Welcome to the Luton and Dunstable University Hospital publication scheme.
To make a Freedom of Information request please email us.
About Our Publication Scheme
This publication scheme is a complete guide to the information routinely published by Luton and Dunstable University Hospital. It is a description of the information about our Trust, which we make publicly available. The purpose of having this scheme is to make information available to the public. The scheme has been defined by the information commissioner.
Under Section 19 of the Freedom of Information Act 2000 the Luton and Dunstable University Hospital (L&D) has a legal duty to adopt and maintain a publication scheme for the publication of the L&D information. The purpose of the Act is to promote greater openness by public authorities (of which the L&D is one).
The L&D will also respond to requests about the information that it holds recorded in any form and it will create a right of access to that information. These rights are subject to some exemptions.
The Freedom of Information Act does not change the right of patients to protection of their confidentiality in accordance with Article 8 of the human rights convention, the data protection act and common law. Maintaining the legal right to patient confidentiality continues to be an important commitment on our part.
The Caldicott Guardian is responsible for ensuring the protection of patient confidentiality throughout the Trust in accordance with your legal rights.
The L&D’s Caldicott Guardian is:
The Medical Director
Luton and Dunstable University Hospital (L&D)
Information which comes under our publication classes will be retained in line with the L&D’s retention and disposal schedules which comply with circular HSC1999/53 and Public Record Office Guidance. Information not required for the business purposes of the Trust is stored either at the Trust or at a place of deposit approved by the Lord Chancellor for the purpose of holding public records.
We welcome suggestions about how the publications themselves might be improved.
Any questions, comments or complaints about this scheme should be sent in writing to:
FOI Communications Manager
Luton and Dunstable University Hospital
or you can send a message by emailing us.
If you have a complaint about the operation of the Publication Scheme, or how the L&D has dealt with your request for information from the Scheme, please write to: The Chief Executive at the above address.
Rights of Access to Information
At the present time, in addition to accessing the information identified in this Publication Scheme, you are entitled to request information about the L&D under the NHS Openness Code 1995. Copies are available free of charge from:
Department of Health
PO Box 777
08701 555 455
Sometimes, some or all of the information cannot be provided. We will explain the reason if this happens.
The Freedom of Information Act recognises that as a member of the public, you have the right to know how public services such as the NHS are organised and run, how much they cost and how you can make complaints if you need to. You have the right to know which services are being provided, the targets that are being set, the standards of services that are expected and the results achieved.
Under the Data Protection Act 1998, you are also entitled to request access to your clinical records or any other personal information held about you by the L&D. This could incur a charge.
To request access you need to contact:
The Health Records Manager
Luton & Dunstable University Hospital
If you have any concerns regarding Data Protection, you can contact the Data Protection Officer at the above address or by email.
The Classes of Information
This information is grouped into broad categories as follows:
We will state how you can obtain the information outlined within each group. This will be either via the website or as a hard copy or other media as stated within each group. The publications are all free unless otherwise indicated. Where information is provided at a cost the charges will be calculated as set out in 15 below.
The L&D’s commitment to publish information excludes any information that can legitimately be withheld under the exemptions set out in the NHS Openness Code 1995 or the Freedom of Information Act. Where individual classes are subject to exemptions, the main reasons are the protection of commercial interests and personal information under the Data Protection Act 1998. This applies to most classes within the publication scheme.
The publication scheme will be available in both hard copy and on our web site.
1: The NHS And How We Fit In
The L&D is one of over 300 Hospital Trusts in the country, a full list of which can be found on the NHS website. All Trusts are accountable to the Department of Health and performance managed by Strategic Health Authorities. In our case this is the:
Bedfordshire and Hertfordshire Strategic Health Authority
63-77 Victoria Street,
Primary Care Trusts (PCTs) fund and commission health care services. Luton and Bedfordshire Heartlands Primary Care Trusts are the two main commissioners of the Trust’s services. The Trust provides local acute hospital services (outlined in more detail in section 6of this publication scheme) to the population living in the area covered mainly by the Luton Borough Council and South Beds District Council areas.
One of the L&D’s main tasks is to deliver the targets laid down in the Department of Health’s National Plan, and subsequent annual planning and priority documents and to provide services in line with national service frameworks. Details of these policy documents are accessible through the Department of Health website.
2: Who We Are
The Luton and Dunstable University Hospital is a large modern hospital providing general medical and surgical services and a number of specialist services. The hospital has 550 inpatient beds and employs over 2,500 staff. Each year we spend over £100 million providing healthcare for:
We serve over 300,000 people in Luton, South Bedfordshire as well as parts of Hertfordshire and Buckinghamshire. We provide some specialist services including Breast Screening, neonatal intensive care and limb fitting which each serve over one million people. Twenty five percent of Luton’s population are from different cultural and ethnic backgrounds; the main groups are Pakistani, Bangladeshi, Indian, African-Caribbean and Eastern European. Luton is an area of high deprivation; consequently many of the health issues and conditions are more usually associated with those of an inner city area. It was designated a Health Action Zone in 1998.
Details of the Trust and key personnel are set out in its annual report, published usually in September. The latest copy is on the L&D’s website and paper copies are available from the communications unit at the hospital, free of charge. Copies are available for most years from 2000-2001 onwards.
The Trust’s corporate governance framework follows the recommended framework in the National Corporate Governance Manual. It has in place standing Orders, standing financial instructions, and a formal document describing the powers reserved to the Board, and those delegated to officers. A register of the pecuniary interest of Directors and senior staff is maintained, as is a register of hospitality and sponsorship. On appointment, all directors confirm that they will observe the code of conduct and code of accountability included in the Corporate Governance Manual. Paper and electronic copies of these documents are available from the communications unit at the hospital. The register may be inspected by arrangement with the communications unit.
Some information under this category will be withheld, including confidential information about individuals, which is protected by the Data Protection Act.
3: Financial and Funding Information
The Trust obtains its funds mainly from the local Primary Care Trusts, who commission its services. Other sources of funding include educational sources and income generated by the Trust from providing services to other health bodies, staff and the general public. Fuller details are contained in the Trust’s annual accounts, including the accounts of its charitable funds, copies of which are available in paper form from the Communications Unit at the hospital, from 2000/1 onwards.
A Summary of the annual accounts is included in the annual report each year.
Annual budgets are presented to the Trust Board every year, normally in April or May. A routine report on the Trust’s financial position is presented to the Board at every routine meeting. Paper copies of all these documents, from 2003 onwards are available from the communications unit at the hospital.
The Trust has adopted a procurement strategy. A paper copy is available from the communications unit at the hospital. In line with NHS Policy, purchasing and contracting is conducted within the Trust using the appropriate standard terms and conditions issued by the NHS Purchasing and Supply Agency (NHS PASA). Paper and electronic copies of these are available from the buying department.
Where possible, the Trust purchases under national contracting arrangements, or through NHS Logistics, who operate a warehouse system for supplying a whole range of standard items. The Trust’s buying department manages the procurement process. The standing orders and standing financial Instructions of the Trust govern the purchasing methodology in respect of the use of tenders and quotations.
In accordance with the EU Supply Directive, contracts, which exceed the stated thresholds in value, are advertised in the Official Journal of the European Union (OJEC). The Trust does not operate an approved list for tenders, but relies on other, existing lists, suppliers approved by the NHS Purchasing and Supplies Agency or other statutory body, response to OJEC advertisements and similar methods to identify prospective suppliers.
4: Corporate Information
The Trust publishes an annual report and accounts and also an annual Business Plan. Both the annual report and a summary version of the business plan (known as the summary service plan) are available via the hospital website. The Trust also publishes a fortnightly newsletter for staff called staff link. Paper copies of the annual report and the other publications described above are available from the communications unit at the hospital, free of charge.
Agendas and minutes of the Trust Board meetings are available on the L&D’s website, and paper copies are available from the communications unit at the hospital, free of charge. These documents are available from 2003 onwards. Supporting documents are available electronically or on paper from the communications unit at the hospital. The website also provides profiles of the current Trust Board members.
Agenda and minutes of the audit, risk management, and clinical governance committees, and copies of the local development plan, (previously business plan), the strategic direction, and similar documents are available electronically or on paper from the communications unit at the hospital. These documents are available from April 2003 onwards.
Exemption from publication may apply to various items under this category, when it is intended for future publication, is personal and confidential information or other confidential information, such as that relating to the health and safety of specific individuals, or it involves criminal, regulatory audit investigative material or law enforcement material or the Board has resolved that it would be prejudicial to discuss the matter in public.
5: Aims, Targets And Achievements
Financial targets, aims and objectives and key performance indicators.
Performance ratings for NHS Trusts in England, covering the year ending March 2003 are the first to be produced and published by Commission for Health Improvement. This year is also the first in which primary care trusts and mental health trusts have received full star ratings.
The CHI is the independent regulator of NHS performance. The Government is responsible for setting priorities which in turn determine the indicators relating to key targets. Other indicators have this year been designed by CHI and the Department of Health to reflect a wide range of performance issues, following consultation with the service and other stakeholders.
This document accompanies the internet publication, and summarises the star ratings and indicator scores for each trust.
The ratings and indicators provide people working in the NHS and the public with accessible and easy to understand information about the performance of local health authorities
All aspects of quality whether clinical or non-clinical are managed through the Quality Management Committee. This is a board sub committee which produces a monthly quality report to the management executive and the Trust Board. This report is available from the communications unit at the Trust.
The Quality Management Committee (QMC) oversees the work of the Clinical Management Teams (CMT), which are led by the clinical directors for each area. The Clinical Management Teams report progress against the Clinical governance plans on a twice-yearly basis and members of the QMC attend CMT meetings on a rolling programme.
Implementation of National Service Frameworks and NICE Guidance.
The National Service Frameworks are clinically led by the relevant consultants. However their work is coordinated by the assistant general manager for Medicine and Medicine for the Elderly. Quarterly reports are produced for the Quality Management Committee. Copies of these reports are available from the communications unit.
The Trust has a well-developed system for the dissemination of NICE guidance. This is led by the associate medical director (quality) who considers each piece of guidance and assigns a clinical lead to consider and implement the guidance. They then report progress with implementation to the clinical audit and effectiveness committee. Copies of these reports are available from the communications unit.
Essence of Care Project
Using the Essence of Care document as a template, benchmarking of clinical care is well established within the Trust. A pilot is being planned to agree care with patients who will sign their care plans to state they agree with the plan and were involved in its development.
6: Our Services
The L&D offers a comprehensive range of general medical and surgical services.
The Clinical Services provided for patients are as follows:
In addition, the Hospital has developed more specialist services including cancer and neonatal intensive care units. The breast screening unit is one of the country’s largest. The Trust also specialises in neurophysiology and obesity research.
Clinical Support Services
There is an extensive range of clinical support services. They include: pharmacy, medical photography, physiological measurement, physiotherapy, speech and language therapy, occupational therapy, foot health services, dietetics and orthotics.
The Trust has close links with Mount Vernon Hospital and Great Ormond Street Hospital (GOSH). Visiting consultants from these hospitals hold joint outpatient clinics at the Hospital. They provide services in oncology, plastic surgery (Mount Vernon) and specialist paediatrics (GOSHSC). Patients are usually referred to the Royal Free Hospital for neurosurgery.
Non-clinical Services (Supporting the Trust clinical activity)
Provision of a full meals and beverage service to inpatients and restaurants for outpatients, visitors and the Trust’s staff. Additionally, a WRVS shop and a commercial outlet, Upper Crust, provide a snack service.
This encompasses all aspects of internal cleaning and also includes pest control measures.
This is provided to maintain the Trust buildings and technical services in a good state of repair and extends to including medical equipment.
This is predominantly provided by a housing association in partnership with the Trust.
The Trust has its own production facility to process surgical instruments and other sterile products used in surgical procedures.
A 24-hour service is provided to the hospital which encompasses patient movements, post and other deliveries to wards and departments and waste disposal.
This also includes the management of car parking and is aided by a comprehensive CCTV system and access control system.
The Health Records Library holds Medical records and X-Rays of all current patients. Medical records and X-Rays of past patients are stored either at the Trust or at a place of deposit approved by the Lord Chancellor for the purpose of holding public records
Concerns about these services are dealt with either by the health records service manager at the hospital, or by the arrangements set out in class eleven of this publication scheme.
7: Reports And Independent Enquiries
The Trust is subject to inspection and regulation by a wide range of external agencies.
The Commission for Health Improvement (CHI) review team visited the Trust in June 2002. The CHI review team commended the Trust for its organisational team spirit and highly effective leadership. At the time of the review there was only one other Trust in the UK to receive a higher score. Following the successful visit the Trust agreed an action plan with CHI and this has been used to inform the Trust’s quality management strategy and direction. Copies of the report, clinical governance development plan and the annual report are available electronically or in hard copy from the communications unit.
The Trust is a two star Trust which has been accredited by The Health Quality Service. The Trust also has clinical pathology accreditation and holds risk pooling scheme for Trusts and level one clinical negligence scheme for Trusts.
8: Policies And Procedures
There are a variety of Policies and Procedures relating to the Management of the Trust. For ease of reference these are categorised into five general subject areas:
A complete list of the Trust’s current policies is available electronically or on paper from the Freedom of Information unit at the hospital.
Click here for the Hospital’s Policies. For copies of any of these Policies please e-mail FOILeads@ldh.nhs.uk and we will supply them within a period of 20 working days.
9: Involvement And Consultation
The Trust is committed to working with patients and the local population to improve the services we provide. Our Patient and Public Involvement (PPI) strategy is available in paper copy format from the communications unit at the hospital.
A Patient Advice & Liaison Service (PALS) is available in the hospital to provide advice, information and support to patients and their carers. The service is available 9:00-18:00 Monday to Friday and has an out of hours answer phone (01582 497 990) and fax (enquire). The PALS Manager provides support to the hospital’s patient representative group. Members of this group attend many of the Trust’s committees and also participate in implementing the PPI strategy by carrying out ward and departmental audits with the staff. Minutes of the patient representative group bi-monthly meetings and the PPI audit reports are available in paper copy format from the Communications Unit at the hospital.
The Trust takes part annually in the national patient survey as well as following a schedule of internal audits and patient surveys. Summary reports are available on request. There are also a number of focus groups planned for individual specialties. If you wish to become involved in any of these contact the PALS Manager on 01582 497 014.
10: Regular Publications And Information For The Public
In addition to its annual report and accounts, the Trust publishes an annual summary service plan. We also publish a regular newsletter for GPs called L&D Community. Patient information leaflets that are widely available cover such issues as
The patient information working group reviews the need for patients to have accurate and readable information about surgical operations and medical procedures. Our PALS office holds a full database of patient information leaflets. Copies of these leaflets available on request from the communications unit.
The Trust has an internal compliments, concerns and complaints procedure; which is based on Department of Health complaints procedures. Target response monitoring and formal complaints monitoring reports are provided to the Trust Board on a monthly basis. These identify the number of complaints responded to within the target date and the number of formally logged complaints received by each directorate across the Trust, and complaint trends. The reports also provide information on independent review.
Complainants are requested to put their concerns in writing to the chief executive officer. Complainants may also request assistance with their concerns either within the local department or ward, the patient affairs office or through the PALS (Patient Advice and Liaison Service)
12: Human Resources
Details of Employment policies are available on the L&D’s website and on paper from the communications unit at the hospital. These cover areas such as maternity leave, harassment and bullying, equal opportunities, flexible working, and health and safety.
Workforce and Other Human Resources Information
Details of the workforce, and key performance data are reported regularly to the Trust Board.
Communications Within the Trust
A joint Staff and Management Committee considers key policies and debates matters of concern to staff generally.
There is an occupational health service available to advise on health issues in the workplace.
Education, Training and Development
The Trust’s training activities are based on an annual training needs assessment. All staff are required to join an induction course, and have an annual training in topics such as fire, manual handling, (and for specified staff members) resuscitation. The hospital is also a recognised centre for the European computer driving licence qualifications and NVQs. The Trust has recently been awarded associate teaching hospital status with the University of London.
Close liaison takes place with the Bedfordshire and Hertfordshire Workforce Development Consortium over training requirements to ensure an appropriately skilled workforce is available.
Vacancies in the Trust are published on its web site, and are advertised in appropriate media.
Information is available on paper and some electronically from the Communications Unit at the hospital, free of charge.
13: Communications With The Press And Media
The Trust issues regular press releases to the local media. Copies are posted on the web site and are available on paper from the communications unit at the hospital, free of charge.
14: Environmental Information
The Trust occupies some ten hectares of land a short distance from Junction 11 of the M1 Motorway. The Hospital was first constructed in 1939 and has been expanded in phases to provide 57,000 square metres of accommodation. Approximately 60% is used directly for patient care, which includes wards and operating theatres. The remainder is used to accommodate support services including sterile services, main kitchen, medical records storage and office accommodation. A Private Finance Initiative partner has built 5,000 square metres of accommodation which is used for care of the elderly wards and therapy department accommodation, including physiotherapy, and speech and language therapy. Further details are available from the communications unit at the hospital free of charge.
15: The Publication Scheme
We will use this class to communicate any changes or additions to the scheme since its original publication in October 2003. We shall also inform you of any contact details that have changed.
Cost of Information
For the most part, we will charge you only for hard copies or copying onto media (e.g. CD ROM). Some information is available free, but for others there may be a charge. The charges will vary according to how information is made available. Charges are as follows:
The charges will be reviewed regularly.
The material available through this publication scheme is subject to the L&D’s (copyright policy) unless otherwise indicated.
Permission to reproduce material does not extend to any material accessed through the publication scheme if the copyright is held by a third party. You must obtain authorisation to reproduce such material from the copyright holders concerned. For HM Stationary Office guidance notes on a range of copyright issues, see the (HMSO website) or contact,
HMSO Licensing Division
St Clements House,
Tel: 01603 621 000
Fax: 01603 723 000
Freedom of Information
Bodies Involved In The Inspection and Monitoring of Our Services
These bodies are involved in the monitoring and/or inspection of our services: