs benefits Recharged to Other Organisations (1,487) 51 (1,487) 51 0 (1,361) 124 (1,361) 124 0
Agency/contract Less Termination staff Costs Recharged to Other Organisations 2,1400 0 2,1400 1,446 (12) (12) 0 1,4460
Less Salary Costs Recharged to Other Organisations (1,487) (1,487) 0 (1,361) (1,361) 0
Less Termination Costs Recharged to Other Organisations 0 0 0 (12) (12) 0
Employee benefits expense 123,090 115,877 7,213 119,593 112,891 6,702
Of Employee the total benefits above: expense 123,090 115,877 7,213 119,593 112,891 6,702
Charged to capital 919 898 21 789 789 0
Charged Of the total revenue above:
Charged to capital
122,171
123,090 919
114,979
115,877 898
7,192
7,213 118,804
119,593 789
112,102
112,891 789
6,702
6,7020
Charged to revenue 122,171 114,979 7,192 118,804 112,102 6,702
6.5 Average number of people employed
123,090 115,877
31 March 2013
7,213 119,593 112,891
31 March 2012
6,702
6.5 Average number of people employed
Total Permanently Other Total Permanently Other
31 March employed 2013 31 March employed 2012
Total Permanently Other Total Permanently Other
Number employed Number Number Number employed Number Number
Medical and dental Number 403 Number 398 Number 5 Number 399 Number 394 Number 5
Administration and estates 702 665 37 709 660 49
Medical Healthcare and assistants dental and other support staff 403 392 398 319 74 5 399 308 394 259 49 5
Administration Nursing, midwifery and and estates health visiting staff 702 793 665 725 37 68 709 816 660 745 49 71
Healthcare Scientific, therapeutic assistants and and other technical support staff staff 392 368 319 355 74 13 308 365 259 356 499
Nursing, midwifery and health visiting staff 793 725 68 816 745 71
Scientific,
Total
therapeutic and technical staff
2,658 368 2,461 355 197 13 2,597 365 2,414 356 183 9
Total Of the above:
2,658 2,461 197 2,597 2,414 183
Of Number the above: of whole time equivalent staff engaged on capital projects 15 15 0 12 12 0
Number of whole time equivalent staff engaged on capital projects 15 15 0 12 12 0
6.6 Exit Packages 31 March 2013
Exit package cost band (including any special payment element)
Total
6.6 Exit Packages 31 March 2013
*Number of
*Cost of
number of Total cost of
Exit package cost band (including any special payment element) compulsory compulsory
Total exit exit
redundancies
*Number of redundancies *Cost of
number packages of Total packages cost of
compulsory Number compulsory £000s Number exit £000s exit
£200,001 0 0 0 0
Total 2 51 2 51
6.6 Exit Packages 31 March 2012
Exit package cost band (including any special payment element)
Total
6.6 Exit Packages *Number of
*Cost 31 of March 2012 number of Total cost of
Exit package cost band (including any special payment element) compulsory compulsory
Total exit exit
redundancies
*Number of redundancies *Cost of
number packages of Total packages cost of
compulsory Number compulsory £000s Number exit £000s exit
£200,001 0 0 0 0
Total 5 112 5 112
Annual accounts
139
Page 27

The Hillingdon Hospitals NHS Foundation Trust -- Annual Accounts 2012-13
7 Better Payment Practice Code
7.1 Better Payment Practice Code -- measure of
compliance
31 March 2013 31 March 2012
Number £000 Number £000
Total Non-NHS trade invoices paid in the year 56,422 68,300 48,339 59,804
Total Non NHS trade invoices paid within target 13,849 23,206 9,058 19,232
Percentage of Non-NHS trade invoices paid within target 25% 34% 19% 32%
Total NHS trade invoices paid in the year 2,418 14,085 2,579 13,934
Total NHS trade invoices paid within target 453 5,516 442 4,719
Percentage of NHS trade invoices paid within target 19% 39% 17% 34%
The
The Better
Better Payment
Payment Practice Practice
Code Code
requires requires
the the
Trust Trust
to to
aim aim
to to
pay pay
all all
undisputed undisputed
invoices invoices
by the
by the due date or within 30
due days date of receipt or within of goods 30 days or of a receipt valid invoice, of goods whichever or a valid is invoice, later. whichever is is later.
7.2 The Late Payment of Commercial Debts (Interest) Act 1998 31 March 2013 31 March 2012
£000 £000
Amounts included in finance costs from claims made under this legislation 8 3
8 Finance income 31 March 2013 31 March 2012
£000 £000
Interest on bank accounts 14 14
9 Other non -operating income 31 March 2013 31 March 2012
£000 £000
Change in fair value of investment property 1,692 2,347
Total 1,692 2,347
10 Finance expenses 31 March 2013 31 March 2012
£000 £000
Interest expense:
Finance leases 142 128
Interest on late payment of commercial debt 8 3
Interest on Loans from the Department of Health 284 297
Interest on LIFT contract 1,344 1,260
Total 1,778 1,688
140 Annual accounts

The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
Page 29
11 Intangible Assets 31 March 2013
£000
Cost brought forward at 1st April 2012 0
Reclassification from Property, Plant and Equipment 3,933
Additions - purchased 20
Cost at 31 March 2013
3,953
Amortisation Brought Forward at 1st April 2012 0
Reclassification from Property, Plant and Equipment 1,494
Amortisation provided in Year 511
Amortisation at at 31 31 March March 2013 2013
2,005
Net Book Value at 31 March 2013
1,948
Intangible Assets consists of Software Licences
Intangible assets consists of software licences.
During the year Management identified that assets included in
Property, Plant and Equipment within the heading Information
Technology, would be more accurately disclosed as intangible
During the year, management identified that assets included in Property, Plant and
assets.
Equipment within the heading information Technology, would be more accurately disclosed
as intangible assets.
Annual accounts
141

* The Prior Period Adjustment relates to the reversal of accumulated depreciation as at 31st March 2012 following a
revaluation exercise of the Trust’s operational land and buildings.
** Protected assets are assets which are used in the Trust’s primary purpose for treating Page NHS 30 patients.
* The Prior Period Adjustment relates to the reversal of accumulated depreciation as at 31 March 2012 following a revaluation exercise of the Trust's operational land and buildings.
Protected Assets* 71,147 17,276 53,871 0 0 0 0 0 0
Unprotected Assets 43,770 15,193 8,142 653 4,106 9,014 0 6,609 53
Total 31 March 2013 114,917 32,469 62,013 653 4,106 9,014 0 6,609 53
Ownership Analysed as follows:-
Net book value
Owned 98,326 32,119 48,932 653 4,106 6,927 0 5,536 53
Finance leased 2,256 0 0 0 0 1,183 0 1,073 0
LIFT 10,783 350 10,433 0 0 0 0 0 0
Donated 3,552 0 0 2,648 0 904 0 0 0
Total 31 March 2013 114,917 32,469 59,365 3,301 4,106 9,014 0 6,609 53
Net Book Value (A - B) 114,917 32,469 62,013 653 4,106 9,014 0 6,609 53
Depreciation at 1 April 2012 38,017 762 11,544 874 0 14,359 18 8,193 2,267
Prior Period Adjustments* (13,180) (762) (11,544) (874) 0 0 0 0 0
Provided During the Year 7,108 0 3,326 163 0 2,340 0 1,269 10
Impairments 36 0 36 0 0 0 0 0 0
Reclassifications (1,494) 0 0 0 0 202 0 (1,696) 0
Disposals (8,795) 0 0 0 0 (6,558) 0 0 (2,237)
Depreciation at 31 March 2013 (B) 21,692 0 3,362 163 0 10,343 18 7,766 40
Additions - purchased 6,321 0 499 0 3,928 1,415 0 479 0
Additions - Leased 2,256 0 0 0 0 1,183 0 1,073 0
Additions - donated 194 0 0 0 0 194 0 0 0
Impairments (16) 0 0 0 0 (16) 0 0 0
Reclassifications (3,933) 0 719 0 (1,978) 269 0 (2,943) 0
Revaluations 420 420 0 0 0 0 0 0 0
Disposals (9,241) 0 0 0 0 (7,004) 0 0 (2,237)
Cost or valuation at 31 March 2013 (A) 136,609 32,469 65,375 816 4,106 19,357 18 14,375 93
Cost or valuation at 1 April 2012 153,788 32,811 75,701 1,690 2,156 23,316 18 15,766 2,330
Prior Period Adjustment* (13,180) (762) (11,544) (874) 0 0 0 0 0
.
12.1 Property, plant and equipment Total Land Buildings Dwellings Assets under Plant and Transport Information Furniture &
excluding
construction machinery equipment technology fittings
dwellings
31 March 2013 £000 £000 £000 £000 £000 £000 £000 £000 £000
The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
142 Annual accounts

The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
12.1 Property, plant and equipment
Total Land Buildings Dwellings Assets under Plant and Transport Information Furniture &
Continuation
excluding
construction machinery equipment technology fittings
dwellings
and POA
31 March 2012 £000 £000 £000 £000 £000 £000 £000 £000 £000
Cost or valuation at 1 April 2011 145,932 34,595 69,573 1,238 602 22,243 18 15,333 2,330
Additions purchased 5,425 0 1,763 0 2,156 1,073 0 433 0
Additions donated 1,281 0 1,281 0 0 0 0 0 0
Reclassifications 0 (1,558) 2,160 0 (602) 0 0 0 0
Reclassified as held for sale 0 0 0 0 0 0 0 0 0
Revaluation/indexation gains 6,212 1,519 4,241 452 0 0 0 0 0
Impairments (5,062) (1,745) (3,317) 0 0 0 0 0 0
Reversal of impairments 0 0 0 0 0 0 0 0 0
At 31 March 2012 153,788 32,811 75,701 1,690 2,156 23,316 18 15,766 2,330
Depreciation at 1 April 2011 26,338 - 5,111 413 0 12,103 18 6,445 2,248
Impairments 4,197 762 3,343 92 0 0 0 0 0
Charged during the year 7,482 - 3,090 369 0 2,256 0 1,748 19
Depreciation at 31 March 2012 38,017 762 11,544 874 0 14,359 18 8,193 2,267
Net Book Value (A - B) 115,771 32,049 64,157 816 2,156 8,957 0 7,573 63
Net book value
Ownership Analysed as follows:-
Owned 98,063 31,699 50,789 815 2,156 7,343 0 5,198 63
Finance leased 1,301 - - 0 0 1,301 0 0 0
LIFT 11,043 350 10,693 0 0 0 0 0 0
Donated 2,989 - 2,675 1 0 313 0 0 0
Total 31 March 2012 113,396 32,049 64,157 816 2,156 8,957 0 5,198 63
Protected Assets 70,169 17,276 52,893 0 0 0 0 0 0
Unprotected Assets 45,602 14,773 11,264 816 2,156 8,957 0 7,573 63
Total 31 March 2012 115,771 32,049 64,157 816 2,156 8,957 0 7,573 63
Page 31
Annual accounts
143

The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
12.2 Revaluation reserve balance for property, plant & equipment
Land Buildings Dwellings Plant and machinery Furniture &
Total
excluding
fittings
dwellings
£000 £000 £000 £000 £000 £000
At 1 April 2012 12,800 9,683 772 152 29 23,436
Depreciation Adjustment 0 (543) (154) (44) (9) (750)
Impairment 0 0 0 (16) 0 (16)
Revaluation 420 0 0 0 0 420
At 31 March 2013 13,220 9,140 618 92 20 23,090
Land Buildings Dwellings Plant and machinery Furniture &
Total
excluding
fittings
dwellings
£000 £000 £000 £000 £000 £000
At 1 April 2011 13,026 9,287 640 271 38 23,262
Depreciation Adjustment 0 (529) (319) (119) (9) (976)
Impairment (1,745) (3,316) (1) 0 0 (5,062)
Revaluation 1,519 4,241 452 0 0 6,212
At 31 March 2012 12,800 9,683 772 152 29 23,436
Page 32
144 Annual accounts

The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
13 Economic lives of fixed assets Min life Max life
Years
Years
Buildings exc Dwellings
5 50
Dwellings 5 5
Plant and Machinery 2 15
Transport Equipment 0 0
Information Technology 1 15
Furniture and Fittings 5 15
Intangible assets (Software licenses) 5 15
14 Investment Property 31 March 2013 31 March 2012
£000 £000
At Fair Value
Balance at Beginning of Period 13,124 10,777
Net gain/(loss) from Fair Value Adjustments 1,692 2,347
Balance at End of Period 14,816 13,124
Income from Investment Properties 1,399 1,172
Expenses of Investment Properties (895) (818)
Surplus 504 354
15 Impairments 31 March 2013 31 March 2012
£000 £000
Loss on Land 0
762
Loss on Plant and Equipment 0
3,343
Loss on Building 36
92
Total 36 4,197
16 Capital Commitments 31 March 2013 31 March 2012
£000 £000
Property, plant and equipment 366 0
Intangible Assets 21 0
Total 387 0
Contracted capital commitments at 31 March not otherwise
included in these financial statements:
Annual accounts
145
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The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
17 Inventory Movement - 2012/13 Total Drugs Consumables Energy Other
£000 £000 £000 £000 £000
Carrying Value at 1st April 2,916 1,084 1,705 10 117
Additions 24,148 11,498 12,440 7 203
Inventories recognised as expenses (24,022) (11,387) (12,435) (7) (193)
Carrying Value at 31st March 2013 3,042 1,195 1,710 10 127
17 Inventory Movement - 2011/12 Total Drugs Consumables Energy Other
£000 £000 £000 £000 £000
Carrying Value at 1st April 2,994 1,159 1,714 9 112
Additions 23,977 10,828 12,967 6 176
Inventories recognised as expenses (24,055) (10,903) (12,976) (5) (171)
Carrying Value at 31st March 2012 2,916 1,084 1,705 10 117
146 Annual accounts
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The Hillingdon Hospitals NHS Foundation Trust - - Annual Accounts 2012-13
18.1 Trade and other receivables 31 March 2013 31 March 2012
£000 £000
Current
NHS receivables - - revenue 10,140 7,015
NHS receivables - - accrued income 1,302 2,834
NHS provision for credit notes (2,143) (1,328)
NHS PDC Dividend Receivable 65 0
Sub Total NHS 9,364 8,521
Prepayments 1,526 1,706
VAT receivable 392 326
Other receivables 3,237 5,035
Provision for impaired receivables (1,200) (1,079)
Total current trade and other receivables 13,319 14,509
Non-Current
Other receivables 1,473 1,344
Total non-current trade and other receivables 1,473 1,344
18.2 Provision for impairment of receivables 31 March 2013 31 March 2012
£000 £000
At 1 April 1,079 1,170
Increase/Reduction in in provision) 523 333
Amounts Utilised (403) (426)
Amounts Reversed 1 2
At end of Period 1,200 1,079
18.3.1 Ageing of impaired receivables 31 March 2013 31 March 2012
£000 £000
0 - - 30 days 209 311
30 - - 60 days 4 11
60 - - 90 days 6 10
90 - - 180 days 114 63
over 180 days 867 684
Total 1,200 1,079
18.3.2 Ageing of non-Impaired receivables 31 March 2013 31 March 2012
past their due date £000 £000
0 - - 30 days 2,257 567
30 - - 60 days 671 2,998
60 - - 90 days 517 233
90 - - 180 days 592 649
over 180 days 3,147 3,075
Total 7,184 7,522
19 Cash and cash equivalents 31 March 2013 31 March 2012
£000 £000
Balance at at 1 April 1,897 500
Net increase in in year 2,009 1,397
Balance at at end of Period 3,906 1,897
Made up of
Cash with Government banking services 3,667 1,887
Commercial banks and cash in in hand 239 10
Cash and cash equivalents as in in statement of financial position 3,906 1,897
Cash and cash equivalents as in in statement of cash flows 3,906 1,897
Page 35
Annual accounts
147

The Hillingdon Hospitals NHS Foundation Trust Annual Accounts 2012-13
The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
20 Trade and other payables 31 March 2013 31 March 2012
20 Trade and other payables 31 March 2013 31 March 2012
£000 £000
£000 £000
Current
Current
Receipts in advance 1,111 142
Receipts in advance 1,111 142
NHS payables revenue 2,506 1,525
NHS payables - revenue 2,506 1,525
Amounts due to other related parties revenue 1,633 1,442
Amounts due to other related parties - revenue 1,633 1,442
Other trade payables capital 584 563
Other trade payables - capital 584 563
Other trade payables revenue 7,768 8,527
Other trade payables - revenue 7,768 8,527
Social Security costs 2,802 2,802
Social Security costs 2,802 2,802
Other payables 380 42
Other payables 380 42
NHS PDC Dividend Receivable 61
NHS PDC Dividend Receivable 0 61
Accruals 3,662 3,244
Accruals 3,662 3,244
Total Trade and Other payables 20,446 18,348
Total Trade and Other payables 20,446 18,348
21.1 Borrowings 31 March 2013 31 March 2012
21.1 Borrowings 31 March 2013 31 March 2012
£000 £000
£000 £000
Current
Current
Loans from Department of Health 390 390
Loans from Department of Health 390 390
Obligations under finance leases 705 705
Obligations under finance leases 705 705
Obligations under LIFT contracts 258 256
Obligations under LIFT contracts 258 256
Total current borrowings 1,353 1,351
Total current borrowings 1,353 1,351
Non-current
Non-current
Loans from Department of Health 7,075 7,465
Loans from Department of Health 7,075 7,465
Obligations under finance leases 1,990 585
Obligations under finance leases 1,990 585
Obligations under LIFT contracts 12,877 13,136
Obligations under LIFT contracts 12,877 13,136
Total non current borrowings 21,942 21,186
Total non current borrowings 21,942 21,186
The Trust is party to two Department of Health loans relating to capital investment as follows:
The Trust is party to two Department of Health loans relating to capital investment as follows:
The Trust is party to two Department of Health loans relating to capital investment as follows:
• Loan 1 received 15th December 2009 for £4.0m. Repayments commenced on 15th March 2010 and will continue
Loan until received 15th September 15th December 2034. 2009 The loan for £4.0m. carries Repayments a fixed interest commenced rate at on 4.11%. 15th March 2010 and will
- Loan 1 received 15th December 2009 for £4.0m. Repayments commenced on 15th March 2010 and will
continue until 15th September 2034. The loan carries fixed interest rate at 4.11%.
• continue Loan until 2 received 15th September 15th September 2034. The 2010 loan for carries £4.6m. a fixed Repayments interest rate commenced at 4.11%. on 15th March 2011 and will continue
until 15th September 2030.The loan carries a fixed interest rate at 3.25%.
Loan received 15th September 2010 for £4.6m. Repayments commenced on 15th March 2011 and will
- Loan 2 received 15th September 2010 for £4.6m. Repayments commenced on 15th March 2011 and will
continue until 15th September 2030. The loan carries fixed interest rate at 3.25%.
continue until 15th September 2030. The loan carries a fixed interest rate at 3.25%.
21.2 Loans Payments Scheduled 31 March 2013 31 March 2012
21.2 Loans Payments Scheduled 31 March 2013 31 March 2012
£000 £000
£000 £000
to Year 658 674
0 to 1 Year 658 674
to years 644 658
1 to 2 years 644 658
Years 1,849 1,891
2 - 5 Years 1,849 1,891
More Than Years 7,045 7,647
More Than 5 Years 7,045 7,647
Total Future Gross Loan Commitments 10,196 10,870
Total Future Gross Loan Commitments 10,196 10,870
Less Interest Element (2,731) (3,015)
Less Interest Element (2,731) (3,015)
Total Future Net Loan Commitments 7,465 7,855
Total Future Net Loan Commitments 7,465 7,855
148 Annual accounts
Page 36
Page 36

The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
22 Finance lease obligations
lease arrangements relate to a number of equipment leases which vary in length from three
The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
to seven years.
22 Finance lease obligations
Minimum lease Minimum lease
payments payments
The lease arrangements relate to a number of equipment leases
31
which
March
vary
2013
in length
31
from
March
three
2012
to seven years.
Amounts payable under finance leases £000 £000
Minimum lease Minimum lease
Gross lease liabilities
payments payments
Within one year 814 782
Between one and five years 31 March 2,226 2013 31 March 2012 611
Future Amounts Finance payable Charges under finance leases (345) £000 (103) £000
Present value of minimum lease payments 2,695 1,290
Gross lease liabilities
Net Within lease one Liabilities year
Within Between one one year and five years
814
2,226 705
782
705 611
Between Future Finance one and Charges five years (345) 1,990 (103) 585
Present The LIFT value agreement of minimum is for a lease 25 year payments period which commenced in December 2,695
2008. The scheme 1,290
is
for the provision of clinical accommodation on the Mount Vernon Hospital site which comprises
Net
23 four lease
NHS surgical Liabilities
Local theatres Improvement and outpatient Finance suites. Trust The (LIFT) lease contract payment (inclusive of capital and services)
Within is £1,557k one per year annum (before RPI indexing).Under IFRIC 12, the asset is treated 705 as an asset of the 705
Between Trust; the one substance and five of years the contract is that the Trust has a finance lease and 1,990 payments comprise 585
23.1 two LIFT scheme on-Statement of Financial Position
The LIFT
elements:
agreement
imputed
is for
finance
a 25 year
lease
period
charges
which
and
commenced
service charges.
in December
There are 2,695 2008.
no guarantees,
The scheme 1,290 is
obligations
for The the LIFT provision agreement or other
of is clinical
rights for a associated 25 accommodation year period with which the
on
scheme.
the commenced Mount Vernon in December Hospital 2008. site The which scheme comprises
for the provision of clinical
accommodation on the Mount Vernon Hospital site which comprises four surgical theatres and outpatient suites. The
23 four NHS surgical Local theatres Improvement and outpatient Finance suites. Trust The (LIFT) lease contract payment (inclusive of capital and services)
Total is lease £1,557k payment obligations per annum (inclusive for on-statement (before of capital RPI indexing).Under and of financial services) is position £1,557k IFRIC LIFT 12, per the contracts annum asset (before is due: treated RPI indexing). as an asset Under of the IFRIC 12, the asset is
Trust; treated the as substance asset of of the the Trust; contract the substance is that the of Trust the contract has a finance is that lease the Trust and has payments a finance comprise lease and payments comprise
23.1 two elements: LIFT scheme imputed on-Statement finance lease of charges Financial
and and Position service charges. 31 There There March are are 2013 no no guarantees, 31 March obligations 2012 or other rights
LIFT obligations associated Payments with or other Scheduled scheme. rights associated with the scheme.
£000 £000
Not later than one year 1,160 1,198
Later Total than obligations one year, for not on-statement later than of five financial years position LIFT contracts due: 4,481 4,559
Later than five years 22,300 23,383
Sub total Gross Payments 31 March 27,941 2013 31 March 29,140 2012
LIFT Payments Scheduled £000 £000
Less: Not later interest than element one year (14,806) 1,160 (15,748) 1,198
Later than one year, not later than five years 4,481 4,559
Total Later Future than five Net years LIFT Liabilities 13,135 22,300 13,392 23,383
Sub total Gross Payments 27,941 29,140
23.2 The Trust Charges is committed to expenditure to the following service charge payments over the life
Less: of the interest LIFT scheme:- element (14,806) (15,748)
Total Future Net LIFT Liabilities 31 March 13,135 2013 31 March 13,392 2012
LIFT Expenditure £000 £000
Not The 23.2 later Trust Charges than is committed to one expenditure
yearto the following service charge payments over the life 397 357
Later of the than LIFT one scheme:-
The Trust is committed year, not to later the following than five service years charge payments over the life 1,747 of the LIFT scheme:- 1,669
Later than five years 7,031 7,506
Total 31 March 9,175 2013 31 March 9,532 2012
LIFT Expenditure £000 £000
Not later than one year 397 357
Later than one year, not later than five years 1,747 1,669
Later than five years 7,031 7,506
Total 9,175 9,532
Annual accounts
149

The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
24 Related party transactions
During the year none of the Trust board members or members of the key management staff, or parties related to any of
them, has undertaken any material transactions with The Hillingdon Hospitals NHS Foundation Trust.
The United Kingdom Government is regarded as a related party to the extent that it controls the Department of Health and
National Health Organisations through legislation and funding by the taxpayer. During the year The Hillingdon Hospitals
NHS Foundation Trust has had a significant number of material transactions with the Department, and with other NHS
entities as well as directly with the UK Government. These transactions are itemised below subject to a minimum of £100k for
transactions and £50k for balances for the year to 31st March 2013. These limits are in accordance with the Agreement of
balances exercise for Whole Government Accounts.
24.1 Balances
Current
Receivables as at
31 March 2013
Current
Receivables as at
31 March 2012
Current Payables
as at 31 March
2013
Current
Payables as at
31 March 2012
Entities £000s £000s £000s £000s
Central And North West London MH NHS Foundation Trust 749 572 343 67
Chelsea And Westminster Hospital NHS Foundation Trust 70 91 52 7
Royal Brompton And Harefield NHS Foundation Trust
139 103 67 149
East And North Hertfordshire NHS Trust 2,839 1,745 624 197
Imperial College Healthcare NHS Trust 78 46 223 391
North West London Hospitals NHS Trust 23 112 64 32
Royal Free Hampstead NHS Trust 37 239 154 110
London Strategic Health Authority 22 181
Barnet PCT 79 27
Buckinghamshire PCT 77 61
Croydon PCT 28 66 502
Ealing PCT 474 1,420 10
Hammersmith And Fulham PCT 2 82
Hampshire PCT 142
Harrow PCT 317 166
Hertfordshire PCT 382 253
Hillingdon PCT
3,264 3,311 3 7
Hounslow PCT 670 148
Surrey PCT
NHS Blood and Transplant (excluding Bio Products Laboratory)
NHS Business Services Authority (incl NHS Supply Chain)
110 72
160
685
Bexley NHS Care Trust PCT 4 1 63
Greenwich Teaching PCT 9 91 24
Islington PCT 55
Other NHS 704 1,037 181 189
Total NHS 10,140 9,849 2,506 1,907
Charitable Funds 0 131 0 0
Central and Local Government 392 326 4,435 4,244
Total 10,532 10,306 6,941 6,151
150 Annual accounts

The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
24.2Transactions
Revenue Year to 31
March 2013
Revenue Year to
31 March 2012
Expenditure Year to Expenditure Year to
31 March 2013 31 March 2012
Entities £000s £000s £000s £000s
Central And North West London MH NHS Foundation Trust 1,352 222 654 659
Chelsea And Westminster Hospital NHS Foundation Trust 113 170 7 1
Kings College Hospital NHS Foundation Trust
Moorfields Eye Hospital NHS Foundation Trust
205 210
90
Royal Brompton And Harefield NHS Foundation Trust
169 126 195 120
Royal Free London NHS Foundation Trust 276 206
University College London NHS Foundation Trust 138 84
East And North Hertfordshire NHS Trust 6,462 6,577 1,075 451
Imperial College Healthcare NHS Trust 5 784 636
North West London Hospitals NHS Trust 549 576 402 20
Royal Free Hampstead NHS Trust 309 121
West Hertfordshire Hospitals NHS Trust 108 113 79
London Strategic Health Authority 6,975 7,058
Barnet PCT 189 251
Bedfordshire PCT 159 124
Brent Teaching PCT 552 527
Buckinghamshire PCT 102
Croydon PCT 5,069 4,976
Ealing PCT 12,914 12,365 10
Hammersmith And Fulham PCT 370 495
Hampshire PCT 4,465 3,900 1
Harrow PCT 4,965 4,339
Hertfordshire PCT 4,985 4,553
Hillingdon PCT
131,997 128,391 0
Hounslow PCT 2,647 1,773
Kensington and Chelsea PCT 146
Leicestershire and Rutland PCT 125
Luton Teaching PCT 123 104
Redbridge PCT
104
South East Essex PCT 506 514
Surrey PCT 446 434
West Sussex 101
Westminster PCT 111 1,388 1
NHS Blood and Transplant (excluding Bio Products Laboratory)
NHS Business Services Authority (incl NHS Supply Chain)
1,207 1,485
3,720
NHS Litigation Authority 5,286 4,684
Department of Health 189
Other NHS 2,737 5,365 825 560
Total NHS 188,904 184,757 10,984 12,932
Central and Local Government 0 0 21,147 19,784
Total 188,904 184,757 32,131 32,716
NHS Business Agency is no longer included in related
NHS party Business transactions. Agency It is now longer classified included as a in related party transations. It is now classidied as a commercial company.
commercial company.
Page 39
Annual accounts
151

The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
25 Provisions Current Non-current
31 March 2013 31 March 2013
£000 £000
Pensions relating to other staff 165 1,948
Total 165 1,948
Current
Non-current
31 March 2012 31 March 2012
£000 £000
Pensions relating to other staff 162 1,930
Total 162 1,930
Analysis of Movements 31 March 2013 31 March 2012
£000 £000
At start of period 2,092 2,120
Arising during the year 123 87
Utilised during the year- accruals (42) (40)
Utilised during the year- cash (123) (122)
Unwinding of discount 63 47
At end of period 2,113 2,092
Expected timing of cash flows:
Within one year 165 162
Between one and five years 660 648
After five years 1,288 1,282
Total 2,113 2,092
Provisions are liabilities that are of uncertain timing or amounts which the Trust expects to be
settled by a transfer of economic benefits. The provision for staff pensions has been calculated using
information supplied by NHS Business Service Authority Pensions Division.
£29,487k is included in the provisions of the NHS Litigation Authority at 31st March 2013 in respect
of clinical negligence liabilities of the Trust. (£25,482k 31st March 2012).
152 Annual accounts

The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
26 Contingent liabilities 31 March 201331 March 2012
£000 £000
Contingent liabilities 46 16
Total 46 16
The Trust's contingent liabilities include £40k relating to employee work injuries and £6k relating to public
slips or falls. Further liabilities relate to the excess payable on claims made against the Liabilities to Third
parties Scheme which is a non-clinical risk pooling scheme operated by the NHS Litigation Authority.
27 Financial instruments 31 March 2013 31 March 2012
Book Value Fair Value Book Value Fair Value
27.1 Financial Assets £000 £000 £000 £000
NHS Receivables 10,140 10,140 9,849 9,849
Non NHS Receivables 518 518 1,663 1,663
Other Investments 14,816 14,816 13,124 13,124
Cash and cash equivalents (at bank and in hand) 3,906 3,906 1,897 1,897
Total at end of period
29,380 0 29,380 26,533 26,533
31 March 2013 31 March 2012
Book Value Fair Value Book Value Fair Value
27.2 Financial Liabilities £000 £000 £000 £000
Borrowings excluding Finance lease and LIFT liabilities 7,465 7,465 7,855 7,855
Obligations under finance leases 2,695 2,695 1,290 1,290
Obligations under LIFT contract 13,135 13,135 13,392 13,392
NHS Trade and Other payables excluding non financial assets 2,506 2,506 1,874 1,874
Non-NHS Trade and Other payables excluding non financial assets 12,394 12,394 12,088 12,088
Provisions Under Contract 2,113 2,113 2,092 2,092
Total at end of period 40,308 40,308 38,591 38,591
31 March 2013 31 March 2012
27.2 Maturity of Financial Liabilities £000 £000
In one year or less 15,576 15,475
In more than one year but not more than two years 1,307 1,081
In more than two years but not more than five years 4,539 1,571
In more than five years 18,886 20,464
Total 40,308 38,591
Annual accounts
153

The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
28. 28 Financial Risk Risk Rating Rating
31 March 2013 31 March 2012
Metric Criteria Actual Rating Weighting Rating Weighting
EBITDA Margin Underlying Performance 5.1% 3 25% 3 25%
EBITDA, % achieved Achievement of Plan 88.4% 4 10% 3 10%
Return on investment Financial Efficiency -1.4% 2 20% 2 20%
I&E surplus margin Financial Efficiency -0.9% 2 20% 2 20%
Liquid ratio Liquidity days 17.7 3 25% 3 25%
Weighted Average Weighting 2.70 100% 2.60 100%
Financial Risk Rating 3 3
Financial Risk Rating boundaries:
Weighting 5 4 3 2 1
EBITDA Margin 25% 11.0% 9.0% 5.0% 1.0%

The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
29 Prudential borrowing limit
31 March 2013 31 March 2012
£000 £000
Total long term borrowing limit set by Monitor per Terms of
Authorisation
23,700 37,100
Working Capital Factilty Facility limit set by by Monitor
13,800 13,800
Total Prudential Borrowing Limit 37,500 50,900
Borrowing (as defined in the Prudential Borrowing Code) at 1 April 22,537 23,889
Net actual borrowing/(repayment) in year 758 (1,352)
Long term borrowing at 31 March 23,295 22,537
The NHS foundation trust is required to comply and remain within a prudential borrowing limit. This is
The made NHS up Foundation of two elements:- Trust is required to comply and remain within a prudential borrowing limit. This is
made up of two elements:
1) The maximum cumulative amount of long-term borrowing. This
1. is set The by maximum reference cumulative to the four amount ratio tests of long-term set out in the borrowing. Prudential This Borrowing is set by reference Code for to NHS the foundation four ratio
trusts.
tests
The
set
financial
out in the
risk
Prudential
rating set
Borrowing
under Monitor's
Code for
Compliance
NHS foundation
Framework
trusts.
determines
The financial
one
risk
of
rating
the ratios
set
and therefore can impact on the long term borrowing limit; and
under Monitor’s Compliance Framework determines one of the ratios and therefore can impact on the
2) The amount of any working capital facility
long term borrowing limit; and
approved by Monitor.
Further information on the
2. Prudential The amount Borrowing of any Code working for NHS capital foundation facility approved trusts and by Compliance Monitor. Framework can be found on
Further Monitor's information website. on the Prudential Borrowing Code for NHS foundation trusts and Compliance
Framework can be found on Monitor’s website.
Annual accounts
155

The Hillingdon Hospitals NHS Foundation Trust - Annual Accounts 2012-13
30 Third 30 Third party party assets assets
The Trust held £3,432 cash and cash equivalents at 31 March 2013 (£1,823 at 31 March 2012) which relates to monies held by the
NHS Trust on behalf of patients. This has been excluded from the cash and cash equivalents figure reported in the accounts.
31 March 2013 31 March 2012
31 Losses 31 Losses and and Special Special Payments Payments
Cases Value Cases Value
£000 £000
Losses of cash:
Theft/Fraud 1 1 0 0
Overpayment of salaries, wages,fees and allowances 3 9 4 1
Bad debts and claims abandoned
Private patients 18 61 3 1
Overseas overseas visitors 168 338 157 353
Other 0 0 2 2
Totals 190 409 0 166 357
Amounts Recovered 1 1 1 2
The amounts reported in this note were incurred as actual costs for the year to date and do not contain any accrued costs. These
sums have been reported to and approved by the Audit Committee of the Trust.
156 Annual accounts

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Annual accounts
157