integrated performance report · an elective taskforce covering rtt and cancer has now commenced...

Integrated Performance Report

September 2017

Mid Essex, Southend and Basildon Hospitals

Joint Working Board - 15th November 17

Contents



Section Content Page

Performance Overview Introduction by CEO 3

Domain Scorecards Quality of Care 4

Operational Performance 7

Workforce, Leadership and Improvement Capability 16

Finance and Use of Resources 23

Appendices Maternity Dashboards 31


Joint Working Board - 15th November 17 The Single Oversight Framework (http://bit.ly/2eq8SNE) places Providers into “Segments” based on NHS Improvement’s judgement of the seriousness and complexity of issues faced by each Provider.

Introduction by CEO September 2017

http://bit.ly/2eq8SNE

Quality of Care Celia Skinner & Diane Sarkar

(CQC – Safe, Caring, Excellent, Well Led) September 2017



Harm Free Care - Mortality

Quality of Care

Performance

The latest SHMI publication for the 12 months up to Mar 17 shows SUHFT as above expected (1.19) and MEHT (1.08) and BTUH (1.06) within expected limits, as reported at the last Board. Crude mortality rates are following usual seasonal trends.

Critical actions in the next period are: • Further training for structured judgment reviews, initial training attended in

October 2017. • Acadiant on track to begin implementation of electronic mortality review tool in

December at SUFT • Initial output from cross site palliative care review has shown opportunity to

harmonize palliative care coding. • Respiratory pathway meeting occurring in November. • Unified reporting structure developing across the three sites.

Mortality SUHFT BTUH MEHTSHMI to Mar 17

1.19 1.06 1.08

Higher than expected

As Expected

As Expected

Number of deaths

Number of mortality reviews conducted

% Reviews completed

Number of deaths with an element of avoidability

Basildon 380 172 45.3% 3Mid-Essex 346 92 26.6% 1Southend 378 327 86.5% 2

Q1

Commentary Actions / Mitigations

Basildon Mid-Essex SouthendDeaths in month (June) 122 103 99Leading cause of death (CCS) Septicemia Septicemia Pneumonia

Harm Free Care – Infection Control and Never Events / Other Quality Updates

Quality of Care

Issues There were no never events in September. Themes and trends are now being reviewed across the three sites and a group risk and compliance group has been established where clinical risks are reviewed and appropriately escalated.

Infection Control • Master –classes have been provided by NHSi on the

good model to monitor infection control compliance and BTUH progress was reviewed, they subsequently have been de-escalated to Green as actions were complete.

• 1 MRSA at SUHFT which is being investigated

Performance Commentary Actions / Mitigations

Operational Performance Yvonne Blucher

Lisa Hunt Clare Culpin

(CQC – Responsive) September 2017



The three trusts have agreed their recovery trajectories with NHSI against: – A&E 4 hour performance – 62 day cancer performance – RTT 92% incomplete performance

The expectation is to have all three trusts delivering 85% for 62 day cancer performance. For RTT there is an expectation to treat the current 52 week breaches and eliminate risk of further 52 week breaches jumping on to the PTL over the next couple of months although Mid Essex DIEP trajectory for recovery is March 2018. The 92% RTT performance should be delivering by March 2018.

In month key issues for August A&E 4 hour performance Significant improvements in performance have been seen in recent months, with a group performance of 90% in September. Cancer The recent quarterly review meeting with NHSI stressed the 85% target for 62 days must be met in September. An elective taskforce covering RTT and cancer has now commenced and a plan has been produced highlighting target treatments and breaches that will be booked over the next few days. All three trusts have seen a continued reduction in 104 day waits – all have been through a harm review process and the majority of these patients have been dated. However, across the MSB, September delivery remains an amber risk. RTT 92% is the agreed trajectory and all three sites expect to achieve trajectory by end March 2018. 52 weeks 52 week breaches are stabilising and reducing however there is a residual risk around DIEP breaches at MEHT as the tariff for treatment in the private sector is yet to be agreed. This has been escalated to NHSE who are supporting. Winter resilience Each Trust has worked within its own local health community and submitted a system-wide plan to NHSI on 25th August. Any gaps in assurance or opportunities for a collective MSB approach to facilitate the sustainability of performance has been addressed through the Performance Oversight Committee and is highlighted in a separate report.

Operational Performance Overview

Operational Performance

Accident and Emergency 4 Hour Standard - MEHT



• The emergency 4 Hour Performance standard increased from 90.5% in September to 92.9% in October , reaching the trust’s internal trajectory objective

• 265 extra admissions via ED compared to October last year (8 extra admissions per day).

• 93% bed occupancy for October remaining stable from last month

• 627 breaches with full breach analysis available and displayed weekly in control room

• 5% increase in attendance for October against the same period last year (averaging 13 extra attendances per day)

• Ambulance attendances remain as expected

• Red 2 Green data now being captured and reported on daily basis.

• Different ways of working (workforce innovation etc) are being implemented eg ACPs appointed and awaiting start dates.

• Flow and Discharge steering group chaired by ADO with Foureyes support. Focusing on related work streams and monitoring continues.

• Flow and discharge group showing benefits in discharge lounge use, r2g tracking, Stranded patient improvement and trust data quality.

• Non-elective task force now in place to identify

improvements daily reporting into ADO. • Daily mobile stranded patients meetings are now in

place and monitoring all patients with a LOS of 7day+.

• Daily reviews of DTOCs and deep dive against

national guidance - ongoing • GP Streaming – on target for delivering national

requirements.

Aug-17 Sep-17 Oct-17

Target 95% 95% 95%Performance 83.6% 90.5% 92.9%Attendances 7,944 8,412 8,782 Waits over 4-hours 1,299 796 627

MEHT

Accident and Emergency 4 Hour Standard - BTUH



Improving care for emergency patients continues to be a Trust priority, has seen recent improvement but remains fragile. Performance for September is 91.3% and October 90.2% of patients being seen and treated/admitted within 4 hours. Issues • Staffing – Remains a risk for Trust • Breach analysis confirms that most breaches are due

to lack of capacity and flow • The high numbers of Medically Fit patients continues

to be high and DTOCs fluctuate week on week • Health and social care provision and capacity within

the community

Actions and Mitigations • Increased capacity in Ambulatory care from 8 to 13

beds, although capacity demands use 4 beds overnight, this service continues to pull patients through from the A&E including GP referrals and supported improvement in A&E performance

• Protection of 2 beds on AMU West for Frailty Ambulatory unfortunately failed due to capacity demand, 4 beds on Frailty unit protected for ambulatory until building work completed on AMU West mid December.

• Daily Breach analysis and weekly meetings to discuss issues and promote learning and solutions

• Bed modelling for medicine and surgery completed by Four Eyes Insight

• Dedicated manager of day in all specialities • Revising bed management model including roles and

responsibilities of all divisions to support performance

• Red2Green(R2G), SAFER bundle and Clinical Utilisation Reviews (CUR) are now live and being utilised by staff on 18 wards on daily Board Rounds

• Continue to promote and embed use of Red2Green and SAFER bundle

• Daily monitoring of MFFD and DTOC data to escalate delays to external partners

• Weekly LOS meetings for all patients over 7 and 14 days

• Elective activity continues and steady improvement of theatre utilisation

• Robust weekend planning • Consultants/therapies, social care/pharmacy in place

at weekends which is now improving weekend discharge numbers

• Planning with community and social care partners via A&E Board and Stepping Up Board.

• Winter plans both local and system wide tested by tabletop exercise.

• Winter Sitreps commenced


Performance 92.4% 91.3% 90.2%Attendances 11,384 11,470 12,367 Waits over 4-hours 862 995 1,216

BTUH

Accident and Emergency 4 Hour Standard - SUHFT



Issues Performance improved slightly in October. • October saw our highest ever attendance figure of

363 • Medical workforce shortage continues to be a

challenge • Discharges still occur too late in the day • ED Nursing vacancy position has improved but recent

Long and short term sickness remains a challenge • Overnight remains a challenge with high acuity

particularly through Resus • Conflicting priorities between planned and

unplanned work

Performance for October is 89.4%, but remains above 91% for the year to date.

Actions and Mitigations • Surges/spikes continue to be a theme in ED between

18.00 – 02.00 and remained a constant pressure in resus. The nursing rota changes have been implemented but are not consistently filled due to short term sickness and vacancies. This is improving but remains fragile

• Although the medical rota has been aligned with the surges in activity, due to the medical workforce vacancies, consistently delivering the new rota remains a challenge particularly in respiratory and DME.

• Medical workforce recruitment – 8 new starters joined the team in Sept, 36 vacancies remain with 16 out to offer. Dedicated recruitment officer remains in place

• We have seen a increase in DTOC figures this month. Conference calls reinstated to provide additional escalation opportunities

• Plans to change the AMU consultant rota to increase consultant cover in the afternoon/evening this remains inconsistent due to vacancies . This will provide in-reach to ED and allow the development of hot clinic pathways – recruitment remains an issue

• Estates work and recruitment continues in line with winter planning. The first of the planned escalation beds are on target to open in November

• CDU continues to work well. Currently accepting c50 patients a week resulting in 50 less referrals to Medicine

• Initial system wide winter plan submitted to NHSi and internal plan finalised, some of the actions already completed

• Primary care streaming on target – Estate ready • Continue to embed use of Red2Green and SAFER

bundle • New acute medicine general manager started and

providing additional support to the pathway • Senior management cover in ED continues till 21.00

every weekday • Foureyes team supporting patient flow


Performance 91.1% 87.5% 89.4%Attendances 8,355 8,205 8,770 Waits over 4-hours 743 1,022 931

SUHFT

Cancer 62 day Standard



• The number of patients waiting over 62 and 104 days continues to reduce.

• Backlog reduction has been driven by both increased treatment numbers and changes to shorten pathways overall.

Key issues across the group: • Significant diagnostic capacity challenge across

the group in both endoscopy and cross sectional imaging (CT & MRI)

• MEHT challenges are Skin (plastics), Urology, Lower GI, Upper GI

• SUHT challenge in Lung • BTUH challenges in Urology, Lower GI, Lung

Actions and Mitigations Group actions:

• STP-wide events were held in October to review

four of the most challenged areas in Urology, Lung, Lower GI and Skin. These were focussed on moving towards best practice with short, medium and long term actions identified.

• Working to roll out the Southend straight to test Prostate pathway across the group.

• Focus on endoscopy capacity and demand on each site with support from FourEyes consulting. Solutions include outsourcing and insourcing.

• Expectations set for diagnostics within 7 days for all cancer pathways. Escalation lists are now in place on each site for Radiology and Pathology to ensure senior oversight of waiting times and daily updates of progress.

• A number of issues across the skin plastics pathway have been identified with MEHT and these are being worked through.

• The MEHT cancer taskforce is embedded and driving the recovery with increased pace with Plastic surgery as one of their priority areas for support.

• NHSI Improvement Coach continues to support in high priority areas including LGI, UGI and Lung pathways. This has included analytical review of current pathways to inform improvements including a focus on early diagnostics through straight to test and one stop models.

• Cancer Alliance colleagues are also supporting with a number of areas including attempt to introduce the Southend Prostate referral guidance across the group.

Jul-17 Aug-17 Sep-17 Jul-17 Aug-17 Sep-17 Jul-17 Aug-17 Sep-17 Jul-17 Aug-17 Sep-17

62- day performance 76.6% 70.7% 79.5% 70.4% 81.0% 74.6% 68.0% 72.4% 75.7% 71.3% 75.4% 76.3%Treatment Points 70.5 73.5 78.0 101.5 113.0 132.0 89.0 96.0 70.0 261.0 282.5 280.0 Treatment Points over 62 days 16.5 21.5 16.0 30.0 21.5 33.5 28.5 26.5 17.0 75.0 69.5 66.5 Treatment Points over 104 days 4.5 4.0 3.0 5.5 5.0 3.5 11.5 7.5 4.0 21.5 16.5 10.5

SUHFT MSB HospitalsBTUHMEHT


2ww performance 95.2% 94.2% 96.4% 91.2% 90.2% 93.0% 84.6% 87.9% 90.8% 89.2% 90.2% 92.8%

Referrals 787 845 686 1,294 1,292 1,139 1,560 1,589 1,372 3,641 3,726 3,197

Referrals seen after more than 2 weeks 38 49 25 114 126 80 240 192 126 392 367 231

SUHFT MSB HospitalsBTUHMEHT

Cancer 62 day Standard


Breach Re-allocation

Background • Published cancer waiting times (CWT) performance is collated from data that each provider submits to the openexeter system. These are the

published figures that are referenced in this performance report on slide 12. • Where a patient has breached the 62 day standard and was treated by a different Trust than received the original referral, the openexeter

system shares the breach with 0.5 points allocated to those 2 Trusts (ie the Trusts where the pathway started and ended). Similarly the treatment is also split between the 2 Trusts.

• There are many types of cancer treatment that are not provided in every hospital (including specialist surgery, Radiotherapy and chemotherapy). In order to understand overall CWT and identify where there may be delays in treatment, a more refined approach to breach sharing is required.

Regional guidance • In 2012 the East of England Cancer Network published regional guidance on breach re-allocation. This was a voluntary process and did not

replace the formal openexeter method. This was intended as a tool for Trusts and sub-regions to better understand their pathways. • Southend and Basildon adopted the EoE method and used this information for internal analysis. • Mid Essex recently adopted the EoE method. • Under this approach breach re-allocation takes account of how long each Trust took in completing their respective elements of the patients’

pathway. The breach is then allocated based on where the delays occurred.

National guidance • In 2016 NHS Improvement published national guidance on breach re-allocation. This was similar in format to the EoE guidance but with specific

differences. • From April 2017 the openexeter CWT data submissions will be changed and at that time the formal published CWT performance data will

reflect the NHSI national breach re-allocation rules. • Southend and Basildon have adopted the national rules for breach re-allocation whilst Mid Essex have not yet transitioned and continue to use

the regional rules.

Performance • Southend performance in August improved by 1.9% overall after re-allocation with a net change of -2.0 breaches. Southend picked up 1.0

additional breaches due to late referrals out. However, Southend also lost 3.0 breaches due to late referrals received from other Trusts. • Basildon performance in August reduced by 0.8% overall after re-allocation with a net change of +0.5 breaches. Basildon picked up 1.5 additional

breaches due to late referrals to Southend. However, Basildon also lost 1.0 breaches due to treatment delays at Mid Essex. • Mid Essex started using breach re-allocation analysis in September so do not have data for August. • Regulators advise that the re-allocated performance position be reported to Board for a more nuanced understanding of CWT performance.

18 weeks Referral to Treatment Incomplete Standard



Issues Incomplete 52 week breach at month end MEHT –118- Biggest risk area - Plastic Surgery (Complex Breast) BTUH - 9 - Biggest Risk areas - Neurology and Respiratory Sleep SUHFT – 7. Backlog Positions MEHT – Please see actions/mitigations comment regarding the growth of the PTL following the implementation of Lorenzo BTUH – 4,125 - Neurology, Dexa/Osteoporosis, T&O, Gastroenterology SUHFT – 5,067 - Key areas ; Hot spots - admitted Orthopaedics , ENT and General Surgery, non admitted - Ophthalmology, Chest Medicine, Cardiology and Community Paediatrics

Actions and Mitigations • RTT x-group being formed with initial focus on the development of

cross-site PTLs (and PTL discussions) for long waiting patients to identify opportunities to transfer patients across site to aid earlier booking and prevent excessive waits for patients.

• Examine areas of capacity which could aid backlogs on other site. • Network wide approach to neurology backlog to be discussed. SUHFT

is reviewing their neurology activity in preparation for potential repatriation.

• MEHT - The Plastics team have developed a recovery plan to treat their complex and DIEP patients in 2017/18. The DIEP recovery plan is monitored in weekly meeting between ADO Plastics and Burns and Director of Commissioning at MEH CCG. However there is significant risk to delivery of the plan due to a) outsourcing tariff and b) theatre staffing being increased to support the ramping up of activity.

• MEHT – There has been a significant increase in the overall waiting list size since the implementation of Lorenzo. This is being monitored daily through the control room.

• MEHT – IST visited the trust to support with our data quality and the output report is expected shortly. It is not expected that our PTL size will return to 24000 and is likely to end up around 35000. An action plan is being developed for Board on the back of the IT report.

• MEHT - A large number of the duplicate entries are due to a systems issues which was raised with DXC. They have identified the solution and will be applying a fix in their next update. Unfortunately the recent update did not include this fix and this is being investigated with DXC.

• BTUH – Theatre and Outpatient utilisation and productivity programme continues , now being integrated as business as usual .

• BTUH – Weekly PTL and Access Board meetings continue . • Meeting held with NHSI, NHSE, BBCCG ON 11 October 2017 to assure

delivery of standard by March 2018. • BTUH – Planned move of cystoscopy from endoscopy unit to provide

extra space for endoscopy. • BTUH – Cystoscopy outsourcing to Mayflower, to commenced in

September. Volumes below those anticipated, working with CCG to rectify .

• SUHFT – Monitoring outpatient slot utilisation and short notice cancellation to maximise capacity

• SUHFT - Maximising theatre productivity through the 6 4 2 process – increase in productivity already experienced

• SUHFT – RTT trajectory has been updated against capacity plan and winter pressures


Performance 83.6% 82.7% 82.6% 82.9% 80.1% 80.8% 83.2% 82.3% 82.6% 83.2% 81.4% 81.8%Waiting List Size 28,635 28,739 29,178 37,647 43,469 46,516 24,081 23,928 23,694 90,363 96,136 99,388 Waits over 18 weeks 4,703 4,963 5,067 6,437 8,652 8,931 4,047 4,233 4,125 15,187 17,848 18,123 Waits over 52 weeks 2 5 7 98 99 118 3 4 9 103 108 134

SUHFT MSB HospitalsMEHT BTUH

6 week Diagnostic Standard



Issues Southend • Consultant vacancies covered by locums during

recruitment phase • Implementing new service improvement plan

and business case for safe staffing in nursing being written

• Environment – architect commissioned to develop a reconfiguration of the unit

Mid Essex • Following extensive manual validation, MEHT

submitted a DM01 report for September • DM01 total list for September 2017:5301 • Over 6 weeks: 473 • Due to changes in process following CRIS

implementation (e.g. switching from paper to electronic) the waiting list size has increased. This is more accurately capturing data than the previous method.

• The area with the most 6+ week waits is non-obstetric ultrasound. Other areas remain largely in line with pre Lorenzo/CRIS implementation

• The waits for non-obstetric ultrasound have been impacted by the ongoing sonographer staffing shortages

BTUH • Endoscopy working to full capacity

Actions and Mitigations Southend • Substantive nurse recruitment has now commenced for

Endoscopy • Endoscopy unit flow streamlined to increase productivity • Average points per list has increased from 7.4 to 10.5 due to

reduction in DNA and same day cancellation rate as a result of pre-assessment process

• Triage by pre-assessment is removing inappropriate referrals • Aiming to achieve 99% in November as the backlog has

reduced significantly • The business case going to tender to enable the department to

have contingency equipment

Mid Essex • Validation in CRIS (new reporting system) has been completed • A internal system has been put in place to allow CRIS, Lorenzo

and Tomcat data to merge to produce a DM01 return. • Site visit from HSS (provider of CRIS) took place in October • Further training with HSS being arranged on CRIS statistics for

Radiology data team and Information Services • DM01 Task Force set up with weekly meetings continuing,

now focussing on improved performance • Ongoing recruitment for sonographers • Planned weekend backlog clearance for non obstetric

ultrasound in November • CT: Running additional weekend sessions and continue

outsourcing to InHealth • Exploring further CT outsourcing options • Recruitment drive for radiographers to support further

extended day and weekend working to increase capacity • Introduced contingency appointments to increase capacity

BTUH • Weekend and evening working in endoscopy • Session utilisation improved • Business plan completed for cystoscopy move from Endoscopy

by December 2017 • Additional CT and MRI sessions continue • Cystoscopy capacity to be improved through outsourcing at

Mayflower , although volumes need to be higher.


Performance 97.6% 98.2% 97.2% 91.1% 98.9% 98.7% 97.7% 95.4%

Waiting List Size 4,346 4,581 4,482 5,301 5,673 5,830 6,301 16,084

Waits over 6 weeks 103 81 126 473 63 77 142 741

SUHFT MSB HospitalsMEHT BTUH

Workforce, Leadership and Improvement Capability

Mary Foulkes (CQC - Well Led)

September 2017


Joint Working Board - 4th October 17

Workforce KPIs – Agency Spend


Performance SUHFT MEHT BTUH Mid & South

Essex

KPI Sep-16 Sep-17 KPI Sep-16 Sep-17 KPI Sep-16 Sep-17 KPI Sep-16 Sep-17

Agency Spend (as a % of the pay bill) 5.7% 10.64% 10.61% 8.3% 9.98% 10.87% 5.5% 8.24% 5.19% 6.5% 9.57% 8.78%

Medical Locum Target (actual) spend £000) 465 741 924 567 668 953 1,421 415 400 2,453 1,824 2,277

SUHFT MEHT BTUH

• September has seen an increase in agency spend to 10.61% of pay bill.

• An increase of £2k on previous month

• September has seen an increase in agency spend to 10.87% (10.08% in July)

• The increased cost of £1,974k in September was £467k adverse to the ceiling.

• Medical spend increased in September by £40k • Nursing spend increased in September by £62k • High Medical spend in A&E, Dermatology, Gen Surgery ,

Oral & Paeds • High Nursing spend in all Emer Care Areas, Plastics &

Medical Wards, Surgical Wards and MSK Wards • Increases continuing to be partly driven by the IR35

impact and the loss of previous VAT gains as a result

• September has seen a decrease in agency spend to 5.2% from (5.5% in August)

• Agency spend decreased to under target of £1m a month • Medical spend decreased in September by £125,000. • Nursing spend decreased in September by £15,000. • Administrative and Clerical has increased in September

to £80,000 from the August position of £68,000 which needs to be investigated to reduce

• Vacancies continue to be the main reason for spend, however nursing also reports an increase for patient dependency.

• Increase of bank rates to encourage bank bookings rather than using agency

• Review with Overseas Doctors agencies with introductions to MEHT and BUHT to enable bulk purchasing rates

• Doctors Agency supply meeting on 4th Nov • Group agency spend reduction discussion scheduled for

26.10.17

• Agency controls in place include – strict prior authorisation by senior managers,

• Weekly financial control meetings, • Weekly Agency Rule Breaches approval meeting, non-

Clinical shifts reviewed weekly at SDM. • Project linking areas of high nursing agency spend to

vacancies and specific recruitment plans. • Medical Agency is measured and reported monthly in

the Trust Board Report.

• Open days for specific nursing areas/specialties arranged to take place in October and November

• Planned attendance at the Acute & Medical Conference in November

• Sustained recruitment activity for doctor roles being maintained to fill vacant posts

• Introduce Group Agency review meeting • Standardisation of Locum rates (Q1 2018) • OBC to centralise the bank and agency team across the three trusts Q1/18

Group Actions

Site Actions taken to mitigate

Workforce KPIs – Recruitment

Performance

SUHFT MEHT BTUH Mid & South Essex


Vacancy Vacancy Rate 7% 8.04% 11.53% 7% 13.54% 15.27% 7% 10.41% 10.76% 7% 10.77% 12.55%

Nurses 7% 12.68% 14.07% 7% 15.56% 19.24% 7% 14.10% 17.36% 7% 14.20% 17.05%

Consultants 7% 4.19% 11.86% 7% 13.02% 10.61% 7% 3.64% 3.50% 7% 7.37% 8.71%

• September has seen a slight increase in registered nurses vacancies (from 13.78% in August to 14.07% in Sept -17)

• 33 pre-registered nurses awaiting PIN to add to the nursing figures

• Consultant Vacancies has been reduced to 11.86% in September from 13.57%

• 134 Medical offers (excluding Deanery doctors) have been made since January

• 14 Medical offers due to start in the next 3 months

• September has seen a small increase in registered nurses vacancies (from 284 in August to 293 in September)

• September has seen a small increase in consultant vacancies (from 25 in August to 28 in September)

• Investigating possibility of ‘Golden Hello’ payments to new nurses in certain areas.

• Recent Consultant appointments include Breast Surgery, Palliative Medicine and Obs & Gynae.

• September has seen a slight increase in registered nurses vacancies (from 261.55 in August to 267.81 in September)

• September has seen a slight increase in consultant vacancies (from in 6.5WTE in August to 7.9WTE in September )

• Newly qualified nursing candidates conversion to starters improved significantly since last year due to the keep in touch scheme

• We have two Locum Consultants commencing in October one in Anaesthetics and the other in orthopaedic surgery

Total in Recruitment Process (WTE)

Projected new starters WTE (Oct-Nov)

23 5

136 25 Recruitment Consultants

Nurses



16 2

125 70



4 4

53 53



43 11

314 148

Overseas Recruitment - Nurses

EU

Non - EU



27 6

33 3



0 0

27 4



13 13

3 3



40 19

63 10

Group Actions • Review of Doctors bank rates across 3 Trusts • Nursing and Midwifery Recruitment and Retention Plan

Group Actions • Standardised selection process agreed for consultants • Business case developed to consolidate the recruitment and bank & agency team

Workforce KPIs – Turnover

Performance



Voluntary Turnover (rolling over 12 months) 9.50% 12.54% 13.01% 9.50% 17.85% 17.88% 9.50% 15.34% 12.97% 9.50% 15.24% 14.56%

Voluntary Turnover Nurses 9.50% 12.26% 12.18% 9.50% 18.10% 18.26% 9.50% 15.62% 13.05% 9.50% 15.44% 14.55%

Consultants 9.50% 6.19% 10.24% 9.50% 4.10% 5.08% 9.50% 4.56% 7.03% 9.50% 4.92% 7.34%

Issues SUHFT MEHT BTUH

The rolling 12 month turnover rate reduced from 13.24% in August 2017 to 13.01% in September 2017.

The rolling 12 month turnover rate at the end of September 2017 was 17.88%, a reduction from 18.43% at the end of August 2017.

The rolling 12 month turnover rate at the end of September 2017 was 12.9%, a slight increase from 12.94% at the end of August 2017.

Site Actions taken to mitigate

• Exit interview Feedback and response evaluated monthly and fed back to relevant managers particularly for high turnover areas

• Turnover analysis is included in the Directorate Workforce Board reports

• Analysis of reasons forms part of the Directorate/ HRBP review meetings

• Health and wellbeing action plan in place to support staff

• Reviewing retention initiatives in line with the national programme for nurses

• Exit meetings and questionnaire offered to all leavers Feedback and responses evaluated and fed back to relevant managers.

• HR Managers discuss with leads areas of concern, support managers in addressing issues and improving processes and culture

• Summary analysis will inform staff survey action plans.

• The Trust has been invited to participate in the 2nd cohort of the NHSi Retention Support Programme for Nursing.

• Task and finish recovery plan identified actions to improve retention and increase recruitment activity to fill nursing posts

• Attending the NHSI retention workshop (cohort 2) in October to bring back suggestions to improve staff retention

• Ward/Unit staff survey to be used in those areas where retention is low to determine what is affecting staff and their morale


Group Actions • Joint staff survey action • Recruitment and retention plan for registered nurses • Consultant engagement activities • Develop career pathway outlines for clinical staff • Development of core improvement skills/resilience training for all staff

Workforce KPIs – Training

Performance



Training Statutory and Mandatory Training 85.0% 82.16% 84.67% 85.0% 88.63% 86.99% 85.0% 77.24% 81.50% 85.0% 83.20% 84.79%

Issues

SUHFT MEHT BTUH

Statutory and mandatory training has increased from 82.93% in August 2017 to 84.67% in September 2017

Overall compliance for end of September was 86.99%, an decrease of 0.9% on August (87.9%); 1.6% lower that the same month last year.

• Mandatory training compliance decreased slightly from 82.8% in August 2017 to 81.5% September 2017.

Actions & Mitigation

• Performance impacted by the holiday period, Doctor rotation, introduction of refresher training for safeguarding level 1 and inclusion of CPR Paediatric .

• Analysis of teams and departments compliance highlighted to Directorates for action

• HR working with Directorates on outstanding new junior doctors

• Trial in place for bank staff to raise completion rates

• Focus on increasing safeguarding compliance across the Trust

• Targeted focus continues, and each element has as many modes of delivery as possible to support ease of access.

• Via supervisor self-service in ESR managers are able to access staffs compliance at a time convenient to them

• HR BPs continue to work with Divisions and teams to address areas of low compliance.

• Cleaning and Ward Catering Service are releasing staff during working hours to complete training.

• Hot spot areas continue to offer protected time for staff training in the form of study days to enable staff to get their training done.


Group Actions • Plans to implement same learning platforms

Workforce KPIs – Appraisals

Performance SUHFT MEHT BTUH Mid & South

Essex


Appraisals 90.0% 70.29% 76.57% 90.0% 70.63% 72.51% 90.0% 92.52% 91.00% 90.0% 79.28% 81.03%

Issues

SUHFT MEHT BTUH

The Appraisal compliance rate was 76.57% in September 2017

• The overall appraisal rate increased by 1.95% in September to 72.51% from 70.63% in August.

• The appraisal compliance rate decreased from 92.04% in August 2017 to 91% in September 2017.


• An updated improvement plan with monthly targets is in place to reach the agreed target of 90% by the end of the financial year – the Trust is only 0.4% behind the trajectory of 77% for September

• HRBP’s continue to work with Directorates to improve compliance, with further focus in hot spot areas.

• Focus is also on ensuring outstanding appraisals of 18 months + are cleared by the end of 2017 – with central monitoring and tracking.

• Performance is being reviewed at Directorate Board and SLT Directorate performance review meetings.

• Appraisal data is being reviewed to ensure it is accurate and up to date.

• Appraisal compliance is now incorporated into the monthly mandatory training report at both directorate and department level

• Via ESR managers are able to pull their own reports at a time convenient to them

• On going support to utilise the supervisor self-service functionality in regards to uploading appraisal dates continues with drop in sessions, small group sessions and bespoke 1:1’s

• Improvement plan agreed by JWB update to be presented in March 2018

• Appraisal rates are monitored continually in divisional performance reviews and smaller departmental meetings.

• The appraisal paperwork and process has been revamped to improve the appraisal process in line with the Trust values and the need to show compliance with mandatory training.


Group Actions • Share best practice to increase compliance in Southend and Mid Essex

Workforce KPIs – Sickness Absence

Performance


KPI Aug-16 Aug-17 KPI Aug-16 Aug-17 KPI Aug-16 Aug-17 KPI Aug-16 Aug-17

Sickness Absence

Sickness Absence (1 month) 3.5% 4.22% 3.35% 3.5% 3.54% 4.14% 3.5% 4.31% 3.44% 3.5% 4.02% 3.65%

Sickness Absence (12 months) 3.5 % 4.11% 3.80% 3.5 % 3.94% 4.04% 3.5 % 3.93% 3.91% 3.5 % 3.99% 3.92%

Issues

SUHFT MEHT BTUH

Sickness Absence In August was 3.80% YTD. This is a reduction on last years August 2016 figure of 4.11%.

August’s Sickness figure of 4.14% is 0.14% Lower than July’s figure of 4.28%. The 12 month figure is relatively stable at 4.04%.

The sickness absence rate has decreased slightly from 3.46% to 3.44% in August.


• HR are working closely on targeted interventions to continue to tackle short term and long term sickness to reach the Trust target of 3.5%

• Health and wellbeing is promoted in the Trust complimented by the recent launch of ‘Your healthy safe’ campaign and the review of the health and Wellbeing strategy.

• The Flu Jab campaign has commenced • Stress management workshops, resilience sessions and

on-line tools are promoted and available to support managers and staff.

• Sickness is proactively managed by HR Operations team with senior managers.

• Trigger reports are analysed and actioned. • Hotspots targeted by managers and action plans are

developed in consultation with leads. • These plans are logged and progressed.HR Managers

advise and support.

we continue to manage sickness absence by : • Identifying hot spot areas and related causes to better

tackle absence issues in divisions. • Monthly case reviews with managers, HRBPs and

Occupational Health to address high profile cases in the first instance

• Ongoing training on managing sickness

Notes: Sickness data for MEHT and BTUH are reported a month in arrears therefore data above is at August 2016 and August 2017 respectively.


Finance and use of Resources James O’Sullivan

(CQC – Use of Resources) September 2017



Finance and Use of Resources

2017/2018 Financial Summary Year-to-date

Revised Plan Actual Variance Fav/(Adv)

Plan Actual Variance Fav/(Adv)


£m £m £m £m £m £m £m £m £m

Income 158.3 157.8 (0.5) 155.2 152.8 (2.4) 150.6 150.6 -Pay (109.2) (110.1) (0.9) (106.6) (107.5) (0.9) (97.2) (95.8) 1.4 Non Pay (55.7) (55.4) 0.3 (52.9) (54.9) (2.0) (54.3) (55.7) (1.4)Financing Costs (7.2) (7.3) (0.1) (13.8) (13.8) - (7.9) (7.4) 0.5 Surplus / (Deficit) (exc. STF) (13.8) (15.0) (1.2) (18.1) (23.4) (5.3) (8.7) (8.2) 0.5

S&T Funding - - - 3.2 1.2 (2.0) 3.1 3.1 -Surplus / (Deficit) (Control Total) (13.8) (15.0) (1.2) (14.9) (22.2) (7.3) (5.6) (5.1) 0.5

DescriptionBTUH MEHT SUHFT

M04 Commentary M06 Commentary

• The Trust deficit is £5.1m for the period to 30 September 2017. This is favourable to plan by £0.5m, but this variance relates entirely to charitable asset donations, and does not impact the control total.

• The deficit includes £3.1m STF income, which is provisionally included.

• Income is on plan overall, with clinical income (excl pass-through) being ahead of plan by £0.9m, due to inpatient activity being high.

• Pay budgets are underspent by £1.4m YTD, but there was no variance on pay in month 6. Agency expenditure continues to exceed the NHSI ceiling.

• Non-Pay budgets are over spent by £1.4m, of which the majority relates to clinical supplies.

M06 Commentary

• The Trust deficit is £22.2m for theperiod to 30 September 2017. Thisis £7.3m adverse to plan.

• This deficit includes £2.0m STFshortfall for Q1 and Q2.

• Income improved slightly in monthand is now adverse to plan by£2.4m. The trust is now 3 monthspost implementation of Lorenzoand continues to scrutinise anymovements in reported activity.

• Pay has again moved adverselybeing over plan by £0.9m YTDbefore planned CIPs. Agencyremains above cap driven bymedical agency and additionalsessions.

• Non-pay is also behind plan largelyrelated to the non delivery of CIPs.

M06 Commentary

• The Trust deficit is £15.0m for theperiod to 30 September 2017. Thisis adverse to revised plan by£1.2m.

• Income is behind plan by £0.5m.This is mainly due to Critical Careand pass-through drugs.

• Pay variance is £0.9m adverse; thisis primarily due to additionalJunior Doctor posts not previouslybackfilled. Also, increased nursingbank employment. Agencyexpenditure is in line the NHSICeiling.

• Non-pay is favourable to therevised plan by 0.3m mainly drivenby an underspend on pass-throughdrugs.

• STF within the revised plan hasbeen phased to be paid in March.


2017/18 Financial Summary Forecast

Revised Plan Actual Variance Fav/(Adv)



£m £m £m £m £m £m £m £m £m

Income 321.1 322.2 1.2 310.4 310.5 0.1 301.7 303.2 1.5 Pay (218.0) (219.7) (1.7) (208.5) (212.0) (3.5) (199.8) (196.5) 3.2 Non Pay (111.9) (111.4) 0.5 (108.1) (104.8) 3.3 (109.3) (113.9) (4.6)EBITDA (8.9) (8.8) - (6.2) (6.3) (0.1) (7.4) (7.3) 0.1

Financing Costs (14.4) (14.5) - (27.4) (27.3) 0.1 (15.8) (15.2) 0.5 Surplus / (Deficit) (exc. STF) (23.3) (23.3) - (33.6) (33.6) - (23.1) (22.6) 0.6

S&T Funding 10.7 10.7 - 9.1 8.3 (0.8) 8.1 8.1 -Surplus / (Deficit) (Control Total) (12.6) (12.6) - (24.5) (25.3) (0.8) (15.1) (14.5) 0.6


. Forecast Commentary

• The Trust is forecasting to meet its control total overall.

• Charitable income for fixed assets is expected to over-achieve, creating a bottom line favourable variance, but this is removed by NHSI in the adjusted control total.

• The forecast includes a plan to achieve the RTT targets which has increased both the income and non-pay.

Forecast Commentary

The Trusts continues to forecastdelivery of the financial Control Totaldespite being significantly adverse toplan at M6. There is a growing risk ofnot delivery should the significantmanagement actions required notdeliver. The Trust has failed to meetthe Q1/Q2 A&E trajectory hence the£0.8m adverse on S&T Funding.

The 3 key risks to delivery remain:-• non-delivery of CIPs to planned

levels.• failing to achieve planned clinical

income as the trust is on cost andvolume contracts and followingimplementation of the EPRLorenzo system. Some signs ofrecovery in M6 but with increasingchallenges from the main CCG(>£5m).

• the consequence of the continuingoperational challenges, primarilypatient flow, DTOCs and discharge

Forecast Commentary

• The Trust is reporting to recover the current financial performance and achieve the Control Total.

• Income favourable variance reflects the level of efficiency and productivity improvements to be delivered by year end in recovering the RTT position.

• Pay is forecast to overspend due to RTT Waiting list Initiative payments pressure, junior Doctor pay and the increased use of bank nursing to reduce reliance on agency use.

• More stringent measures ondiscretionary non-pay, including alower level of spend on clinicalsupplies, is forecast to partlyoffset the adverse pay position.


2017/2018 Agency Ceiling Performance Year-to-Date

Ceiling Actual Variance Fav/(Adv)

Annual Plan


Annual Plan


Annual Plan

£m £m £m £m £m £m £m £m £m £m £m £m

Agency £m 5.8 5.9 (0.1) 12.0 8.8 9.9 (1.1) 17.5 5.9 8.6 (2.7) 11.4 Agency % of Pay -8.3% -8.1% -0.2% -5.6% -9.9% -11.1% 1.2% -8.4% -6.1% -9.0% 2.9% -5.7%


The Trust has breached its Agency ceiling target by £2.7m.

Vacancies: Medical 111, Nursing 179

Expenditure in September remained at the high level seen in August, although there was a decrease in Medical agency and an increase in agency nursing. Despite this high agency cost, the pay budget is not being exceeded overall.

At M6 the Trust has breached its agencyceiling by £1.1m.

Agency staff costs continue to rise withMedical agency driving this increase. Thisis despite Internal authorisation andcontrols having been audited andenhanced and combined with ongoingweekly reporting.

Vacancy levels in medical and nursingcontinue remain high in the face oftargeted recruitment actions. Bank ratesin specialist areas remain under reviewbut as yet unchanged.

The Trust is marginally above the AgencyCeiling.

The Trust has significantly reduced itsagency expenditure in the YTD due toIR35 and management action.

The agency expenditure run-ratecontinued to reduce from 2016/17 levelsin Month 6.

2017/2018 Cost Improvement Programme Year-to-Date



Annual Plan


Annual Plan


Annual Plan

£m £m £m £m £m £m £m £m £m £m £m £m

Recurring 5.4 3.9 (1.5) 10.8 9.6 2.6 (7.0) 16.5 3.4 3.2 (0.2) 6.8 Non Recurring 2.2 1.0 (1.2) 5.5 2.8 2.8 - 1.2 1.2 0.0 2.0 Total CIPS 7.6 4.8 (2.8) 16.3 9.6 5.4 (4.2) 16.5 4.5 4.4 (0.2) 8.8

Description

BTUH MEHT SUHFT

The Trust was behind plan at Month 6 by £0.2m.

The main cause of the shortfall is agency medical staff schemes.

The Trust CIPS plans continue to slip andmove further behind plan. At Septemberthe Trust is £4.2m adverse YTD.

The PMO team has been strengthenedfrom mid August and a Director ofFinancial Improvement has beenappointed mid Oct with externalconsultancy with Foureyes and Strasysongoing.

In addition to the schemes in delivery to31 August 2017, a further £1.1m hasbeen approved by Quality AssuranceGroup (QAG) in September. Also, anadditional £1.3m of schemes have beencompleted since last month, with afurther £3.9m of identified schemes atdifferent stages of the maturityframework prior to QAG sign off.

2017/2018 Capital Expenditure Year-to-Date



Annual Plan


Annual Plan


Annual Plan

£m £m £m £m £m £m £m £m £m £m £m £m

Strategic Schemes 0.8 0.9 (0.1) 9.9 3.1 2.2 0.9 4.2 2.6 1.7 0.9 8.3 Estates 0.9 0.8 0.2 2.7 2.8 1.1 1.7 4.2 1.3 1.0 0.2 3.0 Equipment 0.2 0.1 0.1 3.9 1.0 0.7 0.3 2.6 0.2 0.1 0.1 0.9 IT 2.2 1.5 0.8 1.9 0.2 0.1 0.1 0.7 0.0 0.1 (0.0) 1.1 Contingency/(Planned Slippage) - - - - 0.4 0.5 (0.1) 1.2 Total 4.2 3.3 0.9 18.4 7.2 4.2 3.1 11.8 4.5 3.5 1.0 14.4

Description

BTUH MEHT SUHFT

• Capital is slightly behind plan due to slippages on the MRI Replacement and PACS schemes.

• £1m is now included for GP streaming which is centrally funded via PDC .

• Teletracking and an increase in contingency are funded from the 16/17 STF bonus cash receipt.

• Capital continues to be underspentlargely on estates due to reprofiledmaintenance works and slippage ontwo strategic schemes.

• YTD plan is as per budget followingreview of plan phasing and theaddition of £1m GP streaming fordelivery by November.

• Slippage on all categories with theexception of the strategic schemes.(Radiology scheme spend is ahead ofbudget).

• Non Strategic capital is expected toachieve plan by year end.

2017/2018 Cash and Borrowing Year-to-Date



Annual Plan


Annual Plan


Annual Plan

£m £m £m £m £m £m £m £m £m £m £m £m

Cash Balance 6.0 14.9 8.9 6.0 1.0 4.0 3.0 1.0 1.5 2.7 1.2 1.5

Loans 4.9 - 4.9 8.0 - - - - - - - - Working Capital Facil ity (WCF) 11.5 - 11.5 19.7 - - - - - - - - Uncommitted Revenue Support Loan - - - - 14.9 13.5 1.4 24.5 7.6 3.7 3.9 15.3

Description

BTUH MEHT SUHFT

• Cash is above plan following the receipt of Q1 STF money in September.

• Planned loan drawdown is evenly phased.

• No loan draw down was required in September.

• Cash is ahead of plan by £3.0m due toreceipt of STF at month end.

• The cash plan until year end, as perloan requirements, is £1.0m at eachmonth end.

• Loans are slightly behind plan withSTF funds earned and paidcontinuing to impact loan drawdowns in 2017-18.

• Cash is ahead of plan by £8.9m.• The plan assumed the commissioners

would be paying in 12ths, howeverincome is currently being received in10ths. The cash gain on this is£19.8m. As a result, the planned useof WCF has not been required.


2017/2018 Use of Resources Metric Year-to-Date

1 2 3 4 Weighting BTUH MEHT SUHFT

Capital Service Capacity >2.5x 1.75-2.5x 1.25-1.75x <1.25x 20% 4 4 4 Liquidity (days) >0 (7)-0 (14)-(7) <(14) 20% 4 4 4

Financial Efficiency I&E Margin >1% 1-0% 0-(1)% <=(1)% 20% 4 4 4

Distance from Financial Plan >=0% (1)-0% (2)-(1)% <=(2)% 20% 4 4 1 Agency expenditure <=0% 0%-25% 25%-50% >=50% 20% 2 2 3

Overall Use of Resources 4 4 3

Scoring a '4' on any metric will mean that the overall rating is at least 3.

Scoring either 3 or 4 triggers a concern with NHSI.

All provider’s financial performance is now formally assessed via the UOR metric and this reflects NHS Improvement’s view of the financial risk that a provider faces to the on-going delivery of key NHS services and its overall financial efficiency

Area MetricScore Year to date

Financial Sustainabil ity

Financial Controls

Use of Resources note:

• BTUH is 4.

• MEHT is 4.

• SUHFT is 3.

Appendices: 1. Maternity Dashboard 2017/18



Quality of Care

Maternity Dashboard 2017/18

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