TRUST BOARD – Part I - 4February 2010Agenda Item Number: 06/10

Enclosure Number: (1)

Subject / Integrated Performance Report for Month 9 (December)
Prepared by:
Presented by: / Steve Gooch – Deputy Director of Finance
Jane Lowe – Head of Business Intelligence
Mark Power – Head of Workforce Performance
Robert D Toole – Director of Finance & Investment
Purpose of paper
Why is this paper going to the Trust Board?
Tick as many as appropriate or provide text /
Requires NED decision / Trust Board approval
Requires NED input / guidance

Discussion requested by NEDs

Regular reporting

Statutory requirement

For information / awareness
Key points for Trust Board members
Briefly summarise in bullet point format the main points and key issues that the Trust Board members should focus on including conclusions and proposals / The Trust Board is asked to note:
  • The performance against national targets;
  • The key workforce indicators for the month;
  • The quality metrics which continue to be developed;
  • The financial position of the Trust at the end of month 9;
  • The critical actions to ensure that the Trust delivers against the revised forecast outturn of £12m deficit.

Options and decisions required
Clearly identify options that are to be considered and any decisions required / The Board should note that Performance issues highlighted in this report when considering the specific actions being presented separately by individual Executive Directors.
Next steps / future actions:
Clearly identify what will follow the Trust Board’s discussion / To note the position to the end of Month 9 for actions reflected in separate reports from Executive Directors.
Consideration of legal issues (including Equality Impact Assessment)? / Yes

1.0Introduction

This report highlights the key performance issues covering national targets, finance, workforce and operational performance.

The attached pack will continue to be developed and comprises the following information:

Section 1 – Trust Wide Heat Map (with overview of performance against key targets and plans)

Section 2 – Finance Dashboard

Section 3 – National target performance

Section 4 – Finance Analysis

Section 5 – Workforce dashboard

Section 6 – Efficiency Metrics

Section 7 – Operational activity data

Section 8 – Quality indicators

2.0Performance against National Targets

Section 1 shows the Trust wide heat map which highlights performance against a range of key indicators for the Trust.

Section 3 shows performance against a range of National Targets. The major issues to note at the end of December are as follows:

  • Accident & Emergency 4 hour wait times: This target requires that 98% of patients are seen within 4 hours. The Trust is currently underachieving against this Target with cumulative performance currently standing at 97.37%. There were 904 breaches of the 4 hour target in December compared to 579 in December last year. Performance has continued to be under target during January.

A detailed recovery plan integrated with the Primary Care Trusts and supported by the Strategic Health Authority and Intensive Support Team is in place.

  • 18 week referral to treatment target for admitted patients: For December the Trust achieved the non-admitted target with a performance of 98.3% (target 95%) and has achieved the target for both quarters 1, 2 and 3.

For admitted patients the trust achieved 85.9% for December (target 90%) and therefore underachieved against the target. Cumulative performance to date is 87.7%

This target is measured separately for each month and the trust has underachieved against this target for 6 of the 9 months to date, (underachievement is above 80%) However the revised guidance published in December indicates that this will be applied to individual specialties for the last quarter. To date ENT has failed to achieve more than 80% for all 9 months, T&O, Maxillo-facial, ophthalmology and gynecology have failed to achieve more than 80% in more than 2 months.

Performance in the last quarter is expected to further deteriorate as the trust treats the backlog of patients already past their breach date.

Detailed modeling of the impact of treatment of breached patients has been completed and a detailed recovery plan integrated with the Primary Care Trusts and supported by the Strategic Health Authority and Intensive Support Team is in place with plans to treat the majority of the backlog patients by the end of March.

  • New outpatients waiting longer than 13 weeks to be seen: Cumulatively there have been a total of 24 breaches resulting in under-achievement against the national target.

The target is 0.03% of all GP referrals seen and currently performance is 0.0329%. If there are no further breaches, the Trust would recover the target by the end of January provided activity remains consistent with delivery to date.

  • Thrombolysis Call to Needle time: The Care Quality Commission has just published the detail for this indicator which now includes primary angioplasty within 150 minutes in addition to Thrombolysis within 60 mins of call for professional help measured between April – December 2009.

The Thrombolysis part of the target requires 68% of patients to be treated within a 60 minute target time. The Trust is currently underachieving with cumulative performance of 50%.

There were 6 eligible patients during December, 3 of these breached the target. Of these 2 had long ambulance journeys and arrived with only 7 and 11 minutes respectively of the target remaining to diagnose and safely administer the drug. The third arrived after 33 minutes, but the initial ECG was not diagnostic of myocardial infarction and treatment was initially delayed.

For the Primary Angioplasty part of the target the trust has provided treatment within the 150 minute target for 95.2% of patients for the year to date.

Both parts of the indicator will be considered together but no further details or thresholds have been published.

  • Last minute non-clinical cancellation of procedure: Cumulatively 261 patients have been cancelled on the day compared to 215 for the same period last year, this equates to 0.61% of elective activity against a target of 0.8%.

Tighter controls have been introduced to ensure all potential non-clinical cancellations are escalated to Divisional Manager before the final decision is made, so all possible actions can be initiated to avoid cancellation

This has seen performance improve to within the threshold for the target. It will be important to maintain this tightened control going into the winter months as there is a seasonal increase in cancellations, particularly post Christmas when emergency capacity is at a premium.

  • Cancer referral to treatment within 62 days: The target is 85% for first treatments, 90% for screening referrals and 86% for consultant upgrades. Whilst cumulative performance against this indicator overall is 87.138. November performance in total was 85.9%, consultants upgrades 84.6%, screening referrals 95.24% and first treatments 85.2% which is a slight improvement on last month, however as the margin of safety is minimal close monitoring of performance will continue.
  • Infant Health Inequalities % of new mothers smoking: Cumulatively 18.4% of new mothers were smoking at time of delivery compared to 17.51% for 2008/9. Note the target is to improve over time to 15%.
  • Delayed transfers of care: This target is measured cumulatively using the number of patients whose transfer of care is delayed each week as a % of all admitted patients from April to December.

At the end of December the trust position was 5.14% against a target of less than 3.5%, greater than 5% equating to a fail.

Overall Performance against Existing National Priorities: To achieve a rating of fully met for Existing National Priorities (based on 2008/9 published methodology) the trust must achieve 28 out of a maximum 30 points for the 10 indicators. This means the trust cannot fail any indicator and can only afford to underachieve against 2 of the indicators. Accident and Emergency 4 hr wait, 13 wk Outpatients and Non-clinical cancellations, and delayed transfers of care all form part of this set of indicators therefore further deterioration in performance could impact adversely on the trusts overall performance rating.

3.0Financial Performance

Sections 2 and 4 detail the Trust’s financial performance at the end of the December.

The major issues to note at the end of month 9 reporting are as follows:

  • Income and Expenditure Performance (year to date): The Trustis reporting a deficit of £13.1m on income and expenditure at the end of December. This position excludes the costs associated with the move to international financial reporting standards and any impairment charges. The planned position for the Trust at this point of the financial year is to be recording a £2.6m deficit so the Trust has a £10.5m variance from plan at the end of month 9.
  • Income and Expenditure Performance (in-month): The in-month income and expenditure deficit for the Trust was £400k. It should be noted that the in-month position includes £1.1m of additional income from Hampshire PCT to assist the Trust in performance against the 18 week target. Excluding this one-off item the in-month run rate for the Trust is £1.5m deficit which represents an improvement on the £1.9m run rate reported in November but is still not sufficient to ensure the Trust delivers against its year end target of a £12m deficit.
  • Expenditure Trends:Although the overall financial position remains a huge cause for concern high level expenditure trends continue to move in the right direction albeit not at a fast enough rate to achieve the £12m forecast outturn. The Trust’s overall pay bill reduced again in the month to £20.5m which is the 2nd lowest month of the year so far. This was again supported by a continued reduction in temporary staffing expenditure as the controls in place continue to impact.
  • Temporary Staffing: Total expenditure for temporary staffing in the month was £1.2m as compared to an average of £1.8m for the first six months of the financial year. This represents the lowest level of temporary staffing spend this year. Whilst this demonstrates an improvement, it continues to be significantly higher than can be afforded to deliver the £12m forecast outturn and still represents 5.9% of total pay costs, compared with the target of 5% that needed to be delivered throughout the year.
  • Activity and Income: Year to date activity levels remain broadly unchanged at the end of December. The Trust continues to experience a significant overheat of 5% compared to plan on A&E attendances and to a lesser degree on emergency activity (1.2%). The Trust remains underperforming on elective activity (5.6% lower than the corresponding period last year). The Trust continues to reflect £1.3m of over-performance income within the financial position at month 9 and is still forecasting that this will be the end of year position.

There remains a degree of risk that the £1.3m over-performance included within the current position may not be sustained over the remaining months of the year. This will depend on the impact of PCT demand management schemes over coming months and a further risk is now presented by the poor weather during January which has led to the cancellation of some outpatient and elective work.

  • Cost Improvement Plans: The Trust is now showing fully identified savings plans totaling the annual targetof £19.8m.

At the end of month 9 savings have been delivered to a value of £9.8m. This is compared to planned savings at this point of the year of £12.7m meaning there is a shortfall of £2.9m compared to the plan. Divisions need to ensure that all schemes in the Trust’s original cost improvement programme continue to be delivered.

In addition to the original cost improvement programme, the Trust continues to develop a turnaround plan under the guidance of Terry Watson, Turnaround Director. This will include a range of additional actions with the aim of ensuring that the Trust achieves a £12m year end deficit and is well placed in terms of developing savings plans for 2010/11.

  • Capital and Cash: The Trust’s cash balance reduced by £0.7m in the month and stood at £4.9m at the end of the month. The combination of the deficit position on income and expenditure and the large capital programme associated with the new hospital has placed considerable pressure on the Trust’s cash reserves during the year. As reported last month the Trust has received a further £5m Capital Investment Loan (received 15th December) and discussions are continuing in respect of the £5m working capital loan.

4.0Workforce Performance

Section 5 summarises key workforce performance issues at the end of December in a dashboard format.

  • Workforce Capacity

Overall change in workforce capacity, derived from the net effect of changes in both Substantive and Temporary Staff (expressed as FTE).

The net movement in total workforce capacity (i.e. substantive staff and temporary staff capacity, combined) from Month 8 to Month 9 is a reduction of 77FTE. Overall workforce capacity is now 169 FTE below the Mar 09 baseline level, mainly due to the reduction in temporary staffing.

  • Temporary Workforce Rate

Total expenditure on temporary staff usage (bank and agency), converted to FTE, and expressed as % of total workforce capacity - i.e. substantive staff + temporary staff + overtime.

The Temporary Workforce Rate reduced from 5.7% in Month 8 to 5% in Month 9, but remains 1% above the 3% target (i.e. 50% reduction against Month 8 year to date average). Premium payment expenditure (predominantly WLI related) increased in month. The justification for, and authorisation of this expenditure is being further examined.

  • Unit Staff Costs

Cost of Substantive Workforce divided by Total Substantive FTE expressed as £s (indicative gross cost per employee).

At Month 9 Unit Staff Costs have increased marginally to £39.1k, which is marginally above target.

  • Workforce Productivity

Total value (£) of all SLA Activity delivered within the period, divided by the FTE Total Workforce Capacity for the period, expressed as £s. (i.e. indicative average revenue per employee) NB. Workforce Productivity is one month in arrears, therefore currently reporting Month 8 data.

Overall workforce productivity decreased marginally in month, reflecting a modest decrease in both the overall pay bill and activity levels.

  • Projected Outturn

Total Workforce Capacity

The Trust Workforce Plan reflects a Total Workforce Capacity planned outturn of 6009.8 FTE.

The projected outturn (Mar 10) is 6,064.6 FTE (i.e. 54.8 FTE above plan).

This projection takes account of planned reductions through the redundancy programme, confirmed leavers, at Month 10, and anticipated additional turnover between Month 10 and Month 12, as detailed in Table 1.

Table 1 - Projected Outturn - Total Workforce Capacity
FTE
Planned Total Workforce Capacity Outturn (Mar 10) / 6,009.8
Month 9 (Dec) Total Workforce Capacity / 6,211.7
Planned reductions through Redundancy (92 headcount) / 86.0
Confirmed Leavers (24 headcount) / 21.1
Anticipated Turnover (M10 -12) / 40.0
Projected Total Workforce Capacity at Mar 10 / 6,064.6
Variance to Planned Outturn / 54.8

Substantive Workforce

The projected outturn (Mar 10) for substantive workforce is 5,708.4 FTE, which is consistent with the Trust Workforce Plan year end position.

5.0Operational Performance

Sections 6 and 7 summarises key operational information and the Trust’s performance against a range of efficiency metrics. The key issues to note at the end of December are as follows, please note Dr Foster will not be publishing data until the 29th January for November therefore the efficiency metrics are as October:

  • Do Not Attend (DNA) Rates: the Trust’s DNA rate for October improved to 7.9% from8.5% last month but requires further improvement to achieve national top quartile rate of 6%.
  • Day of Surgery Admission – Non-Elective: The percentage of non-elective patients admitted on day of surgery was 46.7% for October. This compares to national top quartile performance of 56%. If performing at top quartile the trust could have potentially saved 464 bed days (13 beds at 85% occupancy) However, significant improvements have taken place in respect of elective day of surgery admissions.
  • Length of stay: Whilst at an overall summary level our length of stay appears reasonable, this disguises the position at HRG level. Information has been presented to Divisional teams exploring significant opportunities for improvement to reach National top quartile performance.
  • Trends in activity: in several areas activity levels are significantly reduced compared to that performed last year. For example, elective admissions being 5.9% lower than last year and out-patient attendances being 1% and 7% lower for new and follow up’s respectively. However, within emergency activity this trend is reversed with both A&E attendances (5%) and Emergency admissions (2.9%) recording increases on the corresponding period last year.
  • Activity compared to plan: The Trust is currently performing above plan in all areas apart from elective inpatient activity which is remains 1.9% below plan. However, it needs to be recognised that there can be no assurance that over-performance will be funded, especially in respect of new to follow-up exceeding the contracted levelwhich will not be paid for (value £1.1m) and there needs to be recognition that as part of the local health economy there is an overall financial constraint.

6.0Quality Indicators

Section 8 details how the Trust is performing against a range of quality indicators at the end of December.

7.0Forecast Outturn and Recovery Actions

The Trust original financial plan was to deliver a £9m deficit. This forecast was revised to £12m at the end of month 6 in light of the continued deterioration in the Trust’s financial position.

In response to this position a range of urgent recovery actions were implemented by the Executive Team in October which included stringent restrictions on recruitment and an escalation of controls on temporary staffing. Evidence from the reported numbers over the last three months is that these controls are having the desired impact with both substantive staff numbers and temporary staffing costs reducing on a month by month basis. However the pace of this reduction is currently not sufficient for the Trust to achieve its year end target of a £12m deficit.

The Turnaround Director is working with Divisions and Corporate functions to finalise plans across a range of workstreams with the aim of achieving the required improvement in financial performance over the final quarter of the financial year. The scale of improvement required is extremely challenging however, with circa £1.5 to 2m per month improvement needed in the financial position in each of the remaining months. It is critical that all staff understand our financial and performance position. Particular awareness is of the direct impact of poor performance on patient experience and care e.g. the 4 hour target. It is also critical that everyone in all areas are involved, and actively participate individually and as part of their team to contribute to make necessary changes and improvements.