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Integrated Performance Report Page 1 of 55 26 October 2016

Agenda item:

9.1, Public Board meeting

Date: 26 October 2016

Title:

Integrated Performance Report

Prepared by:

Pete Adey, Operations Director Tracey Cottam, Director of Transformation & Organisational Development Adrian Harris, Medical Director Paul Southard, Acting Chief Financial Officer Em Wilkinson-Brice, Deputy Chief Executive / Chief Nurse

Presented by:

Tracey Reeves, Deputy Chief Nurse / Midwife

Responsible Executive:

Pete Adey, Operations Director Tracey Cottam, Director of Transformation & Organisational Development Adrian Harris, Medical Director Paul Southard, Acting Chief Financial Officer Em Wilkinson-Brice, Deputy Chief Executive / Chief Nurse

Summary:

To advise the Board of the Trust’s performance against key performance standards and targets; and progress on the implementation of the Trust Strategy and key supporting projects.

Actions required:

The Board is asked to receive the Performance Report and note the current risks and the proposed action plans to mitigate the risks against performance delivery.

Status (*): Decision Approval Discussion Information

x

History:

This is a standing agenda item at each meeting of the Board of Directors.

Link to strategy/ Assurance framework:

This paper details the Trust’s performance in respect of key performance standards and targets. Achievement of these performance standards and targets is a key objective within the Trust’s Strategy.

Monitoring Information Please specify CQC standard numbers and tick other boxes as appropriate

Care Quality Commission Standards Outcomes

Monitor Finance

Service Development Strategy Performance Management

Local Delivery Plan Business Planning

Assurance Framework Complaints

Equality, diversity, human rights implications assessed

Other (please specify)


1. PURPOSE

1.1 To advise the Board of the Trust’s performance against the key performance standards and targets.

2. SUMMARY

2.1

During September the Trust saw continued operational pressures in terms of patient flow, which increased towards month end. Against the Trust’s Capacity Plan framework criteria there were 11 days rated green, 10 amber and 11 consecutive days red ending the month. The number of medical outliers increased from around 25 in August to around 40 in September. As would be expected, the period of bed capacity constraints resulted in patient flow challenges and increased pressure on the Emergency Department (ED) with an increase in breaches of the 4-hour A&E standard. ED 4-hr performance also continued to be affected by the system-wide challenges outlined in last month’s Integrated Performance Report (IPR). As a consequence compliance against the 4-hour target was 88.64% excluding the WIC and 90.27% including the Walk In Centre (WIC). An update of progress against the actions identified to improve target compliance is provided on pages 11 and 12, although a broad summary would be that actions are progressing well and an ongoing improvement in performance is expected as these measures are implemented. Specifically, the following actions are now complete:

Honiton Minor Injuries Unit (MIU) transferred to the RD&E on 1st October 2016.

The NHS 111 service transferred to Devon Doctors on Call (DDocs) on 1st October 2016, which has resulted in 14 additional urgent GP appointments for patients being available each week day and 40 each weekend day.

The workforce demand and capacity review has been completed.

All nursing posts required to increase the ED nursing establishment by 1 nurse per shift have been recruited to with new staff commencing between now and January 2017.

Some specialty orthopaedic patients who were required to attend ED with surgical complications are now receiving specialist review in the Surgical Assessment Unit.

There continues to have been no Norovirus or other infection control outbreaks in the month. During September the Trust continued to deliver 7 out of the 9 key cancer targets. At the time of writing this report performance against the Referral to Treatment (Incomplete Pathways) target was in the final process of validation. A verbal update of performance will be provided to the Board of Directors on 26th October.


3. ANALYSIS & KEY ISSUES

3.1

Patient Experience

Latest

month

72

97.2%

Scale

120 ⁻

45 ₋

105% ⁻

80% ₋

| Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | Q4 |

2014 - 2015 | 2015 - 2016 | 2016 - 2017

Low

Medium

Risk for next

3 monthsIndicator

Complaints & Concerns

acknowledged within 3

days

100%

Number of Complaints and

Concerns

Target

line

<70

Complaints & Concerns There were 72 complaints and concerns received during September which is a decrease from August (83). The top themes relate to communication issues and providing and receiving of information. The categorisation process ensures that all aspects of the complaint are captured. While most will have a communication element, our overall level of complaints and concerns is low and there is no concentration in a particular area. Cases referred to the Parliamentary Health Service Ombudsman (PHSO) The PHSO has not requested any new cases for review during September. There were no final reports received in September. Compliments There were 33 written compliments received during September which are mainly for Medical Services and Surgical Services. The main theme relates to staff attitude. Not all compliments and commendations are captured centrally on a monthly basis, but are detailed in the quarterly report reviewed by the Patient Experience Committee. CQAT During September four wards were audited with three achieving Silver and one Bronze. OQAT There was one outpatient area audited during August which achieved Bronze. Mixed Sex Accommodation There were no clinically unjustified single sex accommodation breaches recorded in September. Demonstrating Difference In the last month the mid-year Divisional Performance Reviews took place with the Executive Team and therefore, as planned, no examples of Demonstrating Difference have been formally submitted by the Clinical Divisions. Divisions continue to develop and redesign services as a result of patient feedback, and further examples of Demonstrating Difference will be included in next month’s Integrated Performance Report.


3.2 Safety & Safe Staffing

Specialling requirements across the 3 Divisions totalled 55.0 WTE for the following reasons.

7 x cognitively impaired patients at high risk of falls

3 x patients requiring RMN specialling, one requiring 24/7 specialling for the complete month

1 x Sepsis patient with high acuity

5 x Aggressive patients

2 x patients with neurological trauma requiring enhanced observation Up to 28 additional unplanned escalation beds remained open for 15 days during September requiring an additional 14.2 WTE. This month 18 wards have not met their planned hours at some stage during the month. On all wards the Ward Matron and Senior Nurses reviewed the acuity and dependency of patients and were satisfied having exercised professional judgement that the wards were safely staffed. With effect from next month’s report, further detail will be routinely included as to the volume of occasions that this represents. The Head of Safety, Risk and Patient Experience has commenced the work in relation to the impact of specialling in relation to patient harm. Further validation of the work is required so this will be reported back to the November Board of Directors meeting.


Safety

6 ⁻

0 ₋

1 ⁻

0 ₋

5.8 ⁻

-0.2 ₋

35 ⁻

0 ₋

13 ⁻

6 ₋

175 ⁻

75 ₋

3 ⁻

0 ₋

0.7 ⁻

-0.1 ₋

12 ⁻

0 ₋

115 ⁻

85 ₋

130 ⁻

70 ₋

135 ⁻

75 ₋

Scale

100% ⁻

84%₋

98% ⁻

86% ₋

Summary Hospital-level

Mortality Indicator (SHMI)

Rolling 3 months - Medical

Services

As

expect

ed or

lower

Low



Rolling 3 months - Surgical

Services

As

expect

ed or

lower

Low



Rolling 3 months -

Specialist Services

As

expect

ed or

lower

Low

77.78

83.45

135 ⁻

75 ₋

170 ⁻

50 ₋

180 ⁻

45 ₋



Rolling 3 months

As

expect

ed or

lower

Low



Rolling 3 months -

Weekday Admissions

As

expect

ed or

lower

Low



Rolling 3 months -

Weekend Admissions

As

expect

ed or

lower

Low

140 ⁻

70 ₋

As

expect

ed or

lower

Latest

month

Low

≤0.15 Low

Low

Low

Low

Low

Low

Low

≥90%

0

2014 - 2015 | 2015 - 2016 | 2016 - 2017 Risk for next

3 months | Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | Q4 |

0.15

Low

Low

Low

Low

E-coli Bacteraemias (Trust

apportioned)

MRSA Bacteraemias (Trust

apportioned)

≤5

IndicatorTarget

line

National Summary

Hospital-level Mortality

Indicator (SHMI) - Rolling

12 months

≤2

Rate of Grade 3- 4 pressure

Sores /1000 bed days

NRLS moderate, major or

catastrophic incident

count

MSSA Bacteraemias (Trust

apportioned)

Rate of Grade 1- 4 pressure

Sores /1000 bed days≤1.5

NRLS incidents /100

admissions

Inpatient Slips, Trips and

Falls≤160

Safety Thermometer – Harm

Free Care≥90%

≤10

≤30

Safety Thermometer –

Absence of New Harm

Clostridium difficile cases

(Trust apportioned)

Trajec

tory

6

8.8

129

98.0%

93.3%

0.00

3

0

1

7

101.63

98.45

96.36

105.85

105.07


Infection Control Clostridium difficile The number of cases of Clostridium difficile is below trajectory to the end of September. Each case is investigated using the principles of root cause analysis to determine whether there were any lapses in care that contributed to the acquisition of the infection and thus whether the incidents were avoidable. All of the Q2 investigations have been concluded and agreed with the CCG lead for healthcare associated infection as unavoidable.

MRSA There have been no hospital apportioned MRSA bacteraemia (blood stream infections) for 5 years and this has been celebrated with communications made internally and externally.

E.coli Twenty four E.coli bacteraemia were identified in September and, unusually, seven of these are hospital apportioned having occurred more than 48 hours after admission. This is within normal variation and over Q2 in totality the number of cases is below the trajectory. Six of the incidents have been investigated and conclusions drawn. One which occurred at the end of September is still being investigated. Of those investigated, the urinary tract was identified as a possible source for the bacteraemia for three patients. Two of these had urinary catheters in place. No lapses in care were identified. Catheter care appears to have been appropriate in hospital and no learning was identified. However, the two cases occurred on the same ward so the Infection Control Team will be keeping a close watch of catheterised patients in that area. Influenza Planning Influenza vaccination has commenced and was so successful in the first 10 days that pharmacy supplies were exhausted before the next delivery arrived. This meant that there was one day when vaccine was not available but peer vaccination recommenced immediately following delivery. Serious Incidents & Coroner Reports There have been no Never Events or Coroners reports to the Trust during September. General Medical Council Concerns There were no cases referred to the GMC during September; nor did the GMC raise any concerns with the Trust.


3.3 Clinical Effectiveness

100% ⁻

69% ₋

100% ⁻

60% ₋

100% ⁻

60% ₋

100% ⁻

65% ₋

101% ⁻

54% ₋

100% ⁻

84% ₋

100% ⁻

80% ₋

100% ⁻

75% ₋

100% ⁻

60% ₋

94.7%

94.5%

100% ⁻

90% ₋

100% ⁻

75% ₋

| Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | Q4 |

≥90%

≥90% Low

Low

Low

Low≥90%

Risk for next

3 months

High

High

Low

Medium

High

High

Medium

2014 - 2015 | 2015 - 2016 | 2016 - 2017Scale

Antimicrobial prescribing -

Indication specified on the

drug chart


Empirical therapy as per

guidelines

Trajec

tory

≥90%

VTE Thromboprophylaxis -

% of surveyed patients with

appropriate prophylaxis

≥90%

MUST General - % of

patients screened for

Malnutrition on weekly

review

MUST Triggers actioned

(High Energy Menu)


Duration specified on the

prescription

IndicatorTarget

line

Trajec

tory

≥95%

Surgery within 36hrs for

Patients with a Fractured

Neck of Femur (excluding

medically unfit)

≥90%

Trajec

tory

MUST Initial - % of

patients screened for

Malnutrition within 48hrs

of admission

% of Stroke Patients

spending ≥90% of their

time on a Stroke Unit

≥80%

VTE risk assessment - % of

eligible admissions

assessed for risk of VTE on

admission

MUST Triggers actioned

(Food Record Chart)

Latest

month

69.4%

82.5%

78.8%

88.1%

92.4%

96.0%

93.5%

100.0%

98.4%

Time to Surgery for Patients with a Fractured Neck of Femur In Sept, 69.4% of Fractured Neck of Femur patients received surgery within 36 hours, which is 10 patients fewer than required to meet the 90% target. There has continued to be a significant volume of Trauma Admissions throughout September. Eighteen elective patients were cancelled in September to accommodate Trauma patients. Trauma theatre capacity is an issue; therefore the feasibility of an additional Fractured Neck of Femur list on a Saturday has been scoped and this proposal has subsequently been approved to commence from November 2016, as part of the winter plan. An exception report detailing the actions taken and those planned to address performance is included on page 42. Antimicrobial prescribing – compliance with duration and indication on the drug chart, and compliance with guidelines Trust wide figures for antimicrobial prescribing compliance in September were: 78.8% (238/302) for inclusion of a duration on the drug chart; 88.1% (266/302) for inclusion of an indication on the drug chart; 92.4% (171/185) for guideline compliance.


Proportion of Eligible Admissions Assessed for Risk of VTE on Admission The reported proportion of eligible admissions assessed for the risk of VTE on admission in July (94.6%), August (95.1%) and September (94.7%) remains a provisional position only. It is anticipated that the actual performance is likely to improve following further data validation prior to submission of the national return. The final position will be reported in next month’s Integrated Performance Report.


3.4 Operational Effectiveness

Risk for next

3 months

Low

Low

Low

Low

Low

≥95%

A&E: maximum waiting

time of 4hrs from arrival to

admission/ transfer/

discharge (including WIC)

≥95%

Maximum time of 18 weeks

from point of referral to

treatment in aggregate -

Non-admitted

≥95%

Scale

98% ⁻

88% ₋

99% ⁻

90% ₋

High

High

Medium

Medium

Low

Ambulance Handovers

Delayed >30 mins

Trajec

toryMedium

60 ⁻

0 ₋

97% ⁻

83% ₋

100% ⁻

92% ₋

98% ⁻

86% ₋

1.8% ⁻

0% ₋

30 ⁻

-2 ₋

100% ⁻

85% ₋

101% ⁻

81% ₋

100% ⁻

86% ₋

101% ⁻

79% ₋

101% ⁻

91.5% ₋

101% ⁻

96% ₋

Not Set

0




Incomplete Pathways

≥92%




Admitted

≥96%

≤0.8%

Patients not treated within

28 Days of same day

cancellation due to non-

clinical reason

31 Day Wait for Second or

Subsequent Treatment (All

Cancers) - Anti-cancer drug

treatments

14 Day Wait from referral

to date first seen (Cancer) -

Symptomatic Breast

Patients

≥93%



Cancers) - Radiotherapy

Same Day Cancellations

for non-clinical reasons as

a proportion of elective

admissions

96.33%

97.96%

96.79%

Not Set

≥94%

High

2014 - 2015 | 2015 - 2016 | 2016 - 2017

≥94%

Target

line | Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | Q4 |

A&E: maximum waiting

time of 4hrs from arrival to

admission/ transfer/

discharge (excluding WIC)

14 Day Wait from referral

to date first seen (Cancer) -

All Urgent Referrals

≥93%

31 Day Wait from

Diagnosis to First

Treatment (All Cancers)

Indicator

≥90%

≥98%



Cancers) - Surgery

Latest

month

88.64%

90.27%

19

85.94%

96.44%

92.07%

0.24%

0

94.44%

98.52%

100.00%


Medium

High

Medium

Medium

Medium

101% ⁻

70% ₋

101% ⁻

80% ₋

100% ⁻

70% ₋

≥85%

≤10% Not Set

45% ⁻

0% ₋

79.3%

≥90%

Outpatient Appointment

Unavailability (ASIs)

62 Day Wait for First

Treatment (All Cancers) -

Consultant Upgrade

Not Set

Not Set

Low

High

High

101% ⁻

92% ₋

80 ⁻

0 ₋

9% ⁻

0% ₋



Urgent GP Referral

≥85%



key diagnostic test

≥99%

Median average number of

patients 'Reportable as a

Delayed Transfer of Care'

on Community Waiting List

≤30

30 Day Emergency

ReadmissionsN/A

Adult Inpatient Average

Length of Stay (excluding

Maternities)

N/A

Medical Bed Occupancy

Surgery Bed Occupancy

Trauma & Orthopaedics

Bed Occupancy

≤90%



Screening Service Referral

≤95%

≤95%

6 ⁻

4 ₋

99% ⁻

85.5% ₋

100% ⁻

75% ₋

100% ⁻

75% ₋

89.68%

82.76%

82.69%

15.8%

97.5%

69

5.0%

5.3

95.3%

91.4%

Delayed Transfers of Care (DTOCs)

Whilst there is not a specific target for DTOCs, the impact of patients medically fit to be discharged who occupy inpatient beds underpins the achievement of a number of key performance indicators, most notably the A&E 4-hour target. Consequently, a great deal of management attention has been placed on working with partner organisations to reduce DTOCs and increase the system capacity for community and domiciliary care. The volume of recorded patients awaiting onward care has reduced from the peak of 92 in July down to a daily average of 69 during September. In total during the month there were 1866 bed days taken up by “delayed transfers of care” (DTOC), which represents approximately 9% of the general and acute inpatient bed stock of the Trust. However, a change in the data collection process by one of the key providers of packages of care is currently being discussed as this may be overstating the reduction. As shown in the table below, the main reasons for delays are unchanged, with the majority of patients being delayed for three key reasons, as shown in the table below.

Reason % of DTOCs

Awaiting further non acute NHS care 47%

Awaiting completion of assessment 27%

Awaiting care package in own home 19%


A&E Maximum Waiting Time of Four Hours from Arrival to Admission, Transfer or Discharge (excluding Walk In Centre activity)

A detailed report on performance against the A&E maximum waiting time of 4 hours was provided to the Board of Directors in August 2016. This report therefore provides a summary of September’s performance and an update on the actions previously described. Performance for the month excluding the WIC was 88.64%, compared to 89.04% in August 2016. The position including the WIC for September 2016 was 90.27%, compared to 90.57% in August 2016. The full quarter position in respect of the Monitor target is 91.42%. Update on actions planned to improve performance Although performance for September remained challenging, and did not meet the Sustainability & Transformation Fund trajectory of 95.0%, implementation of the action plan in place to improve compliance is progressing well. The table below provides an update of the key actions outlined in the August IPR.

Issue Action Timescale Update

MIUs The RD&E is engaged in work to consider how the Trust can support the provision of some MIUs, commencing with Honiton MIU in October.

October 2016

Successful transition of Honiton MIU to ED on the 1

st October

WIC NDHT have committed to the provision of a full service for the WIC from 31

st

October 2016.

31/10/2016 On track.

Date to reinstate original opening hours remains 31

st

October 16

111 The service is transferring to Devon Doctors from 1

st October, after which

improvements are anticipated.

01/10/2016 Transition complete. Devon Doctors also offering directly bookable GP appointments in hours Mon-Fri (14 per day) and Sat and Sun (40 per day)

Psychiatric Liaison

These complex issues are being explored via the Trust Operational Capacity Group and at a system wide level via the System Resilience Group (SRG). At present a long term solution has not yet been identified. In the short term, daily review of all psychiatric patients is in place, with rapid escalation of issues as appropriate.

December 2016

Short term operational mitigation measures continue.

The current mental health bed capacity issues have been further escalated to Devon Partnership Trust and NEW Devon CGG. A senior officer meeting was held on 11/10/16 to consider the current risks and issues and further mitigation actions, however, a longer term action plan has yet to be agreed with partner organisations.

ED Medical staffing

Full review of workforce shift pattern vs. patient demand

Recruitment to existing medical vacancies (SHO and Middle Grade level.) 2.5 out of the 4.5 vacancies have now been filled.

Extension of the “Minors Consultant” (temporary extension, until 31/12/2017)

Introduction of ‘See and Treat’

01/10/2016

01/10/2016

31/10/2016

Complete

1wte SHO and 1wte MG vacancy remain. There is an on-going recruitment process.

Twilight shifts are provided


twilight shift

Consultant establishment demand and capacity review in progress

01/09/2016

whenever possible. GPSI roles currently being explored to help fill twilight shifts on a more regular basis.

Complete

ED nurse staffing

An increase to nursing establishment of 1 additional registered nurse 24/7 has been agreed. Recruitment has commenced.

December 2016

Interviews took place on 11/10/16. All posts filled.

Medical staffing issues in surgical specialties

Detailed planning has been implemented to ensure that medical staffing resources are prioritised and deployed in order to support ED and the care of urgent patients. Further work is ongoing to reduce vacancies during the next round of recruitment for junior medical staff.

12/09/2016

November 2016

Complete.

Work is on currently on track.

Specialty patients

Remove all GP referred expected patients from the ED (Specialist Surgery and Orthopaedics)

01/12/2016

New pathway for septic joints has started.

Plan to remove ENT expected patients from 01/11/016. No dates set yet for other specialties.

Future trajectory Implementing the system-wide action plan summarised above, will be complex and in part reliant upon partner organisations contributing to resilient performance against the 4-hour target. The actions will be completed by the end of Q3 however, given the expected seasonal increase in demand for urgent care services in Q4, it is forecasted that sustainable achievement of the 4-hour target will be delivered from Q1 2017/18. Ambulance Handover Delays In September there were 19 delays greater than 30 minutes and no delays over 60 minutes. This is compared to 14 handover delays greater than 30 minutes and one delay over 60 minutes in August. Work to reduce handover delays continues through monthly meetings with South Western Ambulance NHS Foundation Trust (SWAST) and the regional ambulance handover delay workshops. Cancer Waiting Times Performance

During September, the Trust sustained good performance against the two week wait and 31-day cancer targets and is forecast to achieve seven of the nine cancer targets for the month, as shown in the table below. The Trust continues to be challenged in the delivery of the 62-day GP referral standard and has failed to achieve the 62-day target from consultant screening for the month. For quarter two the Trust is likely to achieve at least 7 of the 9 cancer standards as detailed in table two below. Further validation on the Consultant upgrade target is being undertaken, and a verbal update will be provided at Board.


Performance for September 2016

Standard Required

Performance (%)

Actual

Performance

(%)

Number of Patients

in Excess of the

Threshold*

62 Day Wait from Urgent GP

Referral to First Treatment

85 82.69 5

62 Day Wait from Consultant

screening service to First

Treatment

90 82.76 3

Performance for Q2

Standard Required

Performance (%)

Actual

Performance (%)

Number of Patients

in Excess of the

Threshold*

62 Day Wait from Urgent GP

Referral to First Treatment

85 79.58 32

62 Day Wait from Consultant

upgrade service to First

Treatment

85 84.87 1

*Please note these numbers relate to volumes of patients in excess of the threshold. Data as to the total volumes of patients who were not treated within the target timeframe are detailed in appendix 8.

Urology Pathway - Performance against the 62-day standard In September 17 of the 39 patients that breached were within Urology, with the main areas of delays including histopathology capacity, patient choice and outpatient capacity. Four of the breaches (reflecting 8 patients) were late tertiary centre referrals. The pathway for tertiary referrals is being reviewed in order to eliminate avoidable delays. The Urology team continues to work through the comprehensive action plan to support the recovery of the 62-day pathway. Colorectal Pathway – Performance against the 62 day standard All of the five patient breaches of the 62 day consultant screening target during the month of September were within the Colorectal service. Of these, two had other cancers and required investigation and treatment prior to treatment for their colorectal cancer. A further two others were referred to the Colorectal team at days 47 and 131 due to patients choosing to wait longer for the date for their colonoscopy. The Colorectal team has experienced unforeseen staffing issues in September with one consultant on long term sickness absence, as well as shortfalls in junior medical staffing. This has impacted on elective activity for both for “two week wait” outpatient and operating capacity. Cancer performance summary With the progress being made in implementing the cancer plan, it is forecast that 62-day cancer target performance will continue to improve towards the achievement of the 85% threshold throughout Q3. Diagnostic Test Waiting Times Performance


At the end of September there were 134 patients (equivalent to 2.5% of the waiting list) waiting longer than 6 weeks for a key diagnostic test, against a target of no more than 1%. This is 34 patients in excess of the Trust’s recovery trajectory for September of 1.7%. Diagnostic performance remains challenged in Endoscopy, Cardiac MRI and Urodynamics (44, 47 and 30 patients respectively).

Diagnostic Test Volume of patients waiting

longer than 6 weeks at the end

of the month

Change in volume of patients

waiting longer than 6 weeks

from previous month

Endoscopy 44 Decrease of 1

Cardiac MRI 47 Decrease of 4

Urodynamics 30 Decrease of 2

Sleep Studies 19 Decrease of 1

Aggregate Across all 15 Key

Diagnostic Tests

134 Decrease of 14

Endoscopy At the end of September there were 44 patients waiting longer than 6 weeks for an endoscopic test compared to a trajectory of 25. The number of patients waiting over 6 weeks for an endoscopic diagnostic test has remained static at 44, which is 19 above the remedial recovery plan for the position at the end of September. 28 of these patients chose to wait longer than the 6 weeks; however this cohort of patients is still counted within the 6-week wait benchmark in line with national guidance. The Medicine Division has met with the CCG to discuss the original remedial recovery plan and to review the CCG’s referral management actions. The remedial action plan is being revised following the outcome of the meeting. Cardiac MRI The number of patients waiting longer than 6 weeks for a cardiac MRI at the end of September was 47 compared to a trajectory of no more than 51. Following the above meeting with the CCG there will be a revision made to the remedial action plan for all modalities including Cardiac MRI. Urodynamics There were 38 Urodynamic breaches in September. Clearing the backlog remains a challenge due to long term sickness, with two of the four specialist nurses absent from work for a prolonged period, which has presented a significant challenge to the management team. In order to manage the staffing shortfall, a 4 week programme of training has commenced for a bank member of staff to cover the lists and an additional nurse specialist is due to start in November. An additional member of staff has been appointed and is due to commence working in January 2017. From 18th October 2016, the department will be reinstating an additional list, giving capacity for 5 patients per week, with a second list planned during November. Assuming there is no further sickness in this small team, it is anticipated that Trust will regain full


compliance with this test from January 2017. Sleep Studies At the end of September there were 19 patients waiting longer than 6 weeks for a sleep study, a slight decrease from the end of August. The increasing number of long waiting patients is due to capacity constraints caused by workforce shortages due to high levels of sickness in a small, specialist team. Additional clinics have been established in order to ensure that all patients are treated within the required 6-week timescale. 18 Weeks Referral to Treatment

At the end of September one patient in General Surgery had waited longer than 52 weeks for treatment. The patient, who required a complex procedure jointly undertaken with Gynaecology, was offered a date for their procedure within 52 weeks of referral but chose to delay their operation. A date has now been agreed for surgery to be on the 28th October 2016. This patient has been clinically reviewed and the delay has not resulted in harm to the patient. At the time of writing this report, validation in respect of September’s RTT incomplete pathways position (in aggregate) remained ongoing. A verbal update will be given to Board members at the September Board meeting.


3.5 Workforce

80.5%

85.2%

3.7%

Latest

month

13.0%% 12 Month Turnover10-

12%

Scale

90% ⁻

70% ₋

100% ⁻

50% ₋

5% ⁻

2.5% ₋

13% ⁻

6.5% ₋

% PDR completed ≥80%

Average % Statutory

Training Compliance 75%

Sickness absence – Overall <3.5%

| Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | Q4 |

Low

Low

Medium

Medium

IndicatorTarget

line

2014 - 2015 | 2015 - 2016 | 2016 - 2017 Risk for next

3 months

Overall the key performance indictors relating to workforce are mainly within expected thresholds although sickness and turnover remain challenging. The environment both externally and internally remains challenging and potentially unsettling for staff and this will contribute to these indicators to some extent. Communications including the Executive briefing sessions have been well received. We continue to support managers in identifying underlying causes of sickness and turnover and in improvements to help address issues found. The following provides an overview of performance against the agreed workforce indicators and, where appropriate, has identified the factors affecting performance together with a summary of the actions underway to improve current performance. Statutory Training Compliance The overall statutory training compliance rate for September is 86.9%. Compliance rates across the core safeguarding areas of Child Protection (levels 2 and 3), Safeguarding Adults and Mental Capacity Act remain at an average of 87.5%. We continue to focus on contacting those staff whose training record on ESR indicates that they have not received training in one or more of the statutory or mandatory subjects with an emphasis on the core safeguarding areas. Overall there has been an improvement with 448 trainings completed. Sickness Absence Sickness levels for the month decreased slightly from 3.83% in August to 3.74% in September with the 12 month rolling rate remained at 4.1%. Absence rates for all staff groups have improved this month with the exception of Admin and Clerical staff where the rate has increased from 3.9% to 4.2% with Mental Health related sickness absence attributing to the majority of this increase. During September 57 long term cases were closed and 42 opened with these cases continuing to be managed in accordance with the Attendance Policy. The Divisional and Support function management teams continue to review and implement improvement actions and in addition to stabilising absence rates have resulted in continuing improvements in the number of return to work interviews being completed and the number of sickness episode with no reason recorded. Mental health related sickness absence dropped in September and accounted for 25.86% of the monthly sickness absence total. This saw a drop in 184 WTE days in comparison to August. A ‘Deep Dive’ into this absence type is currently being undertaken and will be reported back in November.


Work progresses in executing the Health & Wellbeing Agenda, which this year includes specific actions to support the CQUIN aimed at improving staff Health & Wellbeing. The first group session ‘Mindfulness for Staff’, which is being delivered by the Staff Support & Counselling staff, will commence on 11th October along with the Stress Management training, which will also recommence in October 2016. It is also planned to deliver Mental Health First Aid courses for staff; all of this activity has the intention of focussing on improving staff mental health with the overall aim of reducing staff sickness absence as a result of mental health issues. Bank, Overtime and Agency Usage The total amount paid to Bank workers has risen this month with increases particularly in registered (£66,000) and unregistered nursing (£42,000). From the beginning of September bank nurses are able to register their availability on RosterPro from their home and it is anticipated this will lead to further increases in the number of shifts filled by them. Agency costs have reduced from £515,117 to £459,077 this month. In the first half of the year, total agency expenditure for the Trust amounted to £2.9m (£469k in September) and is forecast to be £4.6m by year end (excluding community services). This forecast position is favourable position compared to the NHS Improvement ceiling of £608k per month (£7.3m for the financial year) and the RD&E internal target of £5.7m. The number of Agency breaches reported in the weekly submission to NHS Improvement increased slightly during this month to an average of 132 per week. This included small increases in nursing, medical and admin & clerical agency usage with the majority being price cap breaches. Off framework usage is extremely low now with the occasional shift required to meet specialist nursing demand. Price caps still remain challenging. We are developing relationships with Agencies committed to supporting us to meet our demand within the price cap rules and positive outcomes are expected within the next 3 months. Negotiations with those agencies refusing to agree to meet the 1st April cap rates continue as a STP with further meetings arranged in the coming weeks. Communications and support for managers including the new Trust Agency protocol published on our external website, has been has been well received, in particular the guidance covering unsolicited contact. Staffing Numbers and Turnover The total number of contracted staff has increased to 5911 FTE and remains below the agreed funded establishment, providing assurance to the Board that the Trust has not contracted over and above its financial workforce commitment. At the end of September vacancies for band 5 registered nurses reduced to 26 FTE. There were 9 FTE unregistered nurse vacancies. These levels remain low when compared to neighbouring Trusts and in this challenging environment. We remain focused on recruitment of both registered and non-registered nurses through a range of initiatives. We have organised attendance at the Nursing Times event in London during November (in conjunction with other local Trusts) to promote the benefit of working/living in Devon to encourage those contemplating a move to relocate to the area. Work is being completed through the Workforce Governance Committee to provide assurance that the resourcing strategies in place for all ‘hard to fill’ roles e.g. consultants in certain specialities, radiographers and other specialist therapy & scientific roles are effective.


The annual turnover rate for all staff groups has increased again slightly to 13.0%, and is above the Trust target. With regards to the stability of the workforce, however, our annual stability rate has increased to 89.5% very close to our target of 90% indicating that although a higher number of staff are currently leaving than planned, the workforce in its entirety is still stable. Last month the number of staff leaving with less than a years’ service was in line with our expectations. With regards to staff retiring, 12 staff retired during September which, after the significant reduction last month, is in line with the predicted monthly average of 11 per month which has been at this rate for the least 3 years. Although turnover has been stable this month, nursing both registered (14.9%) and unregistered (16.6%) remain challenging. The number of staff returning to their country of origin has slightly increased this month but the indication is still that the decision to exit the EU does not seem to have had an immediate impact. This and other potential impacts resulting from the Brexit vote continue to be closely monitored. Turnover within the AHP staff group continues to recover and further reduced to 15.3% from 16.6% last month. Recruitment plans have been successful and continue to be monitored via the Nursing/Midwifery and AHP Workforce Strategy Group.


3.6

Finance Overview

At the end of September a deficit of £882k has been incurred compared to a budgeted deficit of £1.2m, an improvement of £917k compared to last month’s report. The in-month position has deteriorated by £835k compared to the planned deficit movement during September. This is mostly due to a worsening of income offset with reduced expenditure and slippage on committed Trust reserves. The Trust is currently forecasting a deficit of £6.6m which is in line with budget and the Annual Plan and similar to last month’s report. The forecast income position has deteriorated by £1.2m offset by expenditure improvements and slippage on committed Trust reserves. The Trust’s Financial Sustainability Risk Rating (FSRR) set by NHS Improvement (NHSI) is currently at a level of 3 and is expected to reduce to a 2 by year end. The single oversight framework has set a new “finance and use of resources score” to replace the FSRR with effect from 1st October 2016. The metric assesses five key financial metrics (capital service capacity, liquidity, I&E margin, distance from financial plan and agency spend) and scores providers between 1 (best) and 4 against each metric. As at month 6 the Trust is at a level 2 and is expected to reduce to a 3 by year end. The Eastern Community Services income and expenditure position is forecasted to break even. Income Clinical income (including private patients) at the end of month 6 is under-recovered by £1.6m, a deterioration on last month’s report of £1.0m. Clinical income is forecast to under-recover by £1.0m at year end, a deterioration from last month of £1.2m. The main Divisional over/under performances are;

Surgical Services has underperformed by £4.3m year to date, a deterioration of £1.1m in Month 6. This relates to Orthopaedics (£344k due to further bed pressures), Intensive Care Unit (£207k), General Surgery (£193k consultant leave / junior doctor shortages),

YTD Month 6 YTD Month 5 Change

£’000 £’000 £’000

I&E year to date -882 -1,799 917

I&E forecast -6,565 -6,589 24

I&E year-end forecast variance to budget/plan

32 8 24

Total income variance to date -1,621 -593 -1,028

CIP variance to date 229 327 -98

Pay expenditure variance to date 658 680 -22

Non pay (excl. R&D) expenditure variance to date

737

605

132

Cash at month end 5,813 12,248 -6,435


Ophthalmology (£147k consultant maternity leave/case mix) and a Work In Progress movement (£184k). The division is forecasting at year end an under recovery of income of £4.6m, a deterioration in the month of £1.5m mostly relating to Orthopaedics (£656k), Intensive Care Unit (£207k), General Surgery (£201k), WIP movement (£184k), Rheumatology (£123k) and Plastic Surgery (£103k).

The Medicine Division is currently over recovering by £850k year to date, a favourable movement in the month of £224k. This mostly relates to improvements for General Medicine (£232k) and Healthcare for Older People (£178k) offset with a deterioration for Cardiology of £157k. Medicine is forecasting an over-recovery of income by year end of £2.5m an improvement of £281k in September. This mostly relates to improvements for Healthcare for Older People (£323k) and General Medicine (£125k) offset with a small deterioration in a number of specialities across the Medicine division.

Specialist Services have over performed by £601k, a similar position to last month. Cancer and Diagnostics have over performed by £543k and £409k year to date, offset with under recoveries in Women and Children’s Health (£260k) and Professional Services (£91k). The Division are forecasting an over recovery of £1.4m, an improvement of £328k in the month, relate to improvements in Clinical Genetics (£92k), Medical Oncology (£75k), Pharmacy(£69k), Radiotherapy (£53k) and Neonatology (£49k).

Other clinical income has deteriorated by £126k to an over recovery of £1.3m year to date which is mostly related to an adjustment to reflect a fixed NEW Devon contract value (£1.7m) offset with a reduction in the sustainability and transformation fund of £437k (as outlined below).

Commercial income is on budget year to date and forecast to be over recovered by £38k by year end. The Trust is planning to receive £9.8m of Sustainability and Transformation Funding for the year, in line with guidance. The table below sets out by quarter the planned amount recoverable on each of the 4 main criteria. Income has been reduced by £125k due to not meeting the 62 day cancer access standard in quarter 2, and a further £83k has been anticipated in quarter 3 (month 7 and 8). Also in quarter 2 the Trust has failed the A&E access standard which has meant a further income reduction of £313k.

16/17 STF Funding Quarter

1 Quarter

2 Quarter

3 Quarter

4

Total

£000 £000 £000 £000

£000

RTT Plan 313 313 313 313

1,250

Forecast 313 313 313 313

1,250

Cancer Plan 125 125 125 125

500

Forecast 125 - 250 125

500

A&E Plan 313 313 313 313

1,250

Forecast 313 - 625 313

1,250

Finance Plan 1,750 1,750 1,750 1,750

7,000

Forecast 1,750 1,750 1,750 1,750

7,000

-

Overall Plan 2,500 2,500 2,500 2,500

10,000

Forecast 2,500 2,063 2,937 2,500

10,000

The Trust is planning to submit an appeal to retain STF income relating to both cancer and A&E targets. Cancer mitigations are due to an increase in cancer referrals with 16.7% growth overall and referrals in key cancer specialties such as Urology up by 33%. A&E attendances have increased beyond the Trusts control due to closures of local Minor Injury Units, 44% increase in ED referrals from the 111 service due to service provider issues, unplanned cessation of evening


working at the local walk-in centre and a 39% increase in psychiatric patients attending ED due to

local service changes. The Trust will also discuss this position with NHSI. The forecast assumes the appeal will be successful and there will be no income loss relating to the STF. Expenditure Pay has underspent by £658k year to date, a similar position to last month and is forecast to end the year with an underspend of £382k. The forecast pay position deteriorates from the year to date position by £276k due to additional expenditure being required to catch up on activity (particularly within the Orthopaedic and Cardiology specialities) and there will be increased costs to cover known sickness, maternity, rota changes and an increase in Cardiology medical staffing posts. In the first half of the year, total agency expenditure for the Trust amounted to £2.9m (£469k in September) and is forecast to be £5.9m by year end (including £1.3m for agency use in the community from 1st October). This position is favourable to the NHS Improvement ceiling of £8.3m for the financial year, including an increased agency ceiling for the community of £1.0m. Work continues to improve this position further. Non-pay expenditure at the end of September is £737k underspent, improving by £132k in August, which is mostly related to an activity related reduction in medical and surgical expenditure. Non pay is forecast to end the year with an underspend £60k, an improvement of £201k in the month. The deterioration forecast in non-pay in the second part of the year is mainly related to the additional clinical activity expected to be undertaken in the second part of the year. Cost Improvement Programme (CIP) The total target for 2016/17 is £12.2m which consists of the 2016/17 target of £11.5m in addition to CIP schemes that were planned to be achieved in 2015/16 of £0.7m brought forward. Current Year £8.0m of the £12.2m target has been achieved with £565k being achieved in month 6. Plans are in place for £2.6m of the remaining £4.2m with £1.5m unidentified. Schemes continue to be identified and developed via Divisions and Trust wide schemes and the Trust is currently forecasting to deliver by year end. Recurrently Schemes totalling £4.5m have been achieved on a recurrent basis against the target of £12.2m with £70k having been achieved in month 6. Plans are in place for £3.4m of the remaining £7.7m with £4.3m unidentified, however following recent discussions a number of ideas have been generated and are currently being developed and agreed with relevant managerial leads. There is a risk that the full year CIP target might not be met. The success regime saving targets are currently being finalised for Bed Based Care and Planned Care groups in conjunction with our partner organisations prior to being reflected in contracts. Property, Plant and Equipment Actual capital expenditure for the six month period ended September 2016 was £2.1m, £2.2m lower than the budget (£4.3m). Total forecast capital expenditure for the year is £12.7m, compared to £12.4m per the plan. The


increase in forecast expenditure of £319k relates to schemes slipped from 2015/16, and new charitable / grant funded schemes, totalling £803k, including £340k of expenditure for the 100K Genomes scheme. The additional expenditure has been offset by £484k of 2016/17 schemes which have been deferred to 2017/18. Receivables Trade and other receivables are £5.7m higher than plan. NHS Trade receivables are £5.7m higher than estimated, including £2.1m of Sustainability and Transformation funding not yet received due to timing of the payment. The remaining variance mainly relates to accrued income being higher than expected and overdue receivables including amounts due from SW Specialist Commissioners relating to activity in months 1 to 5 of 2016/17. Payables Trade and other payables are £345k higher than plan. NHS Trade Creditors are £1.1m higher than plan, including charges relating to community theatres, not included in the plan, as the plan assumed that we would be operating those services from 1 June 2016. Other creditors are £563k lower than plan, mostly relating to payroll creditors relating to community theatre staff, not taken on until 1 October 2016. Other Financial Liabilities are £1.4m lower than plan. The plan included an estimated increase in accruals to assist liquidity, not reflected in the actual results to date. Cash The cash balance is £5.8m and is £570k lower than plan and £3.5m lower than budget. The decrease in cash is mainly due to changes in working capital balances, in particular Trade Receivables being higher than planned (as outlined above), offset by the under spend to date on capital expenditure, and the income and expenditure deficit to date being lower than planned. The forecast cash balance at the end of the financial year is estimated to reduce from £6.7m to £5.2m. The reduction is mostly due to the value of trade receivables being higher than planned due to the uncertainty as to when the Sustainability and Transformation funding will be drawn down.

3.7 Leadership and Governance

CQC

The Care Quality Commission (CQC) has issued the Trust with a new Certificate of Registration to reflect the new services which the Trust now provides following the transfer of community services on 1st October 2016. Duty of Candour There were 25 incidents involving patients graded with an actual impact of moderate, major or catastrophic closed between 1st April 2016 and the 30th June 2016. All incidents met the Duty of Candour requirements.

3.8

Regulatory and Contractual Position As a result of the performance reported in Section 3, the following is anticipated: NHS Improvement On the basis of performance in month 6, two NHS Improvement targets have not been achieved


for the quarter.

Maximum Waiting Time of Four Hours from Arrival in A&E to Admission, Transfer or Discharge. Performance including the Walk in Centre of 90.27% in September compared to a target of 95%. The position for Q2 is 91.42%. This represents the fourth consecutive quarter that this target has not been met.

Sixty two day wait from GP Urgent Referral to Treatment. In September 82.69% of patients were treated within 62 days, compared to a target of 85%. The Q2 position is 79.58%. This represents the third consecutive quarter that this target has not been achieved.

Within NHS Improvement’s Risk Assessment Framework these two targets carry an aggregate weighting of 2.0 points. Both targets remain as key operational performance metrics within the Single Oversight Framework, which with effect from October 2016 replaces the Risk Assessment Framework.

3.9 Contract As a result of the performance reported in Section 3 and other data included in Appendix 1 (page 25), the contractual implications are as follows: The total penalty risk for month 6 is £0k, bringing the total penalty position for the year to date to £27k. This is much lower than in 2015/16 because some penalties no longer apply since the introduction of the Sustainability and Transformation Fund (STF). Achievement of the £10m STF for the Trust is dependent upon achieving performance and financial targets.

3.10 Media

In June the Board requested regular quarterly reports on media coverage and Trust press releases. The summaries included in Appendix 9 are taken from our Vuelio media database system and outline over the second quarter: media coverage by tone; media enquiries; and press releases. The data in the report is correct although the figures on uptake are inaccurate (the plug in on media monitoring is not included in our package).

3.11 Future risks

Performance against some key targets continues to be high risk: primarily A&E, RTT, and 62 day cancer waits. Performance will continue to be closely monitored and action plans implemented.


3.12

Appendices

1. Monitor Targets

2. Safer Staffing Return (Ward Level data )

3. Safer Staffing Thermometer Dependency Tool

4. Ward to Board Report

5. Additional Financial Tables

6. Exception Report

7. Cancer Waiting Times Standards Performance by Tumour Site

8. Cancer Waiting Times Performance (62 day wait targets) by Tumour Site (Count of Patients)

9. Media Coverage and Press Releases

10. Data Tables (circulated as a separate appendix)


1. Monitor Targets

IndicatorPosition for

QuarterTarget

Monitor

Weighting

Risk for

Period

Risk for

YearIndicator

Position for

Quarter

Target for

Period

Monitor

Weighting

Risk for

Period

Risk for

Year

Indicates that the target has been achieved for the quarter Indicates that the target has been achieved for that month but the quarter has not yet finishedIndicates that the target has not been achieved for the quarter Indicates that the target has not been achieved for that month but the quarter has not yet finished

Indicates that the target is not enforced

Cancer 62 Day

Screening (pre

breach re-

allocation)

93.06%

(5 of 72)

Area 19

Learning

Disability

Compliance

Not applicable Compliant Compliant 1.0

97.32%

(4 of 149)min. 93% Low Low

96.47%

(166 of

4709)

min. 93%

1.0

Low Low

Area 3

RTT Incomplete

Area 4

A&E - 4 Hour

Target

Area 8.II

Cancer 14 Day

Symptomatic

Breast

Area 6.III

Cancer 31 Day

Subsequent

Radiotherapy

92.05% min. 92%

Cancer 62 Day GP

Urgent (pre

breach re-

allocation)

79.58%

(102.5 of

502)

n/a

n/a

n/a

Area 8.I

Cancer 14 Day

GP Urgent

Area 6.I

Cancer 31 Day

Subsequent

Surgery

96.25%

(9 of 240)min. 94%

Low

Area 6.II

Cancer 31 Day

Subsequent Drug

99.20%

(2 of 250)min. 98%

98.10%

(7 of 368)min. 94%

Area 7

Cancer 31 Day

First Treatment

97.12%

(27 of 937)min. 96%

96.79% n/a n/a

1.0 High

91.4% min. 95% 1.0 High High High

1.0

Low Low

Low

Low Low

Low

1.0 Low

NHS Improvement Dashboard - September 2016

Trend Trend

Area 14

C. difficile

due to lapses

in care

0 (6)max. 31

annual1.0 Low Low

Area 1

RTT Admitted85.75% n/a n/a

Area 2

RTT Non-Admitted

C.Diff cases due to lapses in care has only been calculated since April 2014. The dotted line represents the total cases as reported historically.

High

Area 5.II Cancer

62 Day Screening

(post breach re-

allocation)

93.06%

(5 of 72)min. 90% Medium Low

Area 5.I Cancer

62 Day GP Urgent

(post breach re-

allocation)

80.38%

(98.5 of

502)

min. 85%

1.0

Medium

Trend graphs run from April 2014 to current month

The position for Cancer targets is subject to change when the data is uploaded to the National Cancer Waiting Times Database 6 weeks after month end.

Very Low Very Low


Area Target Jul-16 Aug-16 Sep-16 Q1 Q2 Weighting PositionRisk for

Quarter

Risk for

Year

admitted pathways Area 1 n/a 85.6% 85.7% 85.9% 86.13% 85.75% n/a

non-admitted pathways Area 2 n/a 97.2% 96.7% 96.4% 97.10% 96.79% n/a

incomplete pathways Area 3 92% 92.0% 92.1% #N/A 92.17% 92.05% 1.0 Not Known High Low

Area 4 95% 93.3% 90.6% 90.3% 94.00% 91.42% 1.0 Not Achieving High High

urgent GP referral for

suspected cancer (pre

breach re-allocation)

n/a n/a76.4%

(34.5 of

146)

79.0%

(36.5 of

174)

82.7%

(31.5 of

182)

80.12%

(102 of 513)

79.58%

(102.5 of

502)NHS Cancer Screening

Service referral (pre


n/a n/a100.0%

(0 of 17)

100.0%

(0 of 26)

82.8%

(5 of 29)

94.12%

(2.5 of 42.5)

93.06%

(5 of 72)

urgent GP referral for

suspected cancer (post


Area 5.I 85%78.4%

(31.5 of

146)

79.0%

(36.5 of

174)

83.2%

(30.5 of

182)

80.90%

(98 of 513)

80.38%

(98.5 of

502)

Medium High

NHS Cancer Screening

Service referral (post


Area 5.II 90%100.0%

(0 of 17)

100.0%

(0 of 26)

82.8%

(5 of 29)

94.12%

(2.5 of 42.5)

93.06%

(5 of 72)Medium Low

surgeryArea 6.I 94%

96.2%

(3 of 79)

97.8%

(2 of 89)

94.4%

(4 of 72)

99.17%

(2 of 240)

96.25%

(9 of 240)Low Low

anti-cancer drug

treatmentsArea 6.II 98%

98.9%

(1 of 87)

98.8%

(1 of 84)

100.0%

(0 of 79)

99.29%

(2 of 283)

99.20%

(2 of 250)Low Low

radiotherapyArea 6.III 94%

97.4%

(3 of 115)

98.3%

(2 of 118)

98.5%

(2 of 135)

97.78%

(8 of 360)

98.10%

(7 of 368)Low Low

Area 7 96%98.1%

(5 of 264)

96.7%

(11 of 330)

96.8%

(11 of 343)

97.79%

(20 of 907)

97.12%

(27 of 937)1.0 Achieving Low High

all urgent referrals

(cancer suspected) Area 8.I 93%

96.5%

(53 of

1526)

96.6%

(56 of

1629)

96.3%

(57 of

1554)

96.47%

(171 of

4842)

96.47%

(166 of

4709)

Low Low

for symptomatic breast

patients (cancer not

initially suspected)

Area 8.II 93%93.6%

(3 of 47)

100.0%

(0 of 53)

98.0%

(1 of 49)

97.27%

(3 of 110)

97.32%

(4 of 149)Low Low

total incl. cases deemed

not to be due to lapse in

care & cases under review

n/a n/a 1 2 3 4 6 n/a

cases under reviewn/a n/a 0 2 3 0 5 n/a

due to lapses in careArea 14 30 0 (2) 0 (2) 0 (2) 1 (9) 0 (6) 1.0 Achieving Low Low

Area 19 n/a 1.0 Achieving Very Low Very Low

Achieving

Outcomes

Clostridium (C.) difficile – meeting the C. difficile

objective

Certification against compliance with requirements regarding access to health

care for people with a learning disabilityCompliant

The position for Cancer targets is subject to change when the data is uploaded to the National Cancer Waiting Times Database 6 weeks after month end.

Please note that the sum of C.Diff cases under review and those attributed to lapses in care will not equal the total

NHS Improvement Targets Detail - September 2016

Indicator

Access

Maximum time of 18 weeks from point of referral

to treatment in aggregate

A&E: maximum waiting time of four hours from arrival to admission/ transfer/

discharge

All cancers: 62-day wait for first treatment from:

n/a

1.0 Not Achieving

All cancers: 31-day wait for second or subsequent

treatment, comprising:

1.0 Achieving

All cancers: 31-day wait from diagnosis to first treatment

Cancer: two week wait from referral to date first

seen, comprising:

1.0


2. Safer Staffing Return (Ward Level data )

125% ⁻

95% ₋

130% ⁻

95% ₋

50 ⁻

0 ₋

460 ⁻

200 ₋

530 ⁻

220 ₋

150 ⁻

40 ₋

N/A Not Set

Latest

month

103.5%

Scale

125% ⁻

95%₋

125% ⁻

95% ₋

| Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | Q4 |

Risk for next

3 months

Not Set

Not Set

Not Set

Not Set

Not Set

Not Set

Not Set

2014 - 2015 | 2015 - 2016 | 2016 - 2017

Average fi l l rate (Day) -

registered

nurses/midwives

Average fi l l rate (Day) -

care staff

Average fi l l rate (Night) -

registered

nurses/midwives

Average fi l l rate (Night) -

care staff

Safer Staffing Thermometer

Dependency Tool - Volume

of Patients with a Level 3

Dependency




Dependency




Dependency




Dependency

N/A

N/A

N/A

10

0%

of

bas

elin

e es

tab

lish

men

t

i.e. a

ctu

al h

ou

rs =

pla

nn

ed h

ou

rs

IndicatorTarget

line

100.7%

104.2%

104.4%

44

236

299

73

Key to Safer Staffing Thermometer Indicators:

Dependence Acuity 1 – Independent

Dependence Acuity 2 – Independent with some additional input

Dependence Acuity 3 – Two to four hourly

Dependence Acuity 4 – Constant supervision with up to one-to-one nursing

The top four Safe Staffing indicators relate to the comparison of the volume of planned nursing hours to actual nursing hours worked. The four indicators represent this comparison separately for registered and for non-registered staff, across the day and the night time periods. Individual ward level data for all in-patient wards relating to each of these four indicators are detailed below.


Division Ward Name Planned Actual Planned Actual Planned Actual Planned Actual

Medical Service AMU East 2795.8 3132.5 3094.0 3522.8 2049.0 2298.8 1851.5 2124.0 112.0% 113.9% 112.2% 114.72% 1145 4.7 4.9 9.7

Medical Service Ashburn 1151.5 1206.5 1793.5 1947.0 655.5 684.5 1644.5 1649.0 104.8% 108.6% 104.4% 100.27% 831 2.3 4.3 6.6

Medical Service Avon 978.5 931.5 950.5 1011.0 678.5 678.5 368.0 425.5 95.2% 106.4% 100.0% 115.63% 642 2.5 2.2 4.7

Medical Service Bolham 1081.8 1196.8 2186.5 2214.0 943.0 1035.0 1046.5 1295.5 110.6% 101.3% 109.8% 123.79% 712 3.1 4.9 8.1

Medical Service Bovey 1877.5 1880.3 4343.0 4167.3 1387.0 1329.5 3586.5 3361.5 100.1% 96.0% 95.9% 93.73% 1429 2.2 5.3 7.5

Medical Service CCU 1126.0 1314.0 644.0 714.0 23.0 116.7% 110.9% 167 12.1 0.1 12.3

Medical Service Clyst 1703.0 1797.8 2134.5 2063.5 1058.0 1062.8 1173.0 1237.0 105.6% 96.7% 100.5% 105.46% 826 3.5 4.0 7.5

Medical Service Creedy 1781.5 1826.0 1527.0 1426.5 1000.5 990.0 701.5 736.0 102.5% 93.4% 99.0% 104.92% 699 4.0 3.1 7.1

Medical Service Culm 2603.0 2748.0 3297.0 3228.3 1932.0 2054.5 2261.0 2286.0 105.6% 97.9% 106.3% 101.11% 1519 3.2 3.6 6.8

Medical Service Lowman 1381.0 1607.5 1305.5 1506.0 655.5 874.8 1055.0 1255.5 116.4% 115.4% 133.4% 119.00% 815 3.0 3.4 6.4

Medical Service Mardon Hou 744.5 785.0 2074.0 1886.0 370.0 360.0 715.0 935.0 105.4% 90.9% 97.3% 130.77% 349 3.3 8.1 11.4

Medical Service Okement 1130.0 1263.3 1683.0 1743.4 805.0 816.0 962.5 1063.5 111.8% 103.6% 101.4% 110.49% 776 2.7 3.6 6.3

Medical Service Taw 1334.5 1296.3 660.0 663.5 563.5 621.0 92.0 115.0 97.1% 100.5% 110.2% 125.00% 418 4.6 1.9 6.4

Medical Service Tiverton 2,464.50 2,559.50 2,343.00 2,406.92 1,368.50 1,437.00 1,054.50 1,178.50 103.9% 102.7% 105.0% 111.76% 909 4.4 3.9 8.3

Medical Service Torridge 919.0 971.9 1101.0 984.3 621.0 691.5 655.5 735.5 105.8% 89.4% 111.4% 112.20% 519 3.2 3.3 6.5

Medical Service Yealm 1070.5 1080.5 1573.5 1609.0 621.0 630.8 391.0 397.5 100.9% 102.3% 101.6% 101.66% 597 2.9 3.4 6.2

Medical Service Total 24142.5 25597.2 30066.0 30379.4 15352.0 16278.6 17558.0 18818.0 106.0% 101.0% 106.0% 107.18% 12353

Specialist Services Bramble 3536.5 3648.8 1041.5 884.5 2415.0 2426.5 34.5 57.5 103.2% 84.9% 100.5% 166.67% 574 10.6 1.6 12.2

Specialist Services Maternity 3362.5 3428.1 1857.5 1786.0 2508.0 2552.5 495.0 528.5 102.0% 96.2% 101.8% 106.77% 1139 5.3 2.0 7.3

Specialist Services NNU 2185.5 2285.5 675.0 726.0 1828.5 1920.5 483.0 471.5 104.6% 107.6% 105.0% 97.62% 643 6.5 1.9 8.4

Specialist Services Wynard 1619.5 1678.3 1901.0 1901.5 874.0 932.5 1458.5 1401.0 103.6% 100.0% 106.7% 96.06% 586 4.5 5.6 10.1

Specialist Services Yarty 935.5 924.8 510.8 617.0 644.0 701.5 333.5 379.5 98.9% 120.8% 108.9% 113.79% 380 4.3 2.6 6.9

Specialist Services Yeo 1289.0 1308.8 1069.0 1084.0 678.5 690.0 540.5 577.0 101.5% 101.4% 101.7% 106.75% 577 3.5 2.9 6.3

Specialist Services Total 12928.5 13274.1 7054.8 6999.0 8948.0 9223.5 3345.0 3415.0 102.7% 99.2% 103.1% 102.09% 3899

Surgical Services Abbey 1076.0 1067.0 1677.0 1739.5 655.5 683.0 701.5 701.5 99.2% 103.7% 104.2% 100.00% 512 3.4 4.8 8.2

Surgical Services Dart 1213.5 1296.3 1581.0 1588.0 873.0 907.0 793.5 787.3 106.8% 100.4% 103.9% 99.21% 757 2.9 3.1 6.0

Surgical Services Durbin 1470.0 1528.0 1733.5 1776.5 1012.0 1023.5 1171.0 1180.5 103.9% 102.5% 101.1% 100.81% 935 2.7 3.2 5.9

Surgical Services Dyball 1154.5 1177.8 1066.5 1047.8 690.0 690.0 678.5 644.0 102.0% 98.2% 100.0% 94.92% 581 3.2 2.9 6.1

Surgical Services Exe 1104.0 1150.0 988.5 948.0 632.5 667.0 356.5 448.5 104.2% 95.9% 105.5% 125.81% 529 3.4 2.6 6.1

Surgical Services Lyme 1548.0 1576.0 1127.0 1188.5 920.0 989.0 667.0 829.3 101.8% 105.5% 107.5% 124.33% 792 3.2 2.5 5.8

Surgical Services Mere 1079.0 1144.0 1086.0 1156.5 632.5 632.5 667.0 744.5 106.0% 106.5% 100.0% 111.62% 607 2.9 3.1 6.1

Surgical Services Otter 1391.5 1368.8 1145.0 1057.0 920.0 950.0 805.0 609.5 98.4% 92.3% 103.3% 75.71% 605 3.8 2.8 6.6

Surgical Services Tavy 1101.0 1182.3 1327.5 1388.0 690.0 690.0 1123.5 1007.5 107.4% 104.6% 100.0% 89.68% 501 3.7 4.8 8.5

Surgical Services Teign 4574.5 4263.0 562.0 474.5 3867.0 3946.0 426.0 345.5 93.2% 84.4% 102.0% 81.10% 290 28.3 2.8 31.1

Surgical Services Total 15712.0 15753.0 12294.0 12364.3 10892.5 11178.0 7389.5 7298.0 100.3% 100.6% 102.6% 98.76% 6109

Grand Total 52783.0 54624.3 49414.8 49742.6 35192.5 36680.1 28292.5 29531.0 103.5% 100.7% 104.2% 104.38% 22361 4.0 3.5 7.5

Registered

Nurses/Midwives Care Staff

Registered

Nurses/Midwives Care StaffAverage fill

rate -

registered

nurses/

midwives (%)

Average fill

rate - care staff

(%)

Average fill

rate -

registered

nurses/

midwives (%)

Average fill

rate - care staff

(%)

Day Night Day Night Care Hours Per Patient Day (CHPPD)

Cumulative

count over

the month of

patients at

23:59 each

day

Registered

midwives/

nurses

Care Staff Overall


3. Safer Staffing Thermometer Dependency Tool

Note:

Dependence Acuity 1 – Independent

Dependence Acuity 2 – Independent with some additional input

Dependence Acuity 3 – Two to four hourly

Dependence Acuity 4 – Constant supervision with one-to-one nursing


4. Ward to Board Report





5. Additional Financial Tables

Royal Devon & Exeter NHS Foundation Trust Prior Yr

Actual Budget Actual Actual Budget Actual Actual Budget Actual Annual Mar-16

Income Statement Variance Variance Variance Plan Actual

Period ending 30/09/2016 to Budget to Budget to Budget

Month 6 Fav./(Adv.) Fav./(Adv.) Fav./(Adv.) Fav./(Adv.)

£000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000

Income

NHS Clinical Income 30,806 31,714 (908) 175,479 176,892 (1,414) 1 380,375 381,214 (839) 397,531 330,945

Private patient Income 57 141 (84) 604 814 (210) 1,407 1,617 (210) 1,618 1,332

Research and Development 1,649 1,664 (15) 9,485 9,484 1 18,190 18,190 0 19,029 19,390

Education and Training 1,102 1,102 0 6,623 6,623 0 13,156 13,156 0 13,586 13,549

Other Income 3,441 3,461 (20) 19,253 19,251 2 40,405 40,367 39 44,060 38,271

Total income 37,055 38,083 (1,028) 211,443 213,065 (1,621) 453,533 454,544 (1,010) 475,824 403,487

Expense

Employee Benefits Expenses (Pay) (20,948) (20,926) (22) (124,109) (124,767) 658 2 (268,934) (269,316) 382 (284,677) (244,783)

Drug Costs (4,723) (4,827) 104 (25,715) (25,977) 262 (51,926) (51,975) 49 (51,134) (49,028)

Clinical Supplies (3,621) (3,774) 153 (21,697) (22,169) 472 3 (47,362) (47,596) 234 (48,063) (45,062)

Non Clinical Supplies (464) (408) (56) (2,761) (2,705) (56) (5,380) (5,237) (143) (5,014) (5,401)

Research & Development Expenses (1,485) (1,488) 3 (8,568) (8,569) 1 (17,094) (17,094) 0 (18,669) (18,257)

Misc. Other Operating Expenses (3,286) (3,217) (69) (19,944) (20,003) 59 (41,461) (41,381) (80) (55,607) (39,060)

Cost Improvement Programme 0 98 (98) 0 (229) 229 0 0 (0) 0 0

Reserves 0 (195) 195 0 (300) 300 (8,683) (9,283) 600 0 0

Total Costs (34,527) (34,737) 210 (202,794) (204,718) 1,924 (440,841) (441,883) 1,042 (463,164) (401,591)

EBITDA 2,528 3,346 (818) 8,649 8,346 303 12,692 12,661 32 12,661 1,896

Profit / loss on asset disposals 0 0 0 0 0 0 0 0 0 0 (8)

Exceptional Income / Costs 0 0 0 0 0 0 0 0 0 0 0

Total Depreciation and Impairments (1,009) (1,009) 0 (6,003) (6,003) 0 (12,255) (12,255) 0 (12,255) (15,406)

Total operating surplus (deficit) 1,519 2,337 (818) 2,646 2,343 303 437 406 32 406 (13,518)

3 9 (6) 34 52 (18) 104 104 0 104 84

Total interest payable on Loans and leases (72) (60) (12) (363) (363) 0 (706) (706) 0 (706) (773)

PDC Dividend (533) (533) 0 (3,199) (3,200) 1 (6,400) (6,400) 0 (6,400) (5,848)

Taxation payable

Net Surplus/(deficit) 917 1,753 (835) (882) (1,168) 286 (6,565) (6,596) 32 (6,596) (20,055)

KEY MOVEMENTS

1 Clinical income is under-performing particularly within Orthopaedics, Cardiology, Ophthalmology, General Surgery and Urology. Healthcare for Older People, General Medicine, Dermatology and Medical Oncology are the main areas overperforming.

2 Pay - underspends on Nursing (£483k) and other staff (£738k) are offset with an overspend on Medical staff (£562k). Pay is forecast to be £382k under spent at year end.

3 Clinical supplies expenditure is underspent mainly due to the reduced activity and mostly relate to prosthesis and medical and surgical items.

Current Month Year to Date Outturn

Total interest receivable/ (payable) - inc

committed WC facilities



Actual Budget Actual Annual Actual Actual Budget Actual Annual Actual Mar-16

Statement of Financial Position Variance Plan Variance Variance Plan Variance

Period ending 30/09/2016 to Budget to Plan to Budget to Plan

Month 6 Fav./(Adv.) Fav./(Adv.) Fav./(Adv.) Fav./(Adv.) Fav./(Adv.) Fav./(Adv.)

£000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000

Assets, Non-Current

Property, Plant and Equipment, Net (including intangibles) 196,141 198,681 (2,540) 1 198,681 (2,540) 221,735 221,789 (54) 221,789 (54) 199,991

Non NHS Trade Receivables, Non-Current 1,189 839 350 839 350 839 839 0 839 0 972

Assets, Non-Current, Total 197,330 199,520 (2,190) 199,520 (2,190) 222,574 222,628 (54) 222,628 (54) 200,963

Assets, Current

Inventories 6,847 7,725 (878) 2 7,725 (878) 7,025 7,725 (700) 7,725 (700) 6,664

Trade and Other Receivables, Net, Current 28,774 23,037 5,738 3 23,037 5,738 21,748 18,798 2,950 18,798 2,950 17,618

Non Current Assets held for sale 0 0 0 0 0 0 0 0 0 0 0

Cash 5,813 9,294 (3,481) 4 6,383 (570) 5,247 6,693 (1,446) 6,693 (1,446) 16,507

Other Assets - Current Assets Held by Charitable Funds 0 0 0 0 0 0 0 0 0 0 0

Assets, Current, Total 41,434 40,056 1,378 37,145 4,290 34,020 33,216 804 33,216 804 40,789

Liabilities, Current

Loans, non-commercial, Current (DH, FTFF, NLF, etc) (1,270) (1,270) 0 (1,270) 0 (1,270) (1,270) 0 (1,270) 0 (1,270)

Finance leases - Current 0 0 0 0 0 (65) 0 (65) 0 (65) 0

Trade and Other Payables, Current (11,028) (10,683) (345) 5 (10,683) (345) (11,226) (11,276) 50 (11,276) 50 (14,301)

Deferred Income, Current (2,597) (2,230) (367) (2,230) (367) (2,230) (2,230) 0 (2,230) 0 (1,729)

Provisions, Current (284) (284) 0 (284) 0 (284) (284) 0 (284) 0 (333)

Current Tax Payables (5,272) (5,663) 391 (5,663) 391 (5,622) (5,622) 0 (5,622) 0 (4,586)

Other Financial Liabilities, Current (12,554) (13,955) 1,401 6 (13,955) 1,401 (14,455) (14,455) 0 (14,455) 0 (12,292)

Liabilities, Current, Total (33,005) (34,085) 1,080 (34,085) 1,080 (35,151) (35,136) (15) (35,136) (15) (34,511)

NET CURRENT ASSETS (LIABILITIES) 8,429 5,971 2,459 3,060 5,370 (1,132) (1,921) 789 (1,921) 789 6,278

TOTAL ASSETS LESS CURRENT LIABILITIES 205,759 205,491 269 202,580 3,180 221,443 220,708 735 220,708 735 207,241

Liabilities, Non-Current

Loans, Non-Current, non-commercial (DH, FTFF, NLF, etc) (13,226) (13,228) 2 (13,228) 2 (12,593) (12,593) 0 (12,593) 0 (13,861)

Finance leases - Non-current 0 0 0 0 0 (744) 0 (744) 0 (744) 0

Other Creditors, Non-Current 0 0 0 0 0 0 0 0 0 0 0

Provisions, Non-Current (398) (376) (22) (376) (22) (376) (376) 0 (376) 0 (362)

TOTAL ASSETS EMPLOYED 192,135 191,887 249 188,976 3,160 207,730 207,739 (9) 207,739 (9) 193,018

TAX PAYERS' EQUITY

Public dividend capital 152,444 152,443 1 152,443 1 152,443 152,443 0 152,443 0 152,444

Retained Earnings (Accumulated Losses) 15,540 13,855 1,685 10,944 4,597 9,334 8,427 907 8,427 907 15,898

Charitable Funds 0 0 0 0 0 0 0 0 0 0 0

Revaluation Reserve 24,151 25,593 (1,442) 25,593 (1,442) 45,958 46,874 (916) 46,874 (916) 24,677

Donated Asset Reserve 0 0 0 0 0 0 0 0 0 0 0

TOTAL TAX PAYERS' EQUITY 192,135 191,891 244 188,980 3,156 207,735 207,744 (9) 207,744 (9) 193,019

KEY MOVEMENTS

1

2 Inventories are £878k lower than plan due to the value of inventories held being reduced compared to the value estimated within the plan.

3

4

5

6 Other Financial Liabilities are £1.4m lower than plan. The plan included an estimated increase in accruals to assist liquidity, not reflected in the actual results to date.

Year to Date Outturn

The value of property plant and equipment is £2.5m lower than the plan, due to an underspend on the capital program of £2.2m.

Trade and other receivables are £5.7m higher than plan mainly due to awaiting Sustainability and Transformation funding (£2.1m) and outstanding amounts from SW Specialist Commissioners.

The cash balance is £5.8m. The decrease in cash is mainly due to changes in working capital balances, in particular Trade Receivables being higher than planned.

Trade and other payables are £345k higher than plan. NHS Trade Creditors are £1.1m higher than plan, including charges relating to community theatres, not included in the plan, as the plan assumed that we would be operating those services

from 1 June 2016. Other creditors are £563k lower than plan, mostly relating to payroll creditors relating to community theatre staff, not taken on until 1 October 2016.



Actual Budget Actual Annual Actual Actual Budget Actual Annual Actual Mar-16

Cash Flow Statement Variance Plan Variance Variance Plan Variance

Period ending 30/09/2016 to Budget to Plan to Budget to Plan

Month 6 Fav./(Adv.) Fav./(Adv.) Fav./(Adv.) Fav./(Adv.) Fav./(Adv.) Fav./(Adv.)

£000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000

NET CASH INFLOW/(OUTFLOW) FROM OPERATING ACTIVITIES

Surplus/(deficit) after tax (882) (1,168) 286 (4,079) 3,198 (6,565) (6,597) 33 (6,596) 31 (20,055)

Non-cash flows in operating surplus/(deficit)

Finance (income)/charges 329 311 18 311 18 602 602 0 602 0 689

Depreciation and amortisation 6,003 6,003 0 6,002 1 12,255 12,255 0 12,255 (0) 15,406

Impairment 0 0 0 0 0 0 0 0 0 0 0

PDC dividend expense 3,199 3,200 (1) 3,200 (1) 6,400 6,400 0 6,400 0 5,848

Other increases/(decreases) to reconcile to profit/(loss) from operations 0 0 0 0 0 0 0 0 0 0 8

Non-cash flows in operating surplus/(deficit), Total 9,531 9,514 17 9,514 17 19,257 19,257 0 19,257 0 21,951

Increase/(Decrease) in working capital

(Increase)/decrease in inventories (183) (1,061) 878 (200) 17 (361) (1,061) 700 (200) (161) 1,361

(Increase)/decrease in NHS Trade Receivables (6,827) (1,160) (5,667) 0 (6,827) (4,660) (1,160) (3,500) 0 (4,660) 1,161

(Increase)/decrease in Non NHS Trade Receivables 727 880 (153) 525 202 880 880 0 525 355 (356)

(Increase)/decrease in other receivables 226 103 123 463 (237) 453 103 350 463 (10) 361

(Increase)/decrease in accrued income (536) (402) (134) (756) 220 (2) (2) 0 (356) 354 (700)

(Increase)/decrease in prepayments (4,746) (4,839) 93 (3,838) (908) (801) (1,001) 200 0 (801) 931

Increase/(decrease) in Deferred Income (excl. Donated Assets) 868 501 367 (170) 1,038 501 501 0 (170) 671 (648)

Increase/(decrease) in provisions (13) (35) 22 0 (13) (35) (35) 0 0 (35) 35

Increase/(decrease) in Trade Creditors (2,843) (3,744) 901 (1,643) (1,200) (3,275) (3,525) 250 (1,424) (1,851) 1,256

Increase/(decrease) in tax payable 686 1,077 (391) 1,063 (377) 1,036 1,036 0 1,022 14 30

Increase/(decrease) in Other Creditors (110) 453 (563) 489 (599) 424 424 0 460 (36) 193

Increase/(decrease) in accruals 263 1,663 (1,400) 455 (192) 2,163 2,163 0 955 1,208 45

Increase/(Decrease) in working capital, Total (12,488) (6,564) (5,925) (3,612) (8,877) (3,677) (1,677) (2,000) 1,275 (4,952) 3,669

Net cash inflow/(outflow) from investing activities

Property - new land, buildings or dwellings (183) (469) 286 (469) 286 (595) (1,521) 926 (1,521) 926 (110)

Property - maintenance expenditure (240) (767) 526 (767) 526 (3,039) (1,858) (1,181) (1,858) (1,181) (3,438)

Plant and equipment - Information Technology (818) (162) (655) (162) (655) (1,510) (446) (1,063) (446) (1,063) (1,549)

Plant and equipment - Other (910) (2,920) 2,010 (2,920) 2,010 (6,765) (8,573) 1,808 (8,573) 1,808 (2,848)

Proceeds on disposal of property, plant and equipment 0 0 0 0 0 0 0 0 0 0 0

Increase/(decrease) in Capital Creditors (320) (328) 8 (361) 41 (224) 76 (300) 43 (267) (1,191)

Other cash flows from financing activities 0 (1) 1 (1) 1 0 (3) 3 (3) 3 0

Net cash inflow/(outflow() from investing activities, Total (2,471) (4,647) 2,176 (4,680) 2,209 (12,133) (12,325) 192 (12,358) 225 (9,136)

Net cash inflow/(outflow) from financing activities

PDC Dividends paid (3,200) (3,200) 0 (3,200) 0 (6,400) (6,400) 0 (6,400) 0 (5,848)

PDC Dividend Received 0 0 0 0 0 0 0 0 0 0 652

Interest (paid) on commercial loans (363) (363) 0 (363) 0 (706) (706) 0 (706) (0) (773)

Interest received on cash and cash equivalents 34 52 (18) 52 (18) 104 104 0 104 0 84

Repayment of non-commercial loans (635) (633) (2) (635) 0 (1,268) (1,268) 0 (1,270) 2 (1,270)

Receipt of non-commercial loan 0 0 0 0 0 0 0 0 0 0 0

(Increase)/decrease in non-current receivables (217) 133 (350) 0 (217) 133 133 0 0 133 (133)

Increase/(decrease) in non-current payables 0 0 0 0 0 0 0 0 0 0 0

Net cash inflow/(outflow) from financing activities, Total (4,381) (4,011) (370) (4,146) (235) (8,137) (8,137) 0 (8,272) 135 (7,288)

Net increase/(decrease) in cash and cash equivalents (10,691) (6,876) (3,815) (7,004) (3,687) (11,255) (9,480) (1,775) (6,694) (4,560) (10,859)

Opening cash and cash equivalents 16,507 16,507 0 13,387 3,120 16,507 16,507 0 13,387 3,120 27,366

Closing cash and cash equivalents 5,816 9,631 (3,815) 6,383 (567) 5,252 7,027 (1,775) 6,693 (1,440) 16,507

Year to Date Outturn


Royal Devon and Exeter NHS Foundation Trust

Capital Expenditure

Period ending 30/9/2016

Month 6 Column B Column C Column D Column E Column F Column G Column H

Scheme Approval level

YTD actual

expenditure

YTD planned

expenditure per

annual plan

YTD variance

slippage /

(overspend)

Forecast future

capital

expenditure for

the year

Forecast total

capital

expenditure for

the year

Full year

expenditure per

annual plan

16/17 forecast

slippage /

(overspend)

Expenditure

approved by the

Exec Group

Total

expenditure

forecast for the

scheme

Scheme

variance under

spend /

(overspend)

( C - B) (B + E) (G - F)

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

CRIC 62 702 640 1,731 1,793 1,793 (0) 1,793 1,793 (0) Mar-17

CRIC 0 0 0 1,582 1,582 1,693 111 1,582 1,582 0 Dec-16

CRIC 65 497 432 940 1,005 1,005 0 1,069 1,069 (0) Dec-16

CRIC 0 0 0 1,052 1,052 1,052 0 1,052 1,052 0 Mar-17

CRIC 408 804 396 408 816 804 (12) 816 816 0 Oct-16

Unapproved 0 226 226 0 0 698 698 0 0 0 N/A

CRIC 253 0 (253) 87 340 0 (340) 651 651 0 Nov-16

CRIC 0 0 0 608 608 608 0 635 635 (0) Dec-16

CRIC 371 0 (371) 176 547 0 (547) 547 547 0 Nov-16

Unapproved 0 0 0 383 383 0 (383) 383 383 0 TBC

CRIC / Unapproved 992 2,089 1,097 3,599 4,591 4,745 154

2,151 4,318 2,167 10,567 12,718 12,398 (319)

SOC 0 0 0 0 0 0 0 0 894 (894)

0 0 0 0 0 0 0

2,151 4,318 2,167 10,567 12,718 12,398 (319)

Siemens Magnetron MRI 2

Expected

completion date

Actual expenditure to date compared to budget on

annual plan

Total expenditure forecast for the year compared to the budget on

the annual plan

Total expected expenditure compared to the value

approved by the Exec Group / Board of Directors

Schemes over £500k in progress or planned

Estates Infrastructure

Cath Lab Replacement - Lab1

MRI 1 Replacement

Laundry Continuous Batch Washer & Garment

finishing

Coffee Lounge Theatre 11, 12, & Resus

Total RD&E Capital Schemes

100,000 Genomes

Siemens Sensation 16 CT

TCS VDI and other equipment

ED Reconfiguration

Other schemes < £500k and contingency

Total 2016/17 Capital Schemes excluding EPR

Value not known with certainty until the benefits realisation

Electronic Patient Record (EPR)


Royal Devon & Exeter NHS CY Target FY Target

Foundation Trust Actual Target Variance Actual Target Variance Actual Target Variance Forecast FY

to Budget to Budget to Budget

Cost Improvement Programme Fav./(Adv.) Fav./(Adv.) Fav./(Adv.)

Period ending 30/09/2016

Month 6 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 R/A/G R/A/G

Business As Usual

Medical Services 706 534 171 907 1,744 (837) 1,225 (519) 213 594 (381) 674 R G

Specialist Services 840 837 3 1,175 1,927 (751) 1,981 54 235 607 (372) 667 G G

Surgical Services 699 802 (103) 757 2,207 (1,450) 2,207 (0) 68 935 (867) 961 G G

Operations Support Unit 190 181 9 331 422 (91) 422 (0) 12 223 (211) 223 G G

Corporate 441 303 138 479 528 (50) 622 93 0 270 (270) 291 G G

0 0 0 0

2,876 2,657 219 3,649 6,828 (3,179) 6,456 (372) 527 2,628 (2,101) 2,817

Trustwide Projects

Bed Based Care 0 0 0 0 1,000 (1,000) 0 (1,000) 0 2,000 (2,000) 1,098 R R

Commercial Income 0 0 0 0 0 0 0 0 0 500 (500) 100 G R

Elective Care 0 0 0 0 0 0 0 0 0 730 (730) 401 G R

Specialty Productivity 0 0 0 0 0 0 0 0 0 2,000 (2,000) 0 G R

Workforce - Agency 434 425 9 869 850 19 869 19 869 850 19 869 G G

Workforce - Other 0 0 0 0 0 0 25 25 0 409 (409) 102 G R

Reserves 1,749 1,749 0 3,499 3,499 0 3,499 0 3,060 3,060 0 3,060 G G

0

2,184 2,174 9 4,368 5,349 (981) 4,393 (956) 3,929 9,549 (5,620) 5,630

Central Unidentified (excl BAU and Trustwide Projects) 0 0 1,328 1,328 0 3,730 G G

5,060 4,831 229 8,017 12,177 (4,160) 12,177 (0) 4,456 12,177 (7,721) 12,177

Summary by Planning Status

Achieved 8,017 4,456

Firms Plans Medium Risk 25 0

Low Risk 476 60

Plans being Scoped High Risk 1,418 1,569

Medium Risk 270 1,460

Low Risk 433 304

Unidentified High Risk 1,538 4,328

Total Forecast Plans 12,177 12,177

NB: The total target for 2016/17 is £12.2m which consists of the 2016/17 target of £11.5m in addition to CIP schemes that were planned to be achieved in 2015/16 of £0.7m brought forward.

Year to Date - Achieved Current Year - Achieved Current Year - Forecast Full Year (recurring) - Achieved

Forecast CY Forecast

Variance Fav /

(Adv)

Forecast

Rating

Forecast

Rating


YTD M6 YTD M6

Actual Budget

£m £m

Green

Red

Amber

Green

Green

Amber

Amber

Amber

HEADLINE Key Performance Indicators

Month by Month Variance FY

Forecast

£m

FY

Budget

£m

FY

Risk

Rating

Narrative

A year to date I&E deficit of £882k has been incurred (£286k favourable to plan) and a

forecast year-end deficit of £6.6m is expected in line with plan.

Patient Income variance £'m 176.1 177.7 381.8 382.8

Clinical and Private patient income is under-recovered by £1.6m year to date reflective of the

operational capacity pressures experienced during the first 6 months of the year. Clinical

income is forecast to under recover by £1.0m at year end.

Income and Expenditure - Actual v Budget -0.9 -1.2 -6.6 -6.6

Commercial income is on budget, and forecast to be £39k over recovered at year end.

Pay costs variance £'m -124.1 -124.8 -268.9 -269.3

Pay has underspent by £658k, relating to underspends on Nursing (£483k)mainly in theatres

and other staff (£738k) are whichoffset with an overspend on Medical staff (£562k). Pay is

forecast to be £382k under spent at year end.

Commercial income variance £'m 25.9 25.9 53.6 53.5

Drugs expenditure is underspent by £262k which is spread across the Divisions. An

underspend of £49k is forecast at year end.

Clinical supplies variance £'m -21.7 -22.2 -47.4 -47.6

Clinical supplies are underspent by £472k which mostly relates to reduced expenditure on

prosthesis and medical & surgical items related to activity and Exeter Mobility underspends

in line with reduced income. Clinical supplies are forecast to underspend by £234k by year

end as additional spend is required to catch up activity.

Drug costs variance £'m -25.7 -26.0 -51.9 -52.0

The expenditure on non clinical supplies is overspent by £56k which mostly relates to

cleaning equipment (£43k). Non clinical supplies are forecast to be £44k overspent by year

end, which mostly relates to overspends on cleaning equipment (£86k) and patients clothing

(£32k) offset with an underspend on Laundry (£30k).

Misc other operating expenses variance £'m -19.9 -20.0 -41.5 -41.4

Misc. other operating expenses are currently underspent by £59k, mostly relating to

underspends on training (£109k), Maintenance agreements (£206k) and offset with

overspends on Admin expenses (£75k) and Maintenance equipment (£142k). A year end

overspend of £80k is forecast at year end.

Non clinical supplies variance £'m -2.8 -2.7 -5.4 -5.2

3 6 9 12

Actual


YTD M6 YTD M6

Actual Budget

£m £m

Green

Amber

Red

Red

Green

Red

Amber

Red

Green

Green

Green

HEADLINE Key Performance Indicators

Month by Month VarianceFY

Forecast

£m

FY

Budget

£m

FY

Risk

Rating

Narrative

Year to date EBITDA is favourable compared to budget and is forecast to remain in-line with

the plan for the remainder of the year.

CIP

CY - achieved v budget 8.0 12.2 12.2 12.2

The CIP requirement for 2016/17 is £12.2m. £8.0m of the target has been achieved in the

current year. Schemes totalling £4.5m have been achieved on a recurrent basis.

Recurrent - achieved v budget

EBITDA % 4.09% 3.92% 2.79% 2.79%

The Capital programme has currently underspent by £2.2m plan year to date and is forecast

to be £319k overspent by year end due to the addition of the schemes slipped from 2015/16.

Inventories YTD - Actual v Budget 6.8 7.7 7.0 7.7

Inventories are £878k lower than plan due to a reduction in the value of inventories held at

the year end.

4.5 12.2 12.2 12.2

Capital spend - Actual v Budget 2.2 4.3 12.7 12.4

NHS Trade receivables are £5.7m higher than estimated, including £2.1m of Sustainability and

Transformation funding not yet received.

Trade and Other Payables YTD - Actual v Budget -11.0 -10.7 -11.2 -11.3

Trade and other payables are £345k higher than plan. NHS Trade Creditors are £1.1m higher

than plan. Other creditors are £563k lower than plan, mostly relating to payroll creditors

relating to community theatre staff, not taken on until 1 October 2016. Other Financial

Liabilities are £1.4m lower than plan.

Trade and Other Receivables YTD - Actual v Budget 28.7 23.0 21.7 18.8

The cash balance is £5.8m and is £570k lower than plan and £3.5m lower than budget. The

decrease in cash is mainly due to changes in working capital balances, in particular Trade

Receivables being higher than planned, offset by the under spend to date on capital

expenditure, and the income and expenditure deficit to date being lower than planned.

The forecast cash balance at the end of the financial year is estimated to reduce from £6.7m

to £5.2m.

Capital servicing capacity (x) 3.0 3.0 2.0 2.0

Capital servicing is currently a level 3 and is anticipated that this will drop to a level 2 by year

end.

Cash - Actual v Budget 5.8 9.3 5.2 6.7

Liquidity days is currently a level 4 and is anticipated that this will drop to a level 3 by year

end.

Green

I&E Margin Rating 2.0 2.0 1.0 1.0

I&E margin is currently a level 2 and is anticipated that it will remain at a level 1 at year end.

Liquidity (days) 4.0 4.0 3.0 2.0

FSRR is currently a level 3 and is anticipated that it will remain at a level 2 at year end. This

ratio will change to “finance and use of resources” metric from the 1st October 2016 which

the Trust is also currently at a level 3.Financial Sustainability Risk Rating (FSRR) 3.0 3.0 2.0 2.0

3 6 9 12

Actual


YTD M6 YTD M6

Actual Budget

vol vol

Red = Budget

Black = Actual

Detailed Income Statement Variances

Month by Month Variance

Narrative

Outpatient Activity 62,692 62,893

Outpatient activity for the current month is 3% below plan, 2% lower than September last year and 1% higher than the

previous month. For the year so far activity is on plan and 4% higher than the same period in 2015/16.

Day-case Activity 32,120 31,404

Day case activity for the current month is 3% below plan however 1% above plan year to date. Activity is 2% higher than

August and 1% higher than September last year. The year to date activity is 4% higher than the same period of 15/16.

Elective Inpatient Activity 5,980 6,924

Elective activity for the current month is 13% below plan and 14% below plan year to date. Activity is 2% higher than last

month and 2% lower than September last year. For the year so far activity is 12% lower than the same period last year.

Non-Elective Inpatient Activity 18,639 18,802

Non elective activity for the current month is 1% below plan and 1% below plan year to date. This is 3% higher than last

month and 5% higher than September last year. For the year so far activity is 4% higher than the same period in 2015/16.

NB. This data is forall non elective 1st FCE's.

Combined Elective Care Activity 37,988 38,488

Combined elective inpatient & day case activity for the current month is 5% below plan and 1% below plan year to date.

Activity is 1% lower than the previous month and 1% higher than September a year ago. For the year so far activity is 1%

higher than the same period last year.

GP Referrals 39,173

GP referrals are the 2% higher than last month and 6% higher than first 6 months of the last financial year.

3 6 9 3 6 9 12

Actual


6. Exception Report

CORPORATE TARGET NUMBER & DESCRIPTION:

Time to Surgery for Patients with a Fractured Neck of Femur

CURRENT CORPORATE RATING: High

RESPONSIBLE DIRECTOR: Medical Director

Brief description of how the rating was derived

The National Hip Fracture Database (NHFD) is a clinically led, web-based audit of hip fracture care and secondary prevention. Care is audited against standards defined by the British Orthopaedic Association (BOA) and British Geriatrics Society (BGS).

Target 90% of patients to receive surgery within 36 hours of admission.

Background & Contributing factors

In Sept, 69 % of Fractured Neck of Femur patients received surgery within 36 hours, which is 10 patients fewer than required to meet the 90% target. There has continued to be a significant volume of Trauma Admissions throughout September. Eighteen elective patients were cancelled in September to accommodate Trauma patients. Trauma theatre capacity is an issue; therefore the feasibility of an additional Fractured Neck of Femur list on a Saturday has been scoped and this proposal has subsequently been approved to commence from November 2016, as part of the winter plan.

Details of actions necessary to return performance back to either good or excellent

Action

By Whom

Timescale

Progress

Optimise theatre capacity with PEOC theatres in advance. Use Monday operational meetings to review theatre efficiency and inform Hip Team/Trauma Lead if any availability of lists

Theatre Scheduler/ CM T&O

On-going - Review theatre lists on a daily basis

Daily trauma meetings to review individual patients and list priority.

On Call Consultant

On-going - Trauma meetings held on a daily basis at 8.00am

Evening consultant ward round On Call Consultant

On-going In place - Completed

If 10 cases or more are deemed as fit on the Trauma List, decision to be made whether to cancel elective patients, to increase capacity.

- On Call Consultant - Trauma Lead - CM – T&O

On-going Reviewed and agreed at T&O governance meeting, May 2016.

If 2 or more patients with a NOF on Trauma List who do not have a plan for surgery, decision to be made whether to cancel elective patients, to increase capacity.

- On Call Consultant -Trauma Lead - CM – T&O

On-going Reviewed and agreed at T&O governance meeting, May 2016.

Maintain Hip Fracture database Anna Atkinson and John Charity

On-going Regular auditing

Plan ‘Fire Break’ lists in advance on the theatre schedule, which can be used for any NOF’s.

Theatre Scheduler

On-going In place from Jan 2016 – reviewed on a weekly basis

Scope feasibility of an additional NOF list on a Saturday.

Lynsey King Complete – September 2016

Costings forwarded to Phil Luke as part of the Winter Plan.

Additional NOF lists to be approved as part of the winter plan.

Phil Luke Complete October 2016

Additional Saturday lists to commence from November 2016


7. Cancer Waiting Times Standards Performance by Tumour Site

Month: 9 - 16/17 Inf services check: OK

Census date run: 12/10/2016

Target Position Worst CaseAcute

Leukaemia

Brain &

CNSBreast Gynae Haem

Head &

NeckLower GI Lung Sarcoma Skin Testicular

Thyroid/

Endocrine

Unknown

PrimaryUpper GI Urology Blank

Breaches 57 0 0 4 5 0 10 14 1 3 7 0 0 0 10 3

Total 1554 0 12 224 127 13 154 188 37 55 398 5 11 2 178 150

Position 96.33% 100.00% 98.21% 96.06% 100.00% 93.51% 92.55% 97.30% 94.55% 98.24% 100.00% 100.00% 100.00% 94.38% 98.00%

Breaches 1

Total 49

Position 97.96%

Breaches 11 11 0 0 0 0 0 0 4 1 0 1 0 0 0 0 5

Total 343 209 2 2 50 30 18 16 30 20 3 92 1 4 3 10 62

Position 96.79% 94.74% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 86.67% 95.00% 100.00% 98.91% 100.00% 100.00% 100.00% 100.00% 91.94%

Breaches 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Total 79 70 0 1 30 6 9 1 7 8 1 4 1 0 0 3 8 0

Position 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Breaches 4 4 0 0 0 0 0 0 1 0 0 1 0 0 0 0 2 0

Total 72 58 0 0 24 1 0 0 1 0 0 35 0 0 0 0 11 0

Position 94.44% 93.10% 100.00% 100.00% 0.00% 97.14% 81.82%

Breaches 2 2 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0

Total 135 106 0 3 42 5 5 3 6 10 1 3 0 0 1 7 49 0

Position 98.52% 98.11% 100.00% 97.62% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 66.67% 100.00% 100.00% 100.00%

Breaches 31.5 31.5 0 1 3.5 1 2.5 5.5 0 0 1 2 1 1 13

Total 182.0 115.5 1 26 20 8.5 6.5 10.5 6 3 55.5 2 2 5.5 35.5

Position 82.69% 72.73% 100.00% 96.15% 82.50% 88.24% 61.54% 47.62% 100.00% 100.00% 98.20% 0.00% 50.00% 81.82% 63.38%

Breaches 5.0 5.0 0 0 0 0 0 5 0 0 0 0 0 0 0

Total 29.0 21.0 0 21 0 1 0 7 0 0 0 0 0 0 0

Position 82.76% 76.19% 100.00% 100.00% 28.57%

Breaches 6.5 6.5 0 0 0 0 0 1 2 0 0 0 0 1.5 2

Total 63.0 42.0 1 1 5.5 3 1 11 8.5 0 17 0 1 5 9

Position 89.68% 84.52% 100.00% 100.00% 100.00% 100.00% 100.00% 90.91% 76.47% 100.00% 100.00% 70.00% 77.78%

Tumour site break down

Current Position for Month and tumour site break down.

93%

93%

96%

98%

Symptomatic Breast Patients

First Treatment: All Cancers

Subsequent Treatment: Anti-Cancer Drug

Treatments

14

Day

All Cancer Two Week Wait

Subsequent Treatment: Surgical Treatments

Subsequent Treatment: Radiotherapy

Treatments

62

Day

First Treatment: Urgent GP to Treatment (n.b.

does not include symptomatic breast

referrals despite these being on 62 day

First Treatment: Consultant Screening Service

Referral

First Treatment: Consultant Upgrade Service

Referral 85%

94%

94%

85%

90%

31

Day


8. Cancer Waiting Times Performance (62 day wait targets) by Tumour Site (Count of Patients)

62d patient counts

Count of pts

Acute

Leukaemia

Brain &

CNSBreast Gynae Haem

Head &

NeckLower GI Lung Sarcoma Skin Testicular

Thyroid/

Endocrine

Unknown

PrimaryUpper GI Urology Blank

Breaches 39.0 0 2 4 1 3 6 0 0 2 2 1 1 17

Total 199.0 1 27 23 9 8 11 6 3 61 2 2 6 40

Breaches 5.0 0 0 0 0 0 5 0 0 0 0 0 0 0

Total 30.0 0 21 0 1 0 8 0 0 0 0 0 0 0

Breaches 8.0 0 0 0 0 0 1 3 0 0 0 0 2 2

Total 66.0 1 1 6 3 1 11 10 0 17 0 1 6 9

Tumour site break down

First Treatment: Urgent GP to Treatment (n.b. does not include

symptomatic breast referrals despite these being on 62 day pathways)

First Treatment: Consultant Screening Service Referral

First Treatment: Consultant Upgrade Service Referral

62

Day


9. Media Coverage and Press Releases











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