Nurses Day! - Birmingham Children's Hospital

ANNUAL REPORT
AND ACCOUNTS
2012/13

ANNUAL REPORT VIDEOS
CONTENTS
To go to the section you want, click on the picture above it
This year, to make our Annual Report more
interactive and easy to digest, we are using video
to tell the story of our year.
To watch our short videos visit our hospital website
www.bch.nhs.uk/corporate/annual-report
or scan the QR code on this page.
We have four videos available which show how
we’ve performed against our strategic objectives
throughout the year. These objectives help us
focus on maintaining our high standards, improving
them even further and planning for the future too.
1. Chief Executive’s Introduction
2. Delivering excellent care today
3. Striving to make it even better
4. Shaping excellent care for tomorrow
When you see this icon on a page in
Section One of the report, it means you
can watch a film summarising the key
points in that section.
WATCH THE VIDEO
INTRODUCTION
Chairman & Chief Executive’s Foreword
Who we are and what we do
Our year at a glance
SECTION THREE
Our Quality Report
SECTION ONE
Our journey through the year
SECTION FOUR
Annual Governance Statement
SECTION TWO
The Governance of our Organisation
SECTION FIVE
Summary Financial Statements

INTRODUCTION
WATCH THE VIDEO
BACK TO CONTENTS PAGE
Chairman & Chief Executive’s Foreword
This year we proudly celebrated our hospital’s 150th anniversary – for 150 years we have
been making a difference to the lives of countless children, young people and their families
from Birmingham, the West Midlands, across the UK and beyond.
We’ve taken the opportunity to look back at where
we’ve come from, where we are today and where
we want to be in the future. In true Birmingham
Children’s Hospital style we made sure it was a
year we wouldn’t forget, with lots of events and
activities to celebrate and reward our staff who
work tirelessly, day in, day out, to provide excellent
care to our children and young people. Without
them, we wouldn’t be where we are today.
Keith Lester,
Interim Chairman
However, amongst the
celebrations we’ve
also had our busiest
year ever, with more
patients than we’ve
ever seen before.
We have coped well
by changing our
patient pathways and
making significant
improvements to our
facilities to make sure
we can continue to deliver
our high quality services
to more patients.
This includes
the opening of our Paediatric Intensive Care Unit
(PICU) extension, which increases our capacity
to 26 beds and 31 by 2014, and the launch of
our new outpatient pharmacy, which has made
it significantly quicker and easier for families to
collect their child’s medicine before they go home.
These developments provide a strong foundation
to develop our services for children and young
people with serious heart problems. Congenital
heart services are currently under national review
and at the end of 2012/13 we await the final
outcome.
A number of innovative projects also came to
fruition during the year to help us improve our
services and patient experience, including our 24-
hour Paediatric Assessment Clinical intervention
and Education (PACE) team, which was launched
to further support staff and parents of patients
who they feel may be deteriorating. It has been
a resounding success already and we look
forward to seeing how the team develops further
throughout the year.
Supporting PACE is our revolutionary Parental
Concern Project, funded by the Health Foundation,
to look at how we can help parents play a more
active role in their child’s care by developing an
effective assessment tool which measures their
levels of concern. This will continue into 2013/14.
Our award-winning Maple food ordering system,
which gives children and young people an easy
way to choose the food they want and reduce food
waste has been a big hit, as has our revolutionary
new Feedback App for smart phones, which gives
patients and families a new way to give instant
feedback on their experiences, good or bad, and
allows us to respond and make improvements in
real-time.
Another significant achievement has been our new
Dignity Giving Suit. Working with staff, children
and young people we have created a new outfit
to replace the traditional backless hospital gown
to give our young patients more dignity during all
stages of their care. The impact has already been
huge and some of our patients love them so much
they want to take them home!
Health Promotion has been an important theme
throughout the year for our patients, families and
our 3,300 staff. We’re leading the way regionally
and nationally with our work on the Making Every
Contact Count initiative to use every opportunity
we have with patients and families to deliver
brief health advice. We have also launched our
staff Health and Wellbeing Strategy which details
our commitment to supporting staff with fun and
interactive ways to stay happy and healthy.
We’ve also welcomed a number of high profile
visitors to our hospital during the year. Health
Minister Dr Dan Poulter came to speak to ward
staff about our feedback app and hear how our
Safer Children Audit No Harm initiative (SCAN) is
helping to reduce harm, and Lord Howe came to
learn more about our groundbreaking work in the
field of rare diseases. Secretary of State Andrew
Lansley officially launched our £3.7m 3T MRI
scanner on the 64th anniversary of the NHS and
Prime Minister David Cameron visited a few weeks
later to spend time with our nursing teams on their
ward rounds following the publication of the new
Nursing and Care Quality Forum report in May.
But of course this year has been a landmark
year for the NHS with Sir Robert Francis QC’s
final report into failings at Mid Staffordshire NHS
Foundation Trust. It has given every organisation
the opportunity to pause and think about the
services we provide. We have responded by
generating a large scale discussion across
the Trust to see how we can make further
improvements to ensure we continue to provide
high quality, dignified care at all times. This will
conclude in September 2013 and we already have
some powerful material from staff which we can
act upon to improve patient care further.
Nationally, the NHS has been preparing for
major changes to the way that local and national
specialised services are commissioned. This has
led to the development of fewer larger specialist
centres with more expert staff who can better
treat rare conditions and improve outcomes. It’s
a mark of the clinical excellence at Birmingham
Children’s Hospital that we have been designated
as a specialist centre for both epilepsy surgery and
major trauma.
4 5
Looking forward, we know we face a growing
population of younger people across the West
Midlands over the next few years. Teamed with
a worrying trend of conditions like asthma and
obesity, developments in medical technology
and an increase in demand for our specialised
services, we know we will be treating lots more
children and young people in the near future.
To make sure that we have the world-class
facilities that our children, young people and
families need and deserve, we have been busy
exploring options for a new hospital, either at
Steelhouse Lane or alongside our partners at
the Queen Elizabeth Hospital and Birmingham
Women’s Hospital in Edgbaston. There is still a lot
more work to be done on this, which will continue
throughout the year, and we will be working closely
with staff, our patients and families and partners to
make sure we get this important decision right.
The NHS, like the rest of the public sector, is
facing severe financial pressures as a result of
the national economic situation. During 2012/13
we made over £8 million of efficiency savings. In
2013/14 we will work with our staff to ensure that
we can continue to deliver this level of savings as
the financial challenges are set to continue.
We’ve had another very exciting year at
Birmingham Children’s Hospital
with many significant
developments, achievements
and plans in place for a
great future.
We are well on our
way to achieving
our vision of
becoming the
leading children’s
healthcare provider
and look forward
to continuing our
hospital’s great
legacy for another
150 years to
come.
David Melbourne,
Interim Chief Executive

6 7
BACK TO CONTENTS PAGE
Who we are and what we do
Birmingham Children’s Hospital NHS Foundation Trust provides the widest range of children’s health
services for young patients from Birmingham, the West Midlands and beyond, with over 240,000 patient
visits every year.
We are a nationally designated specialist centre for epilepsy surgery and a trauma centre for the West
Midlands, a national transplant centre, and a centre of excellence for complex heart conditions, the
treatment of burns, cancer, and liver and kidney disease. We also have one of the largest Child and
Adolescent Mental Health Services in the country with a dedicated Eating Disorder Unit and Acute
Assessment Unit for regional referrals of children and young people with the most serious problems (Tier 4).
Our hospital has:
l 354 beds across 22 wards at Steelhouse Lane
and our Child and Adolescent Mental Health
(CAMHS) site at Parkview;
l 34 specialties (including liver transplant surgery,
cardiac surgery, burns, major trauma,
craniofacial surgery, blood and marrow
transplantation, specialised respiratory and
dermatology, neurology, cystic fibrosis, Child and
Adolescent Mental Health Services);
l 11 Nationally Commissioned Services;
l 12 theatres (including our Hybrid and
Laparoscopic theatres);
l £3.7m 3T MRI scanner which supports
pioneering research into brain tumours in
children;
l 150,000 outpatient visits a year;
l 50,000 Emergency Department patients a year;
l 39,000 inpatient admissions to hospital each year;
l 61 parent and family accommodation rooms –
the largest facility in Europe;
l KIDS regional emergency transport service;
l Wellcome Clinical Research Facility;
l 26 bedded PICU (to increase to 31 next year);
l £233m annual income;
l 3,330 staff.
Education
As one of the UK’s leading paediatric teaching
centres we go to great lengths to target, teach,
nurture and develop the skills of our present and
future workforce, to enable access to training and
education and to foster life-long learning. Our aim
is that all staff are appropriately equipped and
qualified for the work they do and continue to learn
and develop in their time with us. We continually
examine our practice and look at ways to innovate
and improve the service we all deliver so that our
children, young people and families receive a firstclass
service.
Research
Research is a fundamental part of what we do
at the hospital and we are leading the way with
pioneering international research into:
l Childhood cancer;
l Inherited metabolic disorders / rare diseases;
l Liver disease;
l Infection, inflammation and immunity;
l Nutrition, growth and metabolism in childhood;
l Drug use in children;
l Relapsed and refractory acute lymphoblastic
leukaemia;
l Infant neuroblastoma; Infant brain tumours.

BACK TO CONTENTS PAGE
Our
Mission
Our
Vision
Our
Values
To provide outstanding care and treatment to all
children and young people who choose and need
to use our services, and to share and spread new
knowledge and practice, so we are always at the
forefront of what is possible.
To be the leading provider of healthcare for
children and young people, giving them care and
support – whatever treatment they need – in a
hospital without walls.
We know that organisations which have strong
values and behaviours do well and that employees
are engaged, happy and motivated in their work.
We’ve worked closely with staff to develop and
embed our values in all that we do at Birmingham
Children’s Hospital and we will continue to ensure
that they underpin the way we care for our patients
and each other.
To help us do this, we have six strategic objectives which focus us on where we
are now and what we want to achieve in
Delivering excellent
care today...
Every child
and young
person
requiring
access
to care at
Birmingham
Children’s
Hospital will
be admitted
in a timely
way, with no
unneccessary
waiting along
their pathway
Every child
and young
person
cared for by
Birmingham
Children’s
Hospital will
be provided
with safe,
high quality
care, and
a fantastic
patient
and family
experience
Striving to make it
even better...
Every
member
of staff
working for
Birmingham
Children’s
Hospital will
be looking
for, and
delivering
better ways
of providing
outstanding
care, at better
value
Every
member
of staff
working for
Birmingham
Children’s
Hospital
will be a
champion for
children and
young people
Shaping excellent care
for tomorrow...
We will
strengthen
Birmingham
Children’s
Hospital as
a provider of
Specialised
and Highly
Specialised
Services,
so that we
become
the leading
provider of
children’s
healthcare
in the UK
Our ‘journey through the year’ section from page 12 details how
we’ve been delivering against each of these strategic objectives.
We will
continue
to develop
Birmingham
Children’s
Hospital as
a provider of
outstanding
local
services:
‘a hospital
without
walls’,
working
in close
partnership
with other
organisations
Trust
Patients and families will trust us to have the
knowledge and ability to give them the very highest
quality of care, and as colleagues we will trust
each other to our jobs well.
Commitment
We will always show commitment to achieving the
very best possible outcomes for our patients and
families, working collaboratively with colleagues to
achieve this.
Compassion
We will always be friendly, approachable and alert
to what our patients, families and colleagues need.
Courage
We will always have the courage to stand up for
what is right, raise concerns, challenge the status
quo and improve care at all times.
Respect
Whatever the needs or beliefs of our children,
young people and families, we will always do all we
can to tailor their care and make their experience a
good one. As colleagues we will respect and value
differences to create a great place to work.
8 9

BACK TO CONTENTS PAGE
Our year at a glance
April May June
July
Oct
Prime Minister David
Cameron joined
nursing teams on ward
rounds, sparked by
the publication of the
new Nursing and Care
Quality Forum report
Our hospital’s
150th
birthday!
Our £4m Children’s
Cancer Centre
fundraising appeal
launched
BCH
Cardiac Surgeon,
Mr David Barron,
became an
ITV Daybreak
Health Hero
Sec of State Andrew Lansley
launches our
£3.7m 3T MRI scanner
Nurses Day!
Celebrating the
outstanding
contribution of our
nursing teams
Nov Dec Jan Feb March
BCH becomes a regional epilepsy surgery centre
Our new outpatient
pharmacy, the
Medicine Chest,
opens to patients
and families
Launch of our
Dignity Giving
Suits
Doors open to our new
Paediatric Intensive Care Unit,
making us the largest unit in the country
JLS gives
some of our
special
young patients
a Christmas
to remember
Launch of our patient
and family feedback
app – an NHS first
10 11

SECTION ONE
WATCH THE VIDEO
BACK TO CONTENTS PAGE
Our journey through the year
Delivering excellent care today
Every child and young person requiring access to care at Birmingham Children’s Hospital
will be admitted in a timely way, with no unnecessary waiting along their pathway.
For yet another year running, the number of
children and young people who used Birmingham
Children’s Hospital has grown. We’ve worked hard
during the year to develop and grow our services
so that we can continue to provide world-class
care for all of our children and young people, and
more quickly, whether this be in our hospital, at our
Child and Adolescent Mental Health Service at our
Parkview site in Moseley, out in the community or
at home.
As one of the country’s leading specialist hospitals,
lots of children and young people with very serious
or life-threatening conditions come to us in need
of care from our specialist teams in theatres and
intensive care. This unfortunately means that from
time to time we have to reschedule less urgent
procedures.
Nobody wants to wait a long time to see a doctor
or consultant or have an operation cancelled,
so over the last year we have made significant
changes to the way we work to help reduce our
waiting times.
We’ve created space for an extra 11 beds in our
brand new, bright and modern Paediatric Intensive
Care Unit (PICU) extension which opened in
November 2012. The unit also includes a new
breast feeding room, two parents’ rooms, a
bedroom and a reception area.
This increases our total capacity to 31 beds, 26 of
which are open now, which will make us the largest
single site unit in the UK. This means we can care
for more of the sickest children and young people
who need our help every year and reduce the wait
for surgery.
Our new £2.1m Paediatric Assessment Unit (PAU),
which opened in February 2012, has been a
resounding success and has gone from strength to
strength throughout the year.
Built in the space which formed the old ward 14,
PAU offers a place for children and young people
needing short medical or surgical admissions to
the hospital (around 24 hours or less), making
access to care quicker and ensuring they get the
right treatment and care in the right place, at the
right time.
This is an important stage in the development
of our emergency care pathway which provides
a much better patient experience overall by
improving patient flows through the hospital as
these patients don’t need to be managed alongside
highly complex patients on other hospital wards.
We are really proud that we have been able
to maintain our high standards of care whilst
increasing our capacity and flow, which is evident
in the positive patient feedback we regularly
receive from our children, young people and
families.
Our Kids Intensive Care and Decision Support
service (KIDS) has gone from strength to strength
with another extremely busy year.
The 24/7 service, which specialises in the
management of critically ill children presenting to
their local hospitals and during transfer to intensive
care, moved to a new bespoke operations centre
with state of the art telecommunications in May
2012. St John Ambulances and drivers are now
onsite with the KIDS team which has dramatically
reduced the KIDS mobilisation time and allows
even closer team working.
12 13
This is the first time I’ve been to children’s with my
little boy I can’t thank the staff enough! They are so,
so polite and kind you forget you’re in a hospital.
Amazing people and place, sounds like I’m talking
about Disneyland lol. I will be talking about it for
weeks to come.

BACK TO CONTENTS PAGE
Having extensively used the KIDS Service over this weekend, I just wanted
to thank you for such a fantastic service that you all provide. It is not just the
securing of intensive care beds and retrieval, but more importantly the support
provided to the paediatricians throughout the region does not make them feel
isolated when faced with a very sick child – I think this is the most valuable part
of the service.
At a time when reconfiguration of children’s services is high on the agenda with
proposed fewer inpatient units, the model that KIDS provides for supporting sick
children and healthcare professionals away from the major centres provides an
excellent model for emulation.
Dr Sanjeev Deshpande,
Consultant Neonatologist, Royal Shrewsbury Hospital
During 2012/13 the service received 1,668
referrals (an increase of 354 from 2011/12) for
advice and transport of young patients between
local hospitals and children’s intensive care units
in the Midlands, as well as to and from other units
across the UK. Of these, 1,275 were transported -
815 by KIDS and 456 on request by KIDS to other
teams.
Another 400 patients received advice and input
from a KIDS consultant which allowed them to
remain at their local hospital. Feedback from these
hospitals has been very positive. Parents and
carers of children who were able to travel with their
child to PICU in our new ambulances have told us
We’ve also had the builders in this year to create
a new state-of-the-art outpatient pharmacy, the
Medicine Chest, which is making it quicker and
easier for families to collect their prescription onsite
before they go home.
The brand new facility, which opened in January, is
bright, modern and child-friendly and gives families
access to specialist paediatric pharmacists to talk
14 15
about their child’s medicine. It’s also home to a
high-tech automated robot which selects medicines
for dispensing.
Having our own dedicated outpatient pharmacy
means we can supply the most suitable medicines
based on our prescriptions which are tailored
specifically for children, ensuring they are of
the highest quality and cost effective. Since we
opened, waiting times have reduced dramatically
from 45 minutes to an average of just 12 which
means our families can get home quicker.

16 17
BACK TO CONTENTS PAGE
Delivering excellent care today
Every child and young person cared for by Birmingham Children’s Hospital will be
provided with safe, high quality care, and a fantastic patient and family experience.
Children, young people and their families have a
right to be treated in a safe environment where no
avoidable harm is suffered. We want to be a place
where safety is everyone’s top priority and this is
reflected in our Safety Strategy.
Our strategy sets challenging annual targets
to measure our progress and the effectiveness
of interventions. The 2012/13 targets included
avoidable pressure ulcers, medication incidents
resulting in harm, Central Venous Catheter (CVC)
related blood stream infections and life threatening
events which could have been predicted and
prevented. A detailed breakdown of these safety
targets and the results ccan be found in the Quality
Report from page 92.
We’re really pleased with how we are doing but
know that there is always more we can to do
improve patient safety. We will continue to monitor
our progress against these targets to ensure that
we work towards eliminating avoidable harm at
Birmingham Children’s Hospital.
Listening to what our children, young people and
families tell us is something that we’re good at.
Over the year we’ve continued to work hard to
embed patient experience into our daily practice
and we are leading the way with our active
participation and engagement with children and
young people.
We have seen the visibility and influence of our
Young Person’s Advisory Group (YPAG) continue
to grow and they have played a key role in decision
making and planning at the hospital as well as
nationally. They have helped plan our Annual Staff
Awards and presented at our AGM in September,
helped us redesign our outpatients area and
theatres and played an important part in the second
consultation with Professor Steve Field about the
role of young people in the NHS Constitution. Plans
are also underway, in collaboration with the Royal
College of Paediatrics and Child Health (RCPCH)
and National Youth Symposium to be held later in
2013 or early 2014.

18 19
BACK TO CONTENTS PAGE
Since April 2012, in preparation for the Department
of Health’s national Friends and Family test, which
commenced in April 2013, we have been asking
parents and carers on their day of discharge how
likely it is they would recommend the hospital
to friends or family. A ‘net promoter’ score is
generated from their responses.
We have asked almost 2,000 parents and carers
and saw a rapid rise from an initial score of 52 to 81
in June 2012 where it has since stayed consistently
within the top quartile score of all acute trusts
across the NHS Midlands and East region.
But as we are a children’s hospital we want to find
out what children and young people think about our
hospital too, so in addition to parents and carers we
introduced a young person’s version of the question
at the same time. 97% of children and young
people ‘agree a bit’ or ‘agree a lot’ that they would
tell their friends and family that this was a good
hospital.
But no matter what we score on the Friends and
Family test we never stop doing all that we can to
improve the way we do things.
We want our patient experience programme
to provide mechanisms and processes
that enable every child and young
person, from all cultures and backgrounds, to tell
us in a way they want to about their experience
of the hospital and their care to influence future
development, design and delivery for all children
and young people. This is why we use a toolkit
approach which includes verbal feedback, mystery
shoppers, focus groups, email and text messaging,
feedback cards, patient experience walkabouts,
creative arts and much more.
Most importantly, it remains our objective to put the
child, young person and family at the heart of all
we do, ensuring that we listen to and respond to
what they are telling us. With that in mind we have
developed and launched our new Birmingham
Children’s Hospital Feedback app to make patient
and family feedback quicker, easier and more
effective than ever before.
The app is the first of its type in the NHS and
enables patients and families to interact with us
in an innovative new way and send their thoughts
and comments directly to the ward or area they
have visited with the simple click of a button.
The anonymous message goes straight to the
manager in charge so it can be addressed in realtime
and also goes unedited on our website so that
other people can benefit from reading it too.
The messages and comments from the app,
alongside our feedback cards, texts and emails,
is collated, reviewed and analysed to pick up any
emerging themes or issues that we need to take
action on.
Following a pilot on two of our wards, we have
rolled the app out across the Trust and have had
hundreds of messages through so far. The vast
majority have been positive, which is great as it’s
important that we celebrate a job well done by our
teams, but we’ve also had constructive feedback
about improvements that we can make too.
One parent used the app to let us know that the
lock on the toilet door was sticking and another
suggested some improvements we could make
to the disabled facilities on one of wards, which
is something we’re looking into as part of future
developments.

20 21
20 21
Case study
BACK TO CONTENTS PAGE
Parents of two year old Lola, Paul Dolan and
Michelle Cook from Redditch in Worcestershire,
used the app for the first time on one of our surgical wards.
Technology is always changing and this is a
great way to give comments about how you
feel as a parent and it lets the hospital know
about the great work they’re doing too.
It was really easy to download the app and give our
feedback and I got a message back from the ward
manager within an hour, which was great. It’s good to
know that someone’s taking what you say seriously
and is there to act on your feedback straightaway.

BACK TO CONTENTS PAGE
Another project we’ve worked on to improve
our patient experience has been to redesign the
traditional backless and fiddly NHS hospital gown.
The dignity of our patients is so important to us
and we want our children and young people to
feel comfortable and secure while they’re with
us. Throughout the year we’ve been working with
young people and fashion industry experts to
produce our innovative new Dignity Giving Suits
which protects our patients’ modesty while allowing
quick, easy and dignified access for their procedure
and follow-up care.
A short sleeved top and cut-off trousers is joined
with Velcro at several key points so it can be used
in every possible theatre and post-operative care
scenario. This could be for complex heart surgery,
the insertion of a neck line or hernia repair, or
accessing a plaster cast on a broken arm.
Based entirely on the needs of our
young patients and their clinical
requirements, the innovative
design is the first of its type in
the NHS, truly fit-for-purpose
and something we know that
children and young people
want. Since its launch in
February 2013 we’ve
had lots of interest from
hospitals around the UK
about how they can use
the suits too.
WATCH THE VIDEO
Artist’s Birmingham impression Children’s of the respiratory Hospital—Sleep centre’s Room— sleep testing Respiratory room Services
Job no. 4271
Option A
In January we started work on a six-month project
to improve the patient and family experience for
children and young people with lung problems,
such as cystic fibrosis, sleep disordered breathing,
asthma and those who may be oxygen and
ventilator dependant.
Thanks to a £500k donation to the hospital’s charity
from a local newspaper, The Sunday Mercury,
we have been able to start work on our new
Respiratory Centre, which brings all our respiratory
services together in one location, rather than being
spread across the hospital site.
The modern unit will have a second lung function
testing area, a counselling room and three purpose
built sleep testing bedrooms.
Sleep disruption or deprivation can be caused by
a vast number of different conditions and can have
a real impact on a child or young person’s school
life and behaviour. The sleep testing rooms will
be decorated just like a child’s bedroom at home
so they feel relaxed and comfortable which will
improve the way our doctors can monitor their
breathing and how it affects their sleep.
We’ve also made changes and improvements over
at our Child and Adolescent Mental Health Service
(CAMHS) Parkview site too.
22 23
Last year we opened our Irwin Ward – a dedicated
inpatient eating disorder unit which is helping our
patients get quicker and better access to treatment.
The 12 bedded unit is one of only four specialist
centres of its type in the NHS which treats 12 to 18
year olds. Since it opened we are pleased to report
a 100% success rate in helping 20 young people
with eating disorders get back to a healthy weight.
This success is testament to the team’s
commitment to not only working with the young
people themselves but their families too. We expect
parents to play a key part in the recovery process
as they know them best and can help hugely while
they are with us, as well as when they’re back at
home, so they can regain control over their lives.
Also at Parkview we ran a successful 12-month
pilot to trial a Place of Safety - a specialised suite
for young people who are detained by police under
the Mental Health Act. The Place of Safety provides
a comfortable and safe alternative to a police cell,
which we know has a detrimental and negative
impact on them and their families in a time of crisis.
The pilot has gone well, with several young people
accessing the Place of Safety over the last 12
months. Future development plans for the Parkview
site include a specially designed suite attached to
one of the inpatient units so that we can ensure
our young patients in need receive an excellent
standard of care in the best environment possible.

WATCH THE VIDEO
BACK TO CONTENTS PAGE
Striving to make it even better
Every member of staff working for Birmingham Children’s Hospital will be looking for and
delivering better ways of providing outstanding care, at better value.
Every day our staff go the extra mile to meet our
strategic objectives of delivering excellent care and
our incredibly talented workforce have taken the
initiative to design and deliver a number of projects
over the year which are already reaping rewards
and leading the way on a national scale.
In January we launched our Paediatric Assessment
Clinical intervention and Education (PACE) team
to give ward staff and parents an additional 24-
hour support service for patients they feel may be
deteriorating but don’t necessarily require intensive
care, or when they are particularly worried about a
child’s condition.
The PACE team acts as an advocate for nurses
and parents with concerns. The strong relationship
they have with senior nursing and medical staff in
our Paediatric Intensive Care Unit (PICU) means
that they are able to escalate concerns quickly and
effectively so that the child is assessed as early as
possible.
In the first two months of operation, the PACE team
saw an average of 30 children a week and both
staff and parents have really seen the benefits.
They feel that their concerns have been listened to
and addressed more effectively and deteriorating
children were helped more quickly. Children are
also coming out of PICU earlier because the ward
staff have felt well supported to care for highly
dependent children, freeing up more bed spaces for
our sickest children.
24 25
Complementary to PACE is another innovative
Birmingham Children’s Hospital project - the
Parental Concern Project – funded by the Health
Foundation’s Shine programme.
Parents have a unique insight about their child’s
health and we take their concerns just as seriously
as other healthcare observations. We value their
views and involve them in the decision making
processes about their child’s care as much as
possible but do recognise that families sometimes
feel that their concerns aren’t listened to with the
seriousness that they would like. This important
project is looking at how we can develop an
observation framework to help parents play a more
active role in their child’s care.
There is currently no assessment tool available
within the NHS to capture parental observations
about when a child might not be ‘themselves’.
Instead we rely on verbal communication between
clinical teams and families around particular
observations, which can sometimes be open to
interpretation around the level of concern and the
appropriate resulting action.
Throughout 2013 the project team will continue to
work with families to develop and test approaches,
put ideas into practice and gather evidence about
what works and what doesn’t, with high hopes that
the outcomes will act as a blueprint for other health
organisations across the UK.

Striving to make it even better
Every member of staff working for Birmingham Children’s Hospital will be a champion for
children and young people.
We are incredibly proud of our staff at Birmingham
Children’s Hospital who day in, day out, deliver
outstanding patient care to our children, young
people and families.
This year has seen the launch of our People
Strategy which sets out to staff how we will support
them now and in the future, bringing together four
key areas:
1. Developing our People
Our staff have established an outstanding
reputation for care and innovative advances in
research, teaching and technology in Birmingham,
the West Midlands, UK and overseas.
We offer excellent education with robust
frameworks to assure the quality of delivery and
assessment. Our portfolio includes accreditation
status for the Institute of Leadership and
Management and our own Vocational Centre
– BCH Live - where we provide access to
apprenticeships for new and existing staff. During
the year we have also expanded our range of
e-learning materials enabling staff to access
learning more flexibly.
We continue to create and embed a culture of
continuous learning so that all staff have the
opportunity to reach their full potential while
enabling us to develop new roles and ways of
working.
2. Managing our People
We have continued to grow our workforce
throughout the year in line with the increased
demand for our services and have redesigned the
way some are delivered so that staff feel more
satisfied about the contribution they make.
We currently employ 3,330 people and at the end
of March 2013 our staff turnover rate was 7.95% -
well within our target of 9%.
Through the Business Planning processes we
have reviewed each service and anticipated where
potential changes in supply and demand of staff
may impact on us in the future. For example, over
the next two years we plan to invest in Nurse
Practitioner roles as we know the number of junior
doctors will reduce in the coming years. This means
we need to consider how we deliver our core
business in alternative ways to ensure our patients
and families continue to get the very best health
care and support.
BACK TO CONTENTS PAGE
Involving staff in changes to the workplace has
been a key focus this year. Our 2012 NHS Staff
Survey showed that we are improving, with 54%
of staff who responded agreeing that they feel
involved in changes that affect their work/area and
department, compared to 46% in 2011.
We have spent this year perfecting a prerecruitment
assessment tool which assesses the
values and behaviours of prospective applicants
who want to work at the hospital, ensuring that
they are well suited and display behaviours
which are aligned to our values. This involved
around 200 staff who took part in workshops and
questionnaires to develop the assessment process
which will begin in April 2013.
26 27

BACK TO CONTENTS PAGE
A robust workforce planning framework has also
been developed to support managers to assess
the productivity of their people as a resource and
predict workforce and educational requirements in
line with service developments.
Diversity and inclusion is also important to us at
Birmingham Children’s Hospital. We want to build
an organisational culture that ensures we deliver
personalised care to children and young people
and make Birmingham Children’s Hospital the
employer of choice, attracting and developing a
diverse workforce to ensure we deliver our strategic
priorities and unlock untapped potential.
We launched our Diversity and Inclusion Action
Plan in April 2013 which aims to meet the needs of
our diverse population, ensure we meet regulatory
requirements and have a strong corporate
reputation and community profile.
3. Caring for our people
The health and wellbeing of our staff, as well as
our patients and families, is incredibly important
to us as because without our staff we wouldn’t be
able to do what we do. To help everyone stay fit
and able to work we have continued to take steps
to support improvements in wellbeing to not only
maximise attendance at work but also to encourage
conversations about health and wellbeing at
appraisal.
The London Olympics provided an opportunity
in summer to get staff involved in fun, healthy
activities, such as a static charity bike challenge,
and the theme for our Annual General Meeting
in September was health promotion, with healthy
food and drink stalls, advice and fun and interactive
activities for staff to get involved in.
In March we launched our Health and Wellbeing
Strategy to bring together everything that we’re
doing to support staff and empower individuals to
make healthy choices and give them the tools to
help improve their physical and mental wellbeing.
We also intend to build upon the success of
challenges such as the pedometer challenge where
staff were encourage to walk as many steps as
possible over six weeks to win a prize. This was
an incredibly successful initiative and hundreds of
people took part.
An exciting new resource for staff is our BCH
Health Club which offers members exclusive
information and access to activities such as
exercise classes, slimming club, stop smoking and
mental health services tailored specifically to their
needs. This has already attracted lots of interest
from staff, with over 500 members so far.
Our Health and Wellbeing Strategy also sets out
our commitment to using the thousands of contacts
that we have with families at the hospital every year
to improve their health and wellbeing too. We do
this through Making Every Contact Count (MECC),
an initiative that trains staff to deliver brief healthy
lifestyle advice in the right way at the right time.
We’ve done this really well at Birmingham
Children’s Hospital, making a positive impact on
the health of many children by supporting parents
to stop smoking, referring children to local healthy
weight groups and giving out healthy start vitamins
to prevent vitamin D deficiency.
28 29
But for us, caring for our people is not just about
supporting health and wellbeing. It’s also important
to recognise and celebrate their successes. This
year we launched our Star of the Month Awards
(see pages 32 and 33 for our Stars Gallery) which
follow on from the success of our Annual Staff
Recognition Awards and give us the chance to
reward staff throughout the year for their great work
and commitment to our Trust Values.
But it’s not just internal awards that our fantastic
workforce is winning - our Learning Disability
Nurse, Raj Jhamat won a national Nursing
Standard Child Health Award this year for creating
the UK’s first Punjabi DVD about autism.
Raj works with patients and families from
Birmingham’s South Asian communities on the
wards and in their homes to help them understand

BACK TO CONTENTS PAGE
autism. She said: “I was surprised and delighted to
have received the Child Health Award. I now feel
even more inspired to continue to develop my work
with the parents of patients with learning disabilities
and continue to make life better for them.”
Dr Jim Gray, Head of Microbiology and his team
were recognised at the national NHS Innovation
Challenge Prizes, where they were highly
commended for their work in reducing MSSA
bloodstream infections in children who receive their
parenteral nutrition at home. The hard work of the
team reduced the numbers of infections by a third
and it is hoped that this example of good practice
will be rolled out across the hospital.
The Facilities team has won a number of awards for
the development of meal ordering system, Maple,
including the Innovation in the use of Technology
and Systems category at the 2012 British Institute
of Facilities Management’s (BIFM) awards; the
i-fm.net Facilities Management Technology
award; Health Estates and Facilities Management
Association (HefmA) Innovation Award and Team
Award 2012.
Several hospital teams were recognised for another
year running at the Birmingham Chamber of
Commerce Awards where we won the Excellence
in Innovation award for Maple, the Formula 1
technology we are using in PICU and our patient
and family feedback app.
Our Staff Library also won the Strategic Health
Authority Library Lead’s Sally Hernando award,
which rewards and recognises innovations in
library and knowledge services. The Library’s
Flickr photostream was entered for the award and
commended for its innovation in marketing library
services.
At Birmingham Children’s Hospital we really care
about what our staff think too as their views are
fundamental to providing high quality care. We
make sure we listen and give everyone the chance
to be involved in decisions about our future strategy
and the development of services.
Consultation with our staff led to the development
of refreshed strategic objectives for 2012/13 and
they also participated in the 10th national NHS Staff
Survey which showed that real progress has been
made in the number of staff appraised in the last 12
months and the sense of job satisfaction felt by staff
(for full Staff Survey results see page 85).
We also have regular staff polls on the intranet
which means we can take a snapshot of how staff
feel throughout the year and whether they would
recommend the hospital to friends and family as a
place to work or receive treatment. This means we
can address any concerns right away and do what
we can to improve their experience at work.
4. Organisational Development
To ensure our hospital is as effective as it can be
it is vital to have a planned approach. Central to
our organisational strategy is that our staff know
what role they have to play and how they will be
supported at work. Our focus this year has been to
develop leadership capabilities at every level within
every profession, and to embed organisational
values and behaviours into everything we do.
This includes internal systems and processes, for
example staff will be asked to assess how they
regularly display our values and behaviours within
their annual appraisal.
Learning Disability Nurse, Raj Jhamat, picking up her Nursing Standard award
The facilities team collecting their BIFM award
WATCH THE VIDEO
30 31

BACK TO CONTENTS PAGE
Our Stars of the Month Gallery
December 2012
Gemma Powell
Junior Sister, Emergency Department
Gemma was nominated
for the ‘Unsung
Hero’ category by
a senior member of
her team for showing
courage, compassion,
commitment and being
caring while she led the
Emergency Department
through a difficult and
very busy period. Her
colleagues said she was
a fantastic role model
for how she ensured
the team was supported
throughout.
February 2013
Dr Shirin Beebeejaun
Foundation Year 1 Trainee Doctor,
Respiratory Medicine
Shirin was nominated by a senior colleague
for demonstrating exemplary commitment,
compassion and respect in her first ever
paediatric posting as a doctor. When the team
was a member of staff short, she stepped up
to the challenge to ensure that all tasks were
completed successfully and that children and
young people received the same high level of
care. She was also nominated for demonstrating
great understanding of patient and family
problems, prioritising them appropriately and
acting in a very caring way.
January 2013
Alison Jeremy
Head of Speech and Language Therapy
Alison received several
nominations from her
colleagues in the ‘Best Boss’
and ‘Unsung Hero’ categories
for remaining cheerful and
positive through challenging
times of change within the
department when she had only
recently taken over the role of
head of the department. She
supported staff throughout and
made sure that the team were
still able to deliver their care to
the best possible standard.
March 2013
Elaine Ross, Domestic, Ward 15
Elaine was nominated by
a family on Ward 15 for
being an ‘unsung hero’.
They particularly wanted to
acknowledge how supportive
and compassionate Elaine
was during a difficult time. The
family specifically mentioned
Elaine’s positive attitude, how
polite she is and her caring and
trustworthy manner. She wholly
demonstrates our Trust values
in everything she does while still
providing a great service in her
regular duties as a domestic on
the ward.
32 33

BACK TO CONTENTS PAGE
WATCH THE VIDEO
Shaping excellent care for tomorrow
We will strengthen Birmingham Children’s Hospital as a provider of Specialised and Highly
Specialised Services, so that we become the leading provider of children’s healthcare in the UK.
In March 2012 we were designated as a Paediatric
Major Trauma Centre for the West Midlands region,
putting us at the heart of a trauma network which is
saving more lives and improving patient care.
Major trauma is a serious injury which threatens
life, such as major head injuries, multiple injuries,
spinal injuries and severe knife or gunshot wounds.
These patients need 24/7 care from a wide range of
clinical services and experts to help them get better
quickly and improve their quality of life.
As part of the designation we have improved
the way that our young patients access
physiotherapists, occupational therapists and
speech and language therapists, and recruited
more consultants, doctors and nurses so that we
can provide everything that a major trauma patient
needs on a single site. More than 100 major trauma
patients have benefited from the new service since
it began.
In November 2012 we also became one of four
nationally designated centres for epilepsy surgery.
Epilepsy is a common condition which significantly
affects quality of life of over 6,000 children in
West Midlands alone. No matter how extreme or
mild they are, seizures caused by epilepsy are
unpredictable and managing them can be very
difficult. On the whole, epilepsy can be controlled
using drugs, however 30-40% of cases are drugresistant,
which is where surgery can help.
The national designation brings with it funding
for additional staff and cutting-edge equipment to
increase the number of dedicated beds for video
telemetry from one to three, so we can treat three
times more children each year and help transform
their lives.
34 35

Case study
Worcestershire
teenager,
Jonathan
Beale,
was diagnosed with epilepsy in October 2011 after ongoing investigations into the
cause of his long-term dyslexia and blackouts.
Since then his condition has been controlled with drugs but his last two brain
scans showed that an abnormality was getting slightly bigger. It was then that
Jonathan decided he wanted it removed so he could lead a normal teenage life,
start driving lessons and become a joiner.
Consultant neurosurgeons, Richard Walsh and Desiderio Rodrigues used a
high-tech navigation system to pinpoint the exact location of the abnormality and
safely remove it without causing damage to his brain.
Patients are usually awake and talking just a few hours after surgery and the
majority are back home within a week. There is over an 80% chance that after a
year Jonathan will never experience seizures again.
Jonathan said: “Despite my parents being a bit anxious about it, it wasn’t a hard
decision for me to take to have the surgery, as I knew this thing in my head was
stopping me lead a normal life.
“Until I’ve got a clean bill of health from the doctors I won’t be able to apply for
my provisional licence, or operate machinery without supervision on my college
course. I hope the surgery has done the job and I can get back to living a normal
life with my friends and family.”
At Birmingham Children’s Hospital we also
specialise in heart surgery, particularly the most
complex conditions thanks to the pioneering skills
of our cardiac surgeons and specialist nursing
teams who help care for so many babies, children
and young people from across the UK each year.
Our £4.9m angiography and hybrid theatre suite
is supporting this by enabling our surgeons to
perform surgery that would have previously
required two operations, in just one, which
drastically reduces the impact of surgery on
children and their families and helps us see more
patients too.
Looking forward, we know we face a population
which is growing and we know that more children
and young people will need our help for more
l 11 PICU beds
l 7 PICU beds (£500k)
l 2 Theatres (£2.3m)
l Cancer Unit (£2m)
l Heart Investigations
Unit (£2m)
l Parkview
development (£10m)
BACK TO CONTENTS PAGE
complex conditions in the future too. We’re
committed to continuing to deliver high quality
care in the present while we plan for the future
and have this year expanded capacity in our
PICU to 31 beds (26 now open and 31 by 2014)
and vastly improved our facilities across the
hospital for our patients and families.
In December our Board of Directors also agreed
an estates strategy (below) which will ensure
that between now and 2020, when we plan to
have a new hospital, we have the space, facilities
and staff to care for more patients. This includes
more PICU and inpatient beds, two new theatres,
a new West Midlands Cancer Centre and
developments at our Child and Adolescent Mental
Health Service (CAMHS) at Parkview.
Now Short Medium Long
31 PICU beds 38 PICU beds 49 PICU beds 50-58 PICU beds
l 38 inpatient beds (£2m)
l 11 PICU beds (£2m)
l HDU/LTV (£1.7m)
New Hospital:
l 15 theatres + 4 high spec
treatment rooms
l Single room accommodation
36 37

Looking specifically at the new hospital, a lot of
work has been carried out during the year to look
at how we can redevelop at Steelhouse Lane, as
well as other options to work more closely and
effectively with our partners to create top quality
facilities that our patients and families deserve.
Although there are benefits to our current Victorian
Steelhouse Lane site, it does have its limitations
as it was built for another era and we have used
nearly every spare inch to squeeze in more
facilities.
A lot of our work crosses over with other services
in the city, such as Birmingham Women’s Hospital
and the Queen Elizabeth Hospital in Edgbaston,
so we have been looking at whether it would be
feasible to have a standalone hospital there or
a joint option with the Women’s Hospital and we
have commitment from all Trusts to work closely
together to develop these proposals further.
But we are still in the very early stages of this
process and any potential expansion or relocation
of our hospital would certainly not happen before
2020, so we’ve got a few years to make sure we
get it right.
Providing excellent care and facilities is central to
all that we do at Birmingham Children’s Hospital
but there is a huge amount of work that goes on
behind the scenes in research that helps us find
cures and better treatments to help our young
patients now and in the future.
As an organisation, research excellence is
measured according to our recruitment onto
clinical trials. Currently there are around 200 active
clinical trials and this year alone we have entered
almost 2,000 patients into clinical trials – a record
for the Trust – and next year we are forecasting
even more. The Medicines for Children Research
Network (MCRN) has been supporting this work,
ensuring that trials are performed efficiently and to
the highest standard across the NHS.
One of our leading researchers, Dr Andrew Peet,
was this year successfully awarded a prestigious
Professorship with the National Institute for Health
Research (NIHR). This support, worth £1.8m,
means that Dr Peet can dedicate more time to
promote research that can be used to improve
treatment straight away – called translational
research. His team is developing scans which can
help diagnose brain tumours, plan surgery and
select patients for the best treatments and he will
be leading the way internationally at the highest
academic levels, putting paediatric research on the
map globally.
In addition, one of our paediatricians, Dr Jeremy
Kirk, has taken on the prestigious role of
Director of the Birmingham and Black Country
Comprehensive Local Research Network (CLRN)
- the only paediatrician in the country to hold such
a role.
The Birmingham and Black Country CLRN is one
of the largest in the UK and one of 25 across
England that form the NIHR’s Comprehensive
Clinical Research Network, which provides support
for clinical trials and other studies so that patients
can benefit from new and better treatments, and
we can learn how to improve NHS healthcare for
the future.
Jeremy has already helped triple the number of
children and young people recruited into research
studies over the last year, ranking us ahead of both
Great Ormond Street Hospital and Alder Hey.
Dr Andrew Peet
Case study
Dr Jeremy Kirk
Director of the Birmingham and Black Country
Comprehensive Local Research Network
Dr Pam Kearns also became a Professor this
year and has now taken up the role as Director of
the Cancer Research Clinical Trials Unit (CTU) at
the University of Birmingham. The CTU provides
support for all children’s cancer trials that are
running across the UK.
Dr Francis Mussai was also appointed as Senior
Lecturer in Oncology in summer 2012. His
research interest is the way in which the body’s
own immune system can be used to fight cancer.
One of the many life-saving research trials which
began this year was the UK National Randomised
Trial of Children and Young Adults with Acute
38 39
BACK TO CONTENTS PAGE
“It’s my job to stimulate research
in all areas of healthcare, and
the experience I have from
Birmingham Children’s Hospital
will be invaluable, as even though
we are a small hospital, we have
run many clinical trials over the
years, and have tripled patient
recruitment in the last year alone.
“This is an exciting time for
research in the UK. There
are huge opportunities for the
health sector in Birmingham,
the Black Country and wider
West Midlands to be involved in
world-class research and I relish
the opportunity to help secure
projects and trials that will benefit
not only children and young
people, but anyone who needs
to use NHS services in the future
too.”
Lymphoblastic Leukaemia and Lymphoma (UKALL
2011) which is led nationally by our Consultant
Paediatric Haematologist, Sarah Lawson.
UKALL 2011 follows a similar trial in 2003 which
resulted in better cure rates and reduced side
effects and brings more hope to our leukaemia
patients and their families as we can continue vital
trials into new drugs and treatment.
It also supports the creation of a research network
across the West Midlands to bridge the divide
between children and young adults, which has not
been done before.

At Birmingham Children’s Hospital we also carry
out world-leading research and treatment for
children with rare diseases which affect less than
one in 100,000 children. Although rare diseases
can affect many different parts of the body, the
one thing that is common is that they all require
care and treatment from several different specialist
areas and if unrecognised they can lead to severe
disabilities.
We are the second largest provider of nationally
commissioned rare diseases services in the UK
with 11, and because of our expertise we aspire to
become a National Rare Diseases Centre and will
be working towards this over the next year.
In March 2013, we became the first centre in the
UK to use a novel new treatment for children with
a rare and life-threatening liver disease - Crigler
Najjar Syndrome. The trial aims to replace the
diseased liver cells by restoring normal function
with the infusions of liver stem cells. The hope is
that these healthy stem cells will ‘seed’ into the
liver and correct the faulty metabolism that children
with this disease suffer with. One patient so far has
had this treatment with more lined up. Results from
this trial should become available within the next
two years.
In July 2012 we were selected as one of four
centres to join a new year-long pilot study for
the Department of Health’s National Newborn
Screening Programme to test for some additional
rare diseases.
Currently, all babies are tested at birth for five
conditions through the ‘heel prick test’. As part of
the pilot, newborns are being tested for five more
to look at outcomes and whether they should
be permanently added to the national screening
programme.
The pilot is going well and to date we have picked
up two cases at Birmingham Children’s Hospital –
one mild isovaleric aciduria and one maple syrup
urine disease – which is a great result as it means
that we can now treat the children much earlier,
prevent severe complications and help them live
longer and healthier lives.
One of these children, Habul Khatoon from
Birmingham was diagnosed in October 2012 with
maple syrup urine disease when she was just a
few days old. This is a serious genetic metabolic
disorder which stops the body breaking down
amino acids in protein rich food. If these acids
accumulate and are left or not managed properly,
it can lead to coma, brain damage and death in
newborn babies.
Thanks to the early intervention and ongoing
treatment from our metabolic team, Habul is
growing and developing normally and looking
forward to a much brighter future.
Case study
BACK TO CONTENTS PAGE
Noah and Ruby
from Sandwell
Baby Habul and mum Fahmeeda Khatoon pictured with Inherited Metabolic Specialists
Professor Anita MacDonald and Dr Anupam Chakropani
Rebekah Youlden and Arron Harvey from Sandwell
are supporting the Newborn Screening Programme
pilot as their two youngest children, Noah (4) and
Ruby (2) have glutaric aciduria type 1 (GA1), which
means that they cannot break down protein which
causes harmful substances to build up in their
bodies.
Noah was just 10 months old when he first became
ill and it wasn’t until he had spent three weeks in a
local hospital that he was diagnosed with GA1. The
length of time from birth until his diagnosis meant
that damage to Noah’s brain had already begun.
He is now in a wheelchair but can take steps in his
specially built walker, he attends school and can eat
with his family after spending two and a half years
being fed through a nasogastric tube.
40 41
Two year old Ruby on the other hand was
diagnosed at just 12 days old and started on a
limited protein diet and medication straight away to
lessen the damage to her body and brain and she
is developing normally for her age.
Her parents are all too aware of the importance of
early diagnosis. Mum Rebekah said: “Noah is a
lovely little boy who always has a smile on his face
but people find it hard to believe that he and Ruby
have the same disease because Ruby is walking
and talking and Noah is in a wheelchair and can’t
do all the things his sister can. If the heel prick test
had been able to test for GA1, Noah’s life would
have been so different.”

Shaping excellent care for tomorrow
We will continue to develop Birmingham Children’s Hospital as a provider of outstanding local
services - ‘a hospital without walls’ - working in close partnership with other organisations.
At Birmingham Children’s Hospital we now have
over 240,000 patient visits every year – more than
ever before - and although we do all we can to
make the hospital experience the best it can be, we
know that nowhere is as comfortable as home.
This is why we’ve been working with partners to
set up services to provide treatment and care out
in the community and in people’s own homes,
giving those with stable conditions a choice for the
first time. Not only does this help increase their
independence, it gives them greater control of their
care.
One new service is our Child and Adolescent
Mental Health Service (CAMHS) Home Treatment
Service which supports many children and young
people at home with their families instead of them
being admitted onto an inpatient psychiatric ward.
The 24/7 service covers the entire city of
Birmingham for young people aged 12 – 18 and
we’ve worked in partnership with Birmingham
and Solihull Mental Health Foundation Trust to
make sure that our older teens have a seamless
transition into adult services for their future care
and treatment.
Our Hospital at Home service has also expanded
over the last year, taking more patients from more
specialties, such as general paediatrics, plastics,
neurology, oncology and haematology.
Working in partnership with community nurses
and health visitors, our team of five supports the
care of children and young people across the city
of Birmingham and Solihull. This helps us save
hospital beds for those who need them the most.
Children and young people from South and Central
Birmingham with diabetes are also benefitting from
care at home through the Diabetes Home Care Unit
which has grown over the year and moved into a
new dedicated unit within our Steelhouse Lane site.
The team works closely with nurseries and schools,
providing expert advice to other regional paediatric
diabetes teams. It offers a 24/7 phone support
service and weekend drop in clinics to the 335
children and young people with Type 1 and Type
2 diabetes, Cystic Fibrosis related diabetes and
secondary diabetes from conditions such as cancer
or organ transplants, Bardet-Biedl, Alstrom and
Wolfram Syndrome.
As the number of diabetes patients we see is
always growing, we have had commitment from
the Board of Directors to expand by recruiting more
staff, including a social worker and family support
worker. This has helped secure funding from local
commissioners to provide more training for staff
and resources for patients and families, helping
us take huge steps closer to becoming a leading
centre in the UK.
BACK TO CONTENTS PAGE
We have also continued to work closely with
our NHS and local authority partners on the
Birmingham and Solihull Acute Paediatric Service
Review and we are leading the development of a
Children’s Health Network.
Networks and their development are a fundamental
priority for the Trust and this particular network
brings together clinicians from providers across
primary, secondary and tertiary care to look at how
we need to work in partnership and plan for the
future to make sure that children and young people
receive high quality, safe and effective care, no
matter what their condition is, how old they are or
where they live.
Other networks at Birmingham Children’s Hospital
include our oncology and cardiac networks which
are delivered in a ‘hub and spoke’ style. This
is where we act as the ‘hub’ of expertise and
deliver care through our ‘spoke’ partners such the
University Hospitals Coventry and Warwickshire
NHS Trust, enabling us to see patients closer to
home and strengthening the expertise of our district
hospital partners. These relationships will become
more important and will be further strengthened as
time continues, particularly if further reconfiguration
plans such as Safe and Sustainable take place.
WATCH THE VIDEO
CAMHS Home Treatment team picking up the Perfect Partnerships staff recognition award
42 43

BACK TO CONTENTS PAGE
The Impact of Fundraising
Fundraising continues to play a vital role in
supporting the work of the hospital. It enables us
to fund additional facilities and equipment, support
medical research and provide the extras that make
being in hospital a more comfortable and less
distressing experience for children, young people
and their families.
Highlights for the year include:
This year we raised more
than ever before
- £4.43m!
Key facts for the year:
l We had a record 4,162 individual supporters.
l In July we launched our biggest fundraising
appeal ever, the £4m Children’s Cancer Centre
Appeal, for a new unit to improve the lives of our
3,000 cancer patients and their families. We have
already reached the £1m mark which means a
brand new state-of-the-art unit is now within
reach.
l Our ‘Hundred Heroes’ event in February
recognised our top 100 supporters for the year
who collectively raised £660,000 over the last
12 months. One of these was the family of
patient Poppy Guilder who has a brain tumour.
They have raised a staggering £180,000 over the
last nine years for research at the hospital
and last year, thanks to new improved scanning
equipment and the research they’ve made
possible, doctors were able to remove more of
their daughter’s tumour than they ever thought
possible.
l Over 1,000 supporters took part in the Great
Birmingham Run, raising £200k for us. This
makes us the largest charity team at the event
with the largest presence on the day.
l We received a £471,000 donation from the Give
a Child Health Charitable Trust, which was our
largest donation of the year and is funding a new
respiratory centre at the hospital.
l General fundraising activities enabled the charity
to award a grant of £300k to Birmingham
Children’s Hospital Research Foundation to fund
high quality, internationally recognised research,
and have enabled our academic trainees to
become leaders of paediatric research.
l 78 corporate partners around the region pledged
their support to the hospital.
l Merging the Trust and fundraising Facebook
pages meant that over 15,000 people now have
regular communication from both teams.
l Our biggest area of growth has been in support
from schools which has doubled since last year.
l Our first ever charity ball raised £75,000 in one
night for the Children’s Cancer Centre Appeal.
What does the future hold for 2013/14?
Looking to the future, we are going to be investing
more in long term sustainable fundraising activities.
Legacy fundraising and Regular Giving are just
two areas that we will focus on that will offer stable
income growth. By developing these we hope to
increase our unrestricted funding streams to enable
more charitable grants to be awarded which in
turn will have a big impact on the hospital and the
patients in our care.
l The fundraising team is looking to increase its
impact even further with an ambitious £5.4m
target.
l £3m still to raise to build our world class
Children’s Cancer Centre; £120k partnership with
national organisation, Wesleyan Assurance
Society.
l £70k specially designed sensory garden that will
cater to the senses of children and young people
with learning difficulties with scented flowers,
calming music and multiple textures to touch
around the garden.
44 45

SECTION TWO
BACK TO CONTENTS PAGE
The Governance of our Organisation
Directors’ Report
Brief history of the Trust and its statutory background
The Birmingham and Midland Free Hospital was
founded in 1862 and moved to Steelhouse Lane
in Birmingham in 1998. The hospital Trust was
granted Foundation Trust status on 1 February
2007 under the Health and Social Care (Community
Health and Standards) Act 2003.
The Trust’s Executive Directors
and Non-Executive Directors in 2012/13
The Trust also owns a second site located at
Parkview in Moseley which hosts the Child and
Adolescent Mental Health Service (CAMHS).
The Trust provides services from a range of
accommodation in the community and in several
partner acute organisations.
Ms Sarah-Jane Marsh Chief Executive Officer (maternity leave from November 2012)
Mrs Michelle McLoughlin
Dr Vinod Diwakar
Chief Nursing Officer
Chief Medical Officer
Mr David Melbourne Chief Finance Officer/Interim Chief Executive Officer (from November 2012)
Mr Phil Foster Interim Chief Finance Officer (from November 2012)
Mr David Eltringham Chief Operating Officer (until September 2012)
Mr Tim Atack Chief Operating Officer (from September 2012)
Mrs Theresa Nelson
Chief Officer for Workforce Development
Ms Joanna Davis Chairman (until sick leave 16 April 2012)
Mr Keith Lester Deputy Chairman/Interim Chairman (from 16 April 2012)
Mrs Judith Green
Mr Colin Horwath
Professor Jon Glasby
Deputy Chairman, Engagement and Participation
Deputy Chairman, Strategy and Partnerships
Non Executive Director
Mr Zubair Khan Non Executive Director (until December 2012)
Mrs Elaine Simpson
Non Executive Director
Mr Roger Peace Non Executive Director (from July 2012)
Statement as to disclosures
to auditors
So far as each individual Director is aware, there
is no relevant audit information of which the Trust’s
auditor is unaware. Each Director has taken all
the steps they ought to have taken as a Director in
order to make themselves aware of any relevant
audit information and to establish that the Trust’s
auditor is aware of that information.
Principle activities of the Trust
Birmingham Children’s Hospital NHS Foundation
Trust provides the widest range of children’s health
services for young patients from Birmingham, the
West Midlands and beyond, with over 240,000
patient visits every year. We are one of the UK’s
four standalone children’s hospitals, one of 37
providers of specialised children’s services, and
one of the UK’s 246 trusts providing hospital
paediatric services to the local population. We
provide 11 national services, 30+ services to
children and young people in the West Midlands,
and general and emergency services to the south
and central population of Birmingham.
We are characterised by a unique collocation of all
the services, specialist expertise and diagnostic
and treatment resources that a sick child needs.
The population is characterised by diseases which
have one or more of the following characteristics:
rarity, complexity, co-morbidity, unresponsiveness
to conventional therapy, age or acuity.
Significant Research &
Development Activities
Information about research and development can
be found at pages 38-41 and 120.
Operating & Financial Review
With 2012/13 being another challenging period for
the NHS it is pleasing that the Trust ended the year
achieving its key financial targets and delivering
another strong set of results. Given the wider
financial environment it was unrealistic to expect a
performance on a par with 2011/12 so the surplus
we reached of £6.3m should be regarded as an
excellent achievement.
The reduced surplus compared to 2011/12 was
mirrored by a reduction in earnings before interest,
tax, depreciation and amortisation (EBITDA) to
7.2% for the financial year, down from 8.1% in
2011/12. This 11% decrease on 2011/12’s position
is a result of:
a) The Trust being increasingly affected by the
method of reimbursement for emergency care
for activity over a specific threshold agreed with
commissioners. This activity is paid at 30% of
the national tariff and does not fully reflect the
costs incurred in treating these patients.
b) Provisions set aside for the impact of workforce
issues in Community CAMHS and junior doctors.
The impact of austerity measures across the
public sector have hit the Trust particularly hard
with a potential 25% reduction in our Community
CAMHs funding which will impact upon the
numbers of staff in this service.
c) The costs of providing additional capacity within
the Trust outside of core working hours.
d) Inflation and cost pressure levels being higher
than expected especially in Estates and on gas
and electricity.
e) Continued difficulty in fully realising the cost
efficiency targets.
The Trust maintains a Register of Interests of Directors and Governors that may be accessed via the Trust’s
Publication Scheme available on the Trust’s website.
46 47

Table 1: Patient Activity 2008/9-2012/13
2012/13 2011/12 2010/11 2009/10 2008/9
Revised Outpatient attendances 152,820 147,276 147,292 143,291 141,088
ED attendances 49,335 47,592 46,274 45,142 45,585
Inpatient (I/P) admissions:
Emergency admissions 14,854 13,935 14,143 11,898 11,544
Day-case admissions 18,951 17,816 16,131 16,258 15,296
Inpatient admissions 6,491 7,532 6,809 6,385 5,980
Total I/P admissions 40,296 39,283 37,083 34,541 32,820
Total patient episodes 242,451 234,151 230,649 222,974 219,493
The increase in Outpatient attendances reversed
the pattern of the previous two years with the
increase in new attendances out-stripping the rise
in follow-ups.
It cost just over £225 million to run the Trust
during the year, a 6.8% increase on 2011/12.
However, there are a number of significant nonrecurrent
or technical costs included within this
figure, which when removed indicate an underlying
movement of 4.3% on 2011/12. The two highest
spend categories, Employees and Drugs, have
seen above average increases of 8.0% and 7.4%
respectively. The cost of running the estate has
experienced a rise of over 25% in 2012/13.
We employed 156 more staff at the end of March
2013 than at the beginning of April 2012, with an
average increase over the year of 102 additional
staff. Doctors and nursing staff saw the largest
year-on-year growth at 9.5% and 6.2%. On average
we paid staff 4% more in 2012/13 than in 2011/12
which reflects the skill mix changes across the
Trust arising out of key developments, such as the
expansion of the Paediatric Intensive Care Unit as
well as the method of delivery of increased activity.
During the year we saved £8.1 million in planned
cost releasing savings (£10.1 million in 2011/12),
which contributed towards the nationally
determined efficiency target. This represents 76%
of the target we set at the beginning of the year
(96% of the 2011/12 target was achieved). Although
£8m was the in-year target for 2012/13 it was the
impact of non-recurrent element of the 2011/12
programme carried forward that caused difficulties.
We have been mindful of this as an issue in setting
our target for 2013/14. In terms of actual financial
savings, this is the second highest level ever
achieved by the Trust. We improved on our system
of ensuring that these cost savings did not impact
on the safety and quality of services delivered; as
part of this every savings scheme was signed off by
at least two clinicians including the Chief Medical
Officer and the Chief Nurse.
Investment in maintaining our estate and the
development of new facilities and equipment
replacement is currently funded from the surpluses
that we make. During 2012/13, £9.5 million was
invested in new capital schemes with some of these
schemes due for completion during the 2013/14
financial year. It is pleasing to note that the level
of assets under construction at the end of the year
has reduced by £4m in year which means that vital
elements of our strategic investment programme
have become operational, with the expanded PICU
capacity being the most notable.
The range of strategic schemes underway included:
l Emergency Department remodelling;
l Refurbishment of Outpatients;
l Trust infrastructure work;
l Respiratory development.
All these developments have helped to increase
the capacity of the hospital and contributed to
improving the care we provide.
During the year the Trust has further developed its
work looking at the provision of a new hospital to
ensure that in 10 years time the Trust continues to
be in a position to deliver world class children’s
services.
The analysis we have undertaken to date indicates
that over the next decade the Trust will need to
develop new facilities if it is to meet the challenges
of continuing to deliver high quality care.
In December 2012 the Board received the strategic
outline case that presented options for the future
site of the hospital. After considering this analysis
it was decided that more detailed work should
continue. This work will examine the development
of a hospital on the Steelhouse Lane site or the
development of a new facility on the health campus
at Edgbaston, in close proximity to University
Hospitals Birmingham NHS Foundation Trust
(UHB). The option of a move to a health campus in
Edgbaston has support from the Board of Directors
and key partners including UHB, University of
Birmingham and Birmingham Women’s Hospital
NHS Foundation Trust. The next stage of the
project is to undertake a more detailed assessment
through the development of an outline business
case followed by a formal public consultation.
Our trading position is reflected in our cash
balances. These have continued to improve over
the medium term such that we had £36.2 million
in cash or cash equivalents at the end of the
financial year (£33.7 million in 2011/12). Despite
the extensive capital programme, cash increased
by £2.4 million in the year, which will allow further
reinvestment in 2013/14.
48 49
BACK TO CONTENTS PAGE
In 2012/13, using the opportunities afforded by
our status as a foundation trust, we established a
wholly owned subsidiary, Birmingham Children’s
Hospital Services Limited, and Birmingham
Children’s Hospital Pharmacy Limited, for the
purpose of building and operating a new Outpatient
Pharmacy, The Medicine Chest. This innovative
and cutting-edge development provides the
opportunity to deliver cost effective, specialist
outpatient pharmacy services. The Medicine Chest
opened in January 2013 and is already having a
positive impact on patient experience, with a better
environment and a much faster service.
Fundraising income through Birmingham Children’s
Hospitals Charities increased - despite the wider
economic recession - at £4.43 million (2011/12
£3.2 million). In 2012/13 we celebrated our 150th
birthday and launched our Cancer Centre Appeal
to raise £3.5 million to improve the facilities for
younger children receiving treatment for cancer at
the hospital.
Given the growth in population, changes in medical
technology and high rates of inflation compared
to that assumed in the NHS financial settlement,
the Trust will have to make £24 million of savings
over the next four years. This is part of the £20
billion of efficiencies that the NHS Chief Executive
announced would be required nationally and is
reflected in Monitor’s financial assumptions for
the same period. With austerity measures due to
continue to at least 2017, the Trust’s approach to
cost improvements and efficiencies has to change.
Our financial position provides a sound foundation
to address the challenges resulting from the
national savings priorities. We have plans in place
to achieve the majority of the required savings in
2013/14 through reducing administration costs,
transforming clinical services and by continuing to
deliver clinical services in the most cost-effective
way. As part of this process we will continue
to work in partnership with our commissioners
to ensure that children are treated in the most
appropriate setting for their condition.
The Trust, along with a number of other NHS
specialist children’s providers, has continued to
successfully work with the Department of Health on
the appropriate level of the ‘top-up’ to the national
tariff for specialist paediatric services. The Trust
currently receives a supplement of £17 million
per annum to recognise the additional costs of
providing specialist children’s services and this
continues to be reviewed by the Department of
Health and from 2013/14, Monitor.

50 51
BACK TO CONTENTS PAGE
During the year the Board approved a revised
financial framework which complemented the
existing financial strategy of the Trust. The aims of
the strategy remain to:
l Imporove the quality of service that reduce variation, waste and harm.
l Provide the resource to deliver world class patient centred care.
l Provide the funding for a productive, motivated and professional workforce.
l Provide better value for money.
l Deliver affordable, world class health services for children and young people.
The strategy will be delivered through the
following six components:
l Using a mixed funding strategy for major new infrastructure investment.
l Developing a clear financial framework - to monitor financial stability and investment .
l Delivering the necessary efficiency savings.
l Improving financial literacy across the organisation.
l Developing NHS and non NHS business opportunities.
l Recognising charitable funds as a core component of the funding mix.
Finance Statements
The Trust’s accounts have been prepared under a
direction issued by Monitor. The Trust has complied
with the cost allocation and charging requirements
set out in HM Treasury and Office of Public Sector
Information Guidance.
The Trust has complied with the requirement that
the income from the provision of goods and services
for the purposes of the health service in England
must be greater than the income from the provision
of goods and services for any other purposes.
Financial risk management objectives
and policies
Our Finance and Resources Committee oversees
the cash management and investment strategy
which is based on Monitor best practice and is
reviewed by our auditors. This places surplus cash
on short-term deposit in the most secure accounts.
During 2012/13 the Committee agreed revisions
to the policy which serve to address concerns
regarding levels of sovereign debt and the strength
of financial institutions. Cashflow forecasts are
updated on a weekly basis to ensure that no
cashflow and liquidity risks are evident. Looking
to the future cashflow planning is undertaken
for the Trust’s long-term modelling with the risk
rating impact - including the new Risk Assessment
Framework and its greater focus on liquidity - now
being incorporated.
The Committee also scrutinises all our major capital
investment and consultant appointments to ensure
they fall in line with our service strategy and are
affordable and provide value for money.
With the increased importance of efficiency savings
the Committee has scrutinised the delivery of the
savings plan during the year to ensure that the
approach does not impact on the quality of services
provided. This has extended to our Commissioners
with whom our CIP Governance Structure has been
shared.
The Trust’s activities expose it to a variety of
financial risks, though due to their nature the
degree of exposure is reduced compared to that
faced by many business entities. The financial
risks are mainly credit and inflation risks with
minimal exposure to market or liquidity risks.
The nature of how the Trust is financed exposes
it to a degree of customer credit risk. The Trust
regularly reviews the level of actual and contracted
activity with commissioners to ensure that any
income risk is resolved at a high level at the
earliest available opportunity. The Trust mitigates
its exposure to credit risk through regular review
of receivables due and by calculating a bad debt
provision.
The Trust has exposure to annual price increases
of medical and non-medical supplies and services
arising out of its core healthcare activities. This risk
is mitigated through, for example, transferring the
risk to suppliers by contract tendering, negotiating
fixed purchase costs and in the case of external
agency staff costs via the operation of the Trust’s
own staff bank.
Details of other risks and uncertainties facing the
Trust are described in the Annual Governance
Statement at page 144.
Details of the impact of the Trust’s business on the
environment are set out in the Sustainability Report
on page 88.
Contractual arrangements
The organisations with whom the Trust has
contractual or other arrangements which are
essential to the business of the Trust are:
l Sodexo – patient, staff and visitor catering
services
l St Paul’s Transport – taxi service for
patients, staff and light goods
l B Braun Sterilog (Birmingham) Ltd –
medical devices sterilisation services
l AAH Pharmaceuticals Ltd – pharmaceutical
wholesaler
l NHS Supply Chain – procurement services
l NHS Blood and Transplant – supply of blood,
organs and tissue
l St John’s Ambulance – PICU retrieval
services
l A4 MTS – non-emergency patient
ambulance services
l McKesson – staff payroll services
l Healthcare at Home –nursing/logistics
services to enable patients to receive
treatments at home
l Medco Healthcare - nursing/logistics services
to enable patients to receive treatments at
home
l NHS Shared Business Services – supply of
procurement and financial services
l PWC, EC Harris and BDO - advisors on the
Trust’s Estate Strategy
l Bupa Home Healthcare Ltd - nursing/logistics
services to enable patients to receive
treatments at home.

Partnerships
During 2012/13 the Trust has entered into formal
arrangements with the following organisations,
which are essential to the Trust’s business:
l Birmingham Children’s Hospital Pharmacy
Limited (BCH Pharmacy). This company
is a wholly owned subsidiary of Birmingham
Children’s Hospital Health Services, which
is a wholly owned subsidiary of the Trust.
BCH Pharmacy is responsible for the
operation of the Medicine Chest, the new
Outpatient Pharmacy located at the front of
our Steelhouse Lane site (see above).
l Sandwell and West Birmingham
Hospitals NHS Trust. We have entered
into an arrangement with Sandwell and
West Birmingham Hospitals NHS Trust for
the provision of a joint Estates Management
Service.
Policy and payment of creditors
We liaise closely with our suppliers to ensure there
are no unintentional cash problems. We are aiming
to comply with the target of all payable invoices to
be paid within 30 days. It is disappointing that this
has deteriorated slightly compared to last year and
there is still more work we can do in this area. We
did not incur any interest charges under the Late
Payment of Commercial Debts Act 1998.
Figure 1: Creditors BPPC Value % Cumulative 2011/12 – 2012/13
100%
95%
Going concern
After making enquiries, the Directors have a
reasonable expectation that we have adequate
resources to continue in operational existence
for the foreseeable future. Monitor’s draft Risk
Assessment Framework assesses the risk to the
continuity of services.
Using the proposed measures we have the lowest
level of risk with a continuity of service rating
reporting that we have sufficient financial headroom
and liquidity. For this reason, the Directors continue
to adopt the going concern basis in preparing the
accounts.
Pensions and Benefits
Accounting policies for pensions and other
retirement benefits are set out in note 1.03 to the
accounts. Details of senior managers’ remuneration
can be found in the Remuneration Report at page 61.
Ill health retirements and redundancies
There were five ill health retirements in 2012/13.
The value of these is £314k, which will be borne
by the NHS Business Services Agency (Pensions
Division).
A number of redundancies occurred during the year.
Details associated with these are as follows.
Table 2: Redundancies 2012/13
Counter Fraud
BACK TO CONTENTS PAGE
One of the basic principles of public sector
organisations is the proper use of public funds.
The Counter Fraud service at BCH aims to prevent
fraudulent activity which threatens this principle.
Informing staff of their responsibilities, encouraging
them to think about how their behaviour is a
major control against fraud, and helping them
spot fraud and raise concerns are at the core of
developing a counter fraud culture. This has been
achieved by the inclusion of counter fraud training
at the core of our mandatory training programme,
supplemented with an online learning module.
Staff have responded, telling us about concerns
where they work and allowing us to tackle those
issues, investigate worries and make necessary
improvements. Together with other sources of
intelligence this has helped us develop a riskprioritised
programme of fraud prevention. We aim
to build on this approach in 2013/14, creating a work
plan which gets to the heart of where fraud may be
a risk in our organisation so that we can put in the
necessary controls to safeguard public funds.
Our Staff
Information and Consultation
We believe that the views of our staff are
fundamental when considering change in the
long, short and medium term, be it in relation to
our estate, clinical matters or the development of
services. We involve our staff in all decisions about
our future strategy and the development of services.
90%
85%
80%
75%
70%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Target
Actual 12-13
Actual 11-12
Exit Package Cost Band Number of Number of Other Total Number of
Compulsory Departures Exit Packages
Redundancies Agreed by Cost Band

BACK TO CONTENTS PAGE
Consultation with our staff led to the development
of refreshed strategic objectives for 2012/13.
At a monthly Chief Executive’s Briefing, open to
all staff members, the Chief Executive and other
Executive Team members and senior staff provide
information to staff on significant issues and
developments in the Trust to ensure they are kept
fully informed and engaged. Presentations made
during the year have covered areas including:
l Developments in the Respiratory Unit, Lung
Function and Diabetes Home Care;
l SHINE 2012: Quantifying Parental Concern to
Strengthen their Voice
l Young Person’s Advisory Group
l Medium Term Estates Strategy
l Our Future Estates Project
l The BCH Feedback App Pilot
l Critical Care
l Flu Campaign
l Hospital Handover
l New Outpatient Pharmacy (Medicine Chest)
l People Strategy 2012-15; The Productive
Operating Theatre
l CAMHS Home Treatment Service
l National NHS staff survey results.
The Trust intranet was redesigned in 2012/13
and provides a central location for a diverse and
continually updated range of information for staff,
from Trust policies and guidance, to recruitment
toolkits and information about each ward and
department. All presentations and videos from
Chief Executive Briefings are also available on the
intranet, allowing access for staff who are unable
to attend the briefing sessions.
We have also implemented a regular staff poll on
the intranet, which surveys staff about things like
whether they would recommend the hospital to
friends and family as a place to work or receive
treatment. We also used this process to find out
the health and wellbeing needs of our staff. The
results of this led to the development of our Health
and Wellbeing Strategy which was launched in
2013.
In addition to encouraging staff to take part in the
annual national Staff Survey, we ask clinical staff
to take part in an annual Staff Safety Survey to
enable us to understand the safety culture of the
organisation and identify areas that may need
development.
Following the publication of the Francis Report
on Mid Staffordshire NHS Foundation Trust in
February 2012 a process was developed to obtain
feedback from staff through a series of listening
events about:
l How we listen to and learn from staff, patients,
families and carers and share this better
throughout the Trust
l How we can work better together in our current
teams to improve patient care and outcomes
with the resources that are available to us
today
l How we can make staff feel more valued and
supported in their jobs.
This process is continuing into 2013/14 and will
culminate in a week-long event in September.
We have also consulted with staff on:
l The behaviours that demonstrate Trust values;
l Internal communications
l Intranet development
l New CAMHS website
l New hospital project
l Feedback App
l Dignity Giving Suits.
Monthly budget reports are distributed to managers
and we continue to report on the financial position
of service lines with this information available to a
range of staff. During the year we have continued
to expand the use of service line financial
information and enhanced the level of information
available to staff and clinicians. Localised training
is undertaken for both core financial duties and
service line information.
Learning from a staff survey undertaken in 2011/12
is shaping the Finance department’s strategy and
objectives. In March 2012 the Finance Department
invested in The Healthcare Financial Management
Association (HFMA) e-learning package which
is suitable for all healthcare professionals and
anyone who wants to gain an awareness and
understanding about aspects of NHS Finance.
The Finance department has assisted in the
Trust’s Consultant Development Programme which
seeks to broaden the knowledge base of the next
generation of clinical leaders.
A detailed Resources Report is contained within
the monthly Public Board of Directors papers which
are available for all staff.
Raising Concerns at Work
Encouraging our staff to have the confidence to
raise any concerns they may have at work has
continued to be of importance to us throughout
2012. To support the updated Whistle Blowing
procedures we have introduced an internal intranet
page to clarify how staff can raise concerns
about work both internally and externally. We
have also updated our Employment Contract to
emphasise the importance of creating an open and
transparent culture with regard to raising concerns
at work.
Mandatory induction and refresher training for
all staff includes risk management training which
encourages staff to report incidents by explaining
why it is important that every incident, including
near misses, is reported. This is so that we can
monitor the safety of processes, identify areas that
must be improved, and learn from our experiences.
54 55
We have also established new systems especially
for trainee doctors to raise concerns. Our Doctors
in Training Safety Hotline provides a mechanism
for concerns about safety to be raised at an early
stage, before any harm is caused. Our Trainee
Advice and Liaison Service (TALS) has been
designed to mimic our Patient Advice and Liaison
Service (PALS). The aim of the service is to help
resolve issues and provide information and advice,
which can include how to escalate any concerns.
Health & Wellbeing
In March 2013 we formally launched our strategy
for improving the health and wellbeing of staff,
children and families. The cornerstone of the
strategy is our responsibility to promote improved
health outcomes for patients. We want to be
ambassadors for initiatives that reduce risk to
health, and to promote healthy lifestyles by
example and through our services. In order to
achieve this we must also meet the health and
wellbeing needs of our most valued resource – our
staff.
We have continued to work closely with
Occupational Health and Staff Support Providers to
ensure the service meets the needs of our staff. In
2012/13 we added a second clinic day which has
allowed more of our staff to access clinical support
onsite, minimising disruption to our services.
Table 3: Table 3:Occupational Health Service Activity 2011/12 – 2012/13
2011/12 2012/13
Number of Referrals 311 376
Number of Pre-employment Screening Assessments 988 1277

A large proportion of staff referrals to the
Occupational Health Service during 2012/13
related to musculoskeletal problems of the lower
limb and back. In response to this, as part of our
Health and Wellbeing Strategy, we are developing
ways to support staff before such problems
develop. We are also reviewing the management
of stress and ways of improving working lives
in addition to the free staff counselling service
available to all staff.
Table 4: Sickness levels –
Trust-wide and directorate 2009/10 – 2012/13
In 2012/13 we repeated our previous year’s flu
campaign with an aim to immunise every staff
member with the flu vaccination.
Throughout 2012/13 the Trust has focused on
improving attendance at work with a combination
of early intervention programmes and facilitating
return to work schemes.
We have set a 3% sickness rate target, which is
regularly monitored and incorporated in our Safety
Dashboard to help us understand where there may
be staff pressures and where this has the potential
to affect the quality of care.
Directorate 2009/10 2010/11 2011/12 2012/13
Clinical Support Services 3.57% 3.68% 3.30% 3.13%
Medical 2.91% 2.90% 3.81% 4.42%
Specialised Services 5.01% 4.33% 4.01% 4.00%
Surgical 4.36% 3.43% 2.98% 3.10%
CAMHS 4.00% 3.85% 4.14% 4.57%
Corporate 4.08% 3.64% 3.52% 2.95%
Trust-wide 4.01% 3.64% 3.66% 3.71%
Equal Opportunities
Our Diversity and Inclusion Strategy sets out our
commitment to ensuring equality and human rights
will be taken into account in everything we do, both
as an employer and a provider of healthcare.
The standards laid out in our Recruitment and
Selection Policy are applied to all candidates for
posts and the Trust’s Recruitment and Selection
Toolkit provides advice on equal opportunities. The
aim of the policy is to ensure that all applicants
who declare a disability are offered an interview if
they meet the minimum requirements for the post.
Monitoring and auditing is used to help identify and
eliminate possible discrimination and to constantly
improve recruitment processes.
All employees that become disabled during their
employment are managed through the sickness
policy or capability policy and all efforts are made
to ensure ongoing employment with reasonable
adjustments, training and career development.
Other Trust policies which ensure equal
opportunities for all staff include:
l Maternity Leave policy;
l Flexible and Family Friendly Working Policy;
l Dignity at Work Policy, which describes
our processes to provide a positive working
environment to with zero tolerance to bullying
and harassment.
Social and Community Issues
It is our ambition to be the employer and service
provider of choice and an advocate for children
and young people in Birmingham and the West
Midlands. This means more than providing acute
health care. It also means taking the opportunities
provided by our position in the community, and
using our specialist knowledge and skills to help
improve health outcomes and future opportunities
for children and young people, whatever their
ethnic, cultural or social background.
Working to meet this ambition requires us to
engage with our service users and the community
to find out what they want and need. It’s also
important that we look to the future to make sure
we are prepared for the challenges to come over
the next 20 years. As the population in Birmingham
and the West Midlands rises it is becoming
increasingly diverse and the population of children
and young people is expected to rise dramatically.
We need to make sure our future strategy is able
to meet the changing needs of our community.
Being a champion for children and young people
is one of our strategic objectives. We believe
that developing our position as an advocate and
provider of public health advice will help improve
the lives of the children and young people who use
our services and who live in the West Midlands.
BACK TO CONTENTS PAGE
We have a range of initiatives that will help us
meet these goals:
l Our Health and Wellbeing Strategy sets out
our commitment to using every opportunity
to improve the health and wellbeing of the
children, young people and families we see
at the hospital. We do this through Making
Every Contact Count (MECC) - an initiative
that asks all NHS staff to deliver brief
healthy lifestyle advice in the right way at
the right time. Over the last year this work
has been having a positive impact through
supporting parents to stop smoking,
referring children to local healthy weight
groups, and giving out healthy start vitamins
to prevent vitamin D deficiency.
l Healthwatch Birmingham is a new
organisation being set up to provide
an independent voice for the people of
Birmingham and to help shape and improve
local health and social care services. We
have started working with them to ensure
that young people are able to participate.
l Our Widening Participation Team helps us
deliver our priority to improve opportunities
for our most junior members of staff by
supporting them to develop their careers.
The team also works with community
partners to offer apprenticeships,
internships and work experience to young
people.
l We are working with the Birmingham
Muslim community to develop a wider
understanding of organ donation.
l The Young Person’s Advisory Group
(YPAG)are growing as an influential voice
both within the hospital and in the
wider NHS community, providing views on
developments to our services and on the
NHS Future Forum and NHS Constitution.
l We are becoming a national leader in
our learning disability work, particularly in
engagement with patients and families from
Asian communities.
56 57

BACK TO CONTENTS PAGE
Health and Safety Performance
The most significant risks to the non-clinical safety
of our patients, staff and visitors are monitored by
our Non-Clinical Risk Coordinating Committee.
A Non-Clinical Safety Report is presented every
two months to our Quality Committee to provide
assurance about what is being done to make sure
our environment and practices are as safe and
secure as they can be.
In 2012/13 there have been:
l No Dangerous Occurrences as defined in
Reporting of Injuries Diseases and Dangerous
Occurrences Regulations (RIDDOR)
l No Diseases as defined in RIDDOR
l One Major Injury as defined in RIDDOR
(a visitor fell down a step in a public corridor)
l No HSE improvement notices
l No HSE prohibition notices
l Two fires:
A small electrical fire in an office block
kitchen
Deep fat fryer oil ignited causing fire in
catering department.
l No Non-Clinical Safety related Serious Incidents
Requiring Investigation
l No non-clinical safety related Never Events.
experience, safeguarding and infection control, as
well as progress against our safety strategy, and
quality projects such as the Safety Thermometer
and our programme of Quality Walkabouts.
This Quality Report is considered by the Board of
Directors every month alongside our Resources
Report, which provides details of the Trust’s
financial performance and examines the Trust’s
activity levels, access to our services and
workforce indicators, such as sickness levels,
turnover, and targets for mandatory training and
appraisal. This report helps the Board identify
where pressures at work may be having an impact
on our staff, which could in turn impact on the
quality of services.
At the beginning of 2012/13 - following an
independent governance review - we established
a new committee structure, which aimed to
support the Board to focus on the right things by
strengthening the committees that report to it.
The Finance and Investment Committee became
the Finance and Resources Committee, with a
widened remit to consider all the Trust’s resources,
including the most important – our staff. A new
Quality Committee was set up which receives
information about patient safety, non-clinical
safety, patient experience, staff engagement
and regulatory compliance. At each meeting
the Committee undertakes a detailed review
of a quality theme identified as an area that
needs greater focus. In 2012/13 the Committee
considered the following themes:
l Learning Disabilities –
Providing Personalised Care;
The Board Assurance Framework (BAF) provides
a structure and process to enable the Board to
understand and focus on the risks to achieving the
organisation’s strategic objectives and to assist the
Board in discharging its responsibility for internal
control. The content of and processes surrounding
the BAF were reviewed by the Internal Auditor in
2012/13. The review gave significant assurance,
but a number of recommendations were made for
improvement, and these are being implemented.
All reports to the Board and its committees detail
any potential impact on compliance with the Care
Quality Commission’s (CQC) 16 core essential
standards of quality and safety. This information -
together with the Board’s regular reviews of quality
- provides an oversight of areas which might be at
risk of non-compliance with the standards.
In 2012 both the Trust’s locations, at Parkview and
Steelhouse Lane, received a routine, unannounced
inspection from CQC. The review of CAMHS at
Parkview found full compliance with the standards
reviewed.
The review at Steelhouse Lane found a minor
non-compliance with standard 14: Supporting
workers. This finding related to a concern raised
by some of our theatre staff about the way
they were supported, particularly in relation to
the implementation of a new way of working in
Theatres.
In response we have changed the way we are
implementing the new process and have engaged
closely with the theatre staff to fully understand
their concerns and address them. In addition, we
have developed new ways of reporting potential
workforce issues to the Board and its committees,
to identify as early as possible when our staff
may be feeling unhappy, unsupported, or under
pressure.
When considering the quality of our services, it
is essential to consider whether anybody is at a
disadvantage because of certain characteristics.
In 2012/13 the Board of Directors held a workshop
to consider diversity and inclusion and began to
prepare a strategy for how the Trust can become
the healthcare provider and employer of choice by
responding to the unique needs of every patient
and every member of staff.
The Board agreed that, while it is not included in
the Equality Legislation, a characteristic that is
relevant to people’s health and the way people
access health services is socio-economic status.
The Quality Committee will therefore consider
in 2013/14 how this characteristic can be
incorporated into the Trust’s Diversity and Inclusion
Strategy.
The Trust is satisfied that there are no material
inconsistencies between the Annual Governance
Statement, the Annual Report, the Quality Report,
and the annual and quarterly Board statements
required by the Compliance Framework.
More information about quality governance and
quality can be found in our Quality Report at page
92 and in the Annual Governance Statement on
page 144.
Enhanced Quality Governance
Reporting
Birmingham Children’s Hospital NHS Foundation
Trust is continually striving to improve the quality
of the services it provides, in terms of safety,
patient experience and clinical effectiveness.
Quality continues to be at the heart of our strategic
objectives which ensures a constant focus on
quality at all levels of the Trust, including meetings
of the Board and its committees.
Every Board meeting agenda is aligned to these
strategic objectives and the Board of Directors
receives reports describing progress in and risks
to achieving our goals. This includes an integrated
Quality Report, which provides an overview of the
main indicators of quality across the Trust. This
includes high risks, incidents, mortality, patient
l Caring for our Staff = Better Care;
l Medication Omission – Sepsis;
l Developing a Palliative Care Service;
l The potential quality impact on our CAMHS and
other services if funding is reduced.
In February 2013 our Internal Auditor completed
a review of the Trust’s Quality Governance
arrangements against Monitor’s Quality
Governance Framework. This review found
that the Trust meets Monitor’s criteria, and
provides ‘significant assurance’ that the Trust’s
arrangements are sound. A small number of areas
were identified that could be improved, and we
are implementing the recommendations of the
Internal Auditor so we can ensure that our quality
governance arrangements are the best they can
be.
58 59

BACK TO CONTENTS PAGE
Consultations
l Providing patient stories
Remuneration Report
Information not subject to audit
Appointments and Remuneration
Committee
We apply the principles of good corporate
governance in relation to the Directors’
remuneration defined in the Companies Act 2006
and interpreted for NHS Foundation Trusts.
The remuneration, terms and conditions of
employment of Executive Directors are determined
by the Appointments and Remuneration
Committee, a committee of the Board of Directors.
The Committee is chaired by the Trust Chairman
and members include two Non-Executive Directors.
The Chief Executive Officer and the Company
Secretary attend by invitation to provide advice
and assist the Committee in their consideration of
matters such as succession planning.
During 2012/13 we consulted with YPAG, children,
young people, patients, parents and families on:
l New CAMHS website; Feeback App
l Dignity Giving Suits
l Outpatient department redesign
l Outpatient Pharmacy design and name
(Medicine Chest)
l Specialist Hospital Services
l NHS Constitution development
l Theatre pathway project.
Children, young people, patients, parents and
families have also participated in:
l Outpatient Department Redesign Steering
Group
l Delivering training for staff on participation and
learning disability issues
l Learning Disabilities Steering Group
l Development of a parent drop-in session
l Emergency Care Pathway development
l Patient handover project
l ‘Shine’ project to develop a tool to measure
parental concerns about their child’s condition
l Leukaemia multi-disciplinary team user survey.
We have also engaged with the Health Overview
and Scrutiny Committee on our future strategy.
Future Developments
In 2012/13 we plan to:
l Develop our Rare Diseases Strategy;
l Commence capital works for the expansion
of theatres, PICU and cancer services and
improvements in the Emergency and main
Outpatients departments
l Develop with our partners a Birmingham
Children’s Network, that enables high quality,
high value health care for children and young
people across Birmingham
l Develop a cultural barometer
l Implement an E-Prescribing system
l Develop our Advanced Nurse Practitioner
workforce.
Table 5: Appointments and Remuneration Committee Attendance 2012/13
Appointments & Remuneration Committee – Members’ attendance 2012/13
Member Sept 2012 Nov 2012 Total
Keith Lester, Interim Chairman 4 4 2/2
Judith Green Senior Independent Director* n/a 4 1/1
Elaine Simpson, Non-Executive Director 4 4 2/2
Roger Peace, Non-Executive Director 4 n/a 1/1
* Judith Green replaced Roger Peace on the Committee in November 2012.
When determining the remuneration of
Directors, the Appointments and Remuneration
Committee considered the advice provided by the
Department of Health in relation to the uplift in
salaries for senior managers, referred to national
benchmarking information and took into account
the recommendations of the NHS Review Body.
In line with the national pay freeze, the Directors
did not receive a remuneration increase in
2012/13. The Directors did not receive the national
pay uplift of 1% from 1 April 2013.
No element of the remuneration of Executive
Directors is subject to performance conditions,
although performance is reviewed through the
appraisal process. There are no non-cash benefits
60 61
or elements of remuneration that are not cash,
other than the Lease Car Scheme. All contracts are
permanent with notice periods of six months.
The terms and conditions of contract and the
remuneration of the Chairman and Non-Executive
Directors are determined by the Nominations
Committee, a committee of the Council of Governors
(see page 82). Non-executive directors receive no
benefits or entitlements other than expenses and are
not entitled to termination payments.
The appointment of the Chairman and Non-
Executive Directors can be terminated by the
agreement of the majority of the Council of
Governors at a general meeting of the Council of
Governors.

Senior Manager Service Contracts
A senior manager is defined as an Executive or
Non-Executive Director of the Board.
Table 6: Senior Manager Service Contract Details
Senior Manager Title Date of Unexpired Notice Provision for
contract term period compensation
for early
termination
Mrs Joanna Davis Chairman 01/11/2003 10 months 1 month none
(informal)
Mr Keith Lester Interim Chairman 01/12/2003 22 months 1 month none
(informal)
Mrs Judith Green Deputy Chairman 01/04/2006 10 months 1 month none
(informal)
Mr Colin Horwath Deputy Chairman 01/05/2008 14 months 1 month none
informal)
Professor Jon Glasby Non-Executive 01/06/2010 3 months 1 month none
Director
(informal)
Mr Zubair Khan Non-Executive 01/06/2011 term ended n/a none
Director
December
2012
Mrs Elaine Simpson Non-Executive 08/02/2012 11 months 1 month none
Director
(informal)
Roger Peace Non-Executive 03/07/2012 3 months 1 month none
Director
(informal)
Ms Sarah Jane Marsh Chief Executive 01/09/2010 n/a – 6 months none
Officer (substantive) permanent
appointment
Mr David Melbourne Chief Finance 01/11/2009 n/a – 6 months none
Officer/Interim Chief
permanent
Executive Officer
appointment
Dr Vin Diwakar Chief Medical 09/10/2009 n/a – 6 months none
Officer
permanent
appointment
Mrs Michelle Chief Nursing 01/08/2007 n/a – 6 months none
McLoughlin Officer permanent
appointment
Mr David Eltringham Chief Operating 06/11/2009 Appointment n/a none
Officer
ended
September
2012
Mrs Theresa Nelson Chief Officer for 06/06/2011 n/a – 6 months none
Workforce
permanent
Development
appointment
Mr Tim Atack Chief Operating 17/09/2012 n/a – 6 months none
Officer
permanent
appointment
Mr Phil Foster Interim Chief 01/11/2012 Fixed term to n/a none
Finance Officer June 2013
Information Subject to Audit: Salary and Pension
entitlements of senior managers
Table 7: Remuneration 2012-13 1st April 2012 to 31st March 2013
62 63
BACK TO CONTENTS PAGE
Name and Title Salary Other
Remuneration
Benefits
in Kind
Notes (bands (bands Rounded
of of to the
£5,000) £5,000) neareste
£100
Mrs Joanna Davis Chairman 4 40-45 0 0
Mr Keith Lester Non-Executive/Interim Chairman 5 25-30 0 0
Mrs Judith Green Non-Executive Director/Deputy 6 15-20 0 0
Chair, Engagement
and Participation
Mr Colin Horwath Non-Executive Director/Deputy 7 15-20 0 0
Chair, Strategy and Partnerships
Ms Sarah-Jane Marsh Chief Executive Officer 8 135-140 0 0
Mr David Melbourne Chief Financial Officer/Interim 9 125-130 0 2,300
Chief Executive Officer
Mr Philip Foster Interim Chief Finance Officer 10 35-40 0 0
Director
Mr David Eltringham Chief Operating Officer 11 45-50 0 0
Mr Tim Atack Chief Operating Office 12 50-55 0 0
Mrs Michelle Chief Nursing Officer
McLoughlin 100-105 0 0
Dr Vinod Diwakar Chief Medical Officer 40-45 115-120 2,400
Mrs Theresa Nelson Chief Officer for 100-105 0 2,400
Workforce Development
Miss Elaine Simpson Non-Executive Director 10-15 0 0
Mr Zubair Khan Non-Executive Director 13 10-15 0 0
Professor Jon Glasby Non-Executive Director 15-20 0 0
Mr Roger Peace Non-Executive Director 14 10-15 0 0
Total
2012/13 935-940 115-120 7,100
Total
2011/12 795-800 145-150 4,600
Notes:
1) The definition of Senior Managers includes only the Chief Officers and the Non-Executive Directors.
These are the senior officers of the Trust having Board of Director voting powers.
2) Benefit in kind relates to lease cars.
3) Other Remuneration relates to work not directly related to Chief Officer duties.
4) Ms Joanna Davis commenced sick leave on 16th April 2012.
5) Mr Keith Lester took up position as Interim Chairman from 4th July 2012.
6) Mrs Judith Green and took up position as Deputy Chair, Engagement and Participation from 4th July 2012.
7) Mr Colin Horwath took up position as Deputy Chair, Strategy and Partnerships from 4th July 2012.
8) Ms Sarah-Jane Marsh started Maternity Leave from 1st November 2012.
9) Mr David Melbourne took up position as Interim Chief Executive from 1st November 2012.
10) Mr Phil Foster took up position as Interim Chief Finance Officer from 1st November 2012.
11) Mr David Eltringham resigned his position as Chief Operating Officer from 14th September 2012.
12) Mr Tim Atack took up position as Chief Operating Officer from 17th September 2012.
13) Mr Mohammed Zubair Khan ended his term as Non Executive Director on 31st December 2012.
14) Mr Roger Peace took up position as Non Executive Director from 4th July 2012.

64 65
Table 8: Remuneration 2011-12 1st April 2011 to 31st March 2012
Name and Title Salary Other Benefits
Remuneration in Kind
Notes (bands of (bands of Rounded
£5,000) £5,000) to the
£000 £000 nearest
£100
Ms Joanna Davis Chairman 50-55 0 0
Ms Sarah-Jane Marsh Chief Executive Officer 155-160 0 0
Mr David Melbourne Deputy Chief Executive 115-120 0 2,300
Chief Financial Officer
Mr David Eltringham Chief Operating Officer 100-105 0 0
Mrs Michelle
Chief Nursing Officer
McLoughlin 100-105 0 0
Dr Vinod Diwakar Chief Medical Officer 3 40-45 115-120 2,300
Mr Garrett Taylor
Mrs Theresa Nelson
Chief Officer for Governance
and Education 4 and 5 20-25 30-35 0
Chief Officer for
Workforce Development 6 60-65 0 0
Mrs Judith Green Non Executive Director 10-15 0 0
Mrs Elaine Simpson Non Executive Director 7 0-5 0 0
Mr Colin Horwath Non Executive Director 10-15 0 0
Mr Keith Lester Non Executive Director 15-20 0 0
Mr Zubair Khan Non Executive Director 8 10-15 0 0
Professor Jon Glasby Non Executive Director 10-15 0 0
Mr Niels de Vos Non Executive Director 9 0-5 0 0
Total 795-800 145-150 4,600
Notes:
1) The definition of Senior Managers includes only the Chief Officers and the Non-Executive Directors.
These are the senior officers of the Trust having Board of Director voting powers.
2) Benefit in kind relates to lease cars.
3) The Other Remuneration relates to work not directly related to Chief Officer duties.
4) Mr Garrett Taylor, Chief Officer for Governance and Education resigned his post with effect from
17th June 2011.
5) The Other Remuneration relates to the contractual package due to Mr Taylor on his resignation.
6) Mrs Theresa Nelson, Chief Officer for Workforce Development took up post with effect from
1st September 2011.
7) Mrs Elaine Simpson took up position as Non Executive Director with effect from 1st February 2012.
8) Mr Zubair Khan took up position as Non Executive Director with effect from 1st June 2011.
9) Mr Niels de Vos resigned his position as Non Executive Director effective from 31st May 2011.
Real
increase/
(decrease)
in pension
and
related
lump sum
at age 60
Total
accrued
pension
and
related
lump sum
at age
60 at 31
March
2013
Notes:
1) The Real increase in pension and related lump sum at age 60 has been compared with a zero balance last year.
Cash
Equivalent
Transfer
Value at
31 March
2013
Cash
Equivalent
Transfer
Value at
31 March
2012
As Non-Executive members do not receive pensionable remuneration, there will be no entries in respect of pensions for Non-Executive members.
BACK TO CONTENTS PAGE
Real
Increase/
(decrease)
in Cash
Equivalent
Transfer
Value
Employers
Contribution
to
Stakeholder
Pension
(bands (bands To To To To
Name and Title Notes of of nearest nearest nearest nearest
£2,500) £5,000) £1,000 £1,000 £1,000 £100
Ms Sarah-Jane Marsh Chief Executive Officer 10.00-12.50 85-90 272 234 38 0
Mr David Melbourne Chief Financial Officer/Interim
Chief Executive Officer 17.50-20.50 150-155 691 587 104 0
Mr David Eltringham Chief Operating Officer 15.00-17.50 115-120 446 372 74 0
Mrs Michelle McLoughlin Chief Nursing Officer 10.00-12.50 125 531 471 60 0
Dr Vinod Diwakar Chief Medical Officer 5.00-7.50 130 523 486 37 0
Mr Tim Atack Chief Operating Officer 1 120.00-122.50 120-125 518 0 518 0
Mrs Theresa Nelson Chief Officer for Workforce
Development 0.00-2.50 35-40 159 151 8 0
Mr Philip Foster Interim Chief Finance Officer 1 102.50-105.50 105-110 414 0 414 0
A Cash Equivalent Transfer Value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are
the member’s accrued benefits and any contingent spouse’s pension payable from the scheme. A CETV is a payment made by a pension scheme, or arrangement to secure pension benefits
in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the
benefits that the individual has accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity to which the disclosure applies. The CETV
figures, and from 2004-05 the other pension details, include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS pension
scheme. They also include any additional pension benefit accrued to the member as a result of their purchasing additional years of pension service in the scheme at their own cost. CETVs are
calculated within the guidelines and framework prescribed by the institute and Faculty of Actuaries.
Table 9: Pension Benefits 2012-13

BACK TO CONTENTS PAGE
The slight reduction in the ratio is a result of the remuneration of the highest paid director remaining
unchanged whilst the median salary has increased slightly. This increase in the median salary is a
consequence of clinical developments that have increased the medical and nursing workforce (6% and 4%
respectively) at a higher rate than non-clinical. The clinical workforce associated with these developments
has an average salary that is higher than the non-clinical workforce.
Signed…………………………………………….. Date: 29 May 2013
David Melbourne, Interim Chief Executive Officer
Real Increase/(Decrease) in CETV - This reflects the increase in CETV effectively funded by the employer. It takes account of the increase in accrued
pension due to inflation, contributions paid by the employee (including the value of any benefits transferred from another pension scheme or arrangement)
and uses common market valuation factors for the start and end of the period.
Real
increase/
(decrease)
in pension
and
related
lump sum
at age 60
Total
accrued
pension
and
related
lump sum
at age
60 at 31
March
2012
Cash
Equivalent
Transfer
Value at
31 March
2012
Cash
Equivalent
Transfer
Value at
31 March
2011
Real
Increase/
(decrease)
in Cash
Equivalent
Transfer
Value
Employers
Contribution
to
Stakeholder
Pension
(bands (bands To To To To
Name and Title Notes of of nearest nearest nearest nearest
£2,500) £5,000) £1,000 £1,000 £1,000 £100
Table 10: Pension Benefits 2011-12
Director and Governor Expenses
Table 11 Expenses paid to Directors
Total Expenses paid
Name on Payslips for 2012/13
Ms Joanna Davis £282.53
Mr Keith Lester £1,996.32
Mrs Judith Green £657.73
Mr Colin Horwath
NIL
Table 12 Expenses paid to Governors
Name
Total Expenses paid
Mr David Akuoko £152.50
Mrs Jenny Robinson £10.00
Mr Anthony Veal £65.65
Ms Sarah-Jane Marsh Chief Executive Officer 6.75-7.00 70-80 234 156 78 0
Ms Sarah-Jane Marsh £33.00
Mr David Melbourne Deputy Chief Executive/
Financial Officer 11.25-11.50 130-135 587 476 111 0
Mr David Eltringham Chief Operating Officer 5.00-5.25 100-105 372 292 80 0
Mr David Melbourne £296.80
Mr Philip Foster £356.19
Mrs Michelle McLoughlin Chief Nursing Officer 10.5-10.75 110-115 471 373 98 0
Dr Vinod Diwakar Chief Medical Officer 5.75-6.00 125-130 486 389 97 0
Mr Garrett Taylor Chief Officer for Governance
and Education 1.00-1.25 40-45 169 161 8 0
Mrs Theresa Nelson Chief Officer for Workforce
Development 1 37.50-38.00 35-40 151 0 151 0
Mr David Eltringham NIL
Mr Tim Atack
NIL
Mrs Michelle McLoughlin NIL
Dr Vinod Diwakar NIL
Notes:
1) The Real increase in pension and related lump sum at age 60 has been compared with a zero balance the previous year.
Mrs Theresa Nelson £601.47
Median Remuneration
Mrs Elaine Simpson
NIL
The banded remuneration of the highest paid director at the Trust in the 2012/13 financial year was £160,000-£165,000 (2011/12, £160,000-£165,000). This was 5.88 times (2011/12, 6.12 times)
the median remuneration of the workforce, which was £27,625 (2010/11, £26,556).
Total remuneration includes salary, non-consolidated performance related pay, benefits-in-kind as well as severance payments. It does not include pension contributions and the cash equivalent
transfer value of pensions.
Mr Zubair Khan £230.48
Professor Jon Glasby £330.00
Mr Roger Peace NIL
66 67

68 69
NHS Foundation Trust Code of Governance
Council of Governors
Constitutionally formed, the Council of Governors
has the following key responsibilities:
l Strategic – Providing advice on our general
direction and ensuring that our plans assist in
the delivery of our long-term goals
l Guardianship – Ensuring that the Board of
Directors conform to the terms of authorisation,
acting as a trustee of the Trust
l Advisory – Providing advice to the Board of
Directors to ensure that we continue to deliver
services to meet the needs of the members,
patients, parents, families and the wider local
communities.
The Council of Governors is specifically
responsible for:
l Representing the views of the members and
acting as a source of information on members’
needs
l Working with the Board of Directors to inform
the future strategic direction and development
plan
l Appointing (and removing) the Chairman and
Non-Executive Directors
l Setting the salary levels of the Chairman and
Non-Executive Directors
l Approving the appointment of the Chief
Executive Officer; Appointing the External
Auditor
l Receiving copies of our annual reports, annual
accounts and the External Auditor’s report
l Holding the Non-Executive Directors individually
and collectively to account
The Board of Directors is legally accountable
for the services we provide and is specifically
responsible for:
l Setting the strategic direction (having taken into
account the Council of Governors’ views)
l Ensuring that clinical services provide highquality
and safe care for patients, parents and
their families
l Ensuring that governance arrangements are
implemented to provide assurance that there
are safe systems of internal control in place
l Ensuring that a rigorous performance
management framework is implemented which
ensures that we continue to be a high performer
against national and local targets
l Ensuring that we are at all times compliant with
our Terms of Authorisation.
The Constitution sets out the key responsibilities
of the Board of Directors. The accountability
framework defines the committees of the Board
and sets out within the approved terms of
reference the responsibilities for each of these
committees. Non-Executive Directors are members
(or the Chair) of each of these committees.
Composition of the Council of Governors
The Council of Governors comprises 18 elected
governors (10 public governors, one carer
governor, three patient governors and four
staff governors) and nine appointed governors
(from four Primary Care Trusts and five partner
organisations). The PCT governor posts are
currently vacant following a review of the
commissioning arrangements for the Trust. One
partner organisation governor post (Extended
Schools) is currently vacant as this organisation
no longer exists. The Council of Governors will
consider an alternative partner organisation to
be represented by a governor. The Council of
Governors is chaired by The Interim Chairman,
Mr Keith Lester. The Vice Chair and Lead
Governor is Public Governor for Birmingham,
Mr Philip Crombie.
l Approving any amendments to the Core
Constitution.
Members of the Council of Governors

BACK TO CONTENTS PAGE
Table 13: Composition of the Council of Governors and attendance at meetings 2012/13
Governor Constituency/Class Tenure Attendance
Mr Philip Crombie Birmingham 3 years from September 2010
(second term) 4/4
Mr Mark Kelly Birmingham 3 years from September 2011 1/4
Mr David Akuoko Birmingham 3 years from September 2010 1/4
Mr Brian Stokes Dudley/Walsall/Wolverhampton 3 years from September 2010
(second term) 4/4
Mr Ian Evans-Fisher Herefordshire/Worcestershire 3 years from September 2010 4/4
Mr Anthony Veal Solihull 3 years from September 2010
(second term) 2/4
Mr Brian Broughton Coventry/Warwickshire Term ended September 2012 2/4
Mr Martin Cossum Sandwell 3 years from January 2011 2/4
Mr Robert Foster Staffordshire/Shropshire 3 years from September 2011
(second non-consecutive term) 4/4
Mr Tim Edwards Staffordshire/Shropshire 3 years from April 2011 4/4
Mrs Sarah Simon Coventry/Warwickshire 3 years from November 2012 2/2
Mrs Jenny Robinson Carer 3 years from September 2010 4/4
Mr Joshua Millwood Patient 3 years from January 2011 2/4
Miss Ellie Milner Patient 3 years from January 2011 2/4
Miss Emma Wilson Patient 3 years from September 2011 2/4
Dr Robert Sunderland Medical/Dental Term ended September 2013 1/2
Mrs Karen Kelly Non Clinical 3 years from September 2011 4/4
Ms Bernadette Weeks Nursing 3 years from September 2010
(second term) 3/4
Mr David Rist Other Clinical Term ended September 2012 0/2
Dr Michael Kuo Medical/Dental 3 years from November 2012 1/2
Carl Harris Other Clinical 3 years from November 2012 2/2
Ms Hilary Brown University of Birmingham 3 years from September 2010 3/4
Professor Stuart Brand Birmingham City University Resigned September 2012 2/3
Professor Ian Blair Birmingham City University 3 years from November 2012 1/1
Table 14: Directors’ attendance at Council of Governors Meetings
Director Position Attendance
Mr Keith Lester Interim Chairman 4/4
Mrs Judith Green Non-Executive Director 2/4
Mr Colin Horwath Non-Executive Director 0/4
Professor Jon Glasby Non-Executive Director 0/4
Mr Zubair Khan Non-Executive Director (until December 2012) 2/3
Mrs Elaine Simpson Non-Executive Director 3/4
Mr Roger Peace Non-Executive Director (from July 2012) 1/2
Ms Sarah Jane Marsh Chief Executive Officer (maternity leave from November 2012) 1/2
Mr David Melbourne Chief Finance Officer/Interim Chief Executive 4/4
Dr Vin Diwakar Chief Medical Officer 3/4
Mrs Michelle McLoughlin Chief Nursing Officer 4/4
Mr David Eltringham Chief Operating Officer (to September 2012) 0/2
Mrs Theresa Nelson Chief Officer for Workforce Development 0/4
Mr Tim Atack Chief Operating Officer (from September 2012) 0/2
Mr Phil Foster Interim Chief Finance Officer (from November 2012) 2/2
Council of Governors Elections 2012/13
One election was held in 2012/13 for three vacant
positions on the Council of Governors, all of which
were filled.
Table 15: Governor Election Results 2012
Governor Election Autumn 2012
Constituency Turnout Successful Candidate
Public: Coventry/Warwickshire Uncontested Mrs Sarah Simon
Staff: Medical Dental Uncontested Dr Michael Kuo
Staff: Other Clinical 18.6% Mr Carl Harris
Ms Caroline Anson
Mrs Katy Cook
Birmingham Voluntary
Service Council Resigned August 2012 0/2
Birmingham Voluntary
Service Council Resigned March 2013 1/2
Cllr Valerie Seabright Birmingham City Council 3 years from November 2012 1/1
Directors are invited by the Council to attend meetings of the Council of Governors to present reports and information.
70 71

72 73
BACK TO CONTENTS PAGE
Declaration of Interests of the Council
of Governors
All members of the Council of Governors are
required to make known at each meeting any
interest they have in the matters being discussed.
They also make an annual declaration of interests
which is recorded in the Register of Interests. The
Board of Directors is satisfied that the Governors
hold no material interests in organisations where
those organisations or related parties are likely
to do business, or are possibly seeking to do
business with Birmingham Children’s Hospital NHS
Foundation Trust.
The Register of Interests of the Council of
Governors is held by the Company Secretary and
can be accessed by contacting:
The Company Secretary
Birmingham Children’s Hospital NHS Foundation
Trust
Steelhouse Lane
Birmingham
B4 6NH
Governors are also involved in the governance
structure through membership of and attendance
at Board sub-committees, including the Patient
Experience and Participation Committee, the
Learning Disabilities Project group and the
Diversity and Inclusion Steering Group. The
Organ Donation Committee is chaired by a public
governor, Mr Ian-Evans Fisher, with support from
the Senior Independent Director.
In 2012/13 the Council of Governors agreed to
establish a Governors Scrutiny Committee, to
provide a forum to support the Council to meet its
new obligations under the Health and Social Care
Act 2012, in particular, to hold the Non-Executive
Directors to account.
Board of Directors
The Board of Directors is made up of the
Chairman, six Non-Executive Directors and six
Executive Directors, including the Chief Executive
Officer, with the Non-Executive members having
the voting majority.
Senior Independent Director/Deputy Chairman
Mr Keith Lester was appointed Senior Independent
Director in October 2008. When he was appointed
Interim Chairman in July 2012, Judith Green,
another Non-Executive Director was appointed
Senior Independent Director. The principal
responsibilities of the role include:
l Representing to the Board any stakeholders’
concerns when all other communication
channels have been exhausted or are
considered inappropriate
l Acting as a point of contact for Governors to
raise concerns which have not been resolved or
addressed by the Chief Executive Officer or
other Executive Directors
l Being available to the Governors through
periodic attendance at the Council of Governors
meetings.
The role of Deputy Chair is shared between Judith
Green and Colin Horwath as follows:
l Judith Green, Deputy Chair, Engagement
& Participation: Deputy Chair of the Council of
Governors
l Colin Horwath, Deputy Chair, Strategy &
Partnerships: Deputy Chair of the Board of
Directors.
Meetings of the Board of Directors
The Board of Directors met a total 11 times in
2012/13. Individual attendance at those meetings
is set out on the next page.
Relationship between the Council of Governors
and the Board of Directors
Governors’ views are shared with the Board of
Directors through the formal meetings of the
Council, which is chaired by the Chairman,
who presides over the Board of Directors. The
Executive and Non-Executive Directors are invited
to attend the meetings to present reports and
information.
In addition, the Council of Governors and the
Board of Directors hold two joint meetings a
year where the Governors contribute to the
development of the
Trust’s strategic
direction and
vision.
All the Non-Executive Directors of the Board are
considered to be independent.
The Trust also has non-voting Directors who attend
the Board for the relevant agenda item to provide
operational advice and support.
Day-to-day management of the Trust is delegated
to the Chief Executive Officer. The Chief Executive
Officer, the Chief Officers, Directors and Clinical
Directors are responsible for the effective delivery
of the strategy and annual plan. They are also
responsible for the operational management of the
organisation.
The appointment, length of appointment and
removal of Non-Executive Directors is agreed by
the Nominations Committee and approved by the
Council of Governors.
Mrs Joanna Davis was reappointed Chairman
of the Trust for a further term of three years
from 1 February 2011. This reappointment was
recommended by the Nominations Committee
and approved by the Council of Governors on 5
January 2011. In April 2012 Joanna Davis was
diagnosed with an illness that would require an
extended period of absence. Keith Lester, the
Deputy Chairman took the role of Chairman on an
acting basis until the Council of Governors formally
appointed Mr Lester as Interim Chairman on 3 July
2012.

BACK TO CONTENTS PAGE
Table 16: Board Meeting Attendance 2012/13
Non Executive Directors
Name Role Appointment/ Board
Reappointment Date Attendance
From
Mr Keith Lester Interim Chairman July 2012 Feb 2015 11/11
Mrs Judith Green Deputy Chair, Engagement & Participation July 2012 Feb 2014 10/11
Mr Colin Horwath Deputy Chair, Strategy & Partnerships May 2010 May 2014 10/11
Prof. Jon Glasby Non Executive Director June 2011 June 2013 10/11
To
Background of Board Members
Mr Keith Lester
Interim Chairman
Appointed:
Experience:
Qualifications: ACIB
February 2007 - reappointed for a further three
year term in February 2010, and for a further
two year term in February 2013 (Interim
Chairman from July 2012)
Previously Regional Director for Lloyds TSB
Corporate and Commercial Banking: Mid
Corporate Business Advisory Consultant
Mr Zubair Khan Non Executive Director June 2011 Dec 2012 7/8
Mrs Elaine Simpson Non Executive Director Feb 2013 Feb 2014 9/11
Mr Roger Peace Non Executive Director July 2012 July 2013 8/8
Executive Directors
Name Role Appointment Date Board
Attendance
From
Ms Sarah Jane Marsh Chief Executive Officer June 2009 Present 6/6
(maternity leave from November 2012) (substantive)
Mr David Melbourne Chief Finance Officer/ Nov 2009 Present 10/11
Interim Chief Executive
Dr Vin Diwakar Chief Medical Officer Aug 2009 Present 10/11
Mrs Michelle McLoughlin Chief Nursing Officer Aug 2007 Present 11/11
To
Mrs Judith Green
Deputy Chairman, Engagement & Participation/
Senior Independent Director
Appointed:
February 2007- reappointed for a further three
year term in February 2010, and for a further
one year term in February 2013 (Deputy
Chairman/Senior Independent Director from July
2012)
Experience: A family lawyer and a children’s advocate for 21
years. Former Member of the Law Society
Family and Children’s Panels. 12 years
experience in post- graduate education
administration and a governor of three King
Edward Foundation Schools. Currently Vice-
Chair of King Edward VI Camp Hill Boys School
and main Foundation Governor since 1994.
Mr David Eltringham Chief Operating Officer Nov 2009 Sept 2012 3/4
Mrs Theresa Nelson
Chief Officer for Workforce
Development Sept 2011 Present 11/11
Mr Tim Atack Chief Operating Officer Sept 2012 Present 6/7
Qualifications: BA Hons English; Solicitor
Mr Colin Horwath
Deputy Chairman, Strategy & Partnerships
Mr Phil Foster Interim Chief Finance Officer Nov 2012 June 2012 5/5
Balance, Completeness and Appropriateness
of the Board
The Executive Directors and Non-Executive
Directors of the Board provide a balance and
breadth of knowledge, experience and skills.
The Executive Directors have at a senior level
considerable NHS experience in a range of
areas including medicine, nursing, strategic and
operational planning, research and workforce
development. Their expertise is complemented
by the Non-Executive Directors who have
extensive experience in commerce, banking,
accounting, audit, research, family law, education,
marketing, social care, education and community
relations. The Nominations Committee and the
Remuneration Committee consider the balance
and breadth of knowledge, experience and skills
required on the Board at each appointment and
reappointment of directors.
Appointed:
Experience:
74 75
May 2008 - reappointed for a further three year
term May 2011 (Deputy Chairman from July
2012)
Audit Partner, KPMG, with responsibility to
develop public sector audit practice in the
Midlands.
Qualifications: BSc, CIPFA, ACA, PIIA.

BACK TO CONTENTS PAGE
Professor Jon Glasby
Non Executive Director
Mr Roger Peace
Non Executive Director
Appointed:
Experience:
Qualifications:
June 2010; reappointed for a further two year
term June 2011
Professor of Health and Social Care and
Director of the Health Services Management
Centre, University of Birmingham. Qualified
social worker.
BA Hons (history), MA/DipSW (social work),
PhD (social policy), PG Cert (teaching and
learning in higher Education)
Appointed:
Experience:
Qualifications:
July 2012 for a one year term
A Chartered Accountant, currently Chief
Financial Officer of learndirect Ltd, the online
training business. Previously held various board
positions with Severn Trent Plc including CFO of
the US division during the 1990s and
subsequently UK divisional Managing Director
BA(Hons) Economics, MBA, FCA
Mr Zubair Khan
Non Executive Director
Appointed: June 2011- term ended December 2012
Ms Sarah-Jane Marsh
Chief Executive Officer
Appointed: June 2009
Experience:
Qualifications:
Forensic Scene Manager with West Midlands
Police; Accredited ACAS Mediator, Chair of
Nelson Mandela Primary school Governing
Body, former member of the General Teaching
Council and Heart of England Magistrates
Advisory Committee.
BA Hons English; Solicitor
Experience:
Joined the NHS via the Graduate Management
Scheme, holding various roles in Primary and
Secondary Care and at the Department of
Health. Previously Director of Planning and
Productivity at Walsall Hospitals NHS Trust.
Appointed Chief Operating Officer at BCH in
December 2007, and Chief Executive Officer in
June 2009.
Qualifications:
BA (Hons), History, MA, Russian and Eastern
European Studies, MSc, Health Care
Management
Mrs Elaine Simpson
Non-Executive Director
Appointed:
February 2012 - re-appointed for a further one
year term February 2013
Mr David Melbourne
Chief Finance Officer/Interim Chief Executive (from
November 2012)
Experience:
Qualifications:
25 years experience in Local Government
working in senior roles across a number of
North-West local education authorities. For five
of those years working in Sefton as the Chief
Education Officer. From 2002-2012 employed by
Serco initially as Managing Director and
subsequently as Global Director of Education
and Children’s Services. Member of the
Association of Directors of Children’s Services.
BSc (Hons) Mathematics, Post-Graduate
Diploma in Guidance and Counselling;
Post-Graduate Management Qualification
Appointed: November 2009
Experience:
Qualifications:
Previously a senior management consultant
at KPMG; various Director of Finance roles in
the NHS in Derbyshire and Lincolnshire from
2001 until 2005. Previously Director of
Resources & Deputy Chief Executive at Heart of
Birmingham Teaching PCT.
BA (Hons) Economics & History, MBA, CPFA,
ACA
76 77

BACK TO CONTENTS PAGE
Dr Vinod Diwakar
Chief Medical Officer
Mrs Theresa Nelson
Chief Officer for Workforce Development
Appointed: August 2009
Experience:
Qualifications:
Chair of the Acute Care Theme, Children and Young
People’s Outcomes Forum; Member of the DH
Future Forum Expert Working Group on the NHS
Constitution; Consultant Paediatrician since 2002,
Undergraduate Clinical Sub Dean 2002-05,
Postgraduate Clinical Tutor 2002-07, Associate
Director for the NHS Clinical Governance Support
Team 2002-04, Associate Postgraduate Dean at NHS
West Midlands Workforce Deanery 2005-07, Member of
the Expert Working Group on Ambulatory Care for the Ill
Child Module of the National Service Framework on
Children and Young People 2003-04. Appointed Interim
Director of Strategy at Birmingham Children’s Hospital in
March 2009, and Chief Medical Officer in September
2009.
MBBS, MRCP (UK), FRCPCH, MMedEd, FHEA
Mr Tim Atack
Chief Operating Officer
Appointed: September 2012
Appointed:
Experience:
Qualifications:
Appointed June 2011 as Director of Workforce.
Appointed September 2011 as Chief Officer
for Workforce Development
Previous roles include Director of Human Resources
at Good Hope Hospital; Deputy Director of Human
Resources & Head of Organisational Development
at Heart of England Foundation Trust and National
Lead for Clinical Leadership for the Department of
Health. Prior to 2003 roles included senior
commercial, financial and HR roles with Marks and
Spencer PLC.
FCIPD; NLP Practitioner and Executive Coach
Mrs Michelle McLoughlin
Chief Nursing Officer
Appointed: August 2007
Experience:
Over 10 years NHS Board experience. Previously Chief
Operating Officer at Sandwell & West Birmingham
Hospitals NHS Trust and at University Hospitals NHS
Trust. Appointed Director of ICT & Performance at BCH in
2010.
Experience:
A career with experience in acute hospitals and the
community in a variety of nursing and management
roles. Previous clinical roles across many paediatric
specialities in district general hospitals and teaching
hospitals. Clinical experience at ward sister and
clinical nurse specialist level. Previous clinical roles
in the community caring for adults, frail elderly,
children and young people. Previous role as Deputy
Director of Nursing.
Qualifications:
BSC (Hons) Mathematics with Computing
Mr Phil Foster
Interim Chief Finance Officer
Qualifications:
MSc, RGN, RSCN, DN
Appointed: November 2012 - June 2013
Mr David Eltringham
Chief Operating Officer
Appointed: November 2009 – September 2012
Experience:
Qualifications:
Joined the NHS after working within private accounting
practice. In over 24 years within the NHS has worked in
various senior roles within acute (district general and
specialist hospitals) and mental health services.
CPFA
Experience:
Qualifications:
Previously worked in a number of nursing roles at
University Hospitals Birmingham and Alexandra Hospital in
Redditch; 2 years working in the private healthcare sector;
Education and Professional Developmen Manager and
subsequently Clinical Lead for NHS Direct (Birmingham
the Black Country and Solihull). Came to Birmingham
Children’s Hospital in 2004 to manage the Medical
Directorate; appointed Assistant Director for CAMHS in
2007. Appointed Interim Chief Operating Officer March
2009 and appointed to the substantive role in November
2009.
MBA, BAEd (Hons); Registered Nurse (Adult);
Diploma in Nursing Science, DNSc
Evaluation of the Board of Directors
The Board of Directors has continuously reviewed
its compliance with the Code of Governance
and has identified one area where it has chosen
to follow a different approach to that set out by
Monitor. This relates to the recommendation
that Executive Directors should be subject to
review and reappointment at regular intervals
78 79
of no more than five years. We have chosen to
maintain our existing management and contractual
arrangements for Executive Directors.
Directors and Governors are required on an annual
basis to give a clear pledge to the code of conduct
and accountability, which encompasses the Nolan
principles and Code of Governance.

BACK TO CONTENTS PAGE
Performance of the Board of Directors, its
committees and individual Directors has been
evaluated in accordance with the Code of
Governance. This included:
l Annual appraisal and Performance
Development Review for each Executive
Director by the Chief Executive (reviewed sixmonthly)
l Annual appraisal and Performance
Development Review of Chief Executive by
the Chairman (reviewed six-monthly)
l Discussion of performance of Executive
Directors at Appointments and Remuneration
Committee
l Annual performance and development
reviews of each Non-Executive Director by the
Chairman
l Discussion of performance of Non-
Executive Directors (including the Chairman)
at the Nominations Committee
l Independent Governance Review by Capsticks
and Good Governance Institute Alliance
– a review of the governance structures and
information flows to the Board. This resulted in
the implementation of a new structure for
2012/13 and redesigned reporting to the Board
l Annual Review of each Board committee
l Internal Audit of quality governance
arrangements.
Declarations of Interests
All members of the Board of Directors are required
to make known at each meeting any interest.
This information is also recorded in the Register
of Interests. The Board is satisfied the Directors
hold no material interests in organisations where
those organisations or related parties are likely
to do business, or are possibly seeking to do
business, with Birmingham Children’s Hospital
NHS Foundation Trust.
The Register of Interests of the Board of Directors
is held by the Company Secretary and can be
accessed by contacting:
The Company Secretary
Birmingham Children’s Hospital NHS Foundation
Trust
Steelhouse Lane
Birmingham
B4 6NH
Audit Committee
The Audit Committee provides an objective review
of our systems and processes for governance,
internal controls and risk management. In addition
the Audit Committee is responsible for:
l Making recommendations to the Council of
Governors on the appointment of the external
auditors, reviewing and agreeing the external
audit plan, receiving external audit reports,
letters and management responses
l Making recommendations to the Board of
Directors on the appointment of the internal
auditors; approving the internal audit strategy
and work plan
l Monitoring and assessing the work of the
auditors, ensuring that they maintain
independence, objectivity and effectiveness
l Reviewing the Annual Report and financial
statements before they are submitted to the
Board of Directors.
The Audit Committee is chaired by Mr Colin
Horwath, a Non-Executive Director. The
membership includes two other Non-Executive
Directors, supported by an independent advisory
member. The meetings are regularly attended
at the invitation of the Chair by the Interim Chief
Finance Officer, the Company Secretary, the
Internal Auditor and the External Auditor.
The Audit Committee has met on six occasions
during the year to carry out its duties. The 2012/13
Annual Programme of the Committee had a
thematic approach to the assurance process
and to meet the requirements of the DH Audit
Committee checklist (designed to assess the
effectiveness of the Committee) and addressed the
following key themes:
a. Value for money and workforce;
b. Quality, patient safety and patient experience;
c. Financial standing;
d. Assurance mechanisms in the Trust;
e. Effectiveness of the Audit Committee;
f. Review of year-end statements;
g. Annual Accounts and Quality Report.
The Committee also:
l Received and considered reports on the work
of the Local Counter Fraud Specialist
l Reviewed and approved draft Annual Accounts,
Annual Governance Statement and the Annual
Report prior to adoption by the Board
l Reviewed the format of and processes in
relation to the Board Assurance Framework,
aligning the thematic review of each Committee
to its content
l Received and considered reports from
the internal and external auditors and in
particular focused on the implementation of the
recommendations arising from these reports.
Where the External Auditor provides non-audit
services, these are overseen by the Audit
Committee. The Audit Committee is assured
that the External Auditor’s internal controls and
appropriate challenge by the Committee ensure
that auditor objectivity and independence is
safeguarded.
Table 17: Audit Committee Attendance 2012/13
Members Apr 201 May 2012 Oct 2012 Dec 2012 Feb 2013 Total
Colin Horwath, 4 4 4 4 4 5/5
Chairman
Judith Green, 4 4 4 4 4 5/5
Non Executive Director
Elaine Simpson, 4 4 4 4 x 4/5
Non-Executive Director
Roger Peace, 4 4 n/a n/a n/a 2/2
Advisory Member*
Maxine Penlington, n/a n/a 4 4 4 3/3
Advisory Member**
* Roger Peace became a Non-Executive Director in July 2012 and ceased membership of the Audit Committee.
** Maxine Penlington became an Advisory Member of the Committee in October 2012.
80 81

82 83
BACK TO CONTENTS PAGE
Nominations Committee
The Nominations Committee is a committee of
the Council of Governors. The Committee is
responsible for the identification and nomination of
non-executive directors (including the Chairman),
giving consideration to succession planning and
the balance of skills, expertise and experience
required on the Board of Directors.
The Committee also oversees the terms and
conditions of employment and remuneration of all
Non-Executive Directors for the approval of the
Council of Governors.
During 2012/13 the Nominations Committee made
the following decisions, which were recommended
to and accepted by the Council of Governors:
1. Keith Lester is appointed Interim Chairman
2. Keith Lester is reappointed for a two year term
from February 2013.
3. Judy Green is reappointed for a one year term
as non-executive director from February 2013.
4. Elaine Simpson is reappointed for a one year
term from February 2013.
5. Roger Peace is appointed Non-Executive
Director for a one year term from July 2012.
Table 18: Nominations Committee attendance 2012/13
Foundation Trust Membership
Eligibility Criteria
Membership of Birmingham Children’s Hospital
NHS Foundation Trust is open to:
l Any person who is or has been a patient/
service user of Birmingham Children’s Hospital
in the last five years
l Any person who is or has been a parent/carer
of a patient/service user of Birmingham
Children’s Hospital in the last five years
l All permanent staff members
l Any member of the public aged 10 or over who
lives in one of the following constituencies:
Birmingham
Sandwell
Solihull
Walsall, Wolverhampton and Dudley
Staffordshire and Shropshire
Coventry and Warwickshire
Herefordshire and Worcestershire
Nominations Committee – Members’ attendance 2012/13
July Nov
Members 2012 2012 Total
Mr Keith Lester, Interim Chairman 4 4 2/2
Mr Philip Crombie, Lead Governor: Public – Birmingham 4 4 2/2
Mr Brian Stokes, Governor: Public – Dudley / Walsall / Wolverhampton 4 4 2/2
Mr Stuart Brand, Governor: Partner – Birmingham City University 4 n/a 1/1
Mr Tim Edwards, Governor: Public – Staffordshire / Shropshire 4 4 2/2
Mr Ian Evans-Fisher, Governor: Public – Herefordshire / Worcestershire 4 4 2/2
Ms Hilary Brown, Governor: University of Birmingham 4 4 2/2
Membership Numbers
The Trust set and achieved a target of 10,000
members by 2010/11 and aimed to sustain this
level for 2012/13. The number of members in each
constituency in March 2012 and March 2013 is
shown below.
Table 19: Membership Growth in 2012/13
Constituency Members 31 March 2012 Members 31 March 2013
Total Public Members 3,947 3,956
Total Patient/Carer Members 4,516 4,524
Total Staff Members 2,913 3,027
GRAND TOTAL 11,376 11,507
Membership Strategy
We met our membership target of 10,000 members
in 2010/11. We maintained a total membership of
over 11,000 members during 2012/13 and aim to
continue to maintain this level during 2013/14 by:
l Focussing membership communication through
the Trust’s new website, including an online
membership application form and the
development of a members area
l Encouraging young people to join the Young
Person’s Advisory Group (YPAG) and thereby
becoming Foundation Trust members if they are
not already
l Demonstrating achievements of members,
such as YPAG, to encourage new members to
join
l Supporting Governors to communicate with
members and the public
l Publicising ways for members to get involved,
including:
Consultations
Council of Governors meetings
Public Board meetings
Celebrations
Events
Annual General Meeting
Members can communicate with Governors by
contacting the Chairman’s Office:
0121 333 8533
foundation-trust.office@bch.nhs.uk
Birmingham Children’s Hospital
NHS Foundation Trust
Steelhouse Lane
Birmingham
B4 6NH
Details of how to contact some of the Governors
by direct email can also be found on the Council of
Governors page on the Trust website:
www.bch.nhs.uk.
l Encouraging members to communicate with
Governors through the Trust website.

Regulatory Ratings
Staff Survey Report
BACK TO CONTENTS PAGE
Table 20: Regulatory Ratings 2011/12
2011/12
Rating Annual Plan Quarter 1 Quarter 2 Quarter 3 Quarter 4
2011/12
Finance risk rating 4 4 4 4 4
Governance risk rating Green Green Green Green Green
Mandatory Services risk rating Green Green Green Green Green
Safety Assurance System in place n/a Green Green Green Green
risk rating (new for 2011/12)
Approach to Staff Engagement
Our staff are the most important part of our
hospital. We cannot deliver excellence for
children and young people unless we have
excellent staff.
Part of our commitment to our staff is to have
excellent communication, excellent engagement
and always be open to listening to new and
innovative ideas.
Table 22: Staff Survey Improvement Plan & Outcome 2011
Our People Strategy - launched in June 2012 - sets
out how we intend to focus on genuine engagement
with our staff to develop their support for radical
service redesign and continued improvements in
organisational performance.
An important element of this is the national staff
survey which our staff take part in every year.
We identified a number of themes for improvement
in the 2011 Staff Survey and made a commitment to
take the following action.
Theme What we said What we did
w Embed the Leading Change framework for
genuine consultation
w Embedded the revised Performance Appraisal
process and provided re-training for managers
Table 21: Regulatory Ratings 2012/13
2012/13
Staff
Involvement
w Embed the revised appraisal process and
provide re-training for managers
w Involve staff in influencing decisions through
the values work
w Enhanced consultation and communication
around organisational change
w Successfully launched and embedded the
Trust values
w Developed new ways to listen to our staff
Rating Annual Plan Quarter 1 Quarter 2 Quarter 3 Quarter 4
2012/13 (predicted)
Finance risk rating 4 4 4 4 4
Governance risk rating Green Green Green Green Green
Mandatory Services risk rating Green Green Green Green Green
Safety Assurance System in place Green Green Green Green Green
risk rating (new for 2011/12)
Health and
Wellbeing
at Work
w Design and implement a health and wellbeing
at work strategy which integrates with the
public health agenda
w Review areas where we know work pressures
are significant and support the implementation
of actions to address this
w Develop a coordinated staff support strategy
enhancing internal and external partnerships
w Identify initiatives to support health and
wellbeing at work
w Reviewed those areas where we know work
pressures are significant, and supported the
implementation of required actions to address
this.
w Identified from staff local interventions /
initiatives which could be offered by the Trust
to support health and wellbeing at work.
w Introduced work-based stress risk
assessments
Explanation of the risk ratings
Monitor uses the risk rating as a guide to the
intensity of scrutiny under which we operate. At
the end of each annual assessment and quarterly
review, each foundation trust receives risk ratings
and a summary of key issues to be followed up by
the Board or Monitor.
The Financial and Governance risk ratings are
primarily based on a defined set of indicators.
Monitor also uses other sources of information to
confirm or challenge this assessment.
The Safety Assurance System in place risk rating
was introduced by Monitor in 2011/12 and is a self
assessment by the Trust. Monitor uses a range of
information sources to assess this response.
Mandatory Services relates to a range of services
that the Trust is required to provide, which were set
as part of its authorisation process. Any significant
reduction or ceasing of these services could impact
on this rating.
Summary of Birmingham Children’s Hospital NHS
Foundation Trust’s performance in 2012/13
The Trust planned to be green across all the
ratings for the year. It has self assessed as being
green rated across all the risk ratings for each
quarter, and this has been confirmed by Monitor for
Quarter 1, Quarter 2 and Quarter 3. Monitor is due
to report in June our Quarter 4 assessment and we
expect this to confirm our self assessment.
All of the Governance performance metrics were
met for each quarter.
Recognising
and
Rewarding
Staff
Culture
and
Working
Environment
w Introduce work based stress risk assessments
w Develop a culture where managers deliver
effective praise and recognition to staff
supported with the launch of Trust values and
the appraisal system
w Increase opportunities for local and Trust wide
recognition
w Review loyalty and long service reward
scheme
w Encourage managers and clinical leaders to
understand the local position
w Work with staff through the values workshops
to create the environment that enhances their
experience at work
w Develop robust methods of reviewing exit data
and put in place mitigating actions
84 85
w Promoted a culture where managers recognise
staff supported by the launch of Trust values
and the appraisal system.
w Increased opportunities for local and Trustwide
recognition via Star of the Month.
w Reviewed loyalty and long service award
scheme.
w Encouraged managers and clinical leaders to
understand the local position
w Worked with staff through the Trust values
workshops to create an environment to
enhance their experience at work
w Developed the staff poll to more regularly test
how staff feel.

BACK TO CONTENTS PAGE
Throughout 2012/13 we have also continued to engage with staff as described at pages 53/54.
Summary of 2012/13 performance
N.B. national average is the average of specialist acute trusts, not all trusts.
Table 23: Staff Survey 2012 – Response Rate
Response Rate
Table 24: Staff Survey 2012 – most improved scores
Most Improved
Where we improved the most compared to 2011
2012 2012 2011 Variance
national Results Results 2011-2012
average
52% 46% 50% - 4%
2012 2012 2011 Variance
national Results Results 2011-2012
average
KF7. Percentage of staff appraised in the last 12 months. 75% 86% 75% + 11%
Action Plans for Improvement and future priorities
and targets
We have identified further themes for improvement
from the 2012 Staff Survey and plan to take the
actions described below.
Table 27: Staff Survey Improvement Plan 2012
Theme
Staff
engagement
& satisfaction
What we will do
w Hold monthly staff forums with Chief Executive and Chief Officers.
w Executive Team will regularly visit areas of the Trust.
w Continue to publicise and embrace ‘star of the month’, publicly recognising employee
contributions.
w Undertake bi-monthly staff polls on the intranet to understand the mood of staff better.
KF23. Staff job satisfaction. 3.45 3.57 3.45 + 0.12
Table 25: Staff Survey 2012 – highest ranking scores
Highest Ranking
Where we ranked the highest against other
acute specialist trusts in England
2012 2012 2011 Variance
national Results Results 2011-2012
average
KF7. Percentage of staff appraised in last 12 months. 83% 86% 75% + 11%
KF8. Percentage of staff having well structured
appraisals within the last 12 months. 36% 39% 34% + 5%
KF14. Percentage of staff reporting errors, near misses
or incidents witnessed in the last 12 months. 92% 92% 93% + 1%
KF17. Percentage of staff experiencing physical
violence from staff in the last 12 months. 2% 1% 0 + 1%
KF18. Percentage of staff experiencing harassment,
bullying or abuse from patients, relative or the public
in the last 12 months. 21% 19% n/a -
Table 26: Staff Survey 2012 – lowest ranking scores
Lowest Ranking
Where we compared least favourably against other
acuter specialist trusts in England
2012 2012 2011 Variance
national Results Results 2011-2012
average
KF3. Work pressure felt by staff. 2.88 3.05 n/a -
KF10. Percentage of staff receiving health and safety
training in the last 12 months. 76% 65% 83% -18%
KF11. Percentage of staff suffering work related stress
in the last 12 months. 32% 43% 29% -14 %
KF20. Percentage of staff feeling pressure in last
3 months to attend work when feeling unwell. 23% 30% 22% -8%
Health,
wellbeing &
safety
Clear roles,
responsibilities
and
rewarding
jobs
Equality &
diversity
Personal
development,
training &
support
w Re-engage the Health and Wellbeing Steering Group.
w Extend BCH offer of health and wellbeing resources to staff at work.
w Help line managers to understand staff stresses and anxieties and manage them appropriately.
w Continue signposting staff support and occupational health services and use staff and patient
feedback to improve services.
w Ensure that patient satisfaction scores are discussed and action plans are formulated to
address any key themes emerging.
w Encourage ongoing, meaningful dialogue between line managers and staff so teams are
aware of activity levels Trust-wide.
w Establish Diversity & Inclusion Steering Group.
w 2012/13 Diversity and Inclusion Plan to be shared with staff and patients.
w Provide personal support to Directorate Management Teams to understand specific personal
development and training needs.
w Continue to promote the Career Advisory service.
w Continue to utilise the revised appraisal process, training managers in using it to its full
potential thereby providing clarity about individuals’ roles and training needs.
w Robustly monitor training statistics at Directorate monthly and quarterly performance reviews
to target improvement drives and share best practice.
KF25. Staff motivation at work. 3.88 3.72 3.77 -0.05
86 87

Sustainability Report
Introduction and Commitment
Birmingham Children’s Hospital NHS Foundation
Trust is committed to reducing its impact on the
environment.
We recognise our environmental obligations and
are committed to delivering carbon savings during
the next 2 years, to meet a 10% saving against the
2007 baseline by 2015.
Energy Consumption
Our total energy consumption has risen during the
year, from 22,967 to 29,647 MWh. Our relative
energy consumption has changed during the year,
from 0.39 to 0.5 MWh/square metre.
As part of our commitment to reduce carbon
emissions, we installed a Combined Heat and
Power (CHP) plant which has been in operation
since September 2010. The CHP generates most of
BACK TO CONTENTS PAGE
the electricity, hot water and heating required at our
Steelhouse Lane site.
Renewable energy represents 12.6% of our total
energy use. In addition, we generate 57.7% of our
energy on site through the CHP. We have made
arrangements to purchase electricity generated
from renewable sources via the GPS energy
procurement service.
Sustainability underpins all aspects of the
Trust’s service delivery and development and
sits alongside quality of patient experience,
effectiveness of services and safety for patients
and staff as a Trust priority. We are, therefore,
encouraged by the progress made so far in
delivering the sustainability strategy.
We have put plans in place to reduce carbon
emissions and improve our environmental
sustainability. Over the next 10 years we expect to
save £85,000 as a result of these measures.
MWh
Figure 3: Energy Consumption 2008/09 - 2012/13
Energy Consumption
35000.00
30000.00
25000.00
20000.00
15000.00
10000.00
?
Electricity
Other
Renewables
Coal
Figure 2: Expenditure on energy 2008/09-2012/13
£1,800,000
£1,600,000
£1,400,000
£1,200,000
£1,000,000
£800,000
£600,000
£400,000
£200,000
0
£
£
£
£
£
£
£
Expenditure on Energy
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
2008/09 2009/10 2010/11 2011/12 2012/13
2008/09 2009/10 2010/11 2011/12 2012/13
Energy costs have increased by 10% in 2012/13 compared to the previous year. Much of this increase
can be attributed to the colder weather over the winter. Water consumption increased by 3,854 cubic meters in 2012/13.
5000.00
0.00
2008/09 2009/10 2010/11 2011/12 2012/13
Figure 4: Water Consumption 2008/09-2012/13
100000
90000
80000
70000
60000
50000
40000
30000
20000
10000
0
88 89
Water consumption in cubic metres
Gas
Oil

BACK TO CONTENTS PAGE
Carbon Emissions
A sustainable, low carbon NHS offers an
opportunity to save money while helping to create
a quality resilient healthcare service. To meet these
challenges we are committed to, and expect to
meet as a minimum, our environmental obligations
to exceed a 10% carbon savings required overall
by the Department of Health by 2015.
Carbon Saving Measures
We have committed resources during 2012/13
to deliver carbon reduction projects and have
identified areas completed and additional areas
for improvement during 2013/14.
Carbon saving projects completed to date
Project area
Objectives
Figure 5: Carbon Emissions 2008/09 - 2012/13
Installation of software which automatically shuts
down PCs when not in use
To reduce the Trust’s electricity demands and
reduce CO2 emissions
12000
Carbon Emissions
Commence programme for installation of variable
speed drives and ensure all new installations are
equipped with VSDs.
To reduce the Trust’s electricity demands and
reduce CO2 emissions
Tonnes CO2e
10000
8000
6000
4000
Project area
Continuation of the replacement of the Ozone
damaging R22 refrigeration plant
Installation of improved roof and plant room
insulation
Carbon saving projects planned or on-going
Objectives
To reduce the risk of detrimental effects on the
environment
To reduce the Trust’s heating demands and
reduce CO2 emissions
2000
0
2008/09 2009/10 2010/11 2011/12 2012/13
Commencement of programme for installation of
intelligent lighting controls
Improved heating and ventilation controls
To reduce the Trust’s electricity demands and
reduce CO2 emissions
To reduce the Trust’s heating demands and
reduce CO2 emissions
(Water &
Waste)
Rail Road Air Gas Electricity
Measured greenhouse gas emissions have increased by 1,047 tonnes this year.
Carbon Reduction Commitment Performance
Our total emissions under the government’s Carbon Reduction
Commitment (CRC) Energy Efficiency Scheme for 2012/13 have
reduced to 5,489 tonnes of CO2 (compared with 5,553 tonnes of CO2
for 2011/12). The carbon allowances required to cover these emissions
for 2012/13 will cost £73,500 (based on the current price of carbon at
£12 per tonne).
Procurement policy
Installation of Smart metering at the main
hospital site
Carry out review and update of current statutory
Display Energy Certificates (DECs)
Introduction / completion of active waste
segregation
Designing new buildings and refurbishments to
be as energy efficient as possible
Moving to paper and bottle free Board meetings
ATOM – Ambulance Taxi Operational
Management
Maple – Electronic Food Ordering
To reduce the risk of detrimental effects on the
environment.
To enable the Trust to accurately measure
energy use to enable management of efficiency
and reduce CO2 emissions
To enable the Trust to accurately report energy
use to enable management of efficiency and
reduce CO2 emissions
To enable the Trust to reduce the impact on land
fill reduce costs’ & reduce the risk of detrimental
effects on the environment
To reduce the risk of detrimental effects on the
environment
To reduce the risk of detrimental effects on the
environment
To reduce the Trust’s heating demands and
reduce CO2 emissions
To reduce the Trust’s heating demands and
reduce CO2 emissions
90 91

SECTION THREE
Our Quality Report
Chief Executive’s Statement on Quality
Our organisation is committed to putting the quality
of care we provide at the centre of everything that
we do. We have ensured that this remains at the
forefront of our agenda by embedding it as the first
of our six strategic objectives.
This commitment is not just about maintaining
the status quo but about continual learning and
improvement. There is no health care organisation
worldwide that can’t in some way improve the
services it provides for its patients and our hospital
is no exception.
During the year our Quality Committee has become
central to this agenda, ensuring that there is a
continual oversight and challenge as to how we
can further improve what we do. This is enhanced
through the work programme of the Board of
Directors - its agenda is structured to focus on
service quality and safety first and foremost. This is
achieved through a range of methods, for example
a detailed quality report is scrutinised, discussed
and debated on a monthly basis. We also use
patient stories and quality walkabouts to ensure
that we look beyond the figures within the report.
We are proud of some of the initiatives and
innovations that have been developed over the past
year to improve quality. We recognise that feedback
from our staff about the services that we provide
and their own experience of working at the Trust
is invaluable in the quality agenda. For example,
we have developed tools to support junior doctors
(Training Advice & Liaison Service) and to capture
their experience of training at the hospital.
Recognising the hard work and commitment of
staff as our most valuable asset is important to the
Trust. We launched a monthly ‘Star of the Month’
award during the last year and some of the stories
of staff working in a diverse range of roles are truly
inspirational. Each year we celebrate the work
of our staff with an annual awards event saying
thank you for their contribution over the past twelve
months.
We have also used technology to improve the
quality of the patient experience. Our App for
Smart Phones allows us to capture the experience
of our patients and their families in real time and
quickly address any issues. All these responses
are captured live on our public website increasing
transparency of the whole process.
We are rightly upheld at a local, regional and
national level for the work that we do on patient
experience. We are proud of the various ways in
which we engage with children and young people
to address how we can improve our services. Our
Young Persons Advisory Group (YPAG) has been
visited most recently by Dr Hilary Cass, president of
the Royal College of Paediatrics and Child Health,
and had input into a range of service areas and
initiatives. For example, the group helped design
a new Dignity Giving Suit to replace the traditional
backless robes used in hospitals.
To the best of my knowledge the information
contained in this Quality Account is accurate.
………………………………………………
David Melbourne, Interim Chief Executive
Priorities for Improvement
At Birmingham Children’s Hospital, ensuring that we
provide a high quality service is central to everything
we do and this is embedded within our strategy.
We are always looking for ways that we can improve
the quality of our services. This can include making
the experience better for the patients and families
that use our services; changing the way we work so
we can treat every patient that needs or chooses
to come to BCH without any delays; making
things safer than ever before and improving health
outcomes for the diverse range of children and
young people that we see every day.
It is important that we focus our resources on making
improvements where they are needed most, so we
continually monitor and analyse a wide range of
information that tells us where we could do better.
This includes:
l Listening to the children, young people and
families that use our services. There are lots of
ways they can tell us what they think, and
we take account of it all to work out what’s most
important to them:
Complaints, comments and concerns
Feedback cards
Surveys
Patient stories
Feedback App
Websites like NHS Choices and
Patient Opinion
Consultations
Mystery Shoppers
l Listening to our staff. The views of the staff who
work in our hospital every day are vital and we
encourage them to tell us what they think
through surveys, consultations and feedback
events. It’s also really important that we keep an
eye on their happiness and make sure they’re
fully supported so that they are able to deliver
the best services they can.
l Listening to others. The views of BCH groups
like the Young Person Advisory Group help us
focus on how to make the improvements that are
needed.
l Analysing information about the quality of
services, such as patient safety incidents and
clinical audits.
l Using best practice examples, national targets
and learning from and benchmarking with other
organisations.
92 93
BACK TO CONTENTS PAGE
Using this information has helped us to identify
Quality Priorities, which are the main areas we
want to focus on to improve quality. Each priority
has a goal and a way of measuring our progress in
reaching it. These relate to the three elements of
quality: Patient Experience, Clinical Effectiveness,
and Safety. The priorities we are reporting on this
year are:
In 2013/14 we will also report on some additional
priorities that we have been developing during
2012/13:
Safety:
Patient Experience:
Patient Experience
Emergency Department Transfers
Staff Survey
Food and Nutrition
Tertiary Inpatient Referrals
Play and Activities
Cancelled Operations
Clinical Effectiveness
Nursing Care Quality Indicators
CAMH Service User Satisfaction
Asthma Care
Health Promotion
Safety
Pressure Ulcers
Preventing MRSA
Reducing Acute Life Threatening Events, and
Cardiac and Respiratory Arrests
Reducing Healthcare Acquired Infections in PICU
Reducing MSSA
Zero Avoidable Deaths Reducing rates of
Clostridium Difficile
Reducing Medication Incidents Resulting in Harm
WHO Safe Surgery Checklist Completion
Extravasation Injuries
Friends and Family test
(for children and young
people)
Clinical Effectiveness: Implementing the Sepsis
Care Bundle
These priorities and what we’ve achieved in
2012/13 are set out over the next few pages of this
Quality Account.

BACK TO CONTENTS PAGE
Listening to Patients and Families: Food & Nutrition
A healthy diet can help patients get better quicker
and go home earlier. Having tasty food, with plenty
of choice, which meets everyone’s needs, is vital to
the wellbeing of our children and young people, and
ensures they have a good experience while they
are in hospital.
Figure 6: Percentage of patients weighed and measured per Quarter 2011/12 - 2012/13
GOAL:
100% patients
weighed and
measured
MEASURE:
% weighed
and measured
per quarter
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
99% 95% 93% 95% 97% 98% 98% 96%
How have we done?
Until 2012 these questions were answered through
a Food Survey but in 2012 we started asking the
questions during our regular Catering Quality
Walkabouts when we carry our checks on food
service on wards and address any immediate
issues. This way we can only ask a few children
and young people at a time, so next year we want
to develop new ways of getting views from as many
people as possible.
What are we doing to improve?
In 2012/13 we introduced a new electronic
food ordering system called MAPLE which was
developed with local software developer Ambinet
and our caterer Sodexo. MAPLE is an interactive,
fun way for our patients to order their meals
and is programmed to meet individual dietary
requirements. MAPLE has been really successful –
our patients and families say it is practical and easy
to use and it has received five awards.
The MAPLE food ordering system means that
children and young people will now always be able
to order what they want from the menu. We will
consult with our Young Person Advisory Group
(YPAG) about new questions we should ask
children and young people to ensure we get the
information we need to help us improve. Food will
also be a theme of YPAG walkabouts in 2013/14.
0%
Quarter 1 Quarter 2 Quarter 3 Quarter 4 Quarter 1 Quarter 2 Quarter 3 Quarter 4
2011/12 2011/12 2011/12 2011/12 2012/13 2012/13 2012/13 2012/13
How have we done?
We have continued to perform really well with this
measure. We will continue to monitor this but as we
have demonstrated sustained high performance we
will not report it separately from the other Nursing
Care Quality Indicators (NCQIs) next year.
In 2013/14 we will be focusing on offering
appropriate healthy eating advice where it is
needed. We will also be using a new electronic
process to collect the NCQI data which will allow us
to monitor this every month rather than quarterly,
which will help us address issues more quickly.
Figure 7: Percentage of patients who choose what they want and are
happy with their choice – 2009/2012/13
GOAL:
year on year
improvement in
patients being
happy with
food
MEASURE:
% of patients who choose
what they want & are happy
with their choice
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2009 May - 10 Dec - 10 2011 2012 2012/13
The food is alright –
better than I expected.
Generally the food
tastes nice.
Everything is good except
for the food. Food needs to
be improved.
I like the way my
food order follows
me round the
hospital on MAPLE
so when I move
wards I still get the
meals I’ve ordered.
I choose what
I want from
the menu
I am happy
with the choice
I am given at
mealtimes
94 95

BACK TO CONTENTS PAGE
Listening to Patients and Families: Play & Activities
Play and activities are important for the wellbeing
of all children and young people who spend time
in hospital. They can also provide an essential
distraction from distressing aspects of care. It’s
important that activities, toys and equipment are
of good quality, are age appropriate, and easily
accessible. We categorise feedback about play and
activities as either ‘positive’ or ‘need to improve’.
Figure 8: Percentage of positive and ‘need to improve’ comments received
2011/12 & 2012/13
Play and Activities Feedback 2012/13
GOAL:
year on year
improvement in
positive
feedback
MEASURE:
% of positive feedback
compared to
‘need to improve’
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
How have we done?
54%
Positive
46%
The picture is very similar to last year. Having the
right toys, equipment and activities continues to
be really important to people who visit and stay
at our hospital. ‘Need to Improve’ comments can
include things we need to change or do better, like
provide more things to do for older children and
young people. These comments also include lots
of suggestions about different toys, games and
activities that children and young people would
really like to be available. It’s important that we
continue to monitor everything that people are
saying so we know where we need to do better
and understand what it is that children and young
people want and need.
Need to improve
53%
2011/12 2012/13
47%
I liked that the nurses gave
me colouring books and
pens when I was bored.
Although my child enjoyed
playing in the playroom it was
quite small and not easily
accessible if the patient is
on IVs etc, and have a dripstand
attached to them.
There was no adolescent
room like there is on
other wards.
l We will run a ‘promoting happy parenting’ course
to help parents with the challenges they face
when their children are in hospital.
l We will improve information about play and
activities so that children, young people and
families know what is available at the hospital.
l We will share our play and activity resources
better between wards to ensure that more
children and young people in the hospital have
opportunities use everything that is available.
l We will ask our volunteers to support
improvements in play and activities.
Listening to Patients and Families: Emergency Department Transfers
Until 2010/11 patients who came to our Emergency
Department were regularly transferred to other
hospitals after treatment because there were no
inpatient beds available. This was a really bad
experience for patients and their families so we
adapted our processes and procedures to ensure
this would change.
Figure 9: Patients transferred out of ED per month 2010/11 - 2012/13
GOAL:
all patients
who attend ED &
require
inpatient care
will be
admitted
MEASURE:
number of patients
transferred out of ED
per month
Number of patients transferred
60
50
40
30
20
10
How have we done?
We have continued to follow the processes we set
in 2010/11 and maintained our objective for most of
the year. In July 2012 one patient was transferred
out. This has been reviewed, and while the decision
to transfer was clinically right, there were processes
that could have been followed that would have
avoided the need for this transfer.
We will continue to monitor this indicator but we
will not report this as a quality priority in our next
Quality Account if we continue to perform well.
0
A M J J A S O N D J F M
2010/11
2011/12
2012/13
What are we doing to improve?
l We will be investing all our 2013/14 allocation
for improving patient experience by upgrading
the ward play areas.
l We have a new weekly Stay and Play group to
provide patients and siblings the opportunity to
play in a supportive environment. Feedback from
initial sessions is really positive.
l We are developing an activity book for children
and young people who come to the Emergency
Department to entertain and educate them
about what they might see and what might
happen to them while they are there. This is
linked to activities in schools to educate young
people about accessing health care.
l We are creating a Play Charter which will allow
us to set some specific, measurable objectives to
support improvements in play.
96 97

BACK TO CONTENTS PAGE
Listening to Patients and Families: Tertiary Inpatient Referrals
When a child or young person needs to come to
BCH for urgent inpatient care from home or from
another hospital, it’s important that their admission
is not delayed as this could have a negative impact
on their care. In 2010/11 we decided to make sure
delays did not happen and put processes in place
to meet our goal.
Figure 10: Number of patients not offered a BCH bed within 24 hours 2010/11 - 2012/13
GOAL:
all children
referred for
urgent inpatient
care will be
admitted
within 24
hours
MEASURE:
number of children
per month not offered
a bed within 24 hours
of urgent referral
30
25
20
15
10
5
2010 - 11
2011 - 12
2012 - 13
Listening to Patients and Families: Cancelled Operations
Patients, families and staff have told us that when
an operation has to be cancelled by the hospital
this can have a huge impact. It might mean travel
arrangements and time off school and work have to
be rearranged and could also mean that tests and
assessments have to be done again. We know this
can be very stressful and inconvenient.
There are times when we can’t avoid cancelling
operations because of emergencies like transplants
which can’t wait, or when another operation is more
complex than expected, so it takes longer than
planned. Sometimes an operation can’t go ahead
because there aren’t enough beds that day on PICU
to care for the patient after the operation.
Over the last few years we have been working hard
to try to reduce the number of operations that we
cancel, especially those that we cancel on the actual
day. At the same time we have been finding ways to
make the experience better for patients and families
when we can’t avoid cancelling their operation.
0
A M J J A S O N D J F M
Figure 11: Monthly cancelled operations 2010/11 - 2012/13
How have we done?
With more people than ever before wanting
to access our services, 2012/13 was a really
challenging year and our staff had to work very
hard to meet our goal.
What are we doing to improve?
Meeting our goal while demand for our services
increases means we need to increase the capacity
in our hospital. This does not necessarily mean
creating physical space for more beds. It’s also
important that we find ways of reducing the time
that people need to spend in hospital, and the
number of times they need to be admitted, so that
more beds are available. Some examples of what
we are doing to achieve this are:
l Developing services like Hospital @ Home so
some children can be discharged earlier
l Improving discharge processes so that once a
child is ready to be discharged this happens
much quicker
l Developing our outpatient services so that
children with long-term conditions like Diabetes
and Asthma are less likely to deteriorate and
need admission to hospital
l Improving flow through the hospital so that
people can get into wards quicker and can be
discharged earlier
l Establishing new services like our Paediatric
Assessment Clinical Intervention and Education
(PACE) team (see page 99) which supports high
dependency patients on wards and allows earlier
access to PICU for children and young people
who need it.
Other examples can be found on page 99 in the
section about cancelled operations.
GOAL:
no more
than 0.8% of
operations
cancelled
on the day
MEASURE:
number of operations
cancelled on the day
per month
60
50
40
30
20
10
How have we done?
We have not met our target, with 1.68% of
operations cancelled on the day. We have been
experiencing our highest ever activity levels, which
has put pressure on our theatres, PICU and wards,
and we were therefore unable to meet our goal
in 2012/13. Opening our new PICU extension in
November 2012 helped us improve, and in January
2013 we launched our new (PACE) team which
frees up more beds for our sickest children when
they have had an operation.
0
A M J J A S O N D J F M
Whoever told us was
very nice, supportive, and
apologetic.
98 99
You learn to understand that
emergencies come first. You put
everything back into perspective a
little while afterwards but at the time
we were really upset.
2010 - 11
2011 - 12
2012 - 13
When you’ve been told how
important it is to get the
operation done you start to
get really worried that it’s not
happening and you get more
and more worried that she
will be getting worse.

What else are we doing to improve?
Improving the experience for children,
young people and families
Because we know that we will always have to
cancel some less urgent operations we have been
talking to patients and families to understand how
we can make the experience better when this
happens. We know that communication is really
important, so they know what’s going on as early
as possible. We also know we need to make sure
our staff are trained in the best ways to talk to
families when their operation is cancelled, so that
they give them all the information they need and
are able to support them when they’re upset or
angry.
Identifying all the reasons for cancellations
and taking action
We have set up a Task and Finish Group which is
examining the reasons for all cancelled operations
very closely to identify ways we can improve.
They are already making progress, for example
patients are now contacted three days before
their operation to make sure they have all the
information they need.
Improving processes like discharge, so beds
are available more quickly
We have changed the model of care on the
Medical Day Care Unit so that it is now nurse-led.
This means that each child and young person
is admitted, treated and discharged by a named
nurse. This has reduced delays for these patients
along every step of their pathway, ensuring not
only a speedy stay with us, but a fantastic patient
journey.
Reviewing patient pathways, to improve flow
through wards
The Surgical Day Care Unit cares for children
requiring short stay surgery. We have changed
the way we work on this Unit to a 23-hour model
which means that some children can have
procedures later in the day, and be discharged
up to 11pm, and other children who require an
overnight stay can be discharged at 7am. Patients,
parents and carers have given very positive
feedback about these changes as they appreciate
being able to return to their home environment as
soon as possible. By switching to this new way of
working, we have maximised capacity, ensuring
cancellations due to lack of beds has been
significantly reduced.
In 2013/14 we will also be:
Opening more beds to increase capacity
l Another five beds are planned in PICU for 2013.
l We are opening more day beds/treatment chairs
in the Medical Day Unit, which will allow us to
treat more patients in the Unit, freeing up beds
on the inpatient wards.
Developing new areas to improve the
experience and increase capacity
Some of our parents and children have said that they
do not like being in a bed before an operation as this
can make them more anxious. To make this better we
are creating a new lounge area in the Surgical Day
Care Unit where children can stay and play until they
are ready to walk to theatre for their operation. Only
once they have had their operation will they need to
be in a bed to recover. This new way of working will
help us free up more beds, allowing us to do more
operations every day.
Expanding our Pre-Admission Service to prevent
avoidable delays
We are developing this service to ensure that all
children and young people will have access to it, which
will help prevent cancellations caused by things like:
l Families changing their minds about having an
operation
l Incorrect listing of an operation
l Children having eaten too close to the planned
operation.
Developing plans to increase physical capacity
We know we need more physical operating capacity
due to increasing demand so we are working on plans
to open more theatres.
Working with other children’s hospitals to see
what we can learn from the way that they work
Every children’s hospital is unique, with different
services meeting a range of different needs, but we
can all learn from each other to make sure all children
have a fantastic experience. We have set up a group
with other children’s hospitals around the country to
see if we can learn from each other about ways of
reaching our goals.
Listening to our Staff: Staff Survey
Staff are our most important resource.
Understanding their views about the quality of our
services is crucial to ensuring that we can make
improvements where they are needed.
Figure 12: Key Staff Survey Results 2009 - 2012
MEASURE:
% of staff who agree that
they would be happy with
the standard of care
at the Trust
MEASURE:
% of staff who agree
that care of patients is
the Trust’s top priority
Figure 13: Staff Satisfaction Score 2011/12
How have we done?
There has been very little change in the results
but we are disappointed not to have done better.
2012/13 was a challenging year for our staff due
to higher levels of activity and more patients with
complex needs, and we know they have been
working really hard to make sure children, young
people and their families have safe, high quality
care and a fantastic patient experience.
What are we doing to improve?
We are developing new ways to monitor how
our staff are feeling - such as sickness absence
and staff turnover - and we integrate this with
information about the safety and quality of
services. This helps us predict which areas might
be coming under pressure. We are also doing lots
100 101
3.45
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
64%
3.58 3.67
BCH Score BCH Score Acute Specialist
2011 2012 Trusts Score 2012
85%
65%
87%
BACK TO CONTENTS PAGE
GOAL:
year on year
improvement in
response to key
staff survey
questions
2009 2010 2011 2012
Care of patients is my Trust’s priority
If a friend or relative needed treatment, I would be happy with the standard
of care provided by this Trust
MEASURE:
staff job satisfaction
score
70%
86% 83%
76%
more to gather the views of our staff throughout
the year, keep them informed and support them
to continue to provide the best services possible.
Other methods we are adopting to improve staff
experience include:
l ‘Star of the Month’ nominated by staff, patients
and families
l Regular polls to help us understand staff mood
l Launch of a new Health and Wellbeing Strategy
with lots of opportunities for staff to improve their
health and get support when they need it
l Helping our leaders to support their staff when
they feel stressed
l Annual Night of Stars and Long Service Awards
to reward outstanding contributions
l Engaging with staff to obtain their views on
themes arising out of the Francis report
(see page 54)

BACK TO CONTENTS PAGE
Providing Even Better Nursing Care:
Nursing Care Quality Indicators (NCQIs)
Excellent nursing care is vital to ensuring our
patients are safe, have a good experience and
have good clinical outcomes. In 2010/11 we
developed quality indicators in the most important
areas. A new indicator was added for cannula care
in 2012/13.
Providing Even Better Nursing Care: Asthma Care
When children and young people with asthma use
an inhaler, it’s essential that they use it properly to
get the full benefits.
It’s also important that we ensure that they are
involved in decisions about their care and we do
this by agreeing their care plan with them and
giving them a copy.
GOAL:
year
improvememnt
in performance
against
each NCQI
MEASURE:
quarterly Trust-wide
performance
Observations:
making sure any
problems are
detected quickly.
Pain management:
understanding the
patient’s pain and giving
the right pain medicine.
Personal hygiene:
helping patients clean
their teeth and wash.
Food and nutrition:
weighing and measuring
patients and providing
the right support.
Drug administration:
keeping drugs secure
and giving the right
medicine.
Cannula care:
avoiding injuries caused
by cannules.
Skin care:
avoiding skin damage
caused by pressure.
Communication:
involving patients and
their families in care
planning and talking to
them in the right way.
MEASURE:
BTS National Audit
- BCH performance compared
to national benchmark
100
80
60
GOAL:
every child with
asthma will
agree a
written care
plan
Figure 15: BTS National Audit Performance 2010 - 2012
GOAL:
every child
will have an
inhaler
health check
every year
2010 2011 2012
40
Figure 14: NCQI Performance 2010/11 - 2012/13
20
100%
90%
80%
70%
60%
50%
2010/11
2011/12
0
BCH
National
BCH
National
BCH
National
Device technique assessed
40%
30%
20%
10%
0%
Observations
Nutrition
How have we done?
Skin
Pain
Drug administration
Communication
Hygiene
Cannula care
2012/13
What are we doing to improve?
How have we done?
We continue to perform above the national
average (which has improved), but our
performance has dipped compared to the last two
years. This is really disappointing as we know from
previous years that we are able to do this well.
What are we doing to improve?
During 2013/14 we will be looking into ways of
ensuring that adherence to the asthma care
pathway is embedded in normal clinical practice.
Written asthma care plan given
We have continued to do really well, with
improvements in every indicator in 2012/13,
especially in pain management. We are also
really pleased with such high performance in our
first year in monitoring cannula care.
We are creating an electronic method to collect
performance data which will allow us to monitor
this every month rather than just quarterly. This will
enable us to identify and address any issues much
earlier.
We will also amend the asthma care pathway to
reflect the new NICE Asthma Quality Standards.
We will report on our progress in our next Quality
Account.
102 103

BACK TO CONTENTS PAGE
Providing Even Better Nursing Care: Pressure Ulcers
Improving Health Outcomes: Health Promotion
Some of our patients - in particular the sickest
patients on PICU - are at risk of developing
pressure ulcers which, if left untreated, can become
very serious. We are working toward the complete
eradication of pressure ulcers, in line with the
ambition of the whole NHS.
We have an important role to play in improving
general health outcomes and reducing health
inequalities for children and young people. Good
general health for the whole family is even more
important when a child becomes ill or has a longterm
condition.
GOAL:
improve health
outcomes in the
long-term
and reduce
health
inequalities
Figure 16: Pressure Ulcer rates 2012/13
GOAL:
zero
pressure ulcers
of
grade 2
or above
2.5
2
Ask 25% of
children aged
over 12 if they smoke
Offer advice to
90% of children
who say they smoke
MEASURE:
number of avoidable
grade 2 or above
pressure ulcers
1.5
1
0.5
0
M A M J J A S O N D J F M
Measures
Ask 25% of
parents/carers
if they smoke
Offer advice to
50% of parents/carers
who say they smoke
How have we done?
We have done really well in 2012/13.
l Whenever a pressure ulcer is identified the
patient’s care is reviewed by a clinical expert.
So far in 2012/13, the care provided in all
cases has been appropriate.
Pressure Ulcers Grades Explained
1: Reddening skin
Ask 25% of
children aged
over 12 if they drink
or take drugs
Offer advice to
70% of children
who say they drink
or take drugs
l There have been no grade 3 or 4 pressure
ulcers.
2: Skin loss to one or two layers of skin
l Zero Grade 2 pressure ulcers have been
categorised as avoidable.
l The number of Grade 2 pressure ulcers has
decreased over the year.
What are we doing to improve?
We have been asked to contribute to the
development of NICE guidance on paediatric
pressure ulcers so that the improvements that
we have achieved will benefit children and young
people in hospitals across the NHS.
3. Full thickness skin loss involving
damage to the underlying tissue
4. Extensive damage to muscle, bone
or supporting structures.
How have we done?
We have done really well in 2012/13.
l We have met all of our goals.
l Referrals to Stop Smoking services have
significantly increased.
l We have achieved status as a World Health
Organisation (WHO) Health Promoting
Hospital so we now part of an international
network of hospitals that aim to improve health
by developing structures, cultures, decisions
and processes.
104 105
What are we doing to improve?
l We are providing training and awareness
sessions for staff.
l We have established a smoking referral
pathway.
l We have new data recording systems so that
we can monitor the impact of our work.
l We are displaying information about alcohol on
screens in the main Outpatients department.

BACK TO CONTENTS PAGE
Improving Health Outcomes: CAMH Service User Satisfaction
Measuring the difference our services make to the
people who use them helps us to understand what
we are doing well and where we might need to
make improvements.
Figure 17: CAMHS Questionnaire Scores 2011/12 - 2012/13
80%
GOAL:
61% of people
feel they have
a better health
outcome as
a result of
using
CAMHS
Reducing Infection: Reducing Healthcare Acquired Infections in PICU
Our sickest patients on our Paediatric Intensive
Care Unit (PICU) are most at risk of healthcare
associated infections (HCAIs). This can be very
serious and means they have to spend more time
in hospital. Reducing the risk of infections for these
patients can help them get well quicker and be
discharged earlier.
Figure 18: HCAIs in PICU 2011/12 - 2012/13
GOAL:
reduce Central
Venous Catheter
(CVC) infections
GOAL:
reduce Ventilator
Associated
Pneumonia
MEASURE:
% of people who say that
since using CAMHS they feel
a bit better/much better
(improvement score)
70%
60%
1.8
1.6
MEASURE:
% of people who say that
using CAMHS has made
their problems quite a lot
or a great deal better
50%
40%
30%
20%
MEASURE:
less than 1.4 CVC
infections
per 1,000 patient days
10%
( helpful score) MEASURE:
0%
Helpful Helpful Improvement Improvement
Parent Service User Parent Service User
2011/12
less than 1.73 incidents
of VAP
per 1,000 ventilator days
1.4
1.2
1
0.8
0.6
0.4
0.2
2011/12
2012/13
2012/13
0
Rate of CVC infections per 1,000
CVC - patient days
Rate of Ventilator Associated
Pneumonia (VAP) per 1,000
ventilator days
How have we done?
We have met the national target for all questions
except the percentage of service users who feel
the service has helped to make their problems
better.
What are we doing to improve?
We are improving the way that we engage with
young people to better understand their views on
CAMHS. We have set up focus groups to ensure
that we ask young people about the specific
care pathways they are on to support redesign
and development. We are also improving our
website with the help of our young people and
their families and providing further opportunities
for them to give us their views through the Trust
feedback app.
How have we done?
We have achieved our goal and improved on
last year’s performance in relation to Ventilator
Associated Pneumonia (VAP). We have shared
the VAP results with the International Forum on
Quality and Safety in Healthcare.
We have seen a small increase in our Central
Venous Catheter (CVC) infection rate in 2012/13.
Although this is still below our target rate of
1.4, we are investigating the reasons for this to
determine what we can do to reduce this rate
even further.
106 107
What are we doing to improve?
We are now monitoring rates of infections in other
areas of the hospital too, with most wards doing
well.
We will continue to develop the practices we have
put in place and to learn from every infection that
does occur to reduce the rate of infections in PICU
and across the hospital to a minimum level.

108 109
Reducing Infection: Reducing Rates of Clostridium Difficile
Clostridium difficile are bacteria present naturally
in the gut of around two-thirds of children and 3%
of adults. C.difficile does not cause any problems
in healthy people. However, some antibiotics used
to treat other health conditions can interfere with
the balance of ‘good’ bacteria in the gut. When this
happens, the bacteria can multiply and produce
toxins, which cause illness such as diarrhoea and
fever. As C.difficile infections are usually caused
by antibiotics, most cases happen in a healthcare
environment. Reducing rates of C.difficile in
hospitals is a national priority.
Figure 19: C.Difficile infections 2010/11 - 2012/13
3
GOAL:
no more than 1
infection during the
year
Reducing Infection: Preventing MRSA
Blood stream infections with MRSA can be very
serious for people who are unwell and can result
in additional treatment and an increased length of
stay.
Figure 20: MRSA infections 2007/08 - 2012/13
3
2
1
BACK TO CONTENTS PAGE
GOAL:
maintain a
zero level
of MRSA
MEASURE:
number of infections
per year
2
1
MEASURE:
number of infections
per year
0
2007/08 2008/09 2009/10 2010/11 2011/12 2012/13
How have we done?
For the second year in a row we have had no
MRSA infections at all.
0
2010/11 2011/12 2012/13
How have we done?
We had one case of C.difficile in 2012/13 and made
sure that the ward where this occurred had extra
cleaning until there was no trace of C.difficile in the
environment. We also carried out tests in other high
risk wards and found no C.difficile at all.
What are we doing to improve?
We have tried out a new sampling technique and
now carry out extra testing to identify patients who
do not have true C.difficile infection but might be
carrying the bacteria which could put other patients
at risk. Early identification and protection measures
reduce this risk.
What are we doing to improve?
Achieving this goal has been a challenge in
2012/13, particularly with some patients who are
at very high risk of MRSA bacteraemia. We will
continue to practice everything we have learned
that has ensured that we have had no MRSA
infections since 2010, and we will continue to
apply new best practice and learning from other
organisations.

110 111
Reducing Infection: Reducing MSSA
MSSA is a common bacteria carried on the skin of
30% of the population. MSSA bloodstream infection
is a risk for some of our patients, especially those
who have a central venous catheter (CVC).
Figure 21: MSSA post 48 hours rates 2011/12 - 2012/13
5
GOAL:
10% reduction
in post 48 hour
hospital acquired
infections
Providing the Safest Possible Care: Medication Incidents
We encourage staff to report every incident, from
the most serious to near-misses. At BCH we use
a lot of medicines so there are many opportunities
for errors to occur, and medication incidents are the
most frequently reported incident type. We want to
see a high number of reported medication incidents
at a low level of harm, as this shows a good safety
culture.
Figure 22: Medication Incidents (Harm Category) 2012/13
80
BACK TO CONTENTS PAGE
GOAL:
reduce proportion
of medication incidents
resulting in harm to less
than 1% of all madication
incidents and keep
those causing
serious harm
at zero
MEASURE:
number of infections
per month
4
3
2
1
2011 - 12
2012 - 13
MEASURE:
medication incidents
resulting in harm
as a % of all
medication incidents
70
60
50
40
No Harm
Minor, Non
Permanent Harm
(up to 1 month)
Moderate, Semi
Permanent Harm
(up to 1 month)
0
A M J J A S O N D J F M
MEASURE:
number of medication
incidents resulting
in serious harm
30
20
10
Severe
Catastrophic,
Death
Near Miss
How have we done?
0
A M J J A S O N D J F M
In 2011/12, our first year of monitoring, we achieved
substantial reductions, exceeding our target. In
2012/13 it has been challenging to reduce this any
further, with a similar number of infections during
both years. We did not therefore meet our target.
We have analysed every MSSA infection to identify
the cause and any opportunity to prevent them.
Dr Jim Gray, Head of Microbiology and his team
were recognised at the national NHS Innovation
Challenge Prizes, where they were highly
commended for their work in reducing MSSA
bloodstream infections in children who receive their
parenteral nutrition at home. The hard work of the
team reduced the numbers of infections by a third
and it is hoped that this example of good practice
will be rolled out across the hospital.
What are we doing to improve?
We believe we can improve even further and will
focus in particular in 2013/14 on reducing MSSA as
contaminants in blood cultures.
How have we done?
We have met both goals: 0.94% of all medication
incidents caused harm. Zero medication incidents
caused serious harm.
We take every incident seriously and next year we
want to see a further reduction in the percentage of
incidents that cause any harm at all.
What are we doing to improve?
We have created detailed easy to read staff
guidance on all high risk injectable drugs.
We have developed standardised labels for
marking high risk drug infusions.
We have reviewed the ward stock arrangements
so that most high risk drugs need to be specifically
ordered from our pharmacy department. This
means that the pharmacy staff can highlight any
guidance when issuing the drug.
We will deliver additional training on preparing
liquid medication.
We will develop standardised guidelines for each
drug which will be reviewed at regular intervals.
We have introduced the role of Medicines Safety
Nurses to act as local educators and champions
of best practice.
We have included additional guidance on good
prescribing practice on the junior doctors’ induction.
We have produced dose calculators for a number
of intravenous medications to minimise the chance
of making a calculation error.

BACK TO CONTENTS PAGE
Providing the Safest Possible Care: Acute Life-Threatening Events (ALTEs),
Cardiac Arrests and Respiratory Arrests
Good monitoring on wards means that we will
pick up deteriorating patients more quickly and
avoid preventable emergency and life- threatening
events.
Figure 23: Emergency Events 2012/13
GOAL:
reduce the number
of life threatening
events which
were preventable
and could have
been predicted by
monitoring to zero
Providing the Safest Possible Care: Mortality
Thankfully, the number of deaths at BCH is very
low relative to the number of patients we treat and
the seriousness and complexity of their illnesses.
We review every individual death to see if there
is anything we can learn, and to ensure that no
death is avoidable.
GOAL:
zero avaiodable
deaths
Figure 24: Deaths and deaths per 1,000 admissions 2011/12 - 2012/13
11
10
MEASURE:
number of cardiac arrests
on PICU and those
that were preventable
MEASURE:
absolute number
of deaths
14
12
9
10
8
7
6
MEASURE:
number of cardiac arrests
on wards, ED and theatres
and those
that were preventable
MEASURE:
number of deaths
per 1,000 admissions
8
6
4
5
4
3
MEASURE:
number of
respiratory arrests
and those
that were preventable
MEASURE:
number of deaths
that were avoidable
2
0
A M J J A S O N D J F M A M J J A S O N D J F M
2011 2012 2013
2
Deaths
Deaths per 1,000 admissions
1
0
MEASURE:
number of ALTEs
and those
that were preventable
M A M J J A S O N D J F M
No of Cardiac Arrests (ex PIC)
No of Respiratory Arrests
How have we done?
During 2012/13 there have been no preventable
acute life-threatening events (ALTEs), cardiac
arrests or respiratory arrests. We have therefore
reached our goal this year.
No of Cardiac Arrests (PICU)
No of ALTEs
What are we doing to improve?
We will continue to review each event to identify
any learning that could prevent or help predict
events in the future.
We are developing a pre-transfer checklist for
Extracorporeal Life Support (ECLS) to ensure all
monitoring functioning is checked.
How have we done?
There were more deaths in 2012/13 than in the
previous year but the number of deaths per 1,000
admissions has remained at a very similar level,
which suggests this reflects the increased number
of patients that we treated. We also, however, look
at a wide range of other information, including
details of every individual death to identify any care
failings that may have contributed to the death.
Our reviews have found that no deaths during
2012/13 were avoidable.
What are we doing to improve?
We will continue to monitor mortality rates in
a number of different ways to ensure that any
concerns are identified and that we learn from
every death in case there was anything we could
have done differently.
In 2013/14 we will also commission independent
reviews of our mortality review processes to ensure
they are of the highest quality and to identify any
ways that they can be improved.
More information about the way we review mortality
can be found at page 131.
112 113

114 115
Providing the Safest Possible Care: WHO Safe Surgery Checklists
Research by the World Health Organisation (WHO)
has confirmed that the use of the WHO Safe
Surgery Checklist significantly reduces surgical
morbidity and mortality. The checklist should be
completed at three stages of surgery.
Figure 25: Overall WHO Checklist Compliance: March 2011 - January 2013
MEASURE:
rate of completion of WHO
checklist in eligible
cases at each stage
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
How have we done?
In September 2012 our theatres department
implemented an e-checklist to improve compliance
and safety by making completion of all fields a
mandatory requirement of the system. Since then
overall compliance has been consistently high.
We will continue to monitor completion of the
checklist but if compliance continues to be high, we
will not report on this in our next Quality Account.
0%
GOAL:
100% completion
of WHO
checklist in
every
eligible case
M A M J J A S O N D J F M A M J J A S O N D J F M
2011 2012 2013
New Priorities for 2013/14:
Extravasation
Why is this a priority?
When medicine is given into a vein, it can leak into
and damage the surrounding tissue and cause a
potentially serious injury. This can be a particular
problem for children.
What have we been doing?
We have developed a Nursing Care Quality
Indicator (NCQI) for cannula care which focuses
on accurate observations, dressing changes and
observations of early signs of an injury. We are
also reviewing medication involved in extravasation
incidents, to identify whether there are specific
associations between the medication used and the
likelihood of injury.
Goal
Reduce the episodes of harm from extravasation
injuries by 25% year on year.
Measure
We will use a new process: SCAN (Safe Children
Audit – No harm) to monitor the number of
extravasation injuries per month.
Sepsis Care
Why is this a priority?
The rate of mortality from Septic Shock in children
is approximately 10%. Survival is significantly
increased if antibiotics are given within an hour
of diagnosis (as well as other treatment such as
intra-venous fluids). At BCH we treat many patients
who are at high risk of sepsis, such as oncology
patients or those who are immuno-compromised.
Our complex patients sometimes need unusual
antibiotics. Sepsis can be difficult to detect so it’s
essential we act quickly as soon as it is detected.
What have we been doing?
We have developed a Sepsis Care Pathway bundle
which describes what must be done when a patient
has sepsis. This has been piloted in the Emergency
Department and is being implemented on PICU
before complete roll-out to other areas in 2013/14.
Goal
All patients needing antibiotics as defined by the
care pathway should receive them within 1 hour of
prescription.
Measure
100% compliance with Sepsis Care Pathway
monitored by way of audit.
Friends & Family Test
BACK TO CONTENTS PAGE
Why is this a priority?
A helpful way for any organisation to
measure what the users of their services
think of them is to ask them whether they would
promote them to their friends or family.
What have we been doing?
Last year our commissioners asked us to ask
this question of all adults within 18-24 hours of
discharge. As all of our patients are under 18, it was
important to us to make sure that their views are
recorded too. So with the help of a group of young
people we developed a similar more meaningful
question for young people and put this to children
and young people from the age of 10. We have
also developed a smart phone app, which people
can use to give us their feedback.
Goal
Improvement on the first quartile score.
Measure
Number of promoters minus the number of
detractors.

116 117
Statements of assurance on the
quality of our services
Review of Services
During 2012/13 Birmingham Children’s Hospital
NHS Foundation Trust provided and/or subcontracted
37 NHS services.
Birmingham Children’s Hospital 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 2012/13 represents 100 per cent of the
total income generated from the provision of NHS
services by Birmingham Children’s Hospital NHS
Foundation Trust for 2012/13.
On a regular basis, the Board reviews the
following data which enables a comprehensive
understanding of the three dimensions of quality
– patient safety, clinical effectiveness and patient
experience across every service provided by the
Trust:
Quality Report – this report includes details of the
following:
l Major clinical risks
l Incident analysis
l Mortality
l Serious Incidents
l Emergency clinical events
l Never Events
l Performance against Safety Strategy objectives
l Patient Feedback
l Quality walkabouts
l Formal complaints
l PALS concerns
l Surveys
Resources Report – in addition to financial
performance this report includes the following:
l Activity
l Performance against our objectives relating to
access to our services
l Workforce indicators including:
Rates of appraisals
Mandatory training attendance
Sickness rates and analysis
Turnover
Use of temporary staff
Consideration of these reports together provides
an overview of areas in the Trust where there
might be concerns about the quality of care.
Members of the Board, senior hospital staff,
Governors and members of the Young People’s
Advisory Group undertake regular Quality
Walkabouts to the wards, where the focus is on
either safety or patient experience.
The walkabout involves ward observations and
discussions with members of the ward multidisciplinary
teams, patients and families to
identify any safety or patient experience issues
or concerns. The outcome of the walkabout is fed
back to the ward staff with a requirement to take
action where improvements are necessary.
The Clinical Risk and Quality Assurance
Committee has delegated responsibility from the
Board for reviewing risks to safety and quality and
identifying and monitoring actions to address these
risks and improve quality.
This Committee reports to the Quality Committee
which is responsible for driving the Trust’s quality
strategy, bringing the three elements of quality
together, allowing integrated reporting to the Board
of Directors.
In 2010/11 we developed a Safety Dashboard,
which acts as an early warning system. It allows an
aggregated comparison of safety metrics against
each ward and department and incorporates a
series of defined ‘triggers’ which, in combination,
may indicate problems with safety or quality in a
specific area.
The dashboard approach allows us to really
focus on the areas where potential for harm is
the highest. Whenever the dashboard identifies
a potential concern a more detailed analysis
is provided for the area in question and this is
considered in depth at the Clinical Risk and Quality
Assurance Committee.
Participation in Clinical Audit and
National Confidential Enquiries
During 2012/13, 15 national clinical audits and
one national confidential enquiry covered NHS
services that Birmingham Children’s Hospital NHS
Foundation Trust provides.
During 2012/13 Birmingham Children’s Hospital
NHS Foundation Trust participated in 100%
of national clinical audits and 100% national
confidential enquiries of the national clinical audits
and national confidential enquiries that it was
eligible to participate in.
BACK TO CONTENTS PAGE
Table 28: National Clinical Audits and National Confidential Enquiries 2012/13 –
eligibility, relevance, participation and percentage cases submitted
Audit
The national clinical audits and national
confidential enquiries that the Trust was eligible to
participate in during 2012/13 are as follows: (see
table below).
The national clinical audits and national
confidential enquiries that Birmingham Children’s
Hospital NHS Foundation Trust participated in, and
for which data collection was completed during
2012/13, 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.
Relevant Participation % Cases
Paediatric asthma (British Thoracic Society) Yes Yes 95%
Childhood epilepsy (RCPH National Childhood Epilepsy Audit) Yes Yes 100%
Fever in children (CEM) Yes Yes 100%
Paediatric intensive care (PICANet) Yes Yes Ongoing
Paediatric cardiac surgery (NICOR Congenital Heart Disease Audit) Yes Yes 100%
Diabetes (RCPH National Paediatric Diabetes Audit) Yes Yes 100%
Potential donor audit (NHS Blood & Transplant) Yes Yes 100%
Ulcerative colitis & Crohn’s disease (UK IBD Audit) Yes Yes 100%
Cardiac arrhythmia (Cardiac Rhythm Management Audit) Yes Yes 100%
Renal replacement therapy (Renal Registry) Yes Yes 100%
Renal transplantation (NHSBT UK Transplant Registry) Yes Yes 100%
Severe trauma (Trauma Audit & Research Network) Yes Yes 100%
Bedside transfusion (National Comparative Audit of Blood Transfusion) Yes Yes 100%
National review of Asthma Deaths (NRAD) Yes Yes 100%
Maternal, infant and newborn programme (MBRRACE-UK)* Yes Yes 100%
Mental Health programme: National Confidential Inquiry into Suicide Yes Yes 100%
and Homicide for people with Mental Illness (NCISH)

118 119
BACK TO CONTENTS PAGE
The reports of 25 national clinical audits were
reviewed by the Trust in 2012/13 and the Trust
intends to take the following actions to improve the
quality of healthcare provided:
The results of 25 local clinical audits were
reviewed by the Trust in 2012/13 and the Trust
intends to take the following actions to improve the
quality of healthcare provided:
BTS Paediatric Asthma Audit (2012)
l The use of the Asthma/Wheeze care pathway will be audited.
l Patients admitted with severe/life threatening exacerbation of asthma will now have a
follow up appointment booked following discharge.
l Feedback will be given to the BTS regarding the use of peak flow and length of stay and its
use in the national audit.
Paediatric cardiac surgery (NICOR Congenital Heart Disease Audit) (2012)
l Continue to liaise with Heart Suite suppliers to rectify the misplacement of co-morbid data
and the placing of more than one code in a diagnostic or procedure field.
l Regularly export the BCH data from the Congenital Database to review the procedures
analysis against the algorithm and locally held data (reverse validation).
l All therapeutic implantable devices and electrophysiological procedures in patients with
congenital heart disease will now be submitted to congenital CCAD.
Severe trauma (Trauma Audit & Research Network) (2012)
l A Working Group is reviewing rehabilitation services including patient journeys.
l Collate data for the region, comparing key metrics between each Major Trauma Centre and
Trauma Unit to inform the ongoing development of trauma networks.
Diabetes(2012)
l The diabetes PREM questionnaire has been distributed in the diabetes clinics.
Tissue Viability - Annual Audit of Pressure Ulcers
The tissue viability assessment tool and wound assessment paperwork will be united into a skin
care bundle.
Burns Ward - Assessment and Referral of Burns in ED
More education is planned for staff regarding referral guidelines and the level of detail required
during assessment.
Emergency Department - Left before treatment / Triage
l Regular triage training for staff to be arranged.
l Clarification of police role to be highlighted to all staff.
l New doctors to be made aware of the Left Before Triage guideline as part of their
induction training.
Palliative Care - Clinical audit on advanced care plan for management of cardiorespiratory
arrest in children and young person with advanced malignancy
Ensure all staff are aware of the importance of early palliative discussions and are aware of and
are using the Palliative Care Toolkits.
Ophthalmology - An innovative approach to paediatric fundus photography
Continue to use this method as it has been proven successful. Audit results to be published in
Ophthalmology Journal 2013.
Pain Management (College of Emergency Medicine 2012)
l Pain set as a priority for the Emergency Department.
l Re-evaluation of scores has improved since the implementation of a reminder stamp
at triage.
Audiology - Bone anchored hearing aids (BAHA) in very young children
The decision to implant a BAHA in children between the ages of three and five years
will continue to be made on a case by case basis with the inclusion of the family and
multidisciplinary team.
Neurology - Guillain Barre syndrome (GBS)
Ensure the departmental guidelines are up to date and accessible. MRI scan to be added to the
list of investigations required for patients with GBS.

Participation in Clinical Research
The number of patients receiving NHS services
provided by Birmingham Children’s Hospital NHS
Foundation Trust that were recruited during that
period to participate in research by a research
ethics committee was 2,863.
This demonstrates our continued improvement
in this area over the last four years as we work
towards our aim that every child and young person
treated at the hospital is either offered participation
in a research project or is aware that research is
a major driver to our desire to deliver the best and
safest clinical care in the country.
Figure 26: Numbers of patients recruited to
participate in research 2009/10 - 2012/13
1797
2079
2573
2863
A good way of finding out how well we are doing
on clinical research is to monitor the number of
peer reviewed research publications - excluding
abstracts and letters - that we deliver each year.
When a research publication is reviewed by other
professionals, or ‘peers’, this ensures that it is of a
high enough standard to be used to help develop
treatments for patients. Another important indicator
of research quality is the impact factor of the
journals in which the research is published, which
reflects the number of times the journal is cited by
other researchers and the number of citations of
particular publications over a period of time.
Figure 27: Peer Reviewed Publications per
year 2008/09 - 2012/13
141
178
225
271
218
BACK TO CONTENTS PAGE
Table 29: Schemes agreed for Quality Improvement and Innovation 2012/13
CQUIN Goal Name WM PCT Cluster WMSCT Total End of year
Goal Weight Value Goal Weight Value Value Performance
Safety Thermometer - National 1 10% £179,659 1 5% £92,320 £271,979 Targets met
Safety Thermometer - 2 10% £179,659 7 5% £92,320 £271,979 Targets met
Paediatric Specific
Friends & Family Test - 3A 4% £71,863 8a 1% £23,080 £94,944 Targets met
Regional
Friends & Family Test - 3B 4% 71,863 8b 1% £23,080 £94,944 Targets met
Board Minutes
Friends & Family Test - 3C 4% £71,863 8c 1% £23,080 £94,944 Targets met
Weekly Reporting
Friends & Family Test - 3D 4% £71,863 8d 1% £23,080 £94,944 Targets met
Performance Improvement
Net Promoter - 4 16% £287,454 9 5% £92,320 £379,774 Targets met
Paediatric Specific
Healthy Lifestyles - Smoking 5A 8% £143,727 £143,727 Targets met
Healthy Lifestyles - Alcohol 5B 6% £114,981 £114,981 Targets met
2009/10 2010/11 2011/12 2012/13 2008/09 2009/10 2010/11 2011/12 2012/13
One of our strategic objectives is to strengthen
Birmingham Children’s Hospital’s position as a
provider of specialised and highly specialised
services, so that we become the leading provider
of Children’s Healthcare in the UK. To help us
achieve this, we are implementing a Research &
Development Strategy towards becoming a leader
in paediatric clinical research.
Clinical research is important as it helps us to
understand conditions and improve and discover
new treatments, resulting in improved quality of
care for patients.
Use of the CQUIN Framework
A proportion of Birmingham Children’s Hospital
NHS Foundation Trust’s income in 2012/13 was
conditional upon achieving quality improvement
and innovation goals agreed between Birmingham
Children’s Hospital NHS Foundation Trust and
any person or body they entered into a contract,
agreement or arrangement with for the provision
of NHS services, through the Commissioning
for Quality and Innovation (CQUIN) payment
framework.
The exception to this is the Quality Improvement
Development Innovation Scheme (QIDIS) used by
the National Specialised Commissioning Team to
support Trusts to improve the quality of care and
clinical outcomes for nationally designated services,
replacing CQUIN arrangements for those services.
Further details of the agreed goals for 2012/13
and for the following 12 month period are available
online at: https://commissioning.supply2health.nhs.
uk/eContracts/Documents/cquin-guidance.pdf
Healthy Lifestyles - 5C 2% £28,745 £28,745 Targets met
Making Every Contact Count
CAMHS QNCC 6 16% £287,454 £287,454 Targets met
Antimicrobial Stewardship 7 16% £287,454 £287,454 Targets met
Implementation of clinical 2 10% £184,641 £184,641 Targets met
dashboards for specialised
services
(PIC) To minimise the number 3 10% £184,641 £184,641 Targets met
of patients undergoing
unplanned extubation
CAMHS Tier 4: Education, 4 5% £92,320 £92,320 Targets met
training and meaningful activity
CAMHS Tier4: Patient 5 5% £92,320 £92,320 Targets met
Involvement in Recruitment
CAMHS Tier4: Feasibility study 6 5% £92,320 £92,320 Targets met
for conversion to single
room accommodation
Local CQUIN: Enhancing HDU 10 25% £461,602 £461,602 Targets met
Local CQUIN: CNS Pathway 11 20% £369,282 £369,282 Targets met
Planned CQUIN income 100% £1,796,585 100% £1,846,409 £3,642,994
Other Commissioners £276,508
Total Planned CQUIN income £3,919,502
120 121

122 123
BACK TO CONTENTS PAGE
The monetary total for the amount of income
conditional upon achieving CQUIN goals in 2012/13
and the monetary total for the associated payment
in 2011/12 is detailed below:
Table 30: CQUIN income data 2011/12 and 2012/13
2011/12 2012/13
Percentage of income conditional upon achieving goals (total value £3.92m) 1.5% 2.5%
Income not achieved 0 0
Table 31: Schemes agreed for Quality Improvement Development Innovation Scheme
(QIDIS) 2012/13
Service Nature of Scheme Contract QIDIS QIDIS
Value Value (of 2.5%)
Alstrom Syndrome Dashboard Scheme 10% / PPE Scheme 20% / 109,842 824 30%
No Strategic Schemes
Bardet Biedl Syndrome Dashboard Scheme 10% / PPE Scheme 20% / 193,017 4,826 100%
(Children) Strategic Schemes 70%
Complex Childhood Dashboard Scheme 10% / PPE Scheme 20% / 712,399 17,810 100%
Osteogenesis Imperfecta Strategic Schemes 70%
Craniofacial Surgery For Dashboard Scheme 10% / PPE Scheme 20% / 2,030,299 50,757 100%
Congenital Conditions Strategic Schemes 70%
Epidermolysis Bullosa Dashboard Scheme 10% / PPE Scheme 20% / 559,367 13,984 100%
Strategic Schemes 70%
ECMO For Reversible No schemes as cost per case and not eligible 273,845 - 0%
Respiratory Failure (Children) for QIDIS payments
Liver Transplantation (Children) Dashboard Scheme 10% / PPE Scheme 20% / 3,740,250 93,506 100%
Strategic Schemes 70%
Lysosomal Storage Disorders Dashboard Scheme 10% / PPE Scheme 20% / 428,579 10,714 100%
(Children) Strategic Schemes 70%
Retinoblastoma Dashboard Scheme 10% / no PPE Scheme / 1,207,673 13,586 45%
Strategic Schemes 35%
Small Bowel Transplantation Dashboard Scheme 10% / no PPE Scheme / 1,215,533 3,039 10%
(Children)
no Strategic Scheme
Specialist Paediatric Liver Dashboard Scheme 10% / PPE Scheme 20% / 2,845,056 71,126 100%
Disease Strategic Schemes 70%
Wolfram Syndrome Dashboard Scheme 10% / PPE Scheme 20% / 160,048 1,200 30%
no Strategic Scheme
Total 13,475,908 281,372 84%
Liver Transplantation Income deferred to 2013/14 to cover costs -54,000
(Children)
not yet incurred
Net Total 227,372
Care Quality Commission
Birmingham Children’s Hospital NHS Foundation
Trust is required to register with the Care Quality
Commission (CQC) and its current registration
status is:
Registered to carry out the following legally
regulated services:
l Transport services, triage and medical advice
provided remotely
l Treatment of disease, disorder or injury
l Assessment or medical treatment for persons
detained under the Mental Health Act 1983
l Surgical procedures
l Diagnostic and screening procedures
l Management of supply of blood and blood
derived products
The Care Quality Commission has not taken
enforcement action against Birmingham Children’s
Hospital NHS Foundation Trust during 2012/13.
Birmingham Children’s Hospital NHS Foundation
Trust has not participated in special reviews or
investigations by the Care Quality Commission
during 2012/13.
On 6 November 2012 the CQC undertook a
routine, unannounced inspection of CAMHS at our
Parkview Clinic, to assess compliance with the
following standards:
04: Care and welfare of people who use services
06: Cooperating with other providers
07: Safeguarding people who use services from
abuse
13: Staffing
The CQC found that the services at Parkview met
all these standards.
On 21 November 2012 the CQC undertook a
routine, unannounced inspection of the Trust’s
services at our main site at Steelhouse Lane, to
assess compliance with the following standards:
04: Care and welfare of people who use services
09: Management of medicines
11: Safety, availability and suitability of equipment
14: Supporting workers
The CQC found that the services at Steelhouse
Lane were compliant with the first three of these
standards, but found that action was needed to
ensure compliance with standard 14: Supporting
workers. The evidence CQC collected in theatres
identified some minor concerns about the risks
relating to how staff were supported in this area.
CQC issued a compliance action to ensure that
improvements to support staff are made. We have
taken the following actions to ensure we are now
compliant with this standard:
l Recruited to vacant posts in theatres
l Changed and improved the way we were
implementing our Integrated Theatre Recovery
Team Project
l Strengthened, developed, and added to
arrangements for supporting and engaging with
staff in theatres.
Data Quality
Birmingham Children’s Hospital NHS Foundation
Trust submitted records during 2012/13 to the
Secondary Uses service for inclusion in the
Hospital Episode Statistics which are included in
the latest published data.
The percentage of records in the published data
which included the patient’s valid NHS Number
was:
98.6% for admitted patient care
99.5% for outpatient care and
98.3% for accident and emergency care
The percentage of records in the published
data which included the patient’s valid General
Practitioner Registration Code was:
100% for admitted patient care
100% for outpatient care and
100% for accident and emergency care
Birmingham Children’s Hospital NHS Foundation
Trust’s Information Governance Assessment Report
overall score for 2012/13 was 82% and was graded
green (satisfactory).

Birmingham Children’s Hospital NHS Foundation
Trust will be taking the following actions to improve
data quality:
l Having made significant improvements against
the data quality items published centrally we are
now progressing to developing further local data
quality indicators. These will include looking at
timeliness of data capture.
l We have expanded our Data Quality Group and
will use this forum to push forward the data
quality agenda.
Birmingham Children’s Hospital NHS Foundation
Trust was subject to the Payment by Results clinical
coding audit during the reporting period by the Audit
Commission and the error rates reported in the
latest published audit for that period for diagnoses,
treatment and investigation coding (clinical coding)
were:
Diagnosis:
N/A
(not part of the 2012/13 audit)
Treatment (procedure): 10.3%
Investigations: 10.4%
150 cases were reviewed within the sample.
Note: the results should not be extrapolated further
than the actual sample audited.
Core National Indicators
Due to the time it takes central bodies to collate and
publish some of the data, sometimes comparative
figures are not available at all (N/A). It should also
be appreciated that some of the ‘Highest’ and
‘Lowest’ performing Trusts on some of the data
may not be directly comparable to Birmingham
Children’s Hospital.
There are several core national indicators that are
not applicable to Birmingham Children’s Hospital,
because they relate to adult patients/services
only, or due to the specialist nature of many of our
services. These indicators include:
l Summary Hospital-level Mortality Indicator
(SHMI) – though we do provide details of a
different mortality indicator at page 113 which
compares our mortality rates with those of a
range of other children’s services.
l The percentage of patient deaths with palliative
care.
l The percentage of patients on Care Programme
Approach who were followed up within 7 days
after discharge from psychiatric in-patient care.
l The percentage of admissions to acute wards for
which the Crisis Resolution Home Treatment
Team acted as a gatekeeper during the reporting
period.
l Patient reported outcome measures scores.
l The Trust’s responsiveness to the personal
needs of its patients.
l Patient experience of community mental health
services.
l The percentage of patients who were admitted
to hospital and who were risk assessed for
venous thromboembolism.
Hospital Readmissions: The percentage of patients readmitted to Birmingham Children’s
Hospital within 28 days of being discharged in 2012/13
AGE 2011/12 2012/13 National Average Highest Trust Lowest Trust
0 to 14
15 or over
N/A
AGE 2010/11 2011/12 2012/13 National Average Highest Trust Lowest Trust
2010/11
0 - 15 11.14% 10.0% 9.97% 10.15%
16 or over 9.9% 11.0% 7.7% 11.42%
N/A
Birmingham Children’s Hospital NHS Foundation
Trust considers that these percentages are as
described for the following reasons:
Between 2010/11 and 2012/13 we undertook a
monthly audit including a detailed review of every
emergency readmission and reported this to our
commissioners. There have been no concerns with
the discharge decision in any of the cases.
Birmingham Children’s Hospital NHS Foundation
Trust intends to take the following actions to
improve these percentages, and so the quality of its
services, by:
We will continue to regularly monitor emergency
readmissions to identify any concerns.
Staff Survey: Percentage of staff who would
recommend the Trust to family or friends
2011 2012 2012 Average Acute Trust
85% 83% 87%
Birmingham Children’s Hospital NHS Foundation
Trust considers that this percentage is as described
for the following reasons:
We acknowledge that the result is slightly below
the national average and that this has remained
consistent over the last few years.
Birmingham Children’s Hospital NHS Foundation
Trust intends to take the following actions to
improve this percentage, and so the quality of its
services, by:
We are taking steps to improve the way we support
and engage with staff and act on their views and
concerns. Central to these plans in 2013/14 is
our approach to responding to the Francis report.
From March 2013 we have been holding listening
events with staff, which over 250 staff members
have attended so far. Staff at these events are
encouraged to be completely open, demonstrating
their commitment to our values – courage, trust,
respect, commitment and compassion. The
listening events will culminate in a week of events
in September when we will focus on actions to
address the issues that have been raised.
Our Quality Walkabouts now also include a focus
on staff health and wellbeing.
We have put in place a process by which
anonymous email contact can be made direct to the
Chief Executive Officer to raise any concerns or to
provide views. We have also put in place processes
124 125
BACK TO CONTENTS PAGE
to ensure we listen to and act upon the concerns
of specific staff groups, for example, our Trainee
Advice & Liaison Service (TALS) and Safety Hotline
for junior doctors.
During 2013/14 we will be regularly undertaking
a staff poll, asking them whether they would
recommend the Trust as a place to be treated to
friends and family, so that we can monitor this
more regularly during the year and act on any poor
results more quickly. The percentage of positive
responses to this question has risen during the
early part of the year to 98%.
C.difficile: rate per 100,000 bed days of cases
of C.difficile infection reported within the Trust
amongst patients aged 2 or over
2011/12 2011/12 2011/12 2011/12
National Highest Lowest
Average Trust Trust
1.9 21.8 50.9 0.0
Birmingham Children’s Hospital NHS Foundation
Trust considers that this rate is as described for the
following reasons: There was one case of C.Difficile
at the Trust in 2011/12.
Birmingham Children’s Hospital NHS Foundation
Trust intends to take/has taken the following
actions to improve this rate, and so the quality of its
services, by: Actions we are taking to minimise the
risk of C.Difficile are described at page 108.
Patient Safety Incidents: the number and rate
of patient safety incidents reported, and the
number and percentage of such patient safety
incidents that resulted in severe harm or death
This year is the first time that this indicator has
been required to be included within the Quality
Report alongside comparative data provided,
where possible, from the Health and Social Care
Information Centre. The National Reporting and
Learning Service (NRLS) was established in
2003. The system enables patient safety incident
reports to be submitted to a national database on a
voluntary basis designed to promote learning.
It is mandatory for NHS trusts in England to
report all serious patient safety incidents to the
Care Quality Commission as part of the Care
Quality Commission registration process. To avoid
duplication of reporting, all incidents resulting in
death or severe harm should be reported to the
NRLS who then report them to the Care Quality
Commission. Although it is not mandatory, it is
common practice for NHS Trusts to reports patient
safety incidents under the NRLS’s voluntary
arrangements.

126 127
As there is not a nationally established and
regulated approach to reporting and categorising
patient safety incidents, different trusts may choose
to apply different approaches and guidance to
reporting, categorisation and validation of 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. This judgement may, acceptably,
Number of patient safety
incidents (acute specialist)
Rate of patient safety
incidents per 100 patient
admissions (acute specialist)
Percentage of such patient
safety incidents that resulted
in severe harm or death
(small acute)
differ between professionals. 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. Therefore, it may be difficult to explain
the differences between the data reported by the
Trusts as this may not be comparable.
Oct 2011-March 2012 Oct 2011-March 2012 Oct 2011-March 2012
BCH Highest Trust Lowest Trust
1,370 1,935 66
7.77 12.03 3.36
0.36% 2.36% 0.00%
Birmingham Children’s Hospital NHS Foundation
Trust considers that this number and/or rate is as
described for the following reasons:
Other information
Linking our priorities to the priorities of the NHS
QUALITY
STRAND
Effectiveness
QUALITY DOMAIN
(NHS OUTCOMES FRAMEWORK)
Preventing people from dying
prematurely
Enhancing quality of life
for people with
long-term conditions
Helping people to recover
from episodes of ill health
or following injury
BACK TO CONTENTS PAGE
BCH QUALITY
INDICATOR
Nursing Care Quality Indicators
Asthma Care
Health Promotion
Implementing the Sepsis Care Bundle
Food & nutrition
Nursing Care Quality Indicators
Asthma Care
Health Promotion
Food & nutrition
Nursing Care Quality Indicators
Health Promotion
CAMH Service User satisfaction
Implementing the Sepsis Care Bundle
We are pleased to note the high number of reported
incidents and the low percentage of these that
resulted in severe harm or death compared with the
national average, as this indicates an open safety
culture.
Birmingham Children’s Hospital NHS Foundation
Trust intends to take/has taken the following actions
to improve this number and/or rate, and so the
quality of its services, by:
Patient
Experience
Ensuring that people have
a positive experience of care
Food & nutrition
Play & activities
Emergency department transfers
Tertiary inpatient referrals
Cancelled operations
Friends & Family Test
l Actions we are taking to monitor and improve our
safety culture are described on page 131.
l We investigate and learn from every incident.
l We take actions to address safety issues
identified through safety monitoring and
analysis.
l Safety themes identified through incident
analysis are addressed through safety targets
as part of our Safety Strategy – for example,
extravasation injuries and medication incidents.
Safety
Treating and caring for people
in a safe environment;
and protecting them
from avoidable harm
Pressure ulcers
Reducing Healthcare Acquired Infections in PICU
Reducing rates of C.Difficile
Preventing MRSA
Reducing MRSA
Medication Incidents
Acute life threatening events, Cardiac Arrests
and Respiratory Arrests
Zero avoidable deaths
WHO Safe Surgery checklists
Extravasation injuries

BACK TO CONTENTS PAGE
Overview of Quality of Care
Complaints
We take all complaints about our services very
seriously and ensure that the way we respond is
tailored to the individual and that we answer all
of their concerns. Our Chief Executive is involved
in every response and writes personally to each
individual. Responding to a complaint can include
meetings with clinical staff and senior managers,
including the Chief Executive.
Formal complaints often originate in a concern
raised with PALS (Patient Advice and Liaison
Service) which supports families in obtaining the
response they need in the best way for them. We
encourage people to use our Formal Complaints
service and PALS as, if something has gone wrong
we want to know about it so we can try to put it
right, learn from it and improve. This information,
when combined with other quality information about
our services, can also help us identify when there
are other problems.
Fortunately, compared to the numbers of patients
we see every day, we receive very few formal
complaints. Each one is considered in detail and
incorporated into our Safety Dashboard and our
Quality Report.
Figure 28: Numbers of formal complaints per month/per 1,000 admissions
(This data is governed by local definitions)
15
10
5
0
J F M A M J J A S O N D J F M A M J J A S O N D J F M
2011
Complaints
Complaints per 1000 Admissions
2012
2013
As part of the formal complaints investigation
process, we identify any areas in which the quality
of the services could be improved, and make
appropriate recommendations. These range from
reminders to staff about proper practices and
behaviour, to fundamental changes in practice and
documentation. We regularly follow up on these
recommendations to make sure action has been
taken.
As a result of these recommendations a number of
changes have been made, including:
l Radiology: An area has been identified where families can discuss issues privately.
l Surgical Day Care: To avoid any discrepancy in recording weight and therefore incorrect
calculation of medication, the same member of staff who checks a child’s weight now also
writes the weight on the drug chart.
l Communication processes between Radiology and Rheumatology secretaries about
appointments have been improved.
l All wards: The handover process has been improved to ensure speciality patients on outlying
wards are more clearly identified.
l All clinical areas: A new discharge form has been designed to prevent failure to follow-up.
l The Breast-feeding training programme has been re-launched.
l Learning Disabilities: increased awareness has been raised amongst staff about the
importance of the Trust Learning Disabilities Passport and care pathways.
l The experience of a family will be used as a learning example for doctors in training.
l Heart Investigation Unit: A test results tracking process has been introduced.
Figure 29: Pattern of complaints per top 5 categories, 2010/11 - 2012/13 admissions
(This data is governed by local definitions)
30
25
20
15
10
5
0
Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
2011
2012
2013
Waiting, delays & cancellations
Staff Attitude
Quality of Treatment
Communication
Other
In order to see whether there are any themes
amongst the complaints we receive, we group the
issues raised in each complaint into categories.
The pattern of complaints received about the 5
main categories is set out above.
In January 2013 the Patient Association published
a report: Complaint handling in NHS Trusts
signed up to the CARE campaign, which is based
on information about the complaint handling
systems and processes of a random sample of
trusts. Birmingham Children’s Hospital was one
of the randomly selected trusts and is included
anonymously within the report. The Patients
Association wrote to us and gave us some
positive feedback about what they have seen of
our systems and processes, in particular they
said: “Birmingham Children’s Hospital appears
committed to being a learning organisation.
An example of this is your unique approach of
measuring complaints against Trust values within
the Quality Report”.
Incidents
We have robust systems for managing incidents
and in 2011/12 were awarded NHSLA level 3, the
highest level for compliance with the NHS Litigation
Authority Risk Management Standards. In 2012 we
128 129
carried out a ‘Lean’ process on our investigation
management system to ensure it is as efficient
as it can be. This means investigations can now
be concluded more quickly, which is better for the
patients and families involved and allows us to start
implementing learning from the incident earlier than
we previously could.
In 2013 our Internal Auditors gave an opinion
of ‘significant assurance’ about our incident
management processes.
We encourage all members of staff to report all
incidents, errors and near misses so we can
make improvements, work out what went wrong,
identify themes and drive quality improvements in
everything we do. We share learning from incidents
through our Safety Circular, a staff publication
which provides news on safety issues and changes
made as a result of incidents and incident analysis.
Our Quality Report - which is published on our
website - also includes information about incidents,
which any member of staff or the public can read.

BACK TO CONTENTS PAGE
Some of the major changes we have made as
a result of learning from incidents and incident
analysis include:
l Development of a sepsis care pathway.
l Development of new techniques for weighing patients on PICU to allow us to manage their
nutritional status more effectively.
l New guidance documents to allow more effective checking of medication in theatres when it is
prepared by anaesthetists.
Patient Safety Incidents by Harm Category 2011/12 - 2012/13
Year Total No Harm Minor, Non Moderate, Semi Severe, Severe Catastrophic,
Incidents Permanent Harm Permanent Harm Permanent Harm Death
2011/12 4198

BACK TO CONTENTS PAGE
Figure 31: SMR Funnel Plot February 2013
250
200
150
Marker by
TRUST NAME
Color by
Alert Level
Amber
Green
Shape by
Peer Flag
Pre-selected Peer(s)
Your Organisation
What are people talking about? This Word Cloud
demonstrates by their size the most frequently used
words in all the patient feedback we received in
2012/13. The larger the word, the more frequently it
has been used.
RRM
100
50
0 20 40 60 80 100 120 140 160 180
Number of Expected Deaths
Patient Feedback
Listening to what our children, young people and
their families tell us about their experiences at BCH
and their views about our services is vital in making
sure we continue good practice, and make changes
where improvements are needed.
It is really important that we gather this feedback in
lots of different ways so we can make sure we are
taking account of everyone’s views. We call this
our Patient Experience Toolbox, and we load all the
information we obtain into our Patient Experience
Database which helps us identify themes or areas
that need closer attention. It also helps us make
sure that we can let our staff know when we receive
really good feedback.
The toolbox includes patient surveys, quality
walkabouts, patient stories, mystery shoppers,
focus groups, feedback cards and direct feedback
like letters and comments. Combining this
with information about patient experience from
other sources – such as PALS contacts and
formal complaints - provides an overall picture
of individual wards and departments and of the
whole Trust. It also helps us see what we do well
and identify areas for improvement. As a result of
this work we have set new quality objectives and
made service improvements in areas like food,
play, communication, environment and patient
information.
As well as looking at what we need to improve,
it is also important to look at what patients and
their families tell us we do well. This provides vital
learning about how we can improve other areas,
and it is important to take this into account when
we are thinking about changing something. Sharing
positive feedback with staff about the work that they
do also supports and motivates them to deliver the
highest quality of care that they can.
132 133

Examples of patient feedback
Very long wait.
None of the vending
machines worked
making the stay even
more unbearable.
Waiting times
should be clearly
published.
I think that you
need to make
more rooms for
people to get
checked
quicker.
Friendly and helpful,
answered all my
questions even though I
was nervous.
Transfer on to theatre
trolley in corridor slightly
embarrassing even
though staff did their best
to maintain my dignity, not
much space.
Could not fault the
whole stay, everyone
so helpful, kind &
friendly. We felt a
little sad to leave.
Patient Information
Too many
questions
get asked on
admission. We
should get
a day or two to
settle in.
Caring and
understanding nature of
the nurses was amazing.
Very supportive. Cannot
put into words what
it meant to have this
service so that we could
be at home at Christmas.
(Hospital @Home)
Didn’t treat me
ike a little kid.
Explained to me so
I understood and it
gave me
confidence.
Your theatre
environment
is brilliant, less
traumatic. You made
us feel at ease
and were always
available to answer
questions.
The Family Health Information Centre provides a
free and confidential health information service for
our children, young people and their families, and
support for staff in the production of quality patient
information.
In direct response to feedback from our patients
and families - who told us they would like to access
information without leaving the ward - we have
looked at new ways of making sure they are able
We have spent
over £100 in car
parking which
has had a huge
impact on our
Christmas.
Pain relief monitoring
could be improved
and planned better
when coming to move
a child around after
operations for
the first time.
When I first came to
Parkview I hated it. I missed
my family and friends. When I
left Parkview, I felt as if
I was leaving behind my
family. The staff are amazing.
If it wasn’t for the
staff at Parkview,
I wouldn’t be
alive today.
To ensure better
communication links
were put into place between
surgeons, specialists, social services
and other services that the OT dept
have to liaise with on a daily basis,
that will allow a better
and smoother
transition between
hospital and home.
Thank you for the
fantastic care and
support we received
from the whole
cardiac team.....from
housekeepers on
the ward to surgeons
in theatre were
outstanding.
An 8 year old girl
commented during
her EEG that she was
happy and enjoying
her test, she said ‘this
test is good, I am not
scared at all’.
A big thank you to all the
A&E staff on Thursday
who looked after my
daughter who was brought
in wheezing. They were all
very caring and she was
constantly monitored by the
team. They were very busy
but still able to give her
excellent care.
Whenever my
daughter was scared
there was always
someone that made
her feel better.
to access the information they need at the right
time along their patient journey. In 2012/13 we
piloted weekly drop-in health information sessions
on wards and in the Parent Accommodation, and
weekly health information and awareness sessions
in the main Outpatients department. In 2013/14 we
will continue to look for new ways to improve the
information service to improve the quality of the
patient experience.
Performance against National Priorities
Table 32: Performance against National priorities 2012/13
134 135
BACK TO CONTENTS PAGE
National Priority Target Performance 2012/13
C-Diff 3 cases or less per year - Target met – 1 case
locally agreed threshold
MRSA 2 cases or less per year - Target met – no cases
locally agreed threshold
MSSA Pre 48 hours Monitoring only (but reduced)
Post 48 hours - 10% reduction
Target not met
E.Coli Pre 48 hours Monitoring only
Post 48 hours
Monitoring only
All cancers; 31 day wait Surgery (94%) Target met
for second or subsequent Anti cancer drug treatments (98%) Target met
treatments Radiotherapy (94%) Target met
All cancers: 62 day wait From GP referral to treatment (85%) Target met
for first treatment From consultant screening service Target met
referral (90%)
18.3 weeks (as of April 2011) Referral to treatment waiting times - Target met
non admitted (95th percentile)
23 weeks (as of April 2011) Referral to treatment waiting times - Target met
admitted (95th percentile)
All cancers: 31 day wait from diagnosis to first treatment (96%) Target met
All cancers: two week wait from referral to date first seen (93%) Target met
Total time in A&E
95% of patients time taken from arrival to Target met
discharge/admission < 4 hours.
18 weeks 90% admitted patients at the end of Target met
each month
95% non admitted patients at the end of
each month
Ambulance Turnaround Number over 60 minutes Monitoring only
% over 60 minutes Monitoring only
Number over 30 minutes
Monitoring only
% over 30 minutes Monitoring only
Operations cancelled on the 95% of those patients we Target met
those not admitted within cancel within 28 days
28 days
Single Sex Accommodation 0 breaches Target not met – 2 breaches
Breaches
Emergency Readmissions Emergency readmissions within 28 days Monitoring only
of discharge from hospital as a % of all Age 0-15: 9.97%
relevant admissions. Age 16+: 7.7%

Targets Not Met
Single Sex Accommodation Breaches
During 2012/13 we reported two single sex
accommodation breaches. In both cases there
was insufficient space for a short period on our
Teenage Cancer Trust ward. We discussed this
with the young people involved and offered them
single sex accommodation on another ward. Both
young people opted to stay on the ward as their
preference was to remain with other people of their
age group.
As part of the planned redesign of our Oncology
Unit we will incorporate more single rooms which
will mean this is less likely to happen.
We continue to ask all our children and young
people when they are admitted whether they would
prefer single sex accommodation, and in 2012/13
we were able to meet everyone’s wishes except
in the two cases described above. The feedback
we have from the majority of children and young
people is that their priority is to be treated with
people of a similar age, rather than the same
gender.
Cancelled Operations
Please see page 80 for details.
MSSA
Please see page 91 for details.
Commissioners
BACK TO CONTENTS PAGE
Statements from stakeholders
Birmingham South Central Clinical Commissioning
Group (BSC CCG) as coordinating commissioner
for Birmingham Children’s Hospital NHS
Foundation Trust (BCH) welcomes the opportunity
to provide this statement for their 2012/13 Quality
Account.
A draft copy of the Quality Account was received
by BSC CCG on the 22nd April 2013 and the
statement has been developed from the information
presented to date. Feedback on the draft account
has been received from Birmingham Cross City
CCG, Solihull CCG and NHS England Area Team
as the lead for specialised commissioning.
We have reviewed the content of the Quality
Account and confirm that this complies with the
prescribed information, form and content as set out
by Monitor and the Department of Health.
This is a comprehensive report that clearly
demonstrates progress within the Trust. It identifies
where the organisation has done well, where
further improvement is required and what actions
are needed to achieve these goals. The Quality
Account sets out the priorities for improving patient
safety, patient experience and clinical effectiveness
in 2013/14 across services provided by BCH.
The information provided within this Account
presents a balanced report of the quality of
healthcare services BCH provides and is, to
the best of our knowledge accurate and fairly
interpreted. The range of services described and
priorities for improvement are representative based
on the information that is available to us. We agree
with and support the priorities set for this year.
in order to drive improvements in the quality of
care. Further development and implementation
of the feedback App and the Children and Young
Person’s version of the Friends and Family Test are
just two examples of initiatives designed to ensure
that users of the service are listened to and issues
addressed can be continually monitored and acted
on.
Cancelled Operations continues to be a challenge
for the Trust and we will continue to work with and
support BCH to review the effectiveness of the
range of interventions currently being implemented
to improve the current position. As part of this work
BCH remain focused on the impact on children
and families when operations are cancelled and
improving the patient experience.
The Quality Account reflects a number of the
performance quality indicators which are monitored
monthly along with areas for improvement at
the CCG / Trust Clinical Quality Review Group
mandated by the service contract. We are also
invited to the Trust’s Clinical Risk and Assurance
Committee and any Root Cause Analysis meetings
following occurrence of serious incidents.
We have made some specific comments to the
Trust directly in relation to their plan. Namely, we
would like further information regarding outcomes
and levels of improvement they are working
towards, the specific actions being taken to address
capacity issues, further narrative and detail to
support analysis of the mortality data, inclusion of
an assurance statement on Equality and Diversity
and Safeguarding and alignment of their priorities to
the five domains of the NHS Outcomes Framework.
BCH places significant emphasis on its safety
agenda, with an open and transparent culture,
and this is reflected throughout the account
with work continuing on the development of the
safety dashboard and further implementation of
the paediatric version of the safety thermometer
(Safety SCAN). A review of the incident
investigation management system to allow earlier
implementation of learning and evidence of
changes that have been made as a result of this
learning reinforces the priority the Trust is placing
on implementing further quality improvements
during 2013/14.
BCH continue to develop innovative ways to
capture the experience of patients and their families
136 137
Through this Quality Account and ongoing quality
assurance process, BCH clearly demonstrate their
commitment to improving the quality of care and
services delivered for children, young people and
families.
We look forward to continuing to work with and
support the Trust in delivering this year’s quality
targets within the Quality Account.
Dr Raj Ramachandram
Chair – Birmingham South Central Clinical
Commissioning Group Quality and Safety
Committee

Birmingham Health Overview and Scrutiny
Committee
Birmingham Health Overview and Scrutiny
Committee have declined on this occasion to
provide comments on our draft Quality Account
2012/13.
Healthwatch Birmingham
We sent our draft Quality Account 2012/13 to
Healthwatch Birmingham for information. As a
newly established organisation they were not able
to provide comments this year.
Council of Governors
The Council of Governors welcomes the
opportunity to comment on Birmingham Children’s
Hospital NHS Foundation Trust’s Quality Account
2012/13.
The Quality Account is an excellent demonstration
of the commitment of the Board of Directors to
continual quality improvement.
The content of the Quality Account reflects well the
matters presented to the Council of Governors by
the Board of Directors and the experience of the
Governors in attending Quality Walkabouts to the
Trust’s wards and departments.
The Account provides a well balanced overview of
safety, patient experience and clinical effectiveness
and brings the patient experience to life through
direct examples of patient and family feedback,
including feedback about areas where the Trust
needs to improve. We would welcome more of the
patient voice in next year’s Account.
We are impressed by the achievements described
within the report and the Trust’s clear ambition to go
beyond these achievements in the delivery of high
quality care and excellent patient experience. This
is demonstrated by the Trust’s innovations, such
as the DG suit which replaces backless hospital
gowns, the MAPLE food ordering system and the
patient feedback app.
The report is open and transparent, making it
clear when the Trust has not met its objectives,
explaining why this is the case and, most
importantly, what is being done to improve the
situation.
successful conclusion. We also acknowledge
and welcome the external scrutiny by the CQC
in helping the Trust identify areas that can be
improved.
We endorse the approach of the Board to listening
and responding to the concerns and views of
patients, families and staff, which is apparent within
the Account. A good example of this approach
is the process adopted to respond to the recent
Francis report, which is centred on listening events
with staff. These listening events are part of a
wider appraisal of the culture of the organisation
as a whole. This appraisal reflects the Trust’s
commitment to promoting a listening culture and
the well-being of patients and staff.
While we won’t compromise on quality of care or
patient experience, we recognise that not all our
future aspirations for the hospital and the patients
and families it serves can be met within the current
site constraints and governors will be working with
the Board on plans for the future development of
the organisation.
We support the Trust in its approach to being a
listening and learning organisation and encourage
all patients, families and staff to use the range of
methods available to provide their views, in the
knowledge that they will be listened to and acted
upon.
Governors’ Scrutiny Committee on behalf of the
Council of Governors of Birmingham Children’s
Hospital NHS Foundation Trust
16 May 2013
BACK TO CONTENTS PAGE
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:
l The content of the Quality Report meets the
requirements set out in the NHS Foundation
Trust Annual Reporting Manual 2012-13.
l 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 June 2013.
Papers relating to quality reported to the
Board over the period April 2012 to June
2013.
Feedback from the commissioners dated
14 May 2013.
Feedback from governors dated
16 May 2013.
The Trust’s complaints report published
under regulation 18 of the Local Authority
Social Services and NHS Complaints
Regulations 2009, dated 29 April 2013.
The national staff survey 2012.
The Head of Internal Audit’s annual opinion
over the trust’s control environment dated.
CQC quality and risk profile dated February
2013.
l The Quality Report presents a balanced picture
of the NHS Foundation Trust’s performance over
the period covered.
l The performance information reported in the
Quality Report is reliable and accurate.
l 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.
l 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
requirements in preparing the Quality Report.
By order of the Board
29 May 2013 .............................................................
Interim Chairman
29 May 2013 ............................................................
This open culture reflects the experience of
Governors at Council meetings where members of
the Board welcome questions, respond positively
to challenge and rapidly address issues to a
138 139
Interim Chief Executive

How we have engaged people in
setting priorities for improving quality
BACK TO CONTENTS PAGE
Foundation Trust Governors
l At quarterly meetings governors are provided
with our Quality Report, Resources Report and
information on Trust developments.
l Governors take part in scheduled Quality
Walkabouts.
l At meetings of the Council of Governors,
governors take part in Quality Walkabouts and
visit new developments to better understand the
Trust’s services and the issues that are
important to patients, families and staff.
l Twice a year we hold a joint meeting between
the Council of Governors and the Board of
Directors to consider the future strategy of the
Trust and developments within the Trust and the
NHS which are relevant to the Trust’s strategy.
l Governors are engaged in our governance
structure, with governors as members of
committees and groups.
l A Public Governor chairs our Organ Donation
Committee.
l A new Committee of the Council of Governors,
the Governors Scrutiny Committee, has been
established, which provides a forum for more
detailed debate and challenge on quality and
resources issues and strategic developments.
l The Governors selected one of the quality
indicators for review by the External Auditor.
Our Staff
l Our Board and Governor Quality Walkabouts
involve engagement with staff as well as patients
and families.
l Surveys, including the national annual Staff
Survey and our own Staff Safety Survey.
l Regular staff polls.
l Staff attendance at public Board meetings.
l Chief Executive Briefings
l Francis Report consultation and listening events.
Our patients and families
l Quality Walkabouts.
l Food walkabouts.
l Direct patient feedback through feedback cards,
feedback app and other means.
l Patient stories which accompany reports to
the Board to help bring issues to life.
l Focus groups on particular issues.
l Mystery Shoppers.
l Taking account of concerns raised through
formal complaints and the PAL Service
l Surveys Consultation on potential new
developments
Young Person’s Advisory Group (YPAG)
l Consultations on Outpatients redesign.
l Consultation on Theatres redesign.
l Consultation on Safer Handover at Night project.
l Regular Quality Walkabouts.
l Reviewing adolescent spaces on wards.
l Parent representatives on the Learning
Disabilities Steering Group
l Feedback from CAMHS parents and young
people by way of an exit interview (Chi Esq)
Healthwatch Steering Group and
Development Group
Our Lead for Patient Experience & Participation
is a member of these groups which will oversee
the consultation process for the development of
Healthwatch England, which will be established
from the existing Local Involvement Networks in
April 2013.
How to provide feedback on the
Quality Report
Despite the improvements in the quality of services
we have seen over the last year, we know we’re
always learning about how things can be done
even better.
At the heart of everything we do are our patients,
their families and the communities that we serve.
That’s why we’re always interested in hearing from
you – whether you have a suggestion on how we
can provide care more innovatively, or whether you
had an experience you think we could improve on.
140 141
We actively encourage people to get in touch and
stay in touch with us, so if you have any ideas
about how we could make this Quality Account
even better we’d like to hear from you.
To tell us about what you think, please contact our
Communications Department on 0121 333 8535
or communications@bch.nhs.uk

142 143
BACK TO CONTENTS PAGE
Statement of the Chief Executive’s
responsibilities as the Accounting
Officer of Birmingham Children’s
Hospital 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
the Independent Regulator of NHS Foundation
Trusts (Monitor).
Under the NHS Act 2006, Monitor has directed
Birmingham Children’s Hospital 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 Birmingham Children’s
Hospital 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:
l Observe the Accounts Direction issued by
Monitor, including the relevant accounting
and disclosure requirements, and apply suitable
accounting policies on a consistent 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.
Signed…………………………………………..
Date: 29 May 2013
David Melbourne
Interim Chief Executive
l Make judgements and estimates on a
reasonable basis;
l 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
l Prepare the financial statements on a going
concern basis.

SECTION FOUR
BACK TO CONTENTS PAGE
Annual Governance Statement
Scope of responsibility
As Accounting Officer, I have responsibility for
maintaining a sound system of internal control that
supports the achievement of the NHS Foundation
Trust’s policies, aims and objectives, whilst
safeguarding the public funds and departmental
assets for which I am personally responsible, in
accordance with the responsibilities assigned to
me. I am also responsible for ensuring that the
NHS Foundation Trust is administered prudently
and economically and that resources are applied
efficiently and effectively. I also acknowledge my
responsibilities as set out in the NHS Foundation
Trust Accounting Officer Memorandum.
The purpose of the system of
internal control
The system of internal control is designed to
manage risk to a reasonable level rather than
to eliminate all risk of failure to achieve policies,
aims and objectives; it can therefore only provide
reasonable and not absolute assurance of
effectiveness. The system of internal control is
based on an ongoing process designed to identify
and prioritise the risks to the achievement of
the policies, aims and objectives of Birmingham
Children’s Hospital 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 Birmingham Children’s Hospital
NHS Foundation Trust for the year ended 31 March
2013 and up to the date of approval of the annual
report and accounts.
Capacity to handle risk
Leadership
The Board of Directors is responsible for the
management of key risks. Key risks are described
within the Board Assurance Framework which is
considered every month by the Board of Directors.
In addition, risks are clearly defined within the
reports presented to the Board by the Executive
Directors. This process is supplemented on a
quarterly basis when the self assessment of the
financial, activity and service risks is made for
submission to the independent regulator, Monitor.
The Trust’s Risk Management policies clearly set
out responsibilities for risk management within
the organisation. As Chief Executive Officer I
have overall responsibility and accountability
for risk management. This is shared with the
Executive Directors who are responsible for
ensuring that the risk management framework is
systematically implemented and developed across
the organisation. In addition they, through the Board
of Directors’ committee structure, are responsible
for providing assurance to the Board of Directors
that risk management continues to be an essential
element of all management systems and corporate
planning, as well as the setting of strategy and
objectives. The committees for 2012/13 included
the Quality Committee and the Finance and
Resources Committee, which are both chaired by
Independent Non-Executive Directors, with nonexecutive
and executive director membership.
The sub-committees which monitor risks to safety,
quality and workforce objectives include the Clinical
Risk and Quality Assurance Committee, the Non-
Clinical Risk Coordinating Committee, the Patient
Experience and Participation Committee and the
Strategic Workforce Committee.
Staff training and guidance
A range of risk management and information
governance training is provided to staff and there
are policies in place to describe their role and
responsibilities in relation to the identification
and management of risk. This includes an online
training resource for refresher training. This
ensures that risks are actively managed at all levels
of the organisation. The importance of feedback to
staff on incidents reported is stressed at all levels of
training.
changes have been made to mandatory training
related to medicines management, observation and
monitoring, and resuscitation.
Bespoke risk management training has also been
developed for Board members and directors to
enable them to fully understand their role and
responsibilities in relation to risk management.
The risk and control framework
The Trust’s risk management policies ensure that
risk management is embedded in the activities of the
organisation in a number of ways:
l Both Corporate and Directorate objectives are
risk assessed and inform the Board
Assurance Framework, which is reviewed
regularly by the Board of Directors and the
Audit Committee.
l The Trust has achieved level 3 compliance with
the NHS Litigation Authority (Clinical Negligence
Scheme for Trusts) Risk Management
Standards. This demonstrates not only that there
are clearly defined and embedded policies in
place to address risk but also that those policies
are monitored on an ongoing basis and that
action is taken when those policies are not
effective.
To ensure the quality of local management of
incidents, we deliver training (level 2) for all local
managers. This is an interactive session which
covers day-to-day management of risks at a
local level, investigation tips and techniques for
managing incidents and complaints and guidance
on how to carry out robust risk assessment and
how to use the risk register appropriately.
Level 3 ‘Risk Leaders’ training has been designed
for members of staff that need a high level of
expertise in risk management. The session is
focused on Root Cause Analysis techniques
and processes, includes some advanced risk
management techniques and introduces the role
and development of assurance frameworks.
Training implications are considered as part of
all Root Cause Analysis investigations. As a
direct result of learning from these investigations,
144 145
l Risks to information are managed
through the use of the NHS Information
Governance Toolkit. The Trust’s policy provides
a documented mechanism for the immediate
reporting and investigation of actual or
suspected information security breaches/ losses
and potential ulnerabilities/weaknesses within
the Trust.
The Information Governance Toolkit
submissions and the annual plan to improve
compliance with the relevant standards is
approved and regularly reviewed by the
Regulatory Compliance Committee, which
reports to the Board via the Quality Committee.
Following a self-assessment and submission the
overall score against the Information
Governance Toolkit for 2012/13 was 82% and
graded Green (‘Satisfactory’).

l There are structured processes in place for
incident reporting and the investigation of
Serious Incidents Requiring Investigation
(SIRIs), complaints and litigation cases. Regular
audits are undertaken of these processes to
ensure they are appropriately followed and are
effective. The outcomes of these audits are
reported to the Clinical Risk and Quality
Assurance Committee.
l Incident reporting is openly encouraged across
the Trust through training, the use of online
incident reporting, and the communication of
positive outcomes as a result of reporting of
incidents, errors and near misses. Ward
inspections to check compliance with CQC
standards provide assurance that staff know how
to repor incidents.
l A non-executive director is invited to participate
in the Root Cause Analysis of every SIRI. This
helps ensure a good Board level understanding
of risk management processes in the
organisation.
l All papers presented to the Board of Directors
and Board committees contain an assessment of
key regulatory or statutory impacts, including
equality, diversity and human rights and
compliance with standards including NHS
Litigation Authority risk management standards
and CQC essential standards of quality and
safety.
l The Trust attends and submits a performance,
compliance and risk report to the Trust’s
Commissioner’s monthly Clinical Quality Review
Group.
l A representative of the Trust’s Commissioners is
invited to attend the Trust’s monthly Clinical Risk
and Quality Assurance Committee and is invited
to participate in the Root Cause Analysis of
SIRIs.
l All quality initiatives and Cost Improvement
Plans require a quality impact assessment,
which is scrutinised by the Chief Medical Officer
or Chief Nursing Officer before approval.
l Risk appetite is determined in relation to specific
matters reviewed by the Board through detailed
consideration of risk and benefit analysis.
Key Quality Governance Arrangements
The Trust has continued to refine its approach to
the analysis of incidents, potential incidents and
near misses, in order to identify and communicate
learning points and necessary actions. This
commitment to developing an environment of
honesty and openness, where mistakes and
untoward incidents are identified quickly and dealt
with in a positive and responsive way, has been
successful in engaging clinical staff. This approach
to learning is also informed by various sources
of information including surveys, patient and staff
feedback, service reviews, and clinical audits.
A regular Safety Dashboard is produced for
each Clinical Directorate, which incorporates an
overview of data such as incident reports, SIRIs,
complaints and Nursing Care Quality Indicators
(NCQI) performance per ward/department to
highlight potential issues or concerns about
safety or quality of services. The dashboard
allows an aggregated review and comparison of
these metrics against each individual ward and
department and incorporates a series of defined
‘triggers’ which, in combination, may indicate
problems with safety or quality in a specific area.
This allows the Directorate Management Teams
and Board committee responsible for safety to
focus attention where it may be required and acts
as an early warning system. From 2012, the Safety
Dashboard has also identified the departments
implementing a Cost Improvement Plan (CIP) so
an assessment can be made as to whether the
project is affecting quality and safety. Workforce
information is also included, as indications of low
staff engagement can act as an early warning
about a possible impact on our services.
In 2011/12 a Patient Safety Strategy was
developed which maps out the Trust’s journey
towards safer care. The Strategy is updated each
year and sets out a series of clearly defined,
measureable safety targets to achieving the Trust’s
aim to eliminate any less than perfect care. These
targets are produced through a process of risk
analysis, identifying areas for improvement through
data sources such as SIRIs, incident reporting,
complaints, litigation and patient experience
feedback, as well as national guidance and best
practice benchmarking. We believe that focussing
our efforts on a targeted list of specific projects will
have a significant impact on the amount of harm
which is suffered by our patients.
The Trust’s Values – which were agreed in
consultation with staff – have been embedded
during 2012/13 in our recruitment, induction
and appraisal processes. This ensures that all
new staff demonstrate our Values and that the
behaviours of all staff and the decisions that we
make are rooted in our values. Commitment to
these values – respect, trust, compassion, courage
and commitment - also encourages openness
and transparency, which supports robust quality
governance arrangements centred on learning.
The Trust commissioned an external review of
its governance structures in 2011/12 to ensure
they are fit for purpose and provide the Board
of Directors with sufficient, high quality, timely
information. As a result of this review, the
governance structure was redesigned to include 2
new Board Committees:
l Quality Committee, the aim of which is to
provide strategic direction and overview of all
issues related to the quality of care and service
provision, allowing integrated quality reporting to
the Board of Directors.
l Finance and Resources Committee, to review all
matters relating to resources, including finance,
investment, workforce and information
technology, and to provide strategic direction on
negotiating the risk environment.
This new structure was implemented in 2012/13
and its effectiveness was assessed at the end of
the year.
The Quality Report provides an overview of
the main indicators of quality across the Trust,
including high risks, incidents, mortality, patient
experience, safeguarding and infection control, as
well as progress against our Safety Strategy and
quality projects such as the Safety Thermometer
and our programme of Quality Walkabouts.
The report is considered every month by the
Board alongside our Resources Report, which,
in addition to giving details of the Trust’s financial
performance, examines the Trust’s activity
levels, including the way people are accessing
our services; and workforce indicators, such as
sickness levels, turnover, and mandatory training
and appraisal targets, to allow an assessment
of the impact of activity levels on our staff. The 2
reports together provide a broad perspective of
all the factors that make up the Trust’s system of
internal control.
In February 2013 our Internal Auditor completed
a review of the Trust’s Quality Governance
arrangements that ensure compliance with
Monitor’s Quality Governance Framework. This
review found that the Trust meets Monitor’s criteria,
146 147
BACK TO CONTENTS PAGE
and provides ‘significant assurance’ that the Trust’s
arrangements are sound. A small number of areas
were identified which could be improved, and
we are implementing the recommendations of the
Internal Auditor so we can ensure that our quality
governance arrangements are the best they can be.
In 2012 both the Trust’s locations, at Parkview and
at Steelhouse Lane, received an unannounced
inspection from CQC. The review of the CAMH
Services at Parkview found full compliance with the
standards reviewed.
The review at Steelhouse Lane found a minor noncompliance
with standard 14: Supporting workers.
This finding related to a concern raised by some
Theatre staff about the way they were supported,
particularly in relation to the implementation of a
new way of working in Theatres.
In response we have changed the way we are
implementing the new process, and have engaged
closely with the Theatre staff to fully understand
their concerns and address them. In addition, we
have developed new ways of reporting potential
workforce issues to the Board and its committees
to identify as early as possible when our staff
may be feeling unhappy, unsupported, or under
pressure. We have also added further workforce
metrics to the Safety Dashboard to help us better
identify when a ward or department may be coming
under pressure, and where that could have an
impact on the quality of care.
The Trust is fully compliant with the registration
requirements of the Care Quality Commission.
As an employer with staff entitled to membership of
the NHS Pension Scheme, control measures are in
place to ensure all employer obligations contained
within the Scheme regulations are complied with.
This includes ensuring that deductions from salary,
employer’s contributions and payments into the
Scheme are in accordance with the Scheme
rules, and that member Pension Scheme records
are accurately updated in accordance with the
timescales detailed in the Regulations.
Control measures are in place to ensure that all
the Trusts obligations under equality, diversity and
human rights legislation are complied with.
The 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.

148 149
BACK TO CONTENTS PAGE
Major Risks
Table 33: Major Organisational Risks
Risk
Failure to ensure the staff
culture is aligned to the Trust’s
strategic objectives could impact
on achievement of the Trust’s
strategic objectives and on the
delivery of high quality care and
patient experience.
Planned reductions in funding
could impact on the delivery
of the Trust’s services, affect
the quality of care and patient
experience and impact on
achievement of the Trust’s
strategic objectives.
Under developed workforce
plans could impact on the
delivery of the Trust’s services,
affect the quality of care and
patient experience and impact
on achievement of the Trust’s
strategic objectives.
Failure to deliver our Cost
Improvement Plans could
impact on the delivery of the
Trust’s services, affect the
quality of care and patient
experience and impact on
achievement of the Trust’s
strategic objectives.
A delay in delivery of the
strategic outline case for the
new hospital project could
impact on achievement of the
Trust’s strategic objectives.
Management & Mitigation
l Seek feedback from staff through a range of means and embed
the output and associated actions into Trust reporting systems
l Embed results from local surveys and staff polls into performance
indicators and leadership appraisals with a goal of 10%
improvement each year
l Develop a cultural barometer for use across all parts of the
organisation
l Improve the regularity and quality of staff briefing
l Work with the Birmingham Director of Public Health to develop a
health impact assessment of proposed funding changes
l Engage with staff, patients and families on the potential solutions
to reduction in resources
l Identify and develop alternative service scenarios that will better
use public resources across the whole of the children’s mental
health budget
l Deliver improved workforce productivity through more efficient
use of the temporary workforce and re-profiling of the total
workforce
l Shift from junior medics to advanced practitioners
l Shift in WTE from nurses to support workers
l Review the medical administration function
l Improve experience and quality of clinical education placements
for all clinical staff
l Improvement in students and juniors recommending BCH as a
place to train by 10%
l Set a financial plan for 2013/14 that requires an achievable
CIP target
l Review legacy CIPs carried forward from 2012/13
l Strengthen PMO function and its monitoring mechanisms
l Revise focus on CIP at performance reviews
l Enhance the CIP Governance framework especially with regards
to Quality Impact Assessments
l Regular formal engagement with key stakeholders
l Board level review of progress and barriers to moving the project
forward
l Programme board with key partners re-established
l Project infrastructure of key partners being established
l Development of detailed plan with key milestones
During 2012/13 some internal control issues
emerged relating to the management of junior
doctor rotas. These issues created risks in relation
to the Trust’s ability to demonstrate full compliance
with the Working Time Regulations and the New
Deal arrangements. The issues also created
financial risks. A detailed risk analysis provided
assurance that the risk to patient safety was low.
Management of these risks and the processes
put in place to address the internal control issues
were closely monitored by the Board of Directors
and its committees, including the Audit Committee.
Support and leadership was provided by Executive
and Non-Executive Directors.
A review by the West Midlands Deanery in March
2013 provided assurance on the quality of the new
processes and systems. An independent review
has been commissioned by the Audit Committee to
provide additional assurance that these processes
and systems are embedded and sustainable.
The Board of Directors is satisfied that the actions
taken have addressed the internal control issues.
Review of economy, efficiency and
effectiveness of the use of resources
The Trust has a range of processes embedded
throughout the organisation to ensure that
resources are used economically, efficiently and
effectively.
In reviewing the key risks of the organisation
through the Board Assurance Framework the
Board considers the effectiveness of the internal
controls compared with the risks. On a regular
basis it also reviews progress against the annual
service plans and the financial plan that results
from this. The Board is supported in the process
by a regular, in-depth review by the Finance and
Resources Committee of the Trust’s financial
position, business cases for significant revenue
and capital investments, and the investment of
cash balances.
Table 34: Internal Audit limited assurance opinion
Clinical Coding: Outpatient &
Emergency
The review found weaknesses
in the coding processes,
including validation and audit.
The Audit Committee supports the delivery of
effective, efficient and economic services through:
l Undertaking a range of thematic reviews,
including workforce, financial standing,
arrangements to deliver quality services and the
effectiveness of the assurance process.
l Considering the coverage of external
and internal audit and reviewing progress
on implementing internal and external audit
recommendations.
The Trust uses a comprehensive internal audit
service as part of its assurance process. An annual
internal audit work programme is risk based and
progress and amendments are reported to the
Audit Committee.
A new Internal Auditor was appointed in 2012/13,
which provided the opportunity for a fresh, in depth
review of the Trust’s risk and quality governance
processes. Significant assurance was given in the
following reviews:
1. Board Assurance Framework
2. Risk Management
3. CQC compliance
4. CAS alerts
5. Clinical Audit
6. SIRI process
7. Quality Governance
8. Directorate Governance
The Internal Auditor gave limited assurance as
follows in table 34 below.
Review Control weakness Action
Programme of formal audit
and regular spot checks to
be established. Longer-term
adoption of automated process.

A range of management processes are
embedded within the operational management
of the organisation that provides a framework for
ensuring that value for money is secured from the
resources available. These include:
l Monthly review of management accounts by
budget holders.
l Monthly performance meetings at directorate
level to assess progress against service and
financial plans, and quarterly meetings to pick
up major performance and service issues.
l The use of a patient level costing system
available to decision makers that identifies the
resources used in the provision of care at a
patient, HRG, specialty and directorate level.
l The use of a programme management
approach to the delivery of efficiency saving
targets built upon a clinician’s assessment of
the impact of any such proposal on the
quality of care.
l The use of a range of benchmark information to
assess the economy and efficiency of services
including with other specialist children’s
hospitals.
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.
Production of the Quality Report is led by the Chief
Medical Officer and by a core group that includes
senior medical and nursing staff with explicit
responsibilities for quality. The quality indicators
contained within the quality report cover the three
elements of quality and arise from: the Trust’s
Strategic Objectives; the Safety Strategy; locally
developed CQUIN schemes (Commissioning for
Quality and Innovation); national schemes; and
engagement with patients, families and staff.
Performance against these indicators is regularly
reported to the Board of Directors.
Data Quality and Security
Each year the External Auditor undertakes a
review of the data quality and accuracy of a
selection of the indicators reported in the Quality
Report. This includes an indicator selected by the
Council of Governors. Since the first Quality Report
the following indicators have been reviewed:
l MRSA
l MSSA
l C.Difficile
l Cancer waits
l 28 day readmissions
l Patient safety incidents resulting in severe harm
l Emergency Department Transfers
l PICU infections
l Cancelled operations
This provides assurance in relation to these
particular indicators and learning about data
quality and accuracy for other data management
purposes.
The Trust recognises the importance of good
data quality to measure the quality of our care
and organisational performance, to identify
where we need to improve and to measure
improvement. The Trust uses data as part of daily
operational management and regular performance
management, with a range of daily, weekly and
monthly performance reports including those
reviewed by the Board of Directors. This led to the
development of additional performance metrics
and identified a need to improve the data quality of
some of our performance metrics. We established
a Data Quality Group to identify and address
data quality issues and meet the Level 3 NHS
Information Governance Data Quality Standards.
A review of Trust data quality is included in the
Internal Auditor’s annual plan.
There have been no serious lapses in data security
in 2012/13.
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 that 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 Committee, the Quality
Committee and the Finance and Resources
Committee, and a plan to address weaknesses
and ensure continuous improvement of the system
is in place.
My review has taken into account the work of the
previous 12 months and is also informed in the
following ways:
l Through the Executive Directors and managers
who have particular responsibilities for the
development and maintenance of the system
of internal control and the Board Assurance
Framework.
l A comprehensive review of all data available
about quality of care across all services which
has been used to inform the Quality Account.
l The Head of Internal Audit provides me with
an opinion on the overall arrangements for
gaining assurance through the Board Assurance
Framework with regard to the principal risks
considered by their work. This is complemented
by a programme of agreed audit activity by
Internal Audit. This programme facilitates a
review of existing controls and recommends
appropriate remedial actions or systems
redesign. Reports from Internal Audit are
presented to the Audit Committee and any
control issues are reported to the Board and
managed by the Executive Directors.
l The results of the work undertaken by
the External Auditors including their opinion
on the annual accounts.
l The assessment of compliance with the CQC
essential standards of quality and safety,
the NHS Litigation Authority risk management
standards, the Information Governance Toolkit
and the results of staff and patient surveys.
150 151
l The published results of the quarterly
performance management process undertaken
by Monitor.
l Annual performance indicators published by
the Department of Health.
l Through the Audit Committee, which receives
the reviews of the Trust’s systems of internal
control, including the governance arrangements,
as part of the audit programme, assisting
the Board with its responsibilities to strengthen
and improve the effectiveness of the assurance
framework.
l Through the Quality Committee which provides
the strategic direction for the development and
implementation of effective quality governance,
ensuring that quality is critically reviewed to
improve outcomes for children, young people
and their families.
l Through the Clinical Risk and Quality
Assurance Committee, (which reports to the
Quality Committee), which provides leadership
on the development and implementation of
effective clinical governance, including clinical
audit, and monitors progress against the Safety
Strategy.
l Through the Finance and Resources
Committee, which provides the strategic
direction for the development of workforce
strategies, and ensures appropriate systems of
control are in place in relation to investments
and the financial position.
The Head of Internal Audit and the Audit
Committee have advised me that substantial
assurance can be given that there is a generally
sound system of internal control on key financial
and management processes, which are designed
to meet the organisation’s objectives, and controls
are generally being applied consistently.
Conclusion
No significant internal control issues have been
identified other than those described within this
statement.
Signed…………………………………………
29 May 2013
David Melbourne
Interim Chief Executive Officer
BACK TO CONTENTS PAGE

152 153
SECTION FIVE
BACK TO CONTENTS PAGE
Summary Financial Statements
The key statements from within the Annual
Accounts are detailed below in the same format
as they are represented in the Annual Accounts.
‘Notes’ cited in each key statement refer to the
Notes to the Accounts, which can be found in the
full set of Accounts.
The summary financial statements do not
contain sufficient information to allow as full an
understanding of the results of the Trust as would
be provided by the full Annual Accounts. A full set of
Annual Accounts are available, free of charge, by
contacting the Chief Finance Officer:
Chief Finance Officer
Birmingham Children’s Hospital NHS Foundation
Trust
Steelhouse Lane
Birmingham
B4 6NH
Or by visiting the Trust’s website:
www.bch.nhs.uk
Foreword
These accounts for the year ended 31 March 2013
have been prepared by Birmingham Children’s
Hospital NHS Foundation Trust in accordance with
paragraphs 24 and 25 of Schedule 7 to the National
Health Service Act 2006 in the form which Monitor
has, with the approval of HM Treasury, directed.
The auditor’s report on the full annual report and
accounts was unqualified.
David Melbourne
Interim Chief Executive Officer
Date: 29 May 2013
Statement of Comprehensive Income for the year ended 31 March 2013
31 March 2013 31 March 2012
Note £000 £000
Operating Income from continuing operations 2 233,709 223,958
Operating surplus from continuing operations 3 (225,082) (210,843)
OPERATING SURPLUS 8,627 13,115
FINANCE COSTS
Finance income 8 668 357
Finance expense - financial liabilities 9 (469) (471)
PDC Dividends payable (2,558) (2,187)
NET FINANCE COSTS (2,359) (2,301)
Surplus from continuing operations 6,268 10,814
SURPLUS FOR THE YEAR 6,268 10,814
Other comprehensive income
Impairments (8,665) -
Revaluations 12,877 40
Other reserve movements (62) (29)
TOTAL COMPREHENSIVE INCOME FOR THE YEAR 10,418 10,825
Prior period adjustments - -
Merger adjustments - -
TOTAL COMPREHENSIVE INCOME FOR THE YEAR 10,418 10,825
All income and expenditure is derived from continuing operations.

BACK TO CONTENTS PAGE
Note: Allocation of Comprehensive Income for the period:
There are no Minority Interests in the Trust, therefore the surplus for the year of £6,268k (2012: £10,814k)
and the Total Comprehensive Income of £10,418k (2012: £10,825k) are wholly attributable to the Trust.
Statement of Financial Position as at 31 March 2013
Statement of Changes In Taxpayers’ Equity
Non-current assets
31 March 2013 31 March 2012
Note £000 £000
Operating surplus from continuing operations 11 178 158
Property, plant and equipment 12 95,040 90,050
Trade and other receivables 22 1,251 1,095
Total non-current assets 96,470 91,303
Current assets
Inventories 21 3,955 3,635
Trade and other receivables 22 12,714 14,957
Cash and cash equivalents 25 36,173 33,730
Total current assets 52,842 52,322
Current liabilities
Trade and other payables 26 (19,564) (25,031)
Borrowings 27 (152) (152)
Provisions 31 (2,562) (223)
Other liabilities 29 (3,841) (8,015)
Total current liabilities (26,119) (33,421)
Total assets less current liabilities 123,193 110,204
Non-current liabilities
Borrowings 27 (1,365) (1,516)
Provisions 31 (2,389) (15)
Other liabilities 29 (1,777) (1,429)
Total non-current liabilities (5,531) (2,960)
Total assets employed 117,662 107,244
Financed by
Public Dividend Capital 86,222 86,222
Revaluation reserve 33 12,771 8,604
Income and expenditure reserve 18,669 12,418
Total taxpayers’ and others’ equity 117,662 107,244
Public
Income and
Dividend Revaluation Expenditure
Total Capital Reserve Reserve
£000 £000 £000 £000
Taxpayers’ Equity at 1 April 2012 107,244 86,222 8,604 12,418
Surplus for the year 6,268 - - 6,268
Impairments (8,665) - (8,665) -
Revaluations - property, plant and equipment 12,877 - 12,877 -
Transfer to retained earnings on disposal of assets - - (45) 45
Other reserve movements (62) - - (62)
Taxpayers’ Equity at 31 March 2013 117,662 86,222 12,771 18,669
Public
Income and
Dividend Revaluation Expenditure
Total Capital Reserve Reserve
£000 £000 £000 £000
Taxpayers’ Equity at 1 April 2011 -
as previously stated 96,419 86,222 8,564 1,633
Surplus for the year 10,814 - - 10,814
Revaluations - property, plant and equipment 40 - 40 -
Other reserve movements (29) - - (29)
Taxpayers’ Equity at 31 March 2012 107,244 86,222 8,604 12,418
The financial statements were approved by the Board of Directors and authorised for issue on their behalf by:
.............................. Date.............................................. Interim Chief Executive
154 155

156
Statement of Cash Flows for the Year Ended 31 March 2013
Cash flows from operating activities
31 March 2013 31 March 2012
Note £000 £000
Operating surplus from continuing operations 8,627 13,115
Operating surplus 8,627 13,115
Non-cash income and expense:
Depreciation and amortisation 3 5,631 5,097
Impairments 3 2,525 -
Loss on disposal 3 30 -
Non-cash donations/grants credited to income 105 -
Dividends accrued and not paid or received - 41
Amortisation of PFI credit 565 -
(Increase)/Decrease in Trade and Other Receivables 2,087 (4,883)
(Increase)/Decrease in Inventories (320) 217
Increase/(Decrease) in Trade and Other Payables (5,467) 3,874
Increase/(Decrease) in Other Liabilities (3,826) 74
Increase in Provisions 4,713 16
Other movements in operating cash flows (390) (208)
NET CASH GENERATED FROM OPERATIONS 14,280 17,343
Cash flows from investing activities
Interest received 668 357
Purchase of intangible assets - (45)
Purchase of Property, Plant and Equipment (9,519) (16,269)
Net cash used in investing activities (8,851) (15,957)
Cash flows from financing activities
Interest element of Private Finance Initiative obligations (469) (319)
PDC Dividend paid (2,517) (2,140)
Net cash used in financing activities (2,986) (2,459)
Increase/(decrease) in cash and cash equivalents 2,443 (1,073)
Cash and Cash equivalents at 1 April 33,730 34,803
Cash and Cash equivalents at 31 March 25.1 36,173 33,730