TRUST BOARD- Part I– 3 December2009Agenda Item Number: 131/09

Enclosure Number: (2)

Subject / Integrated Performance Report for Month 7 (October)
Prepared by:
Presented by: / Steve Gooch – Deputy Director of Finance
Jane Lowe – Head of Business Intelligence
Mark Power – Head of Workforce Performance
Malcolm Dennett – Interim Finance Director
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 deterioration in the financial position of the Trust at the end of month 7 of the financial year;
  • The critical actions to ensure that the Trust delivers against the revised forecast of £12m deficit for the year.

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 7 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 integrated performance pack continues 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 October 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 97.88%. There were 376 breaches of the 4 hour target in October compared to 167 in October last year.

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 October the Trust achieved the non-admitted target with a performance of 98.3% (target 95%) and has achieved the target for both quarters 1 and 2.

For admitted patients the trust achieved 85% for October (target 90%) and therefore underachieved against the target.

This target is measured separately for each month and the trust has underachieved against this target for 4 of the 7 months to date, (underachievement is above 80%) However the guidance also indicates that this applies to individual specialties, ENT has failed to achieve more than 80% for all 7 months and T&O has failed to achieve more than 80% in 2 months.

In addition there is a significant backlog of patients who will breach the target when treated and therefore performance will deteriorate further.

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: There has been a further breach of this National standard at the end of October; cumulatively there have been a total of 23 breaches resulting in under-achievement against the national target.

The target is 0.03% of all GP referrals seen and currently performance is 0.404%. 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: This target requires 68% of patients to be treated within a 60 minute target time. The Trust is currently underachieving with cumulative performance of 52.2%.

There were just 2 eligible patients during October, 1 received treatment within target and the other arrived at 55 minutes leaving insufficient time to diagnose and safely administer the drug within target.

The Care Quality Commission are reviewing this target for 2009/10 and are likely to include emphasis on primary angioplasty as first line of treatment, details of the indicator have not yet been published (18/11/09)

  • Last minute non-clinical cancellation of procedure: Cumulatively 211 patients have been cancelled on the day compared to 139 for the same period last year, this equates to 0.62% 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.

  • Infant Health Inequalities % of new mothers smoking: Cumulatively 18.6% of new mothers were smoking at time of delivery compared to 17.5% for 2008/9.
  • 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 October the trust position was 5.04% against a target of less than 3.5%, performance greater than 5% equates 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 October.

The major issues to note at the end of month 7 reporting are as follows:

  • Income and Expenditure Performance (year to date): The Trustis reporting a deficit of £11.1m on income and expenditure at the end of October against our revised forecast for the year of a £12m deficit. The planned position for the Trust at this point of the financial year is to be recording a £2.0m deficit so the Trust has a £9.1m variance from plan at the end of month 7.
  • Income and Expenditure Performance (in-month): The in-month income and expenditure deficit for the Trust was £2.4m which represents a further deterioration from plan of £1.3m. A contributing factor to the in-month deficit was the loss of £500k of over-performance income previously assumed within the position. This followed an assessment of finalised quarter 2 activity figures.
  • Expenditure Trends:Although the overall financial position remains unacceptable there is some early indication that some of the urgent actions to control expenditure that were instigated during October have started to reduce expenditure. Temporary staffing and overtime payments were both reduced in the month although the scale of the reduction is still insufficient to return the Trust to financial balance.
  • Temporary Staffing: Total spend for temporary staffing for the month was £1.5m 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 and contributed to a reduction in the Trust’s overall paybill for the month to £20.8m (2nd lowest month of the year so far).
  • Activity and Income: The Trust has this month reduced its assessment of over-performance income anticipated from PCT’s following the production of quarter 2 activity monitoring information. The Trust had previously included £1.8m of over-performance income within its year to date financial position based on over-performance agreed with PCT’s at the end of quarter 1, this has now been reduced to a value of £1.3m.

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 and the potential for activity to be transferred to other providers to support capacity issues that the Trust has in certain key specialties.

  • Cost Improvement Plans: The Trust is now showing fully identified savings plans totaling £20m compared to the annual targetof £19.8m. The gap on savings plans has been closed through capturing the impact of the contingency measures that the Trust has introduced (such as the recruitment panel).

The reality of the situation is that all Divisions and corporate areas need to continue to develop robust plans which will eventually take the place of these contingency measures. The opportunities to identify savings do exist as clearly shown by the efficiency metrics included as part of this board report. Whilst overall performance against the metrics may be good in some areas, this often masks individual specialties and HRG’s where the scope to improve performance is significant. Further information has been provided to Divisions identifying the opportunities available for further improvement. These opportunities need to be incorporated within Turnaround Plans with delivery milestones against which performance is monitored and financial savings delivered.

At the end of month 7 savings have been delivered to a value of £6.8m. This is compared to planned savings at this point of the year of £8.7m meaning there is a shortfall of £1.9m compared to the plan. Divisions need to refocus actions to deliver against these agreed plans.

  • Capital and Cash: The Trust’s cash balance reduced by £4m in the month and now stands at £7.3m. The major causes for this reduction in cash remain the Trust’s in-month I&E deficit and the high level of capital expenditure (£2.8m in month).A further £10m of loans are planned to be received over the remaining months of the financial year to ensure that the Trust has enough cash to meet its commitments.

4.0Workforce Performance

Section 5 summarises key workforce performance issues at the end of October 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) during this period between Month 6 and Month 7 is a reduction of 45FTEreflecting the reduction in temporary staffing in the month. Overall workforce capacity remains 53 FTE higher than the baseline level of March 2009.

  • 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 has reduced to 7.4% in Month 7 which is 2.4% above the 5% target for the Trust. It is anticipated this downward trend will continue as the increase in temporary staffing controls continue to impact in November. The target of 5% was based on this level being delivered throughout the year. The level of continued high level spend has been a significant contribution to our level of overspending against plan. The target for the remainder of the year has been reduced further.

  • Unit Staff Costs

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

At Month 7 Unit Staff Costs have reduced marginally to £38.5k, which is marginally below target overall. The most significant variances is within the Women’s and Children’s Services division.

  • 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 5 data.

An increase in SLA activity in Month 6 is reflected in a corresponding increase in overall Workforce Productivity equating to £3.4k.

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 September are as follows:

  • Do Not Attend (DNA) Rates: the Trust’s DNA rate for September was 8.5% compared to the national top quartile rate of 6%.
  • Day of Surgery Admission – Non-Elective: The percentage of non-elective patients admitted on day of surgery was 47.7% for September. This compares to national top quartile performance of 56%. 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 7.5% lower than last year and out-patients attendances being 5.1% lower. However, within emergency activity this trend is reversed with both A&E attendances (5.0%) and Emergency admissions (2.6%) 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 remains 2.0% below plan. However, it needs to be recognised that there can be no assurance that over-performance will be funded and there needs to be recognition that as part of the local health economy there is an overall financial constraint. There is evidence that demand management is beginning to have impact and Portsmouth City PCT has reduced activity below plan

6.0Quality Indicators

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

7.0Conclusion

The information to month 7 exposes a range of challenges for the Trust in relation to finance, achieving national targets and workforce.

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