REPORT 1.14.005 (3)€¦ · The report contains information on patient experience. ... 19 19 21 23 23 24 SECTION 3 Operational Performance Summary Scorecards Elective Access Emergency

Royal Cornwall Hospitals NHS Trust – Integrated Performance Report

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REPORT 1.14.005 (3)

TRUST BOARD 30 January 2014

Subject Integrated Performance Report

Prepared by Jo Davis, Associate Director Commissioning and Performance Richard Johnson, Head of Quality and Safety Compliance Graeme Booth, Financial Planning Manager Garth Weaver, Acting Director of Estates Ruth Bardell, Head of Learning and Development

Approved by Chief Executive

Presented by Chief Executive and Executive Management Team

Purpose

The objective of this report is to set out the Trust’s performance against key national and local targets and draw attention to key areas under review by the Executive Team. The areas of focus in the report are linked to the strategic objectives.

It includes performance against key national and local quality, operational, finance and workforce targets and also, a quarterly review of progress against our key priorities.

To Receive

To Approve

Trust Objectives

Quality Preferred Provider

Partnership Workforce Sustainability Finance

Executive Summary

The Trust continues to have unconditional registration and maintain DH performing status.

The ratings against our key strategic plans are shown by red, amber and green (RAG). Overall the predominant colour continues to be amber. Positive progress is evident with regards to Our People Strategy, Any Qualified Provider (AQP) response, research, and capital investment

The issues of most concern in the short and longer term, pertain to operational performance, productivity levels, elective market share and non-elective activity. It is critical that benefits are realised from recent revenue and capital investments, which should ease capacity issues and allow more productive use of elective theatres.

In terms of our overall Performance position, this is best reflected in the FT overall assessment of amber – this reflects financial performance being on track, (albeit with risks), but countered by red status for ED (4 hour target) and Clostridium Difficile. Furthermore, a reduction in our productivity, combined with increased demand in a number of areas, is generating performance challenges with regard to delivery of the RTT target. Quality indicators are good overall but the increasing number of complaints is of concern. Efforts will also continue to improve the uptake of the Friends and Family Test, and the completion of

Royal Cornwall Hospitals NHS Trust – Integrated Performance Report – Page of 60 2

Dementia screening.

In the last Quarter it is essential that good performance is attained to provide a good starting point for 2014 and to underpin the FT application when it re-starts.

Key Recommendations

The Board are asked to receive, discuss and give guidance.

Assurance Framework

The report provides information on performance on key areas relevant to meeting the Trust’s objectives. It therefore complements the Assurance Framework.

Next Steps

The Trust Board will continue to be updated on Trust performance via the monthly Integrated Performance Report.

Corporate Impact Assessment

CQC Regulations Covered in the Quality section.

Financial Implications Covered in the Finance section.

Legal Implications None.

Equality & Diversity Some of the performance indicators relate to equality and diversity. The report contains information on patient experience.

Performance Management The report is a key element of the Trust's performance management reporting system as described in the Performance Management Strategy.

Communication None.

Acronyms / Terms used in Report

CQC Care Quality Commission

MRSA Methicillin Resistant Staphylococcus Aureus

RTT Referral to Treatment

CIP Cost Improvement Programme

SWAST South Western Ambulance Services NHS Foundation Trust

NHS CIOS NHS Cornwall and Isles of Scilly (former PCT, responsible for commissioning many of Trust’s services up to 31 March 2013)

NHS Kernow NHS Kernow (new Clinical Commissioning Group with responsibility for commissioning many of Trust’s services from 1 April 2013)

NHS TDA NHS Trust Development Authority (responsible for oversight of non-Foundation NHS Trusts)

VTE Venous Thromboembolism


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Royal Cornwall Hospitals NHS Trust

INTEGRATED PERFORMANCE REPORT Page No.

TABLE OF CONTENTS

SECTION 1 Executive Summary

Summary Scorecard

6

10

SECTION 2 Quality & Patient Safety

Summary

Quality & Safety scorecard

CQC Essential Standards and Outcomes

External Review and Assurance

Healthcare Associated Infections

Incidents, Trends and Themes

QUESST

Safety Thermometer

Safety Alerts and NICE Guidance

Research, Development and Innovation

Complaints and Compliments

Delivering Same Sex Accommodation

Friends and Family Test

CQUINs

13

14

15

15

15

17

18

18

19

19

21

23

23

24

SECTION 3 Operational Performance

Summary

Scorecards

Elective Access

Emergency Access

Clinical Pathways

Productivity and Flow

Contract and Commissioning

Monitor Compliance

25

26

28

32

35

38

40

41

SECTION 4 Finance Report

Summary

Key Financial Indicator

44

45

Royal Cornwall Hospitals NHS Trust – Integrated Performance Report – Page of 60 5

Income & Expenditure

Cost Improvement Programme

Balance Sheet

Capital Programme

Financial Risks and Mitigations

Recommendations

46

49

50

51

52

52

SECTION 5 Human Resources

Summary

Staffing

Sickness Absence

Learning and Development

Staff Engagement and Membership

53

53

54

56

56

SECTION 6 Clinical Site Development Plan

Progress

Assurance

59

60


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EXECUTIVE SUMMARY The Trust retains unconditional CQC registration, which means that overall its services are considered of a good standard. 1.2.1 Quality and Safety

The Royal Cornwall Hospitals NHS Trust’s registration status with the Care Quality Commission (CQC) remains unconditional.

The final reports following the CQC inspections of Penrice and West Cornwall Hospital in November 2013 have been received. The reports state that the RCHT met all the outcomes inspected.

There were 0 cases of MRSA bacteraemia during the month of December 2013. At the time of writing 177 days have elapsed since the last case.

There were 4 reported cases of C.difficile for December 2013. This brings the total number reported to 38.

The number of incidents reported across the Trust in December 2013 (950) fell when compared to November 2013 (969) but remains above the number reported in December 2012 (898).

In December, 1 clinical area triggered an early warning score using the Quality, Effectiveness and Safety Trigger Tool (QuESTT).

The NHS Safety Thermometer data showed that in December 92.2% harm free care was achieved, compared with 93.5% in November and a national average of 93.5%.

There were no breached safety alerts in December 2013.

The Trust has 1 NICE Technology Appraisal (TA) where the position was unknown: TA301 (Nov 13) Diabetic macular oedema - fluocinolone acetonide intravitreal implant

The number of complaints received during December 2013 (40) decreased compared to November 2013 (44) but increased when compared to December 2012 (32). The complaints have primarily focused on patients being unhappy with the outcome of their care as well as waiting times being too long

There were no non-clinically justified mixed sex accommodation breaches were reported in December 2013.

The Trust’s Friends & Family Test (F&FT) score for inpatients and ED in December was 64 (range: -100 to 100) based on a response rate of 20%.

The Trust’s Friends & Family Test (F&FT) scores for maternity in December were: o Antenatal care: F&FT Score = 64, response rate: 9% o Birth care: F&FT Score = 69, response rate: 18.6% o Postnatal Ward care: F&FT Score = 64, response rate: 20.5% o Postnatal Community care: F&FT Score = 72, response rate: 10%

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A steady increase in patient recruitment to research studies and a reduction in the time taken to approve new projects make RCHT an attractive place to conduct commercial research.

1.2.2 Operational Performance

The Trust is projecting ‘concerns identified’, the equivalent of ‘amber’, on the Monitor Risk Assessment Framework for Q4.

As in each month this year 4 of the 5 national waiting times targets were achieved in December, with each of the admitted, non-admitted, incomplete and diagnostic waiting times targets achieved but not in every specialty. The position continued to worsen linked to increased cancellations and referral growth, meaning overall RTT admitted performance is at risk. Plans continue to address this through increased activity in key specialties.

The national 95% ED target was failed in month at 91.2%, and for Q3 at 91.3%; predominantly, this was because of medical patient flow. There were also 3 12 hour breaches from the decision to admit, which occurred when flooding caused key IT systems to fail, making it more challenging to track patients through the department.

December 2013 saw the highest in-month levels of non-elective activity since 2011/12 (counting like for like it was 279 spells above December 2012). Total non-elective activity for the year is now 1% above 2012/13 levels, with 2 of the last 3 months following a similar pattern. As well as the higher length of stay seen generally in 2013/14 compared with 2012/13 and 2011/12, this continues to contribute to a challenging overall patient flow position.

The number of operations cancelled on the day by the Trust was the lowest since August 2012, although 6 patients were not able to be rebooked within 28 days.

Delayed transfers of care were 2.3% in month, below the national maximum standard of 3.5%, equating to an average of 17 patients per day.

78% of stroke patients spent 90% of their time on the stroke unit in month (73% YTD), slightly below the 80% local target.

85% of patients with a fractured neck of femur had their operations within 36 hours in month (75% for the year to date – the national upper quartile and local target is 75%). All patients’ assessment met best practice orthogeriatric criteria (94% year to date, again just below the local target of 95%). Both local targets are expected to be met for the year.

All but one of the cancer waiting times targets were met for November, with 84.8% of patients having pathways of less than 62 days from referral to treatment (against a national standard of 85%). Although some risk remains, it is expected that all targets will be met for Q3.

1.2.3 Financial Performance

The Trust delivered a surplus of £2.5m at the end of December which is just over its planned surplus for the year to date.


Expenditure on variable pay increased by £200k when compared to November and remains high even though the number of permanent staff increased by 54 in month. Total pay expenditure increased by c£440k in December. A key priority for divisions is to ensure that staffing levels are maintained but that this is achieved in a cost efficient way.

The forecast outturn of the Trust remains at £3.9m for the 2013-14 financial year. However, due to an increase in the divisional over spends caused primarily by under delivery on core CIP schemes, delivering this surplus is becoming more challenging and will require a sustained focus on maximizing savings and replacing schemes that have not delivered as expected.

Whilst overall the total CIP target of just under £14m is forecast to be delivered by the end of the year, 9.7m (70%) is forecast to be achieved from original CIP schemes with the remainder being achieved through the release of centrally managed resources and income schemes. The delivery of recurrent savings through planned schemes is vital to ensuring ongoing financial stability, especially in an environment when funding to acute providers may reduce in the near future.

Both income and activity at the Trust remains ahead of plan which includes the internal planning increase. The Trust fully expects to exceed the contract cap of £6m, with total income of £8.8m forecast against the NHS Kernow contract. Both non-elective and outpatient income is higher than budgeted for.

The Trust ended December with a cash balance of £8.9m which is below the cash plan of £13.4m. This variance is due to the profile of capital cash spend and the timing delays between delivering higher income levels and receiving the corresponding cash. The year-end cash forecast remains at £12.6m, depending on the timing of the receipt of cash from commissioners relating to higher income levels. Payment of non-NHS invoices at 96% is above per the Government target level.

The capital programme is fully allocated for this financial year and there is continued pressure to fund additional capital investment in 2013-14. The Trust applied for and received approval for a £5m loan of which £1.5m will be spent this year which will help to address in-year pressures and accelerate high impact investments.

1.2.4 Human Resources

The total WTE staffing level for the month was 4985, an increase of 54 in-month.

Sickness absence increased to 4.36% in November (up 0.13%) and was 0.61% above the target of 3.75%. It remained below the 12 month rolling average and the corresponding month in the 2 previous years.

Mandatory training coverage increased slightly to 74.8% in month, whilst appraisal performance reduced marginally at 66.2%. The targets for both remain 80% and work continues to deliver this for both. As explained in previous IPRs, the reduction in reported mandatory training compliance in-year is down to a change in the way this is recorded and calculated.

The Trust has received preliminary results from the national Staff Survey and a full report will be brought to the February public Board meeting.


1.2.5 Clinical Site Development Plan

The final phase of the Trelawny Surgical Floor, incorporating both the St. Mawes Unit and Pendennis Ward was completed on the 6th December and has been operational since mid-December.

The relocation of the surgical wards from the Tower block to Trelawny wing was a key enabler to the Trust’s winter contingency plans enabling a medical ward, the new Frailty Assessment Unit, to be opened on the 27th December in the former Poldark ward in the Tower Block.

The new Emergency Department on the RCH site opened near the end of the month, giving significantly increased majors capacity (up to 22 trolley spaces) and a significantly improved environment in terms of patient experience.

The laparoscopic theatre installation programme has now been completed. The next phase is the upgrade of theatre reception areas throughout January and the relocation of the ophthalmology microscope from the Newlyn Unit to Theatre 3 in Tower in spring 2014.

Site-wide works being undertaken under the Department of Health grant allocation to improve the environment of care for people with dementia are progressing well.

The Carbon and Energy Project is progressing with Cofely Workplace (formerly Balfour Beatty Workplace) appointed as preferred bidder. The project is anticipated to reach final closure in spring 2014.


SUMMARY SCORECARD

Navigating the IPR This section explains the links between the different scorecards in the IPR. The summary scorecard sets out performance on the most important performance indicators for RCHT against each of its strategic objectives. The summary scorecard includes only the most critical measures. It is supported by more detailed scorecards in each section with supported analysis and narrative where required which provide the next level of information. The ‘ref’ column on the right hand side of the summary scorecard gives the section of the IPR where further detail can be found. Cancer is presented in the summary scorecard as a composite measure because of the number of different relevant targets. Detail against individual cancer targets can be found in the Operational Performance 1 (Pathways) Scorecard at the start of Section 3. The Monitor Compliance Framework was replaced by Monitor’s Risk Assessment Framework on October 1 2013 and the Trust has updated its self-assessment processes accordingly. Further detail can be found in section 3.7. The IPR will as usual be reviewed to take account of internal, national and local changes to the key measures against which the Trust assesses itself for the start of the 2014/15 financial year. The new scorecards will be published in draft form in the April IPR, with the May IPR seeing month 1 of reporting against revised scorecards. This month, the summaries at the start of sections 2-5 have been removed to reduce the length of the report to avoid duplication, with the Executive Summary being slightly expanded to take account of the key points.


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Summary Scorecard

Category Performance Indicator Target 2013/14 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Trend YTD YE Proj REF

1 To focus relentlessly on quality of patient care and patient safety

In hospital mortality for all

diagnoses - HSMR<=100

99.22 - 12/13

avge (Apr-

Mar)

111.27 99.74 107.47 108.02 110.38 108.87 81.93 In arrearsIn

arrears104.06


diagnoses -SHMI1.05 1.05 1.05 In arrears In arrears In arrears In arrears In arrears

In

arrears1.05

New never events declared in

month0 2 1 0 0 0 0 0 1 0 0 2 2.5

New Sis declared in month 48 54 6 6 1 3 3 11 4 5 8 47 2.5

MRSA bacteraemia 0 (FY13/14) 0 0 0 0 1 0 0 0 0 0 1 2.4

C Difficile (post 72 hours) 20 (FY13/14) 26 5 5 2 5 4 4 4 5 4 38 2.4

Emergency

Access

ED attenders 4 hours arrival to

disposal95% 93.43% 88.53% 92.48% 89.76% 95.29% 94.67% 90.01% 89.65% 93.39% 91.17% 91.81% 3.3.1

CancerCancer waits against targets -

compositeAll Achieved

All achieved

(quarterly)

In

arrears3.4.1

Stroke

Percentage of patients who have

spent more than 90% of their time

in a stroke unit

80% 77.64% 66.13% 71.21% 83.61% 69.64% 73.77% 63.46% 75.00% 74.42% 77.97% 72.90% 3.4.2

VTE - % of eligible patients risk

assessed95% 97.02% 97.29% 97.58% 97.12% 97.22% 96.84% 95.09% 95.27% 95.03% 95.06% 96.27% 2.13

% of fractured neck of femur

patients having an operation

within 36 hours

75% 74.09% 85.42% 80.00% 75.00% 63.27% 57.50% 87.88% 67.24% 77.27% 85.37% 75.06% 3.4.3

NHS TDA Performance rating

(replacing DH Performance

Framework)

Performing Performing 3 3 3 3not

available

not

available

not

available

not

available

not

available3 3.7

Monitor Compliance Rating

(Q1/2), Risk Assessment

Framework concerns identified

(Q3/4) (most likely case)

Green Amber-green 3.7

RD&I Recruitment

100% expressed

as 1600 new

patients

recruited

79.00% 90.00% 88.00% 96.00% 97.00% 97.00% 102.00% 97.00% 93.00% 93.22% 2.9

2 To remain the preferred provider of acute and specialist healthcare to the people of CIOS

How likely are you to recommend

our ward to Friends & Family if

they needed similar care or

treatment

50 n/a 74 72 76 74 70 69 70 69 64 71 2.12

How likely are you to recommend

our A&E Department to Friends &

Family if they needed similar care

or treatment

50 n/a 62 0 27 19 59 70 65 58 50 46 2.12

Mixed sex accommodation

breachesZero breaches 10 0 0 0 0 0 0 0 6 0 6 2.11

RTT admitted - 90% in 18 weeks 90.00% 94.51% 91.34% 92.64% 92.24% 93.11% 94.09% 92.26% 92.19% 92.78% 92.13% 92.54% 3.2.1

RTT non admitted - 95% in 18

weeks95.00% 98.66% 98.90% 98.28% 96.22% 98.66% 97.81% 98.10% 98.20% 98.57% 97.67% 98.58% 3.2.1

RTT incomplete - 92% in 18 weeks 92.00% 96.60% 94.68% 95.21% 95.62% 95.56% 95.98% 96.07% 95.93% 95.24% 95.05% 95.48% 3.2.1

RTT delivery in all specialties 0 2 10 10 7 4 4 9 10 7 11 11 3.2.1

Proportion of patients receiving

one of the 15 Key Diagnostic Tests

within 6 weeks

99.00% 99.48% 99.40% 99.47% 99.49% 99.75% 99.31% 99.45% 99.78% 99.72% 99.86% 99.60% 3.2.1

LOS over 10 days24.57% (avg

11/12 & 12/13)26.22% 29.02% 26.20% 24.96% 24.12% 26.05% 26.52% 25.91% 25.68% 26.65% 26.12% 3.5.1

Day case rates81.03% (avg

11/12 & 12/13)81.67% 82.24% 81.68% 81.57% 82.87% 83.73% 82.11% 82.88% 81.33% 82.84% 82.38%

Average LOS (days) 2.8 3.1 3.3 3.2 3.1 3.0 3.0 3.2 3.2 3.2 3.1 3.1 3.5.1

22Red

Safety

Healthcare

associated

infections

Quality

Exception

reporting

Overall

external

ratingsRed

Patient

Experience

Productivity

and patient

flow

Access and

waiting times


3 To work as a constructive partner in the community, promoting the integration of health and social care

Delayed

transfers of

care

Delayed transfers of care (days lost

%)< 3.5% 3.60% 4.88% 2.99% 1.79% 3.80% 4.72% 4.52% 3.60% 3.63% 2.31% 3.60% 3.5.1

Category Performance Indicator Target 2012/13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Trend YTD YE Proj REF

4 To value and improve the working lives of our staff, promoting education, training and research

Progress vs

Workforce

Plan

Total Staffing WTE 4770 4684 4883 4856 4829 4878 4900 4913 4992 4931 4985 4907 5.1.1

Sickness

Absence

% of contracted staff WTE lost to

sickness3.75% 4.56% 4.17% 4.03% 4.23% 4.17% 3.88% 4.01% 4.23% 4.36% in arrears 4.14% 5.1.3

Turnover % of contracted staff WTE turnover 10%-14% 11.0% 10.9% 11.0% 11.1% 9.2% 10.7% 10.4% 10.4% 10.2% 10.5% 10.5%

Mandatory

Training

Proportion of staff completed

mandatory training in last 12

months

80% 80.2% 82.8% 84.8% 84.8% 82.7% 83.0% 82.3% 73.0% 74.5% 74.8% 80.3% 5.2

AppraisalProportion of staff appraised in last

12 months80% 70.0% 71.8% 72.4% 70.9% 70.1% 70.1% 69.8% 68.8% 66.5% 66.2% 69.6% 5.1.4

5 To work towards a sustainable, low carbon future

% electricity reduction 2% reduction 4.69% -29.94% -12.20% -6.94% -27.86% 1.75% 5.58% -2.75% 1.59% in arrears -1.82%

% gas reduction 2% reduction -6.09% -17.83% -15.40% -0.56% 42.10% 1.68% -11.42% 6.75% 15.25% in arrears 20.39%

% water reduction 2% reduction -7.29% -3.25% -0.29% 6.32% 2.07% -3.36% 9.00% -4.47% -13.59% in arrears -2.41%

6 To ensure the Trust operates in a financially sustainable way by delivering financial targets, including surpluses sufficient to meet Foundation Trust authorisation

Income Total income position 0 476 248 144 534 918 696 614 1371 2916 3001 3001 0 4.2.3

Botton line

I&E

Cumulative distance from plan

(0.00)0 9 20 29 15 46 34 30 45 68 33 33 0 4.2

CIP Cumulative CIP (£000) 13930 16963 581 1281 1987 3162 4102 4999 6048 6930 8004 8004 13930

Cash Cash available (£000) 12633 11600 11078 9010 9809 9145 7375 5832 8774 9276 8905 8905 12633 4.2

CapitalCapital expenditure against plan

(£000) 15788 15076 164 560 2279 2965 3999 5625 6939 8521 9913 9913 15788 4

Public Sector

Payment

Policy

Performance against the prompt

payment policy 95% 94% 94% 95% 95% 95% 96% 95% 96% 96% 96% 96% 95% 4.4.4

Financial risk

ratingOverall financial risk rating 4 4 3 3 3 3 3 4 4 4 4 4 4

Energy use


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SECTION 2: QUALITY AND PATIENT SAFETY 2.1 INTRODUCTION AND QUALITY SCORECARD This section brings together performance on key quality and patient safety measures for the month ending 31 December 2013. These are summarised in the Quality Scorecard below.


Quality Scorecard

Category Performance Indicator Target 2013/14 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Trend YTD REF


diagnoses - HSMR<=100

99.22 -

12/13 avge

(Apr-Mar)

111.10 99.58 106.43 107.63 109.29 100.54 in arrears in arrears 105.76


diagnoses - SHMIin arrears in arrears in arrears in arrears in arrears in arrears in arrears in arrears

MRSA bacteraemia 0 (FY13/14) 0 0 0 0 1 0 0 0 0 0 1 2.4

C Difficile (post 72 hours) 20 (FY13/14) 26 5 5 2 5 4 4 4 5 4 38 2.4

MSSA BacteraemiaReduction on

2012/13 levels14 2 6 0 4 3 2 1 2 1 21 2.4

E coli infectionsReduction on

2012/13 levels34 3 2 0 8 11 3 2 2 2 33 2.4

How likely are you to

recommend our ward to

Friends & Family if they

needed similar care or

treatment

50 74 72 76 74 70 69 70 69 64 64 2.12

How likely are you to

recommend our A&E

Department to Friends &

Family if they needed similar

care or treatment

50 62 0 27 19 59 70 65 58 50 50 2.12

Number of complaints n/a 397 40 30 37 54 36 33 41 43 40 354 2.10

Mixed sex accommodation

breachesZero breaches 10 0 0 0 0 0 0 0 6 0 6 2.11

Percentage of women who

have seen a midwife or

maternity health care

professional by 12 weeks and 6

days of pregnancy

90% 90.79% 89.86% 88.86% 91.36% 89.79% 90.25% 88.02% 90.98% 91.42% 89.94% 90.06%

Full term babies admitted to

neonatal caren/a 8.01% 9.28% 11.29% 14.68% 13.70% 9.20% 6.92% 8.89% 10.35% 8.54% 10.36%

Percentage of women

receiving one to one care in

established labour

93% by Dec 13,

95% by Apr 1498.11% 98.01% 96.06% 98.96% 98.48% 97.21% 96.77% 97.55% 98.10% 97.68%

New Serious Incidents (SIs)

declared in month48 54 6 6 1 3 3 11 4 5 8 47 2.5

No. of open SIs exceeding

45/60 working day deadline1 2 0 1 2 1 1 0 2 8 3 18 2.5

Number of incidents per 100

admissionsn/a 5.55 7.5 7.1 6.7 5.9 6.1 6.1 5.1 4.6 6.1 2.5

Number of patient slips, trips

and falls120 123 178 137 112 119 114 107 110 85 120 2.5

% incidents of newly acquired

pressure ulcers in categories

2,3 & 4

n/a 1.61% 1.41% 0.33% 0.64% 0.64% 1.76% 1.18% 0.99% 2.04% 1.32% 1.15% 2.5

Medication errors causing

serious harm (% of the local

population)

n/a 0.0004% 0.0000% 0.0000% 0.0000% 0.0000% 0.0000% 0.0004% 0.0000% 0.0002% 0.0002% 0.0007% 2.5

Safety Thermometer- All Harms n/a 92.32% 91.37% 96.03% 94.54% 93.75% 90.22% 93.59% 92.75% 93.55% 92.24% 93.12% 2.7

Safety Thermometer- New

Harmsn/a 96.06% 95.92% 98.68% 96.79% 97.92% 96.15% 97.14% 97.36% 96.70% 97.03% 97.08% 2.7

NICE TAs compliance - where

RCHT is not compliant or the

position is not known.

0 0 0 0 0 0 0 0 1 1 1 2.6

Number of breached NPSA

safety alerts0 1 1 1 1 1 0 0 0 0 0 2.6

Number of other breached

alerts including medical

devices and estates alerts

0 0 0 0 0 0 0 0 0 0 0 2.6

VTE - % of eligible patients risk

assessed95% 97.02% 97.29% 97.58% 97.12% 97.22% 96.84% 95.09% 95.27% 95.03% 95.06% 96.27% 2.13

Incidence of health care

related VTE (% of the local

population)

0.076% 0.006% 0.005% 0.006% 0.007% 0.005% 0.003% 0.007% 0.005% 0.005% 0.049%

Dementia% of eligible patients asked

case finding question90%

99.29%

(March 13)11.49% 10.03% 100.00% 100.00% 99.38% 23.06% 13.30% 16.26% 23.52% 40.56% 2.13

Smoking during pregnancy

Performance no

higher than last

yrs level

(13.85% for

12/13)

13.85% 14.59% 12.19% 14.78% 11.49% 10.86% 14.76% 12.41% 13.39% 16.77% 13.36%

Breast feeding initiation

Within 5% of last

year's RCHT

performance

80.07% 82.43% 83.58% 83.99% 85.90% 78.54% 83.97% 79.90% 82.24% 78.80% 82.21%

Commercial Activity 30 new studies 4 6 8 8 9 10 11 13 15 9 2.9

Research, Management &

Governance (RM&G)

approve studies

in 30 days100.00% 100.00% 100.00% 97.00% 100.00% 100.00% 95.00% 88.00% 100.00% 97.78% 2.9

Recruitment

100% expressed

as 1600 new

patients

recruited

79.00% 90.00% 88.00% 96.00% 97.00% 97.00% 102.00% 97.00% 93.00% 93.22% 2.9

Safety

Healthcare

associated

infections

Patient

Experience

Compliance

with National

Guidelines

Infant health

and

inequalities

VTE

Incidents

Maternity

RD&I


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2.2 COMPLIANCE WITH THE CARE QUALITY COMMISSION ESSENTIAL STANDARDS OF QUALITY AND SAFETY 2.2.1 Registration Status The Royal Cornwall Hospitals NHS Trust’s registration status with the Care Quality Commission (CQC) remains unconditional.

2.2.2 CQC compliance inspections The final reports following the CQC inspections of Penrice and West Cornwall Hospital in November have been received. The reports state that RCHT met all the outcomes inspected. Penrice

Respecting and involving people who use services

Care and welfare of people who use services

Cleanliness and infection control

Management of medicines

Assessing and monitoring the quality of service provision

Records West Cornwall Hospital

Consent to care and treatment

Care and welfare of people who use services

Management of medicines

Requirements relating to workers

Assessing and monitoring the quality of service provision

2.3 EXTERNAL REVIEWS AND ASSESSMENT 2.3.1 External reviews during December 2013 Three external visits took place during December 2013:

4 December 2013: South West Radiotherapy Physics Group (SWPRG) dosimetry audit. A report has not yet been received.

10 & 11 December 2013: Trust Development Agency review of RCHT infection prevention and control practices. A report has not yet been received.

11 December 2013: Water Hygiene Ltd Authorising Engineers water audit. The audit found increased compliance compared to previous audits. The actions required were agreed and included in the report. This audit takes place quarterly; the next one is due in March 2014.

2.4 MANDATORY REPORTING OF HEALTHCARE ASSOCIATED INFECTION 2.4.1 Methicillin Resistant Staphylococcus Aureus (MRSA) There were 0 cases of MRSA bacteraemia during the month of December 2013. At the time of writing, 177 days have elapsed since the last case.


Page 16 of 60

2.4.2 Clostridium Difficile There were 4 reported cases of C.difficile for December 2013 bringing the current total to 38 which is over our annual tolerance. Each of these 4 cases has been reviewed through the root cause analysis process. All specimens have been sent to the reference laboratory for typing but at this point in time it is not thought that any of the 4 cases are as a result of cross infection. Work continues within the Trust to strengthen antimicrobial stewardship.

2.4.3 MSSA Bacteraemia There was 1 reported case in December 2013 that was acute Trust apportioned. The total to date is 21 which is over our local tolerance of 13. Root cause analysis (RCA) has been carried out one of the cases with one RCA underway. It is thought that the infection was from a wound that was infected prior to admission.

2.4.4 E. Coli Bacteraemia


Page 17 of 60

There were 2 cases reported in December 2013 that were acute Trust apportioned. The source of one these infections has been identified as gastrointestinal and the other is unknown at this stage.

2.4.5 GRE Bacteraemia There were 0 reported cases in December 2013.

2.4.6 Mandatory Reporting/Surveillance Data

Infection Apr May June July Aug Sept Oct Nov Dec Total Year Tolerance

MRSA

0 0 0 1 0 0 0 0 0 1 0

MSSA

2 6 0 4 3 2 1 2 1 21 15

E.COLI

3 2 0 8 11 3 2 2 2 33 -

GRE

0 0 0 0 0 1 0 0 0 1 -

C.difficile

5 5 2 5 4 4 4 5 4 38 20

Outbreaks (wards affected)

0 9 8 0 0 0 0 0 0 17 -

2.4.8 Outbreaks No ward areas were closed as a result of outbreaks during December 2013.

2.5 INCIDENTS THEMES/TRENDS 2.5.1 Number of Incidents across the Trust per month, 2011 compared to 2013/14

A total number of 950 incidents were reported by the Trust during December 2013 the chart below illustrates the top five incident categories reported.


Page 18 of 60

2.6 QUALITY, EFFECTIVENESS & SAFETY TRIGGER TOOL (QuESTT) QuESTT identifies the potential for deteriorating standards in the quality of care delivered by a team in a defined area, usually a ward or clinical department. In December there was 1 clinical area that prompted an early warning score. This enables us to support, provide scrutiny and seek resolution to their concerns.

2.7 SAFETY THERMOMETER

The Safety Thermometer data collection on the 18 December 2013 was the seventh data collection date for the CQUIN year 2013/14. Safety thermometer data is presented as a “harmfree” care rating and has become an important benchmark in understanding safety in our inpatient areas.

23 22 24 25 26

8

2013

2415 16

21 18

11

25 2518

29

16

14 26

37

2328 20 29

96% 97% 96% 96% 96%99% 97% 98% 96% 97% 97% 97% 97%

94%93% 92% 93% 91%

96% 95% 94%90%

94% 93% 94% 92%

0%

20%

40%

60%

80%

100%

0

10

20

30

40

50

60

70

80

90

100

Harm Summarynew Harm old harm New Harms % Harm Free


Page 19 of 60

The data shows that in December the trust achieved 92.2% harm free care, compared with 93.5% in November. The rate of new harm free care is 97% for December compared with 96.7% for November, indicating a slight rise in “old” harms (patients admitted with existing harm) and reduction in “new” or RCHT acquired harms. A data quality assurance exercise is conducted following data collection on both the pressure ulcer and falls harms. From January 2014 this will also include VTE harms. Of the 606 inpatients assessed in December the tool highlighted that only 18 patients received a new harm, compared to 21 in November. 29 patients were admitted into our care with an old harm. The distinction between new and old harm is important as it is only the new harms that we have in our power to prevent on our wards.

National Comparison Safety Thermometer harms break down December 2013

RCHT National

Total Patients Assessed 606 186,018

% Harm (all harms) 7.8 6.5

% Pressure Ulcer (all) 5.61 4.7

%Pressure Ulcer (New) 1.32 1.1

All those NHS trusts that successfully collected safety thermometer data in 2012/13 have a locally set safety thermometer quality improvement target to achieve. This constitutes 50% of their CQUIN. The remaining 50% of the CQUIN will be payable for achievement of full data collection for the year 2013/14. The safety thermometer working group will stay in place to monitor, support and advise the existing harm groups in place with a responsibility to drive harm prevention, so that maximum internal and external collaborative support can be given to reduce overall harm.

2.8 SAFETY ALERTS AND NICE GUIDANCE 2.8.1 Safety Alerts The Trust does not currently have any breached safety alerts.

2.8.2 NICE Guidance The Trust has 1 NICE Technology Appraisal (TA) where the position is unknown. TA301 (Nov 13) Diabetic macular oedema - fluocinolone acetonide intravitreal implant - seeking clarification around service issues to compliance. The non-compliant TA reported in the previous month (TA297 Ocriplasmin for treating vitreomacular traction) has now been declared as compliant following implementation of a patient pathway

2.9 RESEARCH, DEVELOPMENT AND INNOVATION (RD&I) 2.9.1 Commercial Activity


Page 20 of 60

Engagement with commercially sponsored research studies will show a real benefit to both the provision of care to the patients taking part in the study and the provision of cutting edge training offered to clinicians running pharmaceutical trials. Commercially sponsored studies are always fully funded. RD&I are keen to develop the commercial portfolio and are looking to open 30 such studies during 13/14. The Trust is behind target for this metric and we are working to identify areas where this can be turned around.

2.9.2 Research Management and Governance (RM&G) The time to set up research studies has long been a factor in attracting further studies into a Trust and is a key marker of the effectiveness and engagement of the research fraternity. The measure is taken from receipt of notification that the site can take part in the study to the permission being granted by the Trust that recruitment can begin. The Trust is targeting 80% of studies being approved within 30 days of first notification and is currently achieving well above 80%.

2.9.3 Recruitment


Page 21 of 60

Increase in overall recruitment remains the key target for RD&I and present data shows the Trust to be performing just below target. Studies in the pipeline due to open in the next few months will increase this figure and the Trust is confident of reaching the 1600 patient target.

2.10 COMPLAINTS & COMPLIMENTS 2.10.1 Complaints A total number of 40 complaints were received in December 2013 which has decreased in comparison to November 2013 in which 44 complaints were received. Additionally the Trust has received 219 Patient Advice and Liaison Service (PALS) concerns in which local resolution has been achieved with support from the Divisions.

The graph has been updated to reflect the current position from April 2013 according to

information held on the complaints module on Datix. The figures can be subject to change


Page 22 of 60

because during the local resolution process patients, relatives and carers may change their mind about how they wish their concerns to be processed. Some prefer to receive correspondence directly from Divisional staff facilitated by the Patient Advice and Liaison Service (PALS), whereas others prefer to make a complaint and receive a response from the Trust Chief Executive.

2.10.2 Complaints and Concerns, Trends/Themes During December 2013 the Surgery, Trauma and Orthopaedic Division received the highest number of complaints, a total of 13. Overall the types of concerns raised relate to concerns about patients being unhappy with outcomes following their care and/or treatment as well as waiting times being too long. PALS continue to work with staff on the frontline to de-escalate concerns.

Total complaints and concerns received by Divisions during October 2013

Division Complaints Received

Corporate 1

Medicine & Emergency Department 11

Surgery, Trauma & Orthopaedics 13

Women’s, Children and Sexual Health 8

Theatres and Anaesthetics 1

Clinical Support Services and Cancer 5

Estate Services 0

Hotel Services 1

Total 40

A total of 154 concerns were raised by complainants during December 2013 demonstrating the increased complexity of complaints being put to the Trust for investigation.


Page 23 of 60

2.10.3 Compliments

The Trust has received a total of 133 compliments during December 2013, at the time of writing this report*. The compliments from April 2013 have been updated in the above graph to incorporate information received from the Divisions to reflect the current position. Whilst compliment reporting overall for the quarter has increased there has been a decrease in those reported in December 2013 by 61% when compared to the previous month.

*Please note that the number of compliments will continue to be received by the Complaints Team

over the coming weeks from returns provided by the Divisions.

2.11 DELIVERING SINGLE SEX ACCOMMODATION There were no reported non-clinically justified mixed sex accommodation breaches in December 2013.

2.12 FRIENDS AND FAMILY TEST (F&FT) The Department of Health (DH) introduced the Friends and Family Test to enable Trusts to obtain regular and timely feedback from patients about their care and treatment, encouraging organisations to take ownership of the results and action the feedback. The score is calculated using the proportion of patients who would strongly recommend minus those who would not recommend, or who are indifferent. The ‘year to date’ figure currently given in the scorecards is an average of the monthly figures; the Trust intends to introduce a cumulative count covering the whole year in 2014/15.

2.12.1 Inpatient and ED The overall F&FT score for the Trust in December was 64 compared to 69 in November. The


Page 24 of 60

overall response rate during December was 20% (823 responses), compared to 21.5% (883 responses) in November. The F&FT score for the inpatient questionnaire was 71 compared to 72 in November. The response rate was 23.1% (533 responses) compared to 28.3% (678 responses) in November The F&FT score for the ED questionnaire was 50 compare to 58 in November. The response rate was 16% (290 responses) compared to 12% November (205 responses) Part of the national patient experience CQUIN is the target that trusts will have an average 15% response rate for the first quarter, rising to over 20% by the fourth quarter. Eleven wards included in the DH submission did not reach 15%.

2.12.2 Maternity The Antenatal F&FT Score was 64, compared to 80 in November. The response rate was 9% (28 responses) compared to 11% (40 responses) in November. The Birth F&FT Score was 69, compared to 63 in November. The response rate was 18.6 (58 responses) compared to 28.7% (104 responses) in November The Postnatal ward F&FT Score was 64, compared to 45 in November. The response rate was 20.5% (47 responses) compared to 31.3% (79 responses) in November. The Postnatal community F&FT Score was 72, compared to 70 in November. The response rate was 10% (32 responses) compared to 10.9% (40 responses) in November.

2.13 CQUINs

2.13.1 Dementia Along with all other acute Trusts in the country, RCHT has a CQUIN target concerning the improvement of dementia risk assessment. This involves the screening of all patients through a ‘case finding’ question and then, where necessary, appropriate diagnostic assessment and referral. To achieve the 2013/14 CQUIN, over 90% must be achieved in 3 consecutive months. Additional screening capacity was released which saw achievement of this year’s target over the months of June, July and August. Since then performance has dropped back but remains higher than pre June levels - currently around 25%. Discussions and preparation for next year's anticipated full year delivery continue.

2.13.2 V.T.E VTE risk assessments remained above the 95% target in December with a slight increase of 0.03% compared to November.


Page 25 of 60

SECTION 3: OPERATIONAL PERFORMANCE

3.1 INTRODUCTION

This section reviews Trust operational performance for the month ending 31 December 2013 and projects performance where applicable.

3.1.1 The scorecards which relate to this section are the Operational Performance 1 –

Pathways and Operational Performance 2 – Resources scorecards.


Page 26 of 60

Operational Performance 1 - Pathways

These indicators appear in the Quality section of the national performance framework, or are related local indicators, and relate to access and patient pathways.


Unplanned reattendance at ED

within 7 days of original

attendance

between 1 - 5%

total ED

attenders

6.10% 6.00% 6.08% 6.41% 7.08% 5.92% 6.74% 5.91% 6.03% 6.57% 6.32% 3.3.1

95th centile of times from arrival

to admission, transfer or

discharge

95th centile

below 240 mins304 421 334 393 240 264 411 425 327 405 405 3.3.1

% who left without being seen below 5% 2.28% 1.99% 1.58% 2.40% 2.33% 1.76% 2.15% 1.36% 1.24% 1.60% 1.85% 3.3.1

95th centile of times from arrival

to initial assessment

95th centile

below 15 mins34 35 28 41 48 36 34 30 24 23 23 3.3.1

Median time from arrival to

treatment

Median below 60

mins42 35 37 53 49 44 42 35 30 35 35 3.3.1

12 hour trolley breaches 0 1 0 0 0 0 0 0 0 0 3 3 3.3.1

ED attenders 4 hours arrival to

disposal95% 93.43% 88.53% 92.48% 89.76% 95.29% 94.67% 90.01% 89.65% 93.39% 91.17% 91.81% 3.3.1

2 Weeks

a) Percentage first seen by cancer

specialist within two weeks of

urgent referral

93% 97.16% 96.80% 98.38% 97.39% 96.70% 94.19% 95.17% 96.46% 94.92%In

arrears96.22% 3.4.1

b) Percentage first seen by

specialist within two weeks of

urgent referral for any breast

symptom.

93% 95.22% 95.88% 99.37% 95.08% 95.17% 93.75% 94.74% 97.97% 96.59%In

arrears96.08% 3.4.1

31 Days

a) Percentage receiving first

definitive treatment for cancer

within 31 Days

96% 98.15% 97.07% 96.64% 98.67% 98.49% 98.22% 99.56% 98.33% 97.66%In

arrears98.03% 3.4.1

b) Percentage of patients

receiving subsequent surgery

treatment for cancer within 31

Days

94% 97.85% 94.64% 95.40% 95.00% 98.55% 98.46% 98.39% 95.65% 97.22%In

arrears96.67% 3.4.1

c) Percentage of patients

receiving subsequent drug

treatment for cancer within 31

Days

98% 99.90% 100.00% 100.00% 100.00% 99.10% 100.00% 100.00% 100.00% 100.00%In

arrears99.88% 3.4.1

d) Percentage of patients

receiving subsequent

radiotherapy treatment for

cancer within 31 Days

94% 96.43% 94.64% 99.02% 100.00% 100.00% 97.44% 100.00% 98.54% 100.00%In

arrears98.70% 3.4.1

62 Days

a)Percentage receiving first

definitive treatment within two

months of urgent referral from GP

85% 86.94% 88.89% 87.65% 91.91% 89.47% 95.61% 88.68% 90.28% 84.75%In

arrears89.51% 3.4.1

b) Percentage receiving first

definitive treatment within 62

days of urgent referral from

national screening service

90% 92.16% 100.00% 90.20% 95.00% 88.89% 88.24% 100.00% 100.00% 90.00%In

arrears94.17% 3.4.1

c) Percentage receiving first

definitive treatment within 62

days of urgent referral from

consultant upgrade

90% 89.02% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%In

arrears100.00% 3.4.1

Percentage of patients who have

spent more than 90% of their

time in a stroke unit

80% 77.64% 66.13% 71.21% 83.61% 69.64% 73.77% 63.46% 75.00% 74.42% 77.97% 72.90% 3.4.2

% of stroke patients with CT scan

within 24 hours95% 93.63% 96.92% 94.20% 96.77% 92.86% 95.31% 90.74% 95.89% 100.00% 91.80% 93.91% 3.4.2

Use of ROSIER standardised

assessment tool80% 73.79% 82.98% 84.00% 80.70% 62.75% 68.75% 73.47% 67.86% 76.09% 80.00% 74.73% 3.4.2

24 hour swallow screening 70% 79.63% 69.23% 65.45% 83.61% 67.27% 72.00% 77.78% 78.18% 78.00% 66.67% 73.39% 3.4.2

Brain imaging within 60 minutes 69.32% 69.23% 69.57% 82.26% 67.86% 85.94% 61.11% 70.15% 80.43% 66.10% 72.51% 3.4.2

CardiologyPrimary PCI 'call to balloon' of

75% within 150 minutes75% 80.50% 81.82% 84.00% 72.22% 50.00% 87.50% 85.00% 69.20% 100.00% 78.90% 78.90%

% of patients with a fractured

next of femur who meet all best

practice orthogeriatric criteria

95% 96.98% 93.75% 94.55% 96.15% 92.16% 90.00% 90.91% 98.28% 95.45% 100.00% 94.59% 3.4.3

% of fractured neck of femur

patients having an operation

within 36 hours

75% 74.09% 85.42% 80.00% 75.00% 63.27% 57.50% 87.88% 67.24% 77.27% 85.37% 75.06% 3.4.3

Cancer

Stroke

Fractured

neck of femur

Emergency

Department

Royal Cornwall Hospitals NHS Trust – Integrated Performance Report – Page 27 of 60

Operational Performance 2 - Resources

These indicators appear in the Resources section of the national performance framework, or are related local indicators.


RTT admitted - 90% in 18 weeks 90% 94.51% 91.34% 92.64% 92.24% 93.11% 94.09% 92.26% 92.19% 92.78% 92.13% 92.54% 3.2.1

RTT incomplete - 92% in 18

weeks92% 96.60% 94.68% 95.21% 95.62% 95.56% 95.98% 96.07% 95.93% 95.24% 95.05% 95.48% 3.2.1

RTT non admitted - 95% in 18

weeks95% 98.66% 98.90% 98.28% 96.22% 98.66% 97.81% 98.10% 98.20% 98.57% 97.67% 98.58% 3.2.1

RTT total number of incomplete

pathways18232 18450 18702 18273 18118 18270 18091 18404 17953 18589 18589 3.2.1

RTT 95% in 18 weeks for direct

access audiology95% 99.65% 100.00% 99.39% 100.00% 100.00% 100.00% 100.00% 99.79% 100.00% 99.27% 99.92% 3.2.1

RTT delivery in all specialties 0 2 10 10 7 4 4 9 10 7 11 11 3.2.1

Proportion of patients receiving

one of the 15 Key Diagnostic

Tests within 6 weeks

99% 99.48% 99.40% 99.47% 99.49% 99.75% 99.31% 99.45% 99.78% 99.72% 99.86% 99.60% 3.2.1

Outpatients not seen within 11

weeks (excludes Orthodontics)<10 per month 489 25 45 33 34 44 44 53 54 30 362

Proportion of patients on the

Follow Up Waiting List who have

been waiting 1 month or more

past their to be seen by date

4.20% 4.81% 4.74% 4.71% 4.32% 4.25% 3.79% 3.83% 3.35% 6.57% 6.57%

Choose and Book slot

unavailability10% 8.02% 13.00% 13.32% 17.45% 12.20% 7.44% 5.80% 8.24% 9.65% 10.73% 10.87% 3.2.3

52 week RTT breaches 0 0 1 0 0 0 0 1 1 0 3

Cancelled operations: 28 day

rebooking breaches

< 5% of elective

operations

cancelled

2.68% 19.35% 30.00% 16.67% 31.58% 12.96% 11.11% 8.82% 16.67% 27.27% 18.09% 3.2.4

Provider cancellation of

Elective Care operation for non-

clinical reasons either before or

after Patient admission

0.8% of electives 0.83% 1.75% 1.05% 1.24% 0.63% 0.96% 1.32% 1.11% 0.54% 0.43% 1.00% 3.2.4

Urgent Operations Cancelled

more than Once0 7 3 1 1 0 0 0 0 0 0 5

Delayed Transfers of Care (days

lost %)< 3.5% 3.61% 4.88% 2.99% 1.79% 3.80% 4.72% 4.52% 3.60% 3.63% 2.31% 3.60% 3.5.1

Number of patients waiting >30

but <60 minutes from arrival to

transfer to A&E

n/a 1010 100 70 143 111 46 67 110 26 66 739 3.3.2

Number of patients waiting

>=60 minutes from arrival to

transfer to A&E

n/a 464 94 23 70 22 6 20 38 0 15 288

Total specialty outliers 26 48 31 28 19 12 17 22 13 19 23 3.5.1

LOS over 10 days24.57% (avg

11/12 & 12/13)26.22% 29.02% 26.20% 24.96% 24.12% 26.05% 26.52% 25.91% 25.68% 26.65% 26.12% 3.5.1

Daycase Rates81.03% (avg

11/12 & 12/13)80.39% 82.24% 81.68% 81.57% 82.87% 83.73% 82.11% 82.88% 81.33% 82.84% 82.38% 3.5

DOSA Rate n/a 88.19% 86.78% 87.55% 90.50% 89.12% 88.15% 87.46% 90.47% 91.05% 88.80% 88.93%

Average LOS

2.8 (10%

reduction on

12/13)

3.10 3.3 3.2 3.1 3.0 3.0 3.2 3.2 3.2 3.1 3.1 3.5

OP DNA Rate n/a 7.49% 7.86% 7.40% 7.37% 7.43% 7.45% 7.27% 7.58% 7.79% 8.78% 7.64%

Net Emergency Readmissions

within 28 daysn/a 4.80% 4.60% 4.80% 5.10% 4.70% 5.30% 5.10% 5.00% 5.10% 5.00% 5.00%

Short notice cancellations n/a 3.13% 3.55% 3.95% 2.28% 2.93% 2.30% 2.72% 3.21% 2.45% 3.95% 3.03%

Ethnic

monitoringData quality on ethnic group 95% 97.11% 98.04% 97.80% 97.95% 97.84% 97.66% 97.75% 97.92% 97.94% 97.72% 97.85%

Cancelled

operations

Flow and

productivity


3.2 ELECTIVE ACCESS This section includes key elective access targets, including referral to

treatment, cancelled operations and Choose and Book slot availability. 3.2.1 WAITING TIME TARGETS National targets on RTT for 2013/14 are:

90% for admitted pathways

95% for non-admitted pathways

92% for incomplete pathways

99% of key diagnostic tests within 6 weeks

Each of the admitted, non-admitted and incomplete pathway targets to be achieved at a specialty level every month

Additionally, there is zero tolerance of 52 week waits (on any stage of the pathway). The specialty level target is the most difficult to consistently achieve for most Trusts, RCHT included. The first 5 of the above targets were in the DH Performance Framework for 2012/13 with the first 3 also in the relevant Monitor framework (both for 2012/13 and 2013/14). As for all areas, it is not yet known which of these are in the NHS TDA’s new performance framework.

83

.1%

90

.4%

90

.3%

90

.1%

92

.3%

92

.3%

93

.8%

93

.3%

93

.6%

91

.4%

93

.9%

95

.9%

94

.0%

94

.3%

95

.8%

95

.8%

94

.7%

94

.9%

94

.1%

94

.4%

93

.6%

92

.8%

91

.3%

92

.6%

92

.2%

93

.1%

93

.3%

92

.3%

92

.2%

92

.8%

92

.1%

70%

75%

80%

85%

90%

95%

100%

Jun-11 Sep-11 Dec-11 Mar-12 Jun-12 Sep-12 Dec-12 Mar-13 Jun-13 Sep-13 Dec-13

3.2.1c RTT admitted - % within 18 weeks

Month actual Target

98

.8%

98

.5%

98

.4%

98

.5%

98

.6%

99

.0%

98

.8%

99

.0%

98

.3%

98

.9%

99

.1%

98

.6%

99

.3%

98

.8%

98

.6%

98

.6%

98

.9%

98

.7%

98

.8%

97

.6%

98

.2%

98

.9%

98

.3%

96

.2%

98

.0%

96

.9%

98

.1%

98

.2%

98

.6%

97

.7%

70%

75%

80%

85%

90%

95%

100%

Jul-11 Oct-11 Jan-12 Apr-12 Jul-12 Oct-12 Jan-13 Apr-13 Jul-13 Oct-13

RTT non admitted - % within 18 weeks

Month actual Target


89

.9%

90

.7%

91

.1%

92

.7%

95

.5%

95

.5%

96

.0%

96

.5%

97

.4%

97

.6%

97

.3%

97

.1%

96

.8%

96

.5%

96

.1%

96

.8%

97

.1%

96

.4%

96

.3%

96

.1%

95

.1%

94

.7%

95

.2%

95

.6%

95

.6%

96

.0%

96

.1%

95

.9%

95

.2%

95

.1%

70%

75%

80%

85%

90%

95%

100%

Jul-11 Oct-11 Jan-12 Apr-12 Jul-12 Oct-12 Jan-13 Apr-13 Jul-13 Oct-13

RTT Incomplete- % within 18 weeks

Month actual Target

3.2.1.1 Overall situation As for every month this year so far, 4 of the 5 national targets were met in December, with each of the overall standards met for admitted, non-admitted, incomplete and diagnostic pathways. There were a total of 11 specialties which did not meet one or other of these targets, which include the planned admitted specialty-level underachievement’s referred to below. This month has continued the general picture seen over the last few months of increasing pressure on the RTT pathways and this is now causing some concern in terms of the overall position going into Q4. As the number of admitted patients over 18 weeks has increased, there is now a risk that it may be necessary to fail the admitted target for 1-3 months on a planned basis to reduce the number of longer waiters. This has occurred because of a continuation of the main factors identified in previous IPRs. Elective cancellations (covered in more detail in section 3.2.4) have been higher this year than in previous years (it should also be noted that the cancellations in that section are last minute hospital cancellations rather than cancellations at all times for all reasons and so underestimate the total impact of cancellations on total activity undertaken). Also, outpatient referrals have increased which is having a knock-on effect on the admitted pathways, increasing waiting lists and pressure on RTT. In terms of activity levels, the Trust is exceeding its overall agreed elective plan as set out in 4.1.3. However, it should also be noted that the overall plan was felt at the start of the year by the Trust to underestimate the necessary activity, particularly in orthopaedics and whilst the Trust is meeting the overall elective plan, it is slightly behind the internal theatre delivery plan which was set which took into account the expected required overperformance.

3.2.1.2 Admitted pathways

92.1% of patients on an admitted pathway treated in month were within 18 weeks, better than the national target of 90%. However, the number of patients waiting over 18 weeks on an admitted pathway was 395 at the end of December, well above the ‘half a week total activity’ good practice guideline of 245. Experience suggests that, although there is no definitive figure (as it depends on the circumstances and sub-specialties of the relevant patients), around 400 is the level at which the delivery of the overall 90% admitted target is threatened because at around


this level, the number of long waiters requiring to be booked in month increases above 10% of that month’s activity. As noted below the standard on incomplete pathways, which prevents these targets from being achieved by allowing long waits once patients have passed 18 weeks, is being comfortably met.

As noted in previous months, this will in the context of referral growth require additional activity in order to reduce back to the half a week levels and the Trust will need to discuss with commissioners how this is best undertaken in the early part of 2014/15. The Trust is already delivering additional activity in the key specialties of ophthalmology, trauma and orthopaedics, gynaecology and general surgery to improve the position through a combination of substantive additional theatre lists, increased locum work, theatre productivity, and weekend sessions.

In order to ensure that as many patients as possible are treated in chronological order at a specialty level it remains necessary for several specialties to undershoot the 90% admitted target. This is likely to continue throughout Q4 in gynaecology, trauma and orthopaedics, cardiology and ophthalmology and this has been discussed with the Trust’s commissioners. 3.2.1.3 Incomplete pathways The proportion of patients on an incomplete pathway waiting less than 18 week remained well above the national 92% target at 95.1%. This is the standard aimed at preventing ‘hidden waits’ of patients who have not been treated by their 18 week date, and ongoing work continues in terms of both treating patients and data quality. There were no patients waiting over 52 weeks.

3.2.1.4 Non-admitted pathways and follow ups pending

Non-admitted pathways comfortably met the target at 97.7%. The number of follow up patients more than a month past their ‘to be seen by’ date’ increased in month to 6.6% (5,600 of 86,300 patients). This is the highest figure of the year to date, reflecting lower levels of follow up activity being undertaken in December. Ophthalmology, where changes to national practice have resulted in the requirement to follow up more patients more often, is the specialty with most pressure (as is the case around the country) and the Trust is currently appointing more optometrists to deal with the increased workload and planning together with commissioners for the significant increases required next year with further changes in NICE guidance. Urology and cardiology are the second and third most significant specialties, with excellent progress having been made in neurology. 3.2.1.5 Diagnostic pathways The proportion of patients meeting the 6 week national diagnostic target met the target comfortably at 99.9%. Cardiology diagnostics continue to be pressured in some areas, meaning the Trust is continuing to outsource some activity in order to ensure waiting times do not increase.

3.2.1.6 Performance projection


In terms of likely trends for future months, the January position is likely to see worsening performance in terms of the admitted backlog, which is expected to increase to 480-500. It is likely that in month as for each month this year all targets will be passed but not at a specialty level. Referral rates and waiting list size and shape indicators continue to point to the need to increase overall activity over the next few months. Specialty-level plans are in place to do this, but this has to be balanced carefully against the available resources and the ongoing Clinical Site Development Plan. Actions continue through the Operational Management Group to ensure that the position on the admitted target is improved and that plans are delivered.

3.2.2 CHOOSE AND BOOK

The Choose and Book 10% target is a local target.

12

.0%

23

.0%

31

.0%

31

.0%

30

.7%

28

.9%

28

.4%

23

.4%

15

.0%

12

.0%

14

.0%

14

.5%

9.1

%1

0.0

%1

0.2

%9

.8%

8.4

%9

.5%

8.8

%6

.0%

2.8

%4

.4%

6.3

%8

.0%

7.2

% 13

.0%

12

.1%

13

.0%

13

.3% 17

.5%

12

.2%

7.4

%5

.8%

8.2

%9

.7%

10

.7%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%3.2.3 Choose & Book slot unavailability

Actual Target

The target was narrowly not met in December following 4 months of achievement. There are several specialties which have seen a short-term increase in pressure, including dermatology where the combination of staffing changes (with the retirement of a key specialty doctor) and the continued impact of increased 2 week wait referrals have created some additional pressure; cardiology and neurology also saw some short-term difficulties in December. However, the position for January at the time of writing has seen improvement in all 3 of these specialties and it looks likely the target will be met. 4.0% of clinics were cancelled at short notice this month (ie less than 6 weeks), above the 12/13 average of 3.1%. Actions to ensure appropriate slot availability and reduce cancelled clinics continue to be taken through the weekly Operational Management Group.

3.2.3 CANCELLED OPERATIONS

Cancelled operations performance did not feature in either performance framework in 2012/13 or in the 2013/14 Monitor frameworks, but levels of cancelled operations remain good practice indicators and important patient quality markers. The 28 day rebooking standard and an expectation that no urgent operation is cancelled twice is in this year’s acute contract. Overall, this was a relatively positive month on overall cancellations. 0.4% of operations were cancelled by the hospital on the day, equating to 22 patients


and well below the former national standard of 0.8%. The number of patients cancelled on the day was the lowest for any month since August 2012. It must be acknowledged that all cancellations on the day are, however, poor patient experience. As flagged last month, the high numbers of cancellations in previous months placed pressure on the 28 day rebookings position (in the context of a low number of cancellations this month) – 6 patients were unable to be rebooked within 28 days. Although this is high in percentage terms, this is because of a reduction in overall cancellations rather than an increase in breaches.

No patient had an urgent procedure cancelled twice. Focus continues through the Theatre Management Group on reducing the number of patients who are cancelled for reasons other than those related to lack of bed availability.

3.3 EMERGENCY ACCESS This section covers Emergency Department indicators as well as ambulance

waits. 3.3.1 EMERGENCY DEPARTMENT

For 2013/14, the main performance target is a 4 hour arrival to disposal time for greater than 95% of patients. The ‘intervention measures’ from the ‘clinical dashboard’ introduced during 2011/12 are no longer in either performance framework, but remain in the national acute Trust contract. They will continue to be reported on the Operational Performance 1 scorecard as they provide a more balanced picture than the 95% target alone. For 2013/14, there is an additional reinforcing for acute Trusts of a zero tolerance of 12 hour delays in ED from the decision to admit.

The top chart is cumulative performance, and the second the weekly count.

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

14/0

4/2

013

28/0

4/2

013

12/0

5/2

013

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5/2

013

09/0

6/2

013

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6/2

013

07/0

7/2

013

21/0

7/2

013

04/0

8/2

013

18/0

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013

01/0

9/2

013

15/0

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013

29/0

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013

13/1

0/2

013

27/1

0/2

013

10/1

1/2

013

24/1

1/2

013

08/1

2/2

013

22/1

2/2

013

05/0

1/2

014

19/0

1/2

014

02/0

2/2

014

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014

02/0

3/2

014

16/0

3/2

014

30/0

3/2

014

Pe

rfo

rma

nc

e (%

)

Actual Traj ect ory


75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

14/0

4/2

013

28/0

4/2

013

12/0

5/2

013

26/0

5/2

013

09/0

6/2

013

23/0

6/2

013

07/0

7/2

013

21/0

7/2

013

04/0

8/2

013

18/0

8/2

013

01/0

9/2

013

15/0

9/2

013

29/0

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013

13/1

0/2

013

27/1

0/2

013

10/1

1/2

013

24/1

1/2

013

08/1

2/2

013

22/1

2/2

013

05/0

1/2

014

19/0

1/2

014

02/0

2/2

014

16/0

2/2

014

02/0

3/2

014

16/0

3/2

014

30/0

3/2

014

Pe

rfo

rma

nc

e (%

)

Actual Traj ect ory

The month of December saw the opening of the new expanded Emergency Department on the Royal Cornwall Hospital site towards the end of the month. This has led to much improved patient experience, with significantly expanded majors capacity and consequently much better privacy and dignity. As planned, this is in place in time for the main winter pressures period which usually peaks in January and February. In terms of performance, the main ED target was not achieved in December at 91.2% or for Q3 (overall performance 91.3% for the quarter).

On the broader ED indicators, the proportion who left without being seen (1.6%) and the median time to treatment were met (35 minutes), with the 95th centile to initial assessment (23 minutes) and unplanned reattendances (6.6%) not met. This is in line with, or slightly better than, most months this year, with particularly the 95th centile time to initial assessment being the best achieved for the year to date.

There were 3 12 hour breaches in December, the only instances incurred for the year to date (these occur where a patient is in the department for longer than 12 hours after a decision to admit has taken place). These all occurred on the same day when flooding caused the failure of a number of key IT systems at the same time which made it more challenging to track patients through the department. An investigation is under way into the flooding incident incorporating the 12 hour breaches; it is likely that one of the key actions coming out of this will be the strengthening of business continuity plans given the criticality of the IT systems to managing patient flow and the difficulties which result when it is necessary to resort to manual systems in the event of system failure. Whilst clearly it must be acknowledged that any 12 hour breach is poor patient experience, the medical notes of all 3 have been reviewed and none came to any clinical harm as a result of the delays.


355, 75%

47, 10%

33, 7%

26, 5%13, 3%

ED reasons for breaches Dec 2013

Medical bed capacity

Clinical exception

Surgical bed capacity

ED internal

Other

The chart above shows the root cause of ED breaches during December. Fundamentally, most breaches occurred due to medical bed capacity flow (75%). Other reasons – clinical exceptions (10%), surgical bed capacity (7%) and internal ED factors (5%) – were relatively less significant. The issues associated with medical flow this month are discussed in more detail in section 3.5.1. In terms of ED-related factors, as noted in previous IPRs during Q3 the works undertaken to improve the department meant a temporary reduction in the number of beds in the Clinical Decision Unit, meaning more patients had to be admitted through MAU. This was an essential part of completing the expanded department which has significantly improved the patient experience in ED, but is likely to have contributed to operational pressure in the short term. This was resolved by the end of December.

A comprehensive action plan covering all aspects of ED and emergency flow continues to be implemented and a range of actions have been taken including as noted in previous IPRs across staffing, additional beds and the improvements to the physical environment described above. Key elements of the winter plan including opening of an additional frailty ward and increased 7 day working in therapies and pharmacy have also been implemented. NHS Kernow has also purchased additional step-down nursing home capacity to ensure more timely discharge of some patients.

However, given the current operational difficulties and the pressures still being experienced in other parts of the system, work is continuing with partners on other contingencies to further strengthen plans. The health economy recently undertook an Intelligence Sharing exercise to further inform the development of plans and the actions from this are being incorporated into strengthened action plans.

3.3.2 AMBULANCE WAITS The 30 minute ambulance turnaround standard is a national contractual target

which involves the levying of fines on hospitals for waits above 30 minutes or


1 hour (payment of which is shared 50:50 between RCHT and NHS Kernow under the agreed 2013/14 contract, reflecting the whole health economy nature of the issues which give rise to such delays).

73

16

31

08

15

11

27

97

78 83

75

70

30 8

12

81

02

11

31

14

20

21

71

10

54

61

37

67

64

10

78

22

50

31

31

94

93

21

31

33

52 8

71

48

26 8

1

0

50

100

150

200

250

300

3503.3.2 Ambulance Delays - Numbers waiting over 30 minutes

Actual

There were 81 over 30 minute ambulance waits in ED in month (15 1 hour plus breaches). Whilst it is acknowledged that this level of delays causes additional operational challenges to partners, this is broadly in line with previous performance in months with comparable patient flow conditions and constituted performance around the regional average, with around 5-6% of ambulance handovers being over 30 minutes. The increased physical size of the RCH ED is expected to mean that resilience improves once the department is fully open, and with this being the case from January this would be expected to have a positive impact on performance.

Joint working arrangements have remained in place between RCHT and SWAST. The Trust recently worked with SWAST and other partners on refreshing and jointly agreeing an ambulance handover reduction plan which is being jointly monitored.

3.4 CLINICAL PATHWAYS This section sets out performance on indicators related to key clinical

pathways, including cancer, stroke and fractured neck of femur. 3.4.1 CANCER

These are national targets and are part of the Operational Performance 1 scorecard. The targets remained unchanged in 2013/14. Cancer continues to be reported a month in arrears when compared with all other performance targets. This is in line with national practice and results from the length of time taken to validate cancer pathways.

One cancer waiting time target was breached in November. This was the 62 days from referral to treatment, where the performance was 0.2% lower than the threshold of 85%.

However, it is expected that patient choice, the impact of the holiday season and some capacity shortfalls will impact on December’s performance and the 62 day wait from referral to treatment is not expected to be passed in month. The 2 week wait for breast symptomatic patients in December is also unlikely to be met. Special measures have been put in place to recover the position and Cancer Services have increased their level of reporting and escalations.


At the time of writing, however, it is expected that all cancer targets will be met for Q3, although there remains some risk on the 62 day from referral to treatment target. The final position will be known by the time of next month’s IPR.

Target Performance Threshold

Nov. Total No. of

Patients

Breach No. of

Patients

% Performance

14 day wait from GP referral with suspected cancer to first appointment

93% 1103 56 94.9%

14 day wait for patients referred with breast symptoms (mandated December 2009)

93% 176 6 96.6%

62 days from referral from GP with suspected cancer to treatment start

85% 141 21.5 84.8%

62 days from screening service to treatment start for suspected cancer

90% 20 2 90%

31 days from date of decision to treat to treatment start for all first treatments

96% 256 6 97.7%

31 days from date of decision to treat to treatment start for subsequent surgical treatment

94% 72 2 97.2%

31 days from date of decision to treat to treatment start for subsequent drug treatment

98% 97 0 100%

31 days from date of decision to treat to treatment start for subsequent radiotherapy treatment 94% 110 0 100%

3.4.2 STROKE

There are no stroke targets in the national acute contract or Monitor frameworks for 2013/14. The Best Practice Tariff, which incentivises direct admission to stroke units and prompt CT scanning, remains. However, the Trust continues to monitor the same targets as for 2011/12 and 2012/13 through the IPR, as stroke remains a high clinical priority and this provides a good way of tracking progress over time. They are all in the Operational Performance 1 scorecard.

52

.0%

61

.0%

49

.0%

49

.0%

46

.0%

50

.0%

69

.4%

73

.0%

66

.1%

74

.1%

71

.2%

79

.7%

81

.0%

82

.8%

83

.1%

85

.4%

78

.3%

85

.1%

71

.7%

75

.9%

78

.7%

78

.9%

81

.7%

71

.2%

74

.2%

73

.1%

73

.9%

66

.1%

71

.2%

83

.6%

69

.6%

73

.8%

63

.5%

75

.0%

74

.4%

78

.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%3.4.2a % of pts spending 90% of their time on stroke unit

Actual National target


December performance on the stroke pathway was around average, with 78% of stroke patients spending more than 90% of their time on a stroke unit. The position for the year to date is 73%. A breakdown of the reasons for patients not spending 90% of their time on a stroke unit is included in the pie chart below. This month, 46 of 59 stroke patients’ stays met this standard. Of the remaining 13, it will be seen that there were 4 ‘pathway failures’ (ie where no stroke bed is available), with the remaining 9 happening for other reasons (4 of these being clinical exceptions either because of patients receiving critical or end of life care, 3 being discharged from the rehabilitation stroke units to other inpatient facilities late in their stays, 1 unclear diagnosis, and 1 short length of stay – the time spent in the ED is counted in the inpatient stay for this particular indicator, so even when prompt admission to the stroke unit occurs direct from ED in line with the pathway, less than 90% of the patient’s ‘stay’ has been on a stroke unit). As noted in previous months it is the ‘pathway failures’ that are the ones which require the greatest focus to resolve, with the other types of situation being allowed for in the 20% tolerance.

46, 78%

4, 7%

3, 5%

1, 1%

1, 2%1, 2% 3, 5%

Stroke unit - breach analysis

Met

No stroke bed availability

Patient transferred offstroke unit

Patient receiving end of lifecare

Delayed diagnosis

Short length of stay

Critical care followingthrombolysis

In terms of joint working the Stroke Programme Board, which has overseen delivery of the stroke agenda across the county in recent years, retains responsibility for ensuring that the pathway operates effectively. All key elements of the pathway including Early Supported Discharge and 2 stroke rehabilitation units remain in place.

The supporting measures saw good performance, although less so than in some previous months. 92% of patients had a CT scan within 24 hours (above the national mean of 82% but below the local stretch ambition of 95%), and 66% of patients brain imaging within 60 minutes. 66% of patients had a swallow screening within 24 hours and 80% a Rosier assessment.


3.4.3 FRACTURED NECK OF FEMUR Fractured neck of femur remains a key shared performance priority with NHS

Kernow and 2 local targets have been agreed for this year. These are the percentage of patients operated on within 36 hours and compliance with the orthogeriatric assessment bundle. The latter relates to a number of indicators relating to the timeliness and quality of specialist assessment. The 2 indicators for 2013/14 have been selected because of the combination of strength of both clinical evidence and benchmarking information.

The agreed thresholds are above the national top quartile in both areas, which would mean that by passing them RCHT is amongst the best quarter of hospitals in the country in this area (the top quartile overall for 36 hour theatre access performance increased from 72% to 75% on this year’s published National Hip Fracture Database report). They are part of the Operational Performance 1 scorecard.

66

.00

%5

3.0

0%

62

.00

%8

0.0

0%

77

.00

%7

3.0

0%

55

.00

%5

1.0

0%

45

.00

%6

2.0

0%

86

.00

%7

9.0

0%

84

.61

%8

8.0

0%

62

.00

%8

4.0

0%

89

.13

%7

2.2

2%

72

.22

%6

6.6

7%

65

.00

%6

5.8

5%

82

.14

%5

3.7

0%

76

.27

%7

6.9

2%

85

.00

%8

5.4

2%

80

.00

%7

5.0

0%

63

.27

%5

7.5

0%

87

.88

%6

7.2

4%

77

.27

%8

5.3

7%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%3.4c % of NOF patients operated on within 36 hours

Actual National UQ/ Local target No. of NOF pat ients

85% of patients in-month with a fractured neck of femur had their operations within 36 hours (75% year to date) and all patients’ care met all the orthogeriatric assessment standards. This was a very good month and means that the 36 hour local target is being met for the year to date. Orthogeriatric assessment, at 94.6%, is improving and also virtually meeting the local target. It should be recalled that these local targets are based on the Trust’s good performance and are therefore benchmarked at what are very challenging levels nationally. However, despite this in view of the seasonal variation in this area (i.e. what is usually the most challenging part of the year is completed) it is anticipated that both targets will be met for year end.

3.5 PRODUCTIVITY AND FLOW This section provides information on some important indicators relating to

patient flow and clinical productivity, including a set of measures related to reducing excess length of stay and day case rates. The targets are largely based on 2012/13 levels of performance. They are also used in appropriate divisions within the Performance Assurance Framework.

Retaining a low level of delayed transfers of care remains a national target for

acute Trusts and was in the DH Performance Framework for 2012/13 (and is in the 2013/14 acute contract). Otherwise, these are all indicators for internal use only.


3.5.1 PATIENT FLOW AND DELAYED TRANSFERS OF CARE A number of measures are used to give an indication of how smoothly

patients are flowing through the hospital from arrival to discharge. These include the number of outliers (patients on wards which do not relate to their admitting specialty), the number of patients with a length of stay over 10 days and delayed transfers of care. All these indicators are part of the Operational Performance 2 scorecard.

21

.8%

21

.0%

23

.9%

23

.6%

22

.2%

23

.8%

22

.6%

22

.4%

24

.2%

21

.1%

22

.8%

22

.8%

25

.3%

24

.8%

25

.8%

27

.7%

25

.2%

24

.9%

24

.0%

24

.8%

26

.3%

24

.9%

28

.5%

28

.0%

29

.1%

29

.0%

26

.2%

25

.0%

24

.2%

26

.0%

26

.5%

25

.9%

25

.7%

26

.7%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

3.5.1b Length of Stay over 10 days

Actual Target

1.5

%2

.0%

2.2

%2

.1%

2.8

%3

.9%

3.8

%3

.4%

3.5

%3

.2%

4.6

%3

.5%

4.3

%2

.9%

4.9

%3

.6%

3.5

%3

.7%

3.2

%2

.8%

2.7

%4

.8%

3.3

%3

.2%

5.1

%4

.1%

3.4

%4

.9%

3.0

%1

.8%

3.8

%4

.7%

4.5

%3

.6%

3.6

%2

.3%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%3.5.1a Delayed transfers of care

Actual Target

29

23

23 2

82

08 1

0 8 10 11 14 15

24 25 28

28

26

20

14 2

0 22

16

25

35 38 39

48

31

28

19

12 1

7 22

13 1

9

0

10

20

30

40

50

60

3.5.1c Outliers

Actual Target

In terms of the main factors affecting this month’s performance, unusually for the year as a whole but for the second time in 3 months non-elective activity levels appear to have had a significant impact on performance. Overall length of stay, at 3.1 days, continued to be above the 12/13 average, as was the percentage of patients staying over 10 days. However, these were


not unusually high for the time of year and didn’t show any change on previous months.

Delayed transfers of care improved this month and at 2.3% for the month as a whole, they were below the national expected maximum of 3.5%. This equates to 17 patients for the month on average, with the 2013/14 average remaining 25 patients per day for the year, slightly higher than 2012/13. This should be seen in the context of Cornwall as a health economy’s relatively high level of delayed transfers of care but the improvement in performance is welcome, as is the commitment by NHS Kernow to the purchase of additional nursing home step-down beds to ensure prompt appropriate discharge of an additional cohort of patients as noted in section 3.3. In-month, there was an improvement at the start of the month where the Fall to Green week of targeted joint action together with partners seems to have had an impact on this indicator – the number reduced to 9 on the 6th December, the joint lowest of the financial year to date. However, increased pressure over Christmas and New Year saw a peak of 35 on 31st December.

December saw a significant rise in absolute non-elective numbers and this contributed significantly to the in-month pressures. It was the busiest month since 2011/12 and was the second month in 3 where non-elective activity levels were significantly above last year. In terms of the overall position as a whole for the year in terms of non-elective numbers, the total is 253 spells (1%) above the same period last year having been running either flat or slightly below for most of the year.

2500

2600

2700

2800

2900

3000

3100

3200

3300

3400

3500

Sp

ell

s

Sp

ell

s

Sp

ell

s

Sp

ell

s

Sp

ell

s

Sp

ell

s

Sp

ell

s

Sp

ell

s

Sp

ell

s

Sp

ell

s

Sp

ell

s

Sp

ell

s

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

RCHT Non-elective spells 2013-14 (all commissioners)

Comparable 2012-13 Activity

Contract Plan

Actual 13/14

As well as keeping focus on the actions within its own control, the Trust continues to work with partners on increasing and maintaining the system’s resilience, and the actions outlined in section 3.3.1 in relation to emergency flow are also relevant here.

3.6 CONTRACT AND COMMISSIONING The 2012/13 contracts are now closed. There were no outstanding contract query notices or contract disputes.


Activity information by commissioner against the main contracts for 2013/14 to date is provided in the finance section below (4.3). Whilst monitoring against this year’s contract will continue throughout the financial year, the process of developing future years’ finance and activity plans is now becoming the main focus of work with commissioners. Much of the national guidance for commissioning and contracting for 2014/15 for both CCG and NHS England activity has now been produced and the Trust is working through the implications of this together with commissioners, which includes the ability if wished to agree multi-year contracts linked to CCGs receiving allocations for the next 2 years. It is anticipated that largely because of the continued pressure on the financial situation of both the Trust and its commissioners (as further outlined in the finance section), together with the increased complexity which has resulted from the changes to commissioning arrangements over the last year, this will be a very challenging contract round.

At the time of writing the Trust has 2 open contract query notices with NHS Kernow on ED and C Difficile which are being managed through the standard contract management process. It has been agreed with commissioners that the likely forecast outturn on the NHS Kernow contract will be around £8.6-9m above the initial contract value, £6m of which will be paid to the Trust in line with this year’s contract agreement. Especially in view of the referral growth referred to in section 3.2 and the additional non-elective activity in section 3.5, this is likely to increase the scale of challenge in 2014/15 as the Trust may need to plan to treat an increased number of patients without commissioners having enough corresponding increased resources automatically to pay for these.

3.7 MONITOR COMPLIANCE AND NHS TDA FRAMEWORKS

As an NHS Trust, the Trust’s performance during 2012/13 was assessed through the DH Performance Framework. The DH Performance Framework now no longer exists and is being replaced by a new performance framework from the NHS Trust Development Authority. This is still being developed at the time of writing and so is consequently not available for self-assessment. As an aspirant Foundation Trust the Trust is also self-monitoring against the Monitor Compliance Framework against which its performance would be assessed if it were an FT. On 1 October the Monitor Compliance Framework was replaced by Monitor’s new Risk Assessment Framework and the Trust’s processes of self-monitoring changed accordingly.

3.7.1 DH Performance Framework/ NHS TDA

Prior to the abolition of the DH Performance Framework in March 2013, RCHT had held ‘performing’ (the highest category) status since Q2 2009/10. At the time of writing the NHS TDA has published its Accountability Framework for NHS Boards but this does not contain sufficient detail in order to create shadow monitoring. As soon as sufficient information is available, shadow monitoring will be included in the IPR and reported to the Board, assuming that the detail of the new Framework allows for this to happen.


The situation has not changed since the last IPR and so the relevant text from the October IPR is included again below. The TDA published a report on 27 September 2013 which set out its current assessment of Trusts. The Trust was assessed as a 3 (in terms of risk), with 5 being the highest risk category and 1 the lowest. Discussions with the TDA through its performance management processes suggest the key elements in this assessment are the combination of Board vacancies and performance against the ED and C Difficile targets, but further detail is not available at the time of writing.

3.7.2 Monitor Self-Assessment 2013/14: Q3/4 – Monitor Risk Assessment Framework

As noted above the Monitor Compliance Framework was replaced for Q3 and Q4 by the new Monitor Risk Assessment Framework.

The new governance rating element of the Risk Assessment Framework which will replace the Compliance Framework has 3 categories, which are:

No grounds for concern – green rating

Concern identified – written description of issue and action considered (noted as amber in the table below)

Enforcement action underway – red rating The Trust will expect its governance rating to be in the middle category of these (concern identified) for the remainder of 2013/14, as its C.Difficile performance being over the yearly tolerance will constitute an identified concern. The projections below also score the Trust for reference against the new Framework for Q1 and Q2. The issues are similar (concern identified for ED in Q1- Q3, and C Difficile for Q2). The best and most likely cases assume only the C Difficile concern is identified for Q4, whilst the worst case adds cancer in Q3 and ED, cancer and RTT admitted in Q4; as noted in section 3.4, it is now likely that all Q3 cancer targets will be passed but the worst case remains that one is failed. Since the last report, the most likely case has been changed to reflect the fact the ED target was not achieved in Q3 but the position in terms of overall projections is otherwise the same. As noted above in section 3.2, the risk on RTT admitted delivery going forward has increased, but this was already noted in the worst case scenario. The best, worst and most likely cases will be reported monthly through this report.

RCHT Monitor Risk Assessment Framework2013-14 Q1 Q2 Q3 Q4

Best 1.0 2.0 2.0 1.0

Most likely 1.0 2.0 2.0 1.0

Worst 1.0 2.0 3.0 4.0


Monitor Risk Assessment Framework 2013-14 -0.184782609

Most likely caseIndicators Threshold Timings Q1 Q2 Q3 Q4 Comments

Clostridium Difficile - meeting the

Clostridium Difficile objective

20 ytd

0.0 1.0 1.0 1.0

CONCERN IDENTIFIED for Q2-Q4. 38 cases as at 17/1 compared with full year target of 20.

RTT admitted patients. Quarterly

assessment; target must be achieved

each month to achieve the quarter

90% quarterly

0.0 0.0 0.0 0.0

INCREASING RISK. Bottom line continues to be passed although target not being fully achieved at specialty

level. Increased referrals coupled with challenging patient flow situation means less leeway going into the

winter than in 12/13; backlog must be held below about 400 overall to ensure sustained target delivery.

Admitted projection for January is 91%, with admitted backlog position 480-500.

RTT non-admitted patients. Quarterly


each month to achieve the quarter 95% quarterly

0.0 0.0 0.0 0.0Target is likely to remain low risk all year. Likely January performance around 97-98%

RTT incomplete pathways. Quarterly


each month to achieve the quarter 92% quarterly

0.0 0.0 0.0 0.0 Target has been passed with good margin since end of 2011/12 although some deterioration over last few

months. Likely January performance around 95%

Cancer indicators (all)

Various quarterly

0.0 0.0 0.0 0.0Although this has been challenging and close at times, all cancer targets have been passed quarterly since

Q2 2010/11. Currently there are particular on the 62 day target but overall expecting to continue to

achieve all targets quarterly.

A&E: Maximum of 4 hours from arrival to

admission/ transfer/ discharge

95% quarterly

1.0 1.0 1.0 0.0

CONCERN IDENTIFIED in Q1-Q3. Q4 projected passed on basis of availability of additional template and

expanded ED, although this is high risk projection in view of recent history.

Certification against compliance with

guidance regarding access to healthcare

for patients with a learning disability Assurance of compliance quarterly

0.0 0.0 0.0 0.0Board Compliance is refreshed and self-certified quarterly.

Quality governance indicators

n/a quarterly

0.0 0.0 0.0 0.0

Monitor will monitor a number of relevant indicators and where a material increase in turnover or

sickness, decrease in satisfaction, material increase in proportions of temporary staff or cost reductions in

excess of 5% in a year occur this may trigger a concern. There are no known such material issues at this

point.

Third Party Reportsn/a quarterly

0.0 0.0 0.0 0.0Adverse Third Party reports may trigger a governance concern a new governance concern, reportable by

the Trust to Monitor. There are no known such material issues at this point.

Continuity of services risk ratingn/a quarterly

0.0 0.0 0.0 0.0Breaching any continuity of services condition as a result of governance failures is the threshold for a

concern being raised in this area. There are no known such material issues at this point.

Formal CQC regulatory actionWarning notice quarterly

0.0 0.0 0.0 0.0Concern is triggered by a warning notice, civil or criminal action. None of these apply at this point.

TOTAL NUMBER OF CONCERNS IDENTIFIED 1.0 2.0 2.0 1.0

Projected


SECTION 4: FINANCE REPORT

The Trust’s Financial Performance 2013-14 (Month 9: 31 December 2013)

4.1 THE INCOME AND EXPENDITURE POSITION OF THE TRUST 4.1.1 At the end of December 2013, the surplus for the year is on plan at just over

£2.5m. Divisional over spends continue and these have been off-set by income being above plan and by the with-holding of some investments. Summary Financial Information table

Measure YTD plan YTD actual VarianceFull year

planForecast Variance Risk rating

Surplus / (deficit) to date (£000) 2,477 2,510 33 3,900 3,900 - G

Total income 245,462 248,463 3,001 320,060 325,277 5,217 G

Total spend (excluding notional adj) 242,498 246,296 3,798 (316,160) (321,431) (5,271) A

Savings delivered to date (CIP and income

schemes) (£000)9,702 7,730 (1,972) 13,930 11,703 (2,227) A

Cash balance (£000) 13,368 8,905 (4,463) 12,633 12,633 - G

Capital spend to date (£000) 10,064 9,913 (151) 17,094 17,161 67 G

Continuity of Services Risk Rating (see

below)3 4 1 4 4 N/A G

External Financing Limit at year end On target On target N/A On target On target N/A G

Capital Resource Limit at year end On target On target N/A On target On target N/A G

Better Payments Practice Code –Non NHS

payments96% 96% 0% 95% 95% N/A G


Key financial indicators

The Trust is in track to deliver a £3.9m surplus.

Savings from original CIP schemes remain below plan so further focus is required on schemes for 2013-14. The Trust remains on plan to deliver a £3.9m surplus due to income over performance and slippage in investments.

The number of invoices paid on time remains over the 95% target for the year to date.

The cash balance is below plan due to NCA income being owed to the Trust which is awaiting resolution of a patient identifiable date issues. A 12 month rolling cash flow forecast is shown at Appendix C.

Variable pay expenditure continues to be high and returned to £1.6m in December, this is only £74k lower than the peak month of August. Variable pay expenditure has increased from an average of £1.1m for the 2012-13 financial year to £1.6m since July 2013. Whilst Agency spend reduced to £348k which is its lowest figure since May 2013, Bank spend has reached a new high of £598k and there has also been a peak in expenditure in overtime and additional sessions with a combined value of £419k. The additional costs reflect the higher than planned levels of activity.


Activity & Income 4.1.2 Overall income is £3,001k above plan at the end of December 2013 of which

£2.1m relates to NHS Kernow. The overall year to date variances is as follows:

£000 £000

NHS Kernow

PbR 5,737

Non-PbR and other 632

Other items and adjustments (4,259)

NHS Kernow income variance 2,110

National Commissioning Board (Specialist Commissioning)

PbR 316

Non-PbR and other 591

Other items and adjustments 0

NHS Commissioning income variance 906

Other core contract income

PbR (51)

Non-PbR and other 1

Other core contract income variance (51)

Total core contract income 2,965

Other income

NCAs (89)

Other income - donated assets (302)

Divisional income 232

NHS services provided 53

Training and education income 0

Other income 142

TOTAL INCOME VARIANCE 3,001

Variance to date

(+ = over performance

4.1.3 Income from the contract with NHS Kernow is £2.1m higher than plan, which

takes into account the need to earn £4.2m over the contracted value for the full year. The table above identifies that the key variations are within the NHS Kernow contract which, is summarised in more detail below;


Current Plan Income Variance

Year Plan To Date To Date to Date

(+ is over

performance)

£000 £000 £000 £000

Kernow Clinical Commissioning Group

Elective Admissions (54,051) (40,538) (41,068) (530)

Non Elective Admissions (56,989) (42,764) (46,481) (3,717)

ED Attendances (6,850) (5,234) (5,166) 68

OP First Attendances (19,091) (14,341) (15,002) (661)

OP Follow Up Attendances (20,645) (15,484) (16,316) (833)

Unbundled Diagnostics (2,653) (1,989) (1,989) 0

Audiology AQP Pathw ay 0 0 (551) (551)

Maternity Pathw ay (16,772) (12,494) (12,008) 486

Specialist Rehabilitation (858) (647) (647) 0

KCCG PBR (177,910) (133,491) (139,228) (5,737)

Non-PbR and other (33,094) (24,820) (25,442) (622)

Patient Transport Services (3,134) (2,350) (2,350) 0

CQUIN (5,375) (4,031) (4,031) 0

MFF (568) (426) (436) (10)

KCCG Other (42,171) (31,628) (32,260) (632)

Internal Planning Increase (4,200) (2,909) 1,350 4,259

Total - Core contract income (224,280) (168,028) (170,138) (2,110)

4.1.4 The internal planning increase of £2.9m relates to the Trust’s expectation that activity would be higher than contracted. Of this the Trust expected 80% to relate to non-elective activity and 20% to relate to outpatient activity. As at 31 December, non-elective and outpatient income is over plan by £5.2m with non-elective work relating to 65% of the additional income earned. The Trust is therefore over performing against outpatient activity by more than originally expected.

Notable over performance against planned outpatient income includes Trauma and Orthopaedics follow up work, new Ophthalmology, Paediatric, Audiology, Urology and Breast Surgery work. The following table is a summary of the activity associated with the KCCG income which supports the over performance in outpatients.

Cumulative Cumulative Cumulative

Plan Activity Actual Activity Variance

Activity

(+ is over

performance)

KCCG Activity (*) (*) (*)

A& E 44,835 44,767 (68)

Elective 36,710 37,638 928

Emergency 21,694 23,284 1,590

New Outpatients 97,859 101,926 4,067

Follow Up Outpatients 177,094 181,512 4,418

Maternity Pathw ay 11,036 10,079 (957)

389,228 399,206 9,978 4.1.5 It is important that the Trust continues to monitor underlying income

performance so it can flex expenditure to cope with demand and understand how it is interacting with its income cap.


4.1.6 National Commissioning Board non-PbR income is also higher than planned

which is due to income exceeding income in month by £714k. This was primarily due to critical care and high cost drug income which will be off-set by extra expenditure.

4.1.7 Donated asset income is lower than planned by £302k although is offset by a

technical adjustment in the Trust’s accounts and so has no impact on financial performance.

4.1.8 The Trust’s contract income includes full recovery of CQUIN income totalling

£6.4m (2.5% of total commissioned income). Expenditure 4.1.9 Overall, the Trust has over spent its core expenditure budgets by £3,798k at

the end of month 9 which is an increase of £401k. Clinical divisional expenditure budgets (including divisional income and income earned through higher than planned activity) are overspent by £3,624k in total at month 9 which is an increase of £765k from last month. Given the impact that the over spend will have in 2014-15, tighter control of costs is essential. For 2013-14, the over-spend is being partially offset by the use of centrally managed resources and reduced investment in services. Corporate budgets are below their budgeted level.

4.1.10 On a subjective expenditure basis, at the end of December:

Due to an in-month over spend of £311k, pay is cumulatively over-spent by £524k The total pay bill for December was £17.267m which is £0.75m higher than at the beginning of the financial year and £1.159m higher than December 2012 which is an annual increase of 6.7% although also matched with higher activity levels.

The Trust expected permanent staff costs to increase in the month although the corresponding reduction in variable pay expenditure has not realised primarily because of the use of Bank staff as well as overtime and additional sessions.

Despite staff in post exceeding the funded manpower limit, variable

pay expenditure returned to an over spend of £1.6m in December. This is £75k lower than the peak month of August but is still extremely high with average variable pay expenditure being £0.5m higher than last year.

Non pay budgets over spend increased by £455k to a cumulative figure of £3,257k over spent against a budget to date of £78.7m which in part is due to delays in delivering CIP schemes.

Income budgets within Divisions are £232k over recovered.

Capital charges and centrally managed resources in total are over

spending by £19k.


Staffing Establishment & Staff in Post 4.1.11 The Trust had a funded establishment at the end of the month of December

of 4,935 whole time equivalents (wte), although this include anticipated changes in staffing levels due to the implementation of saving schemes. After adjusting for schemes which have not taken place, the adjusted funded establishment increases to 5,000. There were 4,985 staff in post at 31 December 2013.

4.1.12 The Trust has put in place regular consolidated recruitment programmes for

key staff groups and expects variable pay to reduce as permanent staff are appointed. Whilst the level of vacancies has significantly reduced, this has not yet been reflected by a reduction in variable costs on a consistent basis, although variable pay costs did reduce in November. Including variable staff, the total number of staff in post at the end of December increased by 54 whole time equivalents. This is graphically represented in the following chart.

4.2 COST IMPROVEMENT PROGRAMME 2013-14

4.2.1 The savings target for 2013-14 is c£14m. The cumulative target as at 31

December 2013 is £9,702k.

4.2.2 As at 31 December, £6,621k (68%% of the year to date target) of savings were delivered through original CIP schemes plus £1,383k through additional income schemes (14% of the year to date target). In addition savings of £694k (8% of the year to date target) were achieved through the use of centrally managed resources and slippage in planned investments.

4.2.3 Of the savings delivered through original CIP schemes, £378k (5.5% of CIP achieved) were delivered non-recurrently.

4.2.4 A critical priority for the remainder of the year is to ensure that CIP schemes are delivered as planned or replaced with new initiatives to deliver savings.

4.2.5 The year-end forecast is that savings from original CIP schemes of £9.7m will be delivered which is a reduction from the previously reported figure of


£10.1m. An additional £1.8m will be achieved through income schemes (assumed to be recurrent at this stage) and financial balance will be delivered through c£2.4m of centrally managed resources and management of investments.

4.3 BALANCE SHEET AND CASH ISSUES Cash and working capital 4.3.1 The Trust’s cash balance at the end of December was £8.9m which, is below

the revised cash plan of £13.4m. This variance is due to the profile of capital cash spend and the timing delays between delivering higher income levels and receiving the corresponding cash. The year-end cash forecast remains at £12.6m, depending on the timing of the receipt of cash from commissioners relating to higher income levels.

4.3.2 As part of the Trust’s cash plan the Trust is assuming loan repayments

totalling £1.6m on its historic loan (before interest charges) will be made during 2013-14 and an additional £571k in relation to the new £4m loan. This has been agreed with the NHS TDA although the formal rescheduling of the historic debt is dependent on achieving Foundation Trust status.

4.3.3 The following table shows that the Trust now has net current assets rather than liabilities which is a good example of the continued improvement in financial position.

Continuity of Services Risk Rating

4.3.4 The five financial risk ratings used by Foundation Trusts was replaced by a Continuity of Services rating from 1 October 2013. The Trust has started to report this in shadow form from this month.

4.3.5 The ratios identify that the year to date rating for the Trust is a 3 for the

Liquidity Ratio and a 4 for Capital Servicing Capacity. As the overall score is ‘rounded up’, this provides the Trust with the maximum overall score of 4.


4.4 CAPITAL PRGRAMME AND PERFORMANCE AGAINST CAPITAL RESOURCE LIMIT

4.4.1 Capital expenditure of £17.1m is planned for 2013-14 (including expenditure

matched by donated and other income) which, due to the approval of a new £5m Capital Investment Loan has increased by circa. £1.5m. This is the proportion of the loan that is planned to be spent in this financial year.

4.4.2 As at 31 December, capital expenditure of £9,913k has been incurred against

a plan of £10,064k. The relatively small shortfall in expenditure relates mainly to delays in delivering committed CSDP projects in particular the Surgical Receiving Unit whilst planned expenditure on the Emergency Department is ahead of schedule.

4.4.3 Capital resources are fully committed in 2013-14 and management of costs to

ensure that the plan is delivered, as well as any additional costs covered, is key for the remainder of the year. This position is reviewed regularly and the Trust Board has applied for and confirmation has been received that a £5m capital investment loan will be received. This will help to address in-year cost pressures as well as accelerate some high impact capital investments.

4.4.4 During 2013-14 the following notable capital expenditure will be incurred to

improve clinical effectiveness and enhance care at the Trust:

o Medical Capital Equipment - £1.9m o Improvement of Emergency Department - £2.6m o Reconfiguration of Trelawny Theatres - £1m o Surgical Floor / Surgical Receiving Unit - £1.4m o Expansion of Theatre Direct - £0.5m o Purchase of Digital X-Ray £0.3m o Health informatics developments - £3m

4.5 STATUTORY I&E ACCOUNT, BALANCE SHEET, CASH FLOW AND

DETAILED CAPITAL PROGRAMME 4.5.1 The Trust’s statutory accounting statements for income and expenditure,

balance sheet and cash flows, together with the detailed capital programme, are available on request.


Page 52 of 60

4.6 FINANCIAL RISKS AND MITIGATING ACTIONS 4.6.1 The key financial risks and mitigating actions for the Trust for 2013-14 are as follows:

Financial risk Mitigating action Delivery of recurrent CIP cost reductions and division’s maintaining expenditure within agreed limits.

The RCHT 2018 programme exists to monitor the creation and delivery of savings programmes.

Forecast divisional over spends are continuing to grow

Increases in income and the control of corporate and centrally held budgets exceed the increases divisional over spend. Control of expenditure at individual budget holder level to improve. Communication and training to be delivered.

Activity and subsequently the income due from NHS Kernow exceed the agreed cap. This means that the Trust will be provided activity at a nil cost.

Risks in relation to this were acknowledged at the start of the year. The forecast outturn will be used when negotiating the 2014-15 contract. Ensure that costs can be flexed to expected increases in activity above that included in the Trust’s baseline contract with NHS Kernow

Agency (excluding locum) spend exceeds that forecast

Control agency (excluding locum) spend and use permanent staff where possible. Ensure clear links between variable pay spend and activity levels

Rescheduling historic debt so that the Trust’s liquidity position improves.

Notification has been received that the debt will be rescheduled upon FT authorisation and an attempt is being made to bring this forward.

Continued management of cash to meet loan and PDC repayments and improvement in the Trust’s financial risk rating.

Cash subject to close review and the continuity of services risk ratings have been adopted with the outcomes closely monitored.

4.7 RECOMMENDATIONS 4.7.1 The Board is asked to note the Trust’s financial performance as at 31 December

2013.


SECTION 5: HUMAN RESOURCES

5.1 KEY PERFORMANCE INDICATORS Human Resources Key Indicators Scorecard

Category Performance Indicator Target 2012/13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Trend

HUMAN RESOURCES

Progress vs

Workforce

Plan

Total Staffing WTE 4987 4684 4883 4856 4829 4878 4900 4913 4992 4931 4985

Sickness

Absence

% of contracted staff WTE lost

to sickness3.75% 4.56% 4.17% 4.03% 4.23% 4.17% 3.88% 4.01% 4.23% 4.36% in arrears

Turnover% of contracted staff WTE

turnover10%-14% 11.0% 10.9% 11.0% 11.1% 9.2% 10.7% 10.4% 10.4% 10.2% 10.5%

Mandatory

Training

Proportion of staff completed

mandatory training in last 12

months

80% 80.4% 82.8% 84.8% 84.8% 82.7% 83.0% 82.3% 73.0% 74.5% 74.8%

AppraisalProportion of staff appraised in

last 12 months80% 68.8% 71.8% 72.4% 70.9% 70.1% 70.1% 69.8% 68.8% 66.5% 66.2%

Figure 1: Key Performance Indicator Summary

5.1.1 Total Staffing The total hours worked for the Trust (inclusive of bank, agency and locums) in December was 4985 wte. This is an increase of 54 wte compared to November and within plan. The increase represents 44 wte additional substantive staff and 10 wte in temporary workers. The utilisation of temporary staff during December represents increases in bank use by 1 wte, agency use by 2 wte and locums by 7 wte.

Figure 2: Total workforce profile


During Q3 2013/14 an analysis of starters and leavers by occupational group highlights the success achieved in assessment centre recruitment events for nurses. Figure 3 identifies strong recruitment to nursing posts which represents 25% of all new starters between October and December 2013.

Figure 3: Starters & leavers by occupational group Q3 2013/14 During the quarter to 31 December 2013 92 wte staff left the Trust and 119 wte were recruited.

5.1.2 Sickness Absence

Trust sickness absence increased slightly during November to 4.36% from 4.23% in October. The monthly sickness rate remains below the annual average but is 0.61% above target.


Figure 4: RCHT sickness absence Sickness at this point in the year remains lower however than the same time during the last two years where in November 2011 the rate was 4.47% and in 2012 4.50%. The year to November saw long-term sickness reduce by 0.02% to 2.52% and short-term absence increase by the same amount to 1.87%. The annual sickness rate remained static at 4.39%. The Attendance Management policy is now agreed and will be formally ratified this month January 2014. Revised KPI reports will now follow with a focus on prevention as well as robust performance management in division supported by local action plans. Improved coding of reasons for absence will help drive the prevention agenda under Health and Well Being, ensuring that our current Occupational Health Services are targeting intervention on those causes that prevent our staff from attending work. The first supporting policy for this activity is in draft format entitled “A policy for the management of work related stress”. This will now be widely consulted on across the organisation.

5.1.3 Performance Development Reviews

Compliance for PDR activity in December reduced slightly by 0.3%, to 66.2%. This leaves the Trust 13.8% below its target.

Figure 5: PDR Compliance

Work continues to determine the reasons that this remains below target. We know that when operational activity is high that engagement with performance development reviews is reduced. However, we have also identified that central reporting of activity is not always representative of activity, which is particularly evident through staff survey results that depict 81% of respondents saying that they have received an appraisal in the last 12 months. We are continuing to work with our operational teams to determine the most effective method for reporting locally that will provide improvements in both the accuracy and timeliness of PDR reporting activity.


5.2 LEARNING AND DEVELOPMENT

Compliance in core mandatory training subjects continues to improve following the change in required competencies made in October. This is a marginal improvement in month of 0.3%, although represents a 5.2% deficit against the target.

Figure 6: Mandatory Training Compliance Timeline

The Learning and Development Team have focussed attention on ensuring that session provision matches compliance demand and are assured that this is in place. We will continue to assess the methodologies of delivery to maximise the accessibility without compromising quality of competency achievement. We will continue to liaise with our specialist advisors in Core topics to ensure that we deliver the competencies through a meaningful and relevant medium for staff incorporating RCHT case studies to disseminate learning.

5.3 Staff Engagement The 2013 National Staff Survey Response rate closed at 49%. This year, all staff responding to the survey will be included in the measured results. Previously the results have been based on the returns from a pre-determined sample of 850 staff, which has led to results published for the Trust based on approximately 300 – 350 responses. Whilst this is usually statistically relevant, the 2013 staff survey response will be based on 2537 staff. A report on the results will be brought to the February Part 1 Board meeting.

5.4 FT Membership Update

Membership Update

Public membership is now at 6,069 and the staff membership is at 5,522 (20 opt out members).


A full analysis in line with Monitor requirements is available in the table below. This identifies the number of members the trust has in each category against how many more are needed to match the demographics of 1% of Cornwall and the Isles of Scilly. The numbers in red are those groups under represented.

Number of members

Cornish Population

Percentage

Total 6.069 532,273 1.0%

Age Group

0 - 16 276 37,521 0.7%

17 - 21 527 25,667 2.04%

22+ 5,266 437,828 1.31%

Not stated 0

Ethnicity

White 5,479 495,761 1.1%

Mixed 38 2,297 0.87%

Asian 31 945 0.92%

Black 14 789 1.86%

Other 19 936 2.31%

Not stated 488

Socio-economic Group

ABC1 3,413 188,910 1.83%

C2 1,575 75,072 2.13%

D 309 67,808 0.5%

E 600 68,308 0.9%

Unclassified 172

Gender

Male 2,329 242,235 0.9%

Female 3,729 258,677 1.4%


Number of members

Cornish Population

Percentage

Not stated 11

Disability

Yes 771 113,715 0.14%

No 5,291 418,558 1%

The Trust is aiming for 2% of the Cornwall and Isles of Scilly population, to reach a Public membership of 10,000. This is not required for election purposes, but it is demonstrating good practice for communication and engagement with the local population.

We have continued to recruit within our target areas – disabled, male and lower socioeconomic groups. To do this we have linked with Cornwall People First and Carers Rights Cornwall as they hold forums all over the county. Whilst we have been actively targeting these groups many are reluctant to formally disclose their disabilities. As the carers’ forums are countywide we are planning to engage the local Governors for each area to attend the meetings with us. This would highlight the communication track between public members, Governors and the Board of Directors.

Since the 01.12.2013 we have recruited 41 members. However, 17 public members have requested to leave our membership. As part of our recruitment we are identifying members who have specific communication requirements or interested in specific topics for future engagement. See below for current interests:

Formats Total

Easy Read 159

Large print 22

Health Interest Total

Audiology 8

Cancer 56

Children and Young People

23

Dermatology 24

Dental 9

Diabetes 42

Elder Care 17

Eyes 8

Heart Disease 40

Lung Disease 32

Maternity 12

RCHT Volunteers 59

Hospital Radio 27

Become a Governor 66

Readers Panel 36

Research 52

Fundraising 1


SECTION 6: CLINICAL SITE DEVELOPMENT PLAN

6.1 Update on Progress

The final phase of the Trelawny Surgical Floor, incorporating both the St. Mawes Unit and Pendennis Ward was completed on the 6th December and has been operational since mid-December. The project has resulted in a major upgrade of the existing ward facilities and has been designed to increase sanitary provision for patients as well as improving the facilities to promote privacy and dignity for inpatients. The inclusion of a new assessment/triage area for surgical patients is anticipated to improve the patient experience. The relocation of the surgical wards from the Tower block to Trelawny wing was a key enabler to the Trust’s winter contingency plans enabling a medical ward, the new Frailty Assessment Unit, to be opened on the 27th December in the former Poldark ward in the Tower Block. The final key phase of the Emergency Department expansion was completed just prior to the 20th December enabling the new area to be fully opened by Christmas Day. The completion of this phase of works creating 9 additional modernised trolley bays for majors provides a total number of 22 trolley bay spaces in the department. The works included improved IT facilities within the assessment bays. The project moves a step closer to the Trust fulfilling one of its strategic objectives for achieving a single point of entry and a new “front door”. Works to upgrade Theatre 9 in Trelawny Wing have now been completed drawing to a close the theatre reconfiguration programme. The programme has provided a further two fully integrated laparoscopic theatres increasing the total laparoscopic theatres across the Trust to 5. The Trelawny Theatre upgrade works include the expansion of recovery from 6 to 8 patient spaces which will improve theatre flow. The theatre completion supports the relocation of the Surgical Wards on the top floor of Trelawny Wing. The plan continues with the upgrade of theatre reception areas throughout January and the relocation of the ophthalmology microscope from the Newlyn Unit to Theatre 3 in Tower in spring 2014. Site-wide works being undertaken under the Department of Health grant allocation to improve the environment of care for people with dementia are progressing well, with works complete on the top floor of Trelawny Wing and the new Frailty Assessment Unit. Works are continuing to progress on the medical wards on the first floor of Trelawny Wing. The Trust is one of twenty pilot schemes working with the Department of Health to measure how environmental improvements can improve patient care. The second project allocated grant funding within the programme will see the re-location of Wheal Prosper to the former Surgical Receiving Unit template in the tower block with a full dementia friendly specification and design. The Carbon and Energy Project is progressing with Cofely Workplace (formerly Balfour Beatty Workplace) appointed as preferred bidder. The project is anticipated to reach final closure in spring 2014. The project involves a significant investment in the Trust’s energy infrastructure which will lead to considerable CO2 emission reductions and substantial revenue savings that will be delivered by entering into an energy services performance contract with the company. In return for a unitary payment, which will cover the operation, maintenance and capital repayments, the company will guarantee the savings. Project planning including enabling works, business case development and design development is progressing for a number of projects in the CSDP programme. This includes:


Replacement Linear Accelerator

Pharmacy robot replacement

Endoscopy re-provision

Trelawny Medical Floor (incorporating Stroke/Neurology Unit, Renal, Diabetes & Endocrine Ward and Medical Gastro Ward)

Tower Surgical Wards (Gynae and Urology)

Maternity Services programme, including Neonatal re-provision and Midwife lead Birthing Centre.

6.2 Finance & Assurance

Capital funding of £8.16M was allocated for CSDP Projects during 2013-14 with expenditure of circa £6M achieved to date and projection to meet the full allocation by financial year end. This will result in a further 9 Phase 1 CSDP projects having been completed during 2013-14, leaving 12 projects remaining to complete Phase 1 at an estimated cost of £18.2M.

6.3 Health and Safety

Communication of planned works activities and risk assessments and method statements continue regularly with clinical teams and key internal stakeholders. Improvements in works permits systems have been made and are being implemented on projects (for example, fire compartmentation). Planning of Health and Safety training sessions continues with the objective of engaging design, construction and in-house project teams. Supervision and contractual management of Balfour Beatty (previously Mansell) and their sub-contractors continues, particularly in live areas adjacent to the main construction sites. Careful planning, co-ordination and communication through project groups as well as Operational Management Group (OMG) and Trust Management Committee (TMC) continues to ensure any impacts on clinical services are minimised.

6.4 Stakeholder Engagement

The latest CSDP update will continue to be made available via the ‘One and All’ staff communication and project information, including: programmes, photographs and architectural drawings will be put up adjacent to work areas to help publicise the works taking place. Project specific stakeholder Working Groups continue throughout the design and construction of projects.

Documents

REPORT 1.14.005 (3)€¦ · The report contains information on patient experience. ... 19 19 21 23 23 24 SECTION 3 Operational Performance Summary Scorecards Elective Access Emergency