Annual Report - Central Manchester University Hospitals - NHS ...

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Statement on Internal Control Scope of Responsibility The Trust Board is accountable for internal control. As Accountable Officer, and Chief Executive of this Trust Board, I have responsibility for maintaining a sound system of internal control that supports the achievement of the organisation’s policies, aims and objectives. I also have responsibility for safeguarding the public funds and the organisation’s assets for which I am personally responsible as set out in the Accountable Officer Memorandum. The Trust’s management structure has established accountability arrangements through a scheme of delegation covering both corporate and clinical division arrangements. This is reflected in the corporate and divisional work programmes/objectives and the governance arrangements within the Trust. 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: 1st April – 31st December 2008 (Summary) ■ Trading Gap Plans – Financial An annual efficiency requirement of over 3% removed from tariff uplifts each year will require significant efficiencies over the next five years. The Trust is proactively identifying, developing and implementing plans in advance of need. Budgetary control measures closely monitor the delivery of the trading gap across each Division of the Trust. ■ New Hospitals Development (PFI Project) - Organisational The Trust recognised that a number of key issues need to be managed through the construction phase of the New Development, including the maintenance of the site, clinical activity and delivery of access targets and the development of integrated service models to match capacity. Work has been particularly focused this year on workforce requirements for the move of the Children’s hospital to the central site in 2009 and the mobilisation of support services staff. The Trust has an established internal implementation group to manage the issues arising during the construction phase. An operational group meets weekly to monitor risks. ■ Identify and prioritise the risks to the achievement of the organisation’s policies, aims and objectives. ■ Evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. ■ The system of internal control has been in place in the Central Manchester and Manchester Children’s University Hospitals NHS Trust for the year ended 30th December 2008 and up to the date of approval of the Annual Report and Annual Accounts. Significant Internal Control Issues The Trust has identified the following significant internal control issues which have been or are being addressed:- Robust operational plans have been developed for all hospital moves, which detail at ward and department level the processes which will be implemented. Communication plans both internally and externally have been prepared and a publicity campaign has been commenced to ensure the public are well informed regarding the moves. The operational plans have been assessed and approved by external experts. ■ Increased Referrals and Activity – Organisational Unprecedented increases in GP and self referrals to A&E has affected the Trust’s ability to deliver the four hour A&E access target in 2008/09. The Trust is working with our host Primary Care Trust to identify and implement alternative service models for urgent care which will address the rise in demand. In page 24 Central Manchester and Manchester Children’s University Hospitals NHS Trust
Annual Report and Summary Financial Statements 2008/09 page 25 addition work is underway to identify additional capacity in the Trust and in the Health Economy. ■ Workforce - Organisational The Trust recognises that to achieve its strategic aims, it needs to ensure the provision of an adequately skilled and flexible workforce. The Trust has produced a Workforce Strategy linked to its business planning process that ensures that we are well prepared to meet the demands for a skilled and flexible workforce to deliver continued improvements in the health and care services it provides. Much work has taken place to ensure following the hospital moves that staff with the required skills are in place. Delivering the European Working Time Directive for Doctors in training targeted for August 2009 is a significant risk to the Trust. New models of care delivery are being considered alongside strenuous recruitment. ■ Adult Critical Care Capacity – Clinical Increasing demands on adult critical care services particularly for specialist referrals has necessitated the Trust to develop increased capacity for critical care beds. Before further planned capacity is provided, other measures are in place to mitigate the risk. ■ Infection Control – Clinical The Trust has continued to demonstrate significant improvement during 2008/09 on all aspects of infection prevention and control. The MRSA target was achieved and the Trust was under trajectory; in addition the target for managing C.Difficile was also achieved and the Trust was under trajectory. The Trust continues to adopt a zero tolerance approach to infection prevention and control and is continually improving services to meet these challenges. ■ Information/Data The Trust has undertaken audits of transfers of personal data and reviewed all transfers of personal data in or out of the Trust. The risks identified in the audits related to faxes, bulk mailing and e-mail. Resolutions included for faxes, the use of safe haven fax or a fax authentication process. Courier services were used for bulk mailings and only NHS mail is used for emails with emails encrypted. The following are a summary of the serious incidents of data loss reported: ● Theft of a laptop from office - person identifiable information for 22 persons No further actions were required and all Trust laptops are being encrypted under the Trust IT Security policy. ● Theft of fifteen laptops from the University offices - one hundred records contained patient identifiable data Data Sharing Agreements between the Trust and University have been developed and all laptops are now encrypted. An action plan to reduce the occurrence of these incidents was developed which involved raising staff awareness through mandatory and induction training, regular team briefings, information on the Trust intranet and meetings with the staff involved. Systems and processes are now in place to ensure that all patient and staff information is now being stored and shared in a secure manner in accordance with Department of Health guidance and Information Governance Good Practice. ■ Annual Declaration on Standards for Better Health The Trust has completed its self assessment exercise against the seven domains of the Standards for Better Health. The organisation has declared compliance against all standards of all seven domains. Therefore the target compliance for 2008/2009, according to our self assessment, has been met. The Trust is fully compliant with the core Standards for Better Health. Mike Deegan, Chief Executive 5th June 2009
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