The foundation trust regulator has voiced “concern” that the Royal Bolton Hospital placed finance ahead of tackling its burgeoning waiting list problems.

Monitor last week found the trust in significant breach of its terms of authorisation, citing failures of board governance and poor performance on accident and emergency and referral-to-treatment waiting times.

The move brings the number of foundation trusts in significant breach to 18, up from just nine a year ago.

In a notice to the Royal Bolton’s chairman, Monitor said the trust had breached the national 18-week waiting target for admitted patients in three consecutive quarters in 2011-12. The trust had not increased theatre sessions or begun planning increased bed capacity until October, despite failing the target since April, it added.

“There is a concern that the that the trust allowed itself to be constrained by a focus on finance, choosing to delay actions which could have prevented or reduced the RTT issue until additional financial support was confirmed,” it stated.

The trust anticipated it would fail the target again in the final quarter of 2011-12, but would be compliant from the start of this year. The regulator said this was only possible because the trust secured one-off funds from its commissioners to help clear the backlog.

However, Royal Bolton chief executive Lesley Doherty said the trust had increased capacity ahead of securing extra funding. It confirmed an additional £800,000 around the start of November, and the trust had “treated patients at [its own financial] risk” prior to that.

She added that the trust’s 2011-12 contract had required it to go back and renegotiate extra funds from its commissioners if demand rose above planned levels. But she said conversations with the area’s clinical commissioning group had been “supportive”, and she was confident its 2012-13 contract would deliver what it needed to meet demand.

Sue Long, interim accountable officer for Bolton Health Consortium CCG, said the 2011-12 contract had included a planned level of activity and a “risk share” for activity above those levels.

“The really unfortunate thing is that what that motivated was risk-averseness, rather than [the trust] seeing the important thing as meeting the needs of patients,” she said.

She believed the CCG was developing a “much more open relationship” with the Royal Bolton, which would mean the trust felt able to “come to us at an earlier stage” to discuss issues.