Agenda item: 9.1, Public Board meeting Date€¦ · The NHS 111 service transferred to Devon...

Integrated Performance Report Page 1 of 47 30 November 2016

Agenda item:

9.1, Public Board meeting

Date: 30 November 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:

Andy Clark, Acting Director of Operational Finance

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

October saw a welcome improvement in Trust-wide operational pressures in terms of patient flow. Against the Trust’s Capacity Plan framework criteria there were 12 “red days” followed by 19 consecutive days rated green. A period of reduced pressure on the system was forecast in the bed capacity modelling undertaken at the start of the year. In addition to this, the situation was further improved by a significant drive to reduce the number of non-elective Cardiology inpatients awaiting angiography, angioplasty or pacemaker implantation, which has improved patient flow and freed up beds on the Acute Medical Unit. As the pressures eased during the month, there was a reduction in the number of medical outliers, with the daily average across the month reducing from 40 in September to twenty three. As planned in the Trusts’ Emergency Department (ED) recovery trajectory, performance against the 4-hour standard improved significantly in October with 91.47% achieved compared to 88.63% in September. An update of progress against the interventions identified to improve 4-hour ED target compliance is provided on pages 11 - 14 and ongoing improvement in performance is expected as the plan is fully 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 (DDocs) on 1st October 2016, which has resulted in the provision of 14 urgent GP appointments available per day for allocation by ED during the week and 40 at weekends.

A process of discharging from triage following consultant review for low risk conditions that can be treated in primary care has commenced.

The co-located Walk in Centre in Emergency Department has returned to normal hours following several months of reduced opening times as a result of staffing shortfalls.

Delayed transfers of care increased slightly from the September position with an average of 67 delayed patients compared to 62 in September, however this remains a considerable improvement from earlier in the year when up to an average of 89 patients had their transfer of care delayed. There continues to have been no Norovirus or other infection control outbreaks in the month and the Trust “deep clean” has been completed as planned. During the period of reduced operational pressure, a process of completing planned maintenance on some of the wards has also been undertaken. The draft position for October forecasts that the Trust will achieve 7 out of the 9 key cancer waiting time targets. The Referral to Treatment (Incomplete Pathways) target continues to be achieved by a narrow margin with achievement of 92.01% against a target of 92% with no patients waiting longer than


52 weeks.

3. ANALYSIS & KEY ISSUES

3.1

Patient Experience

Complaints & Concerns There were 68 complaints and concerns received during October which is a decrease from September (72). The top theme this month relates to communication issues. Communication was raised as an issue 26 times, providing and receiving information 9 times and perceived incorrect diagnosis 8 times. 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 October. There were no final reports received in October. Compliments There were 29 written compliments received during October 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 October three wards were audited with all of them achieving Silver. OQAT There were no outpatient areas audited during October. Mixed Sex Accommodation There were no clinically unjustified single sex accommodation breaches in October. Demonstrating Difference Medical Services Dermatology has developed local services run by GP’s with special interest to deliver skin cancer clinics. These are run in the local community and provide integrated care for patients. Those who

Latest

month

68

97.1%

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


require more complex care are referred to RD&E for surgery or on-going treatment. The initiative has been nominated for a General Practice award and Dr Noel Lawn and team have been shortlisted. Surgical Services PEOC Previously an increase in demand for appointments and complexity of cases meant that clinics often over ran resulting in patients waiting for long periods of time. There were also a large number of patients awaiting routine review due to capacity issues. The service introduced virtual clinics conducted by a nurse practitioner to enable some patients to be reviewed more quickly. In addition patients are able to be seen by their local hospital for x-ray appointments at which time they complete an assessment form which is later reviewed by a Surgical Care Practitioner; the results are then sent to the patient and their GP. This series of changes has improved the overall service and resulted in reduced waiting times for patients. Consideration is now being given to expanding these innovations to other services. Specialist Services Neonatal A concern was raised by the parents regarding availability of vegetarian formula, for a baby whose mother was unable to express milk. A discussion was held with the family and the NNU senior nurse, matron and the infant feeding co-ordinator. The care plans and guidance have been reviewed to ensure that information for vegetarians and other cultural and dietary considerations are included.


3.2 Safety & Safe Staffing

Specialling requirements across the 4 Divisions totalled 85.56 WTE for the following reasons.

9 x cognitively impaired patients at high risk of falls

12 x patients requiring RMN specialling, one requiring security escort

2 x CAMHs patients, one required 2:1 specialling for a week

4 x patients with dementia and delirium

2 x patients with neurological trauma requiring enhanced observation

5 x bays requiring cohort specialling for the majority of the month

2 x acutely ill patients requiring 1:1 specialling for enhanced observations post ITU admission

This is a sharp increase in comparison to previous months. Overall there is a fourfold increase in the casemix requirement for RMN patients requiring specialling compared with last month. These have been reviewed and signed off by the mental health team and Assistant Director of Nursing. There has not been an overall increase in the total numbers of mental health admissions over the month. A proposal to provide an alternative model for specialling / enhanced care has been presented at the Joint Professions and Care Matters Forum. This will now be worked up into a full business case to go forward for approval in the operational planning cycle. Up to 20 additional unplanned escalation beds remained open for 11 days during October requiring an additional 4.52 WTE. This month 22 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.


Safety

0.00

0

0

1

2

101.63

98.45

96.36

105.85

105.07

7

9.8

124

98.8%

94.0%

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

E-coli Bacteraemias (Trust

apportioned)

MRSA Bacteraemias (Trust

apportioned)

≤5

IndicatorTarget

line

Low

Low

Low

Low

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

As

expect

ed or

lower

Latest

month

Summary Hospital-level

Mortality Indicator (SHMI)

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 ₋



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 ₋

Scale

100% ⁻

84%₋

98% ⁻

86% ₋

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 ₋


Infection Control E.coli As expected, the number of hospital apportioned cases has returned to previous levels after a slight increase in September. Neither case was associated with either the urinary tract or catheterisation. A target of a 50% reduction by 2020 was announced a few days ago by NHSE/NHSI and will be introduced from April 2016. This will be a challenging target not least because 80% of the E.coli bacteraemias are community acquired and, therefore, a collaborative approach to investigation and reduction will be required. National reporting from April 2017 will also distinguish between hospital and community acquired cases and it is assumed that this will be based on the date of specimen as for MSSA and MRSA. We have made this distinction internally for the last two years and only the hospital apportioned cases i.e. those occurring on or after day 3 of admission are reported through this Integrated Performance Report. Discussions have already started with the CCG lead for health care associated infection around the planning that will be required between now and April to tackle this target. Influenza Planning Influenza vaccine uptake amongst frontline healthcare workers is progressing extremely well with uptake at 66% against a CQUIN target of 75% uptake by the end of December in the acute hospital. Serious Incidents & Coroner Reports There have been no Never Events or Coroners reports to the Trust during October General Medical Council Concerns There were no cases referred to the GMC during October; nor did the GMC raise any concerns with the Trust. The GMC have however communicated the outcomes of two prior cases reported in the March 2016 IPR, both of these cases have been closed with advice only and no further action is required.


3.3 Clinical Effectiveness

Time to Surgery for Patients with a Fractured Neck of Femur In October 89.7% of Fractured Neck of Femur patients received surgery within 36 hours. This represents 4 patients waiting longer than 36hrs for theatre with only 1 patient more than required to meet the 90% target. This is a great improvement on previous months. Trauma theatre capacity continues to be closely monitored and an additional Fractured Neck of Femur list has been implemented as a pilot on a Saturday. “Fire Break” lists during elective hip lists have been identified during the week, which will also be used for patients with fractured necks of femur. An exception report detailing the actions taken and those planned to address performance is included on page 44 Antimicrobial prescribing – compliance with duration and indication on the drug chart, and compliance with guidelines Trust wide figures for antimicrobial prescribing compliance in October were: 81.3% (278/342) for inclusion of a duration on the drug chart; 88.9% (304/342) for inclusion of an indication on the drug chart; and 93.3% (195/209) for guideline compliance. Work is being undertaken with the Associate Medical Director for Medical Services to support the provision of individualised feedback to medical prescribers who do not comply with the antimicrobial prescribing standards.

100% ⁻

69% ₋

100% ⁻

60% ₋

100% ⁻

60% ₋

100% ⁻

80% ₋

101% ⁻

54% ₋

100% ⁻

84% ₋

100% ⁻

80% ₋

100% ⁻

75% ₋

100% ⁻

60% ₋

93.6%

96.0%

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

89.7%

83.3%

81.3%

88.9%

93.3%

95.6%

92.3%

93.3%

95.0%


Proportion of Eligible Admissions Assessed for Risk of VTE on Admission The reported proportion of eligible admissions assessed for the risk of VTE in October (93.6%) remains a provisional position only and is anticipated to improve following further data validation prior to submission of the national return. The finalised position for VTE risk assessment in July, August and September were 95.2%, 95.1% and 95.2% respectively.


3.4 Operational Effectiveness

A&E: maximum waiting

time of 4hrs from arrival to

admission/ transfer/

discharge (including MIU)

≥95%

98% ⁻

90% ₋

91.47% High

0

Maximum time of 18 weeks

from point of referral to

treatment in aggregate -

Incomplete Pathways

≥92%

≥96%

≤0.8%

Risk for next

3 months

Low

Low

Low

Low

Low

≥95%

Scale

98% ⁻

88% ₋

High

Medium

Medium

Low

Ambulance Handovers

Delayed >30 mins

Trajec

toryMedium

60 ⁻

0 ₋

98% ⁻

86% ₋

1.8% ⁻

0% ₋

30 ⁻

-2 ₋

100% ⁻

85% ₋

101% ⁻

81% ₋

100% ⁻

86% ₋

101% ⁻

79% ₋

101% ⁻

91.5% ₋

101% ⁻

96% ₋

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

96.52%

98.11%

96.57%

≥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


discharge (excluding MIU)

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

≥98%



Cancers) - Surgery

Latest

month

90.77%

29

92.01%

0.74%

0

95.35%

98.14%

100.00%


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

Pressure on the ED was sustained throughout October 2016. For the A&E maximum waiting time of 4 hours, performance for the month was 90.77%, compared to 88.63% in September 2016. Previous reports to the Board have also shown ED performance including the Walk in Centre (WIC,) however as of 1st October the Trust is no longer able to include these patients in the denominator when calculating performance against this target. National performance against the 4-hour target continues to be challenging, with achievement of 86% against the 95% target and only 19 out of 139 trusts with type 1 A&E departments achieving the target. RD&E performance against the trajectory agreed as part of the recovery plan is on track, as shown in the graph below.

≥85%

≤10%

Medium

High

Medium

High

High

101% ⁻

70% ₋

101% ⁻

80% ₋

100% ⁻

70% ₋

High

45% ⁻

0% ₋

78.7%

≥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

Acute 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% ₋

89.16%

78.79%

78.95%

15.4%

97.1%

73

4.8%

5.0

93.3%

88.7%


The achievement of 91.47% in October was above the recovery trajectory target of 90.9%. As shown in the graph below, this improvement has continued into November with a number of consecutive days achieving the 95% threshold.

Update on actions planned to improve performance The table below provides an update of the key actions outlined in the recovery plan.

Issue Action Timescale Update

MIUs The RD&E is engaged in work to consider how the Trust can support the provision of some MIUs,

October 2016

Completed

Successful transition of Honiton MIU to ED on the 1

st October


commencing with Honiton MIU in October.

Full hours 08:00 -22:00

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

st October 2016.

31/10/2016

Completed

WIC now fully staffed.

NHS 111 The service is transferring to Devon Doctors from 1

st October, after which

improvements are anticipated.

01/10/2016

Completed

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 North and Eastern A&E Delivery Board. 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

Management of psychiatric patients continues to be challenging, with long waits for patients requiring psychiatric inpatient admissions.

Short to medium term solutions have been agreed at a multi-agency meeting on the 15

th of November

2017.

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’ twilight shift

Consultant establishment demand and capacity review in progress

01/10/2016

01/10/2016

01/01/2017

Completed

1 WTE SHO and 1 WTE MG vacancy remain following an unsuccessful recruitment process.

Agency cover is in place for the SHO rota and there are currently 2 adverts in circulation.

Due to consultant capacity this has not yet been possible. A longer term plan to increase consultant establishment and extend “Minors” consultant cover has been agreed.

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

ED nurse staffing

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

December 2016

Completed

Interviews took place on 11/10/16. All posts filled and will filter into establishment over the next 2 months.

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 on-going to reduce vacancies during the next round of recruitment for junior medical staff.

12/09/2016

November 2016

Action complete and on-going.

All 12 general surgery middle grade vacancies have been filled with effect from 1

st Dec 2016.

Locum doctors currently employed to support shortfalls in ENT & Plastic Surgery.

Specialty patients

Remove all GP referred expected patients from the ED (Specialist

01/12/2016 New pathway for septic joints has


Surgery and Orthopaedics) started.

A Standard Operating Procedure for ENT patients has been clinically agreed. Equipment is being purchased to facilitate this change.

Future trajectory The Trust continues to forecast improvement in A&E performance, with sustainable delivery of the target from Q1 2017/18. Ambulance Handover Delays There were 29 delays greater than 30 minutes in October compared to 19 handover delays in September. This increase is due to a small number of days where there were a high number of patients brought in by ambulance. Whilst occasional peaks in demand are unavoidable, the Medicine Division are working closely with South Western Ambulance NHS Foundation Trust (SWAST) to ensure that swift escalation and management action takes place during peaks in demand going forward. There were no handover delays greater than 60 minutes in October 2016. Delayed Transfers of Care The average daily number of patients with a reportable Delayed Transfer of Care (DTOC) in October grew slightly to 67 patients compared to 62 in September. Within the wider health and social care system, there are a number of challenges in both the personal care market (domiciliary care) and the care home market, including the closure of a residential home in Exeter, which is resulting in the reduction in 16 local care home beds. A breakdown of the reason for delay is shown below, with the primary causes consistent with previous months i.e. awaiting ‘Completion of assessment’ and ‘Further non acute NHS care’.

Reason for delay - awaiting: Bed Days Delayed

Completion of assessment 524

Public Funding 54

Further non acute NHS care (incl. intermediate care, rehabilitation etc. 1077

Residential Home 41

Nursing Home 38

Care package in own home 304

Community Equipment/adaptations 25

Patient or family choice 3

Disputes 0

Housing -patients not covered by NHS and Community Care Unit 8

Total 2074

Cancer Waiting Times Performance

For the month of October, the Trust is forecast to achieve seven of the nine cancer targets. Performance against both the 62 day GP and 62 day upgrade targets continue to be a challenge as detailed in the table below.


Performance for October 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 77.95 14

62 Day Wait from Consultant Upgrade Referral to First Treatment

85 78.79 3

Performance against the 62-day GP Urgent Referral to First Treatment Standard For the month of October the Trust had 40 breaches within this standard, 14 more than the threshold allowed. As in previous months, the majority of these breaches have occurred within Urology. There is, however, a spread of breaches across other tumour sites which have been reviewed in detail in order to address any pathway issues. A high number of patients in October breached the 62 day standard as a result of unusually complex pathways. Urology Pathway - Performance against the 62-day standard The Urology Team continue to work through their comprehensive action plan to support the delivery of the 62 day target, which is on track. In addition to this, the Trust has agreed a new pathway with Taunton which will have a positive effect on breaches. A joint action plan has been drawn up which will deliver these changes by the end of January 2017. Somerset Dermatology One important issue to bring to the Board’s attention is the unexpected cessation of the Dermatology Service at Taunton from 1st November, which is likely to add pressure to the RD&E service as patients will be referred further afield. Somerset CCG is working closely with providers in Somerset, Devon and Bristol in order to provide the required capacity and manage patients safely. The Trust is supporting the CCG by offering available capacity; however, this is limited and has to be balanced against local pressures. The possible increase in dermatology patients could place pressure on the delivery of the 2-week wait, 31-day and 62-day cancer targets if it were to occur in significant volumes. Cancer performance summary Although seven of the nine targets were achieved, October was a challenging month for a number of services. Actions to address pathways issues continue to be on track in all areas and the Trust continues to forecast delivery of the 62-day standard from the end of Q3. Diagnostic Test Waiting Times Performance

At the end of October there were 163 patients (equivalent to 2.94% of the waiting list) waiting longer than 6 weeks for a key diagnostic test, against a target of no more than 1%. This is 80 patients in excess of the Trust’s recovery trajectory for October of 1.5%. Diagnostic performance remains challenged in Endoscopy, Cardiac MRI, Urodynamics and Sleep Studies.

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 23 Decrease of 11


Cardiac MRI 78 Increase of 31

Urodynamics 23 Decrease of 7

Sleep Studies 21 Increase of 2

Aggregate Across all 15 Key

Diagnostic Tests

163 Increase of 28

Endoscopy At the end of October there were 23 patients of the Endoscopy total waiting list patients waiting longer than 6 weeks for an endoscopic test compared to a trajectory of 18, which represents an improvement of 11 patients. Cardiac MRI The number of patients waiting longer than 6 weeks for a cardiac MRI at the end of October was 78 compared to a trajectory of no more than 27. The deterioration in performance was due to capacity problems within the service relating to workforce absence and is being closely managed by the Divisional team. This is an adverse shift from the recovery trajectory and the Division has initiated an escalation meeting to undertake remedial actions. Amendments to the remedial action plan are to be agreed with the CCG as an outcome of this escalation process. Urodynamics As of 31st October, 23 routine patients had been waiting over six weeks for their Urodynamics diagnostic test, a reduction of seven on the previous month. Three of these were due to patient choice. From 18th October 2016, with the addition of the staff described in the October Integrated Board Report, the department reinstated the list on a Tuesday afternoon. This enabled the team to accommodate a further 5 patients per week and reduce the number of patients waiting over six weeks. The team will reinstate an additional Thursday list as often as it can be staffed, until the remaining staff member is in post, planned for January 2017. Assuming there is no further sickness, it is anticipated that the diagnostic tests will be delivered in target by 6th January 2017. Sleep Studies At the end of October there were 21 patients waiting longer than 6 weeks for a sleep study, a slight increase of 2 from the end of September. 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. This issue will be closely managed by the Divisional team and via the Performance Assurance Framework process in order to ensure that it is resolved as soon as the workforce issues allow. 18 Weeks Referral to Treatment

The Trust achieved the target for referral to treatment times with 92.01% against a target of 92%. The achievement represents a great deal of hard work from clinical and administrative staff. No patients were waiting longer than 52 weeks at the end of October.


Cancelled Operations

There were no breaches of the 28-day rebooking standard for hospital cancellations during October, which represents the fourth consecutive month with 100% performance.


3.5 Workforce

This is the first month of reporting against a revised set of workforce and OD performance indicators including:

Monthly Reporting

Quarterly Reporting Half Year Reporting

- Annual Turnover - Sickness Absence - Pay Bill (NHSI Submitted

Plan) - Agreed Establishment

(NHSI Submitted Plan) - Compliance

- Talent Management

- Equality & Diversity - Staff Engagement

NB: With the exception of Agreed Establishment all indicators exclude staff who joined the Trust as part of

the transfer of Community Services on 1st October 2016. From December onwards all staff will be included.

Overall the Trust performance is mainly within expected thresholds across all indicators with the exception of sickness absence and turnover which continue to report an adverse position. Whilst more detail is provided below, it is recognised that internal pressures around workload demand and the changing external environment (eg: New Devon CCG consultation) remain challenging, and potentially unsettling for staff, and may be contributing to performance of these two indicators. As reported below, there continues to be a determined focus on delivering agreed plans to improve performance across all indicators. In addition to this work, the Executive Team has prioritised action on four core enablers: (1) CEO Briefing – video blog and written brief; (2) Team Brief that is cascaded throughout the organisation, briefed by Leaders within Communication Cell briefings, and on Communication Cell Board for easy access; (3) Observe & Support – the Exec Team will undertake the schedule of Level 3 O&S sessions enabling them to observe and support teams in the workplace; (4) Communication Cells – provision of support to local teams to enable effective use of Communication Cells across the acute and community service settings. This work will further support the programme of Exec Briefings which have been well received by staff. Annual Turnover The aggregate annual staff turnover rate has increased this month to 13.4% with the largest change seen within our registered nurse and midwife staff groups where an increase from 14.9% to 16.2% has occurred. However, this increase is offset by a reduction in turnover within the Allied Health Professional (AHP) staff group to 14.3% from 18.8% at its highest level.

Compliance

All

metric

s on

target

5 ⁻

0 ₋

3 Low

Paybill≤NHSI

Plan

£25M ⁻

£18M ₋

£23.8M Low

Agreed Establishment - FTE≤NHSI

Plan

7.5K ⁻

5K ₋

6911 Low

IndicatorTarget

line

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

3 months

Medium

Medium4.2%Sickness absence – Overall <3.5%

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

5% ⁻

2.5% ₋

13.5% ⁻

6.5% ₋

% 12 Month Turnover10-

12%

Latest

month

13.4%


The Executive Director for Transformation and OD has established a Task & Finish Group to complete a 12 week deep dive exercise – early benchmarking work completed has compared our performance to other organisations and, apart from Yeovil at 15.6%, all other organisations have a lower overall turnover (underlying reasons are being explored). As part of the 12 week work, there will be a specific focus on Medical and Specialist Service Divisions where turnover is the highest, and on our registered nursing/midwifery and unregistered nursing staff groups who each reported a 16.2% turnover in October. The progress and outcomes of the Task & Finish Group will be monitored by the Workforce Governance Committee and reported to the Governance Committee in January 2017.

With regards to the stability of the workforce, however, our annual stability rate remains 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.

With regards to staff leaving within the first 12 months, during the last year 154 people (out of 728 new starters) left within first 12 months with no common themes emerging – this equates to c. 20% compared to 24% in 2013/14. Whilst there is no central benchmarking information on this, the Trusts responding to our data request are reporting between 15% and 25%. Sickness Absence Levels for October have increased from 3.74% to 4.23% in October, with the 12 month rolling rate at 4.17%. For the month of October the cost of sickness absence was £482,524 – this is direct wage cost only and does not include any additional costs of replacement cover. Approximately 70% of the total absence recorded in October spans 5 reasons:

o Mental health related illness 25.27% o Musculoskeletal problems 17.16% o Gastrointestinal problems 11.14% o Cold, Cough, Flu & Influenza 10.59% o Injury/fracture 5.15%

A deep dive into mental health related sickness absence has been completed with a report presented to Health & Safety Group in November 2016. This has highlighted that operational demand as the highest cause for work related stress referrals with the provision of support for staff as second. It also highlighted Medical and Specialist Service Divisions as having the highest mental health related sickness absence which indicates a potential correlation with staff turnover. The Divisions and Support Functions continue to take action to improve performance, as a Trust we have enhanced our Health & Wellbeing Plan including the introduction of group Mindfulness Training, the re-launch of the Stress Management Training, and the roll out of the Managers Mental Health Awareness sessions via the HR Business partners. Work continues to deliver two CQUIN schemes at a value in excess of £1m each; the Flu Campaign and improvements to Health & Wellbeing which is monitored via the Workforce Governance Committee. Of particular note is the great progress on the flu vaccination campaign which, at the time of writing this report, has achieved 66% of front line staff inoculated against a target of 75% of front line staff by 31st Dec 2016. Pay Bill The Trust pay bill for October is 1.8% under the planned expenditure submitted to NHSI as part of the annual workforce plan. The total amount paid to bank staff has increased this month for registered nurses by £47,000 which is a positive signal that our growth plan for the bank is working.


Despite an increase in spend for medical and dental agency workers last month, the overall agency expenditure has shown a small reduction. We are forecasting total year end agency spend of £5.2m (including £468k for agency use in the community) against the NHS Improvement ceiling of £8.3m and our internal target of £6.7m. We continue to negotiate down agency supplier costs and are successfully driving down usage of agency workers. NHS Improvement has issued the first South Region Agency Report and out of 55 organisations the RD&E ranks 4th best organisation in the South with lowest agency spend against the ceiling & and 1st for spend % of total staff cost. This is a tremendous recognition to the leadership of our Agency Plan and the hard work of everyone involved. Agreed Establishment (NHSI Submitted Plan) As a result of the transfer of Community Services the total number of contracted staff has shown a large increase to 6,893 FTE. The agreed establishment is 1.2% (81 FTE) under the workforce plan submitted to NHSI. At the end of September vacancies for band 5 registered nurses increased by 10 to 35 FTE which included an increase in establishment of 9.4 FTE, with 26 FTE unregistered nurse vacancies including an increase in establishment of 10 FTE. 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 including attendance at The Nursing Times event in London (in collaboration with our Trust Partners) to promote the benefit of working and living in Devon which resulted in contact from 140 individuals (including a large number of third year students) who wish to be contacted further to discuss the potential of relocating. Compliance We have seen continued progress against prioritised compliance metrics, with a summary provided below:

The overall statutory & mandatory training compliance rate for October remains well above the 80% threshold at 86.9%

Exit interview response rate is currently at 25% and increasing this has been identified as one of the key targets in the deep dive into staff turnover rates

Roster compliance is at 86% below the target of 95%. Between April and July the rate was averaging 90%, however this dipped in August and has since been recovering. Rosters which are not compliant i.e. not published 6 weeks in advance are escalated to the relevant Assistant Director of Nursing for investigation

Currently 49% of job plans have been fully completed with a further 23% at sign off stage. There are currently 21 records out of 310 which are showing as not having a job plan and these are being managed via the Associate Medical Directors and HR BPs.

Medical staff revalidation is at 100%.

Nursing staff revalidation is at 100% All of the above are monitored via the Divisional Performance Review Meetings and reported to the Workforce Governance Committee.


3.6

Finance Overview

A year to date deficit of £341k has been generated at the end of October compared to a budgeted deficit of £633k, a favourable movement of £541k compared to last month’s report. This mostly relates to pay underspends offset with additional expenditure on non pay items. 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. Income and expenditure relating to Community Services has been included in the report from 1st October 2016. Budgeted income for 2016/7 of £28.9m (£57.8m full year) has been included and offset with expenditure of the same amount. During October, Community Services are under-spent by £100k (excluding contingency), however following month end close un-accounted expenditure on interim staff relating to October has been idenitified which will reduce the underspend. Under the new NHS Improvement (NHSI) Finance and Use of Resources Score (having replaced the Financial Sustainability Risk Rating (FSRR) from the 1st October 2016) the Trust has achieved a level of 2 (out of 4) in October and this is expected to reduce to a level 3 by year end. Income Clinical income (including private patients) at the end of month 7 is under-recovered by £1.5m, an improvement on last month’s report of £95k. Clinical income is forecast to under-recover by £218k at year end, an improvement from last month of £899k. The main Divisional over/under performances are;

The Medicine Division is currently over recovering by £882k year to date, a similar postion to last month. Medicine is forecasting an over recovery of income by year end of £2.8m, an improvement of £280k in October. This mostly relates to improvements in General Medicine (£492k) offset with a deterioration in Gastroenterology (£162k) and Nephrology (£100k).

YTD Month 7 YTD Month 6 Change

£’000 £’000 £’000

I&E year to date -341 -882 541

I&E forecast -6,536 -6,565 29

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

60 31 29

Total income variance to date -1,747 -1,621 -126

CIP variance to date 346 229 117

Pay expenditure variance to date 1,009 658 351

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

332

737 -405

Cash at month end 10,296 5,813 4,483


Surgical Services has underperformed by £4.4m year to date, a deterioration of £131k in Month 7. This is mostly relating to adverse movements in the month for Orthopaedics (£405k - mainly relating to daycase hands and knees), Urology (£108k), Ophthalmology (£90k) and Plastics (£94k) offset with favourable movements in General Surgery (£198k), Trauma (£94k), Rheumatology (£133k), Oral Surgery (£86k) and ENT (£81k). The division is forecasting at year end an under recovery of income of £4.3m, an improvement in the month of £396k. Forecast deteriorations for Orthopaedics (£171k) and Urology (£213k) are offset with improvements in the forecast postions for General Surgery (£308k), Urology (£213k), Orthopaedics (£171k) and Rheumatology.

Specialist Services have overperformed by £716k, an improvement of £103k in month which mostly relates to improvements in diagnostic income especially in Radiology and Interventional Radiology. The Division are forecasting an over recovery of £1.6m, an improvement of £175k in the month, relating to forecast improvements in Paediatrics.

Other clinical income has improved by £64k during October due to an over recovery of £1.4m year to date which is mostly related to an adjustment to reflect a fixed NEW Devon contract value (£1.7m).

Commercial income is under-recovered by £249k year to date which relates to a provision that has been made against a recharge the Trust may not receive. Commercial income is forecast to end the year with an under-performance of £408k. The Trust is planning to receive £10.0m of Sustainability and Transformation Funding for the year. The table below sets out by quarter the planned amount recoverable on each of the 4 main criteria. Year to date income has been reduced by £167k due to not meeting the 62 day cancer access standard in the months July – October 2016, and a further £42k has been anticipated in month 8. Also the Trust has failed the A&E access standard in quarter 2 (an income reduction of £313k) and anticipates not to meet the criteria for quarter 3, a possible further £313k loss of income. However, the Trust will appeal to retain STF income relating to both cancer and A&E targets. Mitigations relate to an increase in referrals and demand for services beyond the organisation’s control. The forecast assumes the appeal will be successful.

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 - 626 313

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 2,062 2,938 2,500

10,000

Expenditure Pay has underspent by £1.0m year to date, a favourable movement of £351k and is forecast to end the year with an underspend of £584k, a £202k improvement. Both year to date and forecast improvements are due to nursing and admin expenditure improvements, please see below.


Medical staffing is overspent by £603k year to date which is similar to last month. By year end the overspend is anticipated to increase to £1.3m as additional expenditure is required to offset activity under-performances in the first part of the year (particularly within the Orthopaedic and Cardiology specialities). There will also be increased costs to cover maternity, junior doctors contract and middle grade rota issues (including backdated payments for rota compliance and cover arrangements due to a national shortage of middle grade doctors). Nursing pay is underspent by £622k to the end of October, a favourable movement in the month of £140k. This mostly relates to a backdated budget increase for the nursing establishment review. For similar reasons the nursing forecast position has improved by £275k to a forecast year end underspend of £800k.This budget increase, as agreed by the board, has met overspends in the areas it relates, however this has highlighted year to date underspends in other areas such as theatres nursing. Other staff costs (A&C, AHP, managerial, etc.) have improved in the month by £251k to an underspend of £1.0m in the first seven months of the year. The improvement is across most categories of staff and Divisions / Departments. Total agency expenditure for the Trust has amounted to £3.4m year to date, with expenditure of £505k in October (including £102k relating to the community). The forecast for agency expenditure is £5.2m by year end (including £468k for agency use in the community). This position is favourable to the NHS Improvement (NHSI) ceiling of £8.3m for the financial year, including an increased agency ceiling for the community of £0.5m. A recent report by NHSI on Trusts in the South of England for months 1 – 6, has ranked the RD&E as the best (out of 55 Trusts) on agency spend as a percentage of total pay bill, and fourth best on agency spend compared to the Trust’s agency ceiling. Non-pay expenditure at the end of October is £332k underspent, a deterioration of £405k compared to last month’s report. The main movements in the month are:

Drugs – favourable movement of £88k to a year to date underspend of £350k.

Clinical supplies – an adverse movement in month of £163k to a year to date underspend of £309k. The deterioration in month mostly relates to Medical and Surgical products (£104k) and Chemicals and reagents (£60k).

Miscellaneous other costs – an adverse movement in month of £318k to an overspend of £259k. The deterioration relates to Admin £76k (including IT equipment and office equipment), Maintenance Agreements £137k (including increased waste spend (£48k) and repair to the Central Heat Processing unit (£50k)), consultancy (£30k), travel expenses (£28k) and maintenance equipment (£27k).

Non pay is forecast to end the year with an overspend of £499k – a deterioration of £560k in the month mostly relating to issues outlined above and as a result of increased activity 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 £9.4m of the £12.2m target has been achieved with £1.4m being achieved in month 7. Plans are in place for £2.0m of the remaining £2.8m with £763k unidentified. Schemes continue to be identified and developed via Divisions and Trust wide schemes and are


currently forecast to deliver by year end. Recurrently Schemes totalling £4.7m have been achieved on a recurrent basis against the target of £12.2m with £252k having been achieved in month 7. Plans are in place for £3.1m of the remaining £7.5m with £4.4m unidentified. Further schemes have been identified and are currently being agreed with relevant managerial leads. There is a high risk that the full year CIP target might not be met and will need to be added to the 17/18 CIP target. A contract note reduction relating to the Success Regime schemes for Bed Based Care and Planned Care is expected during 16/17. This will result in a £2.4m contract income reduction offset by a similar expenditure reduction. Property, Plant and Equipment Actual capital expenditure for the seven month period ended October 2016 was £3.0m, £2.3m lower than the budget (£5.3m). This is mainly due to a delay in procurement of X-Ray equipment (£1.2m) and delays in the estates infrastructure plans (£700k). Total forecast capital expenditure for the year is £12.7m, compared to £12.4m per the plan. The increase in forecast expenditure of £307k relates to schemes slipped from 2015/16, and new charitable / grant funded schemes, totalling £791k, 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 £6.6m higher than plan. NHS Trade receivables are £6.7m higher than estimated, including £2.7m of Sustainability and Transformation funding not yet received. The remaining variance mainly relates to accrued income being higher than expected and overdue receivables including amounts due from SW Specialised Commissioners which are actively being resolved. Payables Trade and other payables are £2.7m higher than plan. NHS Trade Creditors are £2.3m higher than plan, including charges relating to community theatres not included in the plan, as the plan assumed that the Trust would be operating those services from 1 June 2016. Other Financial Liabilities are £1.4m higher than plan, relating to accrued expenses. Cash The cash balance is £10.3m and is £5.6m higher than plan and £1.2m higher than budget. The increase in cash compared to budget is mainly due to changes in working capital balances, in particular Trade and Other Payables being higher than planned, and capital expenditure to date being lower than planned. The forecast cash balance at the end of the financial year is estimated to be £1.4m lower than budget. 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 7, four NHS Improvement targets are not currently being 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 91.47% in October compared to a target of 95%.

Sixty two day wait from GP Urgent Referral to Treatment. In October 78.95% of patients were treated within 62 days, compared to a target of 85%.

Sixty two day wait following NHS Screening Service referral to treatment. In October 78.79% of patients were treated within 62 days, compared to a target of 90%.

Patients waiting no more than 6 weeks for a key diagnostic test. In October 97.1% of patients waited no more than 6 weeks, compared to a target of 99%.

3.9 Contract As a result of the performance reported in Section 3 and other data included in Appendix 1 (page 27), the contractual implications are as follows: The total penalty risk for month 7 is £0k, bringing the total penalty position for the year to date to £30k. 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. An appeal to exempt the Trust from the loss of STF income linked with the achievement of performance targets for the A&E 4-hour wait and the 62-day cancer waiting times target will be submitted to NHSI during November.

3.10 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. NHS Improvement 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. Data Tables (circulated as a separate appendix)


1. NHS Improvement Targets

Indicates that the standard has been achieved for the month

Indicates that the standard has not been achieved for the month

Indicates that the Single Oversight Framework had not yet been applied

Risk for Year | Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | Q4 |

Indicator Standard Scale 2014 - 2015 | 2015 - 2016 | 2016 - 2017 Latest

month

A&E maximum waiting time

of 4 hours from arrival to


discharge

≥95%

98% ⁻

90% ₋

91.47% High

NHS Improvement Single Oversight Framework Operational Performance Metrics Dashboard - October 2016



key diagnostic test

≥99%

101% ⁻

92% ₋

97.1% High



Screening Service Referral

≥90%

101% ⁻

80% ₋

78.79% Low



Urgent GP Referral

≥85%

100% ⁻

70% ₋

78.95% High

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.



treatment in aggregate -

Incomplete Pathways

≥92%

98% ⁻

86% ₋

92.01% High


2. Safer Staffing Return (Ward Level data )

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.

125% ⁻

95% ₋

130% ⁻

95% ₋

50 ⁻

0 ₋

460 ⁻

200 ₋

530 ⁻

220 ₋

150 ⁻

40 ₋

N/A Not Set

Latest

month

100.5%

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

97.6%

101.7%

107.2%

15

252

293

52


Division Ward Name Planned Actual Planned Actual Planned Actual Planned Actual

Medical Service AMU East 3211.5 3370.6 3584.0 3855.5 2134.5 2271.0 2449.5 2607.5 105.0% 107.6% 106.4% 106.45% 4.7 4.9 9.7

Medical Service Ashburn 1884.5 1886.5 2554.8 2449.1 713.0 714.0 2059.0 2086.0 100.1% 95.9% 100.1% 101.31% 2.3 4.3 6.6

Medical Service Avon 1112.0 1022.5 1099.0 1076.0 586.5 563.5 449.5 489.0 92.0% 97.9% 96.1% 108.79% 2.5 2.2 4.7

Medical Service Bolham 1100.5 1151.0 2750.0 2873.7 1058.0 1104.0 1104.0 1438.5 104.6% 104.5% 104.3% 130.30% 3.1 4.9 8.1

Medical Service Bovey 2070.0 2092.0 5440.5 5114.3 1490.5 1442.5 3358.0 3449.5 101.1% 94.0% 96.8% 102.72% 2.2 5.3 7.5

Medical Service CCU 1379.0 1486.0 46.0 46.0 773.0 740.0 11.5 107.8% 100.0% 95.7% 12.1 0.1 12.3

Medical Service Clyst 2274.0 2251.0 2555.0 2377.9 1196.0 1197.8 1276.5 1219.0 99.0% 93.1% 100.1% 95.50% 3.5 4.0 7.5

Medical Service Creedy 1882.0 1863.3 1979.5 1922.5 1046.5 1058.0 770.5 770.5 99.0% 97.1% 101.1% 100.00% 4.0 3.1 7.1

Medical Service Culm 2524.5 2509.0 3525.0 3590.3 2185.0 2242.5 2035.5 2012.5 99.4% 101.9% 102.6% 98.87% 3.2 3.6 6.8

Medical Service Lowman 1565.5 1695.5 1414.0 1517.5 966.0 1000.5 1023.5 1194.0 108.3% 107.3% 103.6% 116.66% 3.0 3.4 6.4

Medical Service Mardon Hou 923.0 932.0 2171.0 1869.8 360.0 372.0 814.0 1133.5 101.0% 86.1% 103.3% 139.25% 3.3 8.1 11.4

Medical Service Okement 1437.5 1445.5 1544.5 1482.5 931.5 993.5 747.5 838.0 100.6% 96.0% 106.7% 112.11% 2.7 3.6 6.3

Medical Service Taw 1330.5 1342.0 794.5 790.5 598.0 714.0 92.0 138.0 100.9% 99.5% 119.4% 150.00% 4.6 1.9 6.4

Medical Service Tiverton 1,916.50 1,838.75 2,603.48 2,531.07 1,237.00 1,233.00 930.00 805.00 95.9% 97.2% 99.7% 86.56% 4.4 3.9 8.3

Medical Service Torridge 1099.5 1069.3 1261.0 1143.0 678.5 704.5 701.5 793.5 97.3% 90.6% 103.8% 113.11% 3.2 3.3 6.5

Medical Service Yealm 1270.5 1350.3 1516.0 1552.5 575.0 598.0 447.5 608.5 106.3% 102.4% 104.0% 135.98% 2.9 3.4 6.2

Medical Service Total 26981.0 27305.2 34838.3 34192.0 16529.0 16948.8 18258.5 19594.5 101.2% 98.1% 102.5% 107.32%

Specialist Services Bramble 4725.0 4730.3 1048.5 1225.3 2882.5 2940.0 57.5 385.0 100.1% 116.9% 102.0% 669.57% 10.6 1.6 12.2

Specialist Services Maternity 4229.5 4330.0 2268.0 2203.3 2552.0 2567.5 671.0 571.5 102.4% 97.1% 100.6% 85.17% 5.3 2.0 7.3

Specialist Services NNU 2903.5 2974.0 1553.5 1561.0 1863.0 1890.0 667.0 694.0 102.4% 100.5% 101.4% 104.05% 6.5 1.9 8.4

Specialist Services Wynard 1957.5 1836.0 2251.0 2308.5 931.5 966.0 1322.5 1356.0 93.8% 102.6% 103.7% 102.53% 4.5 5.6 10.1

Specialist Services Yarty 1000.4 1028.7 497.5 513.5 701.5 713.0 333.5 356.5 102.8% 103.2% 101.6% 106.90% 4.3 2.6 6.9

Specialist Services Yeo 1875.5 1661.5 992.5 1021.5 713.0 724.5 483.0 666.5 88.6% 102.9% 101.6% 137.99% 3.5 2.9 6.3

Specialist Services Total 16691.4 16560.4 8611.0 8833.0 9643.5 9801.0 3534.5 4029.5 99.2% 102.6% 101.6% 114.00%

Surgical Services Abbey 1514.0 1532.5 1457.5 1503.7 678.5 692.0 747.5 734.5 101.2% 103.2% 102.0% 98.26% 3.4 4.8 8.2

Surgical Services Dart 1638.5 1596.2 1938.0 1787.0 908.5 931.5 805.0 840.5 97.4% 92.2% 102.5% 104.41% 2.9 3.1 6.0

Surgical Services Durbin 1668.5 1741.0 1786.0 1852.8 1069.5 1058.0 1230.5 1265.0 104.3% 103.7% 98.9% 102.80% 2.7 3.2 5.9

Surgical Services Dyball 1345.3 1269.5 1105.8 1077.0 747.5 759.0 655.5 685.0 94.4% 97.4% 101.5% 104.50% 3.2 2.9 6.1

Surgical Services Exe 1338.0 1388.0 966.0 960.5 701.5 713.0 345.0 437.0 103.7% 99.4% 101.6% 126.67% 3.4 2.6 6.1

Surgical Services Lyme 1784.5 1768.4 1397.0 1344.5 1069.5 1071.3 644.0 908.5 99.1% 96.2% 100.2% 141.07% 3.2 2.5 5.8

Surgical Services Mere 1333.5 1307.0 1104.0 1050.0 735.5 735.5 701.5 770.5 98.0% 95.1% 100.0% 109.84% 2.9 3.1 6.1

Surgical Services Otter 1486.0 1470.3 1508.0 1442.7 943.0 968.0 655.5 678.5 98.9% 95.7% 102.7% 103.51% 3.8 2.8 6.6

Surgical Services Tavy 1300.0 1362.0 1294.0 1278.2 667.0 719.0 989.0 1003.0 104.8% 98.8% 107.8% 101.42% 3.7 4.8 8.5

Surgical Services Teign 4874.0 4861.0 668.5 532.0 4252.0 4218.0 530.0 458.0 99.7% 79.6% 99.2% 86.41% 28.3 2.8 31.1

Surgical Services Total 18282.3 18295.8 13224.8 12828.3 11772.5 11865.3 7303.5 7780.5 100.1% 97.0% 100.8% 106.53%

Grand Total 61954.7 62161.4 56674.0 55853.2 37945.0 38615.0 29096.5 31404.5 100.3% 98.6% 101.8% 107.93% 4.0 3.5 7.5

Exeter - Budlake 1,026.48 1,111.73 1,681.02 1,692.00 620.00 620.00 620.00 620.00 108.3% 100.7% 100.0% 100.00%

Exmouth - Doris Heard 964.67 970.33 1,362.50 1,337.00 620.00 613.58 310.00 341.00 100.6% 98.1% 99.0% 110.00%

Honiton Medical Ward 891.00 909.50 1,343.00 1,192.75 625.00 627.00 310.00 341.00 102.1% 88.8% 100.3% 110.00%

Okehampton Hospital 943.33 869.08 1,202.33 931.33 624.75 672.75 310.50 301.00 92.1% 77.5% 107.7% 96.94%

Ottery St Mary Hospital 813.00 797.25 1,528.50 1,504.50 652.00 654.00 652.50 599.50 98.1% 98.4% 100.3% 91.88%

Seaton Hospital 1,052.00 1,085.00 1,348.50 1,132.00 620.00 621.50 310.00 315.50 103.1% 83.9% 100.2% 101.77%

Sidmouth Hospital 1,000.00 1,090.33 1,311.50 1,208.50 620.00 623.50 310.00 308.83 109.0% 92.1% 100.6% 99.62%

Night

Average

fill rate -

registere

d nurses/

midwive

Average

fill rate -

care staff

(%)

Average

fill rate -

registere

d nurses/

midwive

Average

fill rate -

care staff

(%)

DayDay Night

Registered Care Staff Registered Care Staff

Care Hours Per Patient Day (CHPPD)

Cumulati

ve count

over the

month of

patients

at 23:59

Register

ed

midwive

s/ nurses

Care

StaffOverall


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 31/10/2016 to Budget to Budget to Budget

Month 7 Fav./(Adv.) Fav./(Adv.) Fav./(Adv.) Fav./(Adv.)

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

Income

NHS Clinical Income 33,896 33,884 12 209,374 210,777 (1,402) 1 379,454 379,545 (91) 1 397,531 330,945

Private patient Income 219 136 83 823 950 (127) 1,490 1,617 (127) 1,618 1,332

Research and Development 1,563 1,533 30 11,048 11,017 31 18,435 18,435 0 19,029 19,390

Education and Training 1,285 1,285 0 7,908 7,908 0 13,611 13,611 0 13,586 13,549

Other Income 3,489 3,740 (251) 22,742 22,991 (249) 38,174 38,582 (407) 44,060 38,271

Total income 40,452 40,578 (126) 251,895 253,642 (1,747) 451,165 451,790 (625) 475,824 403,487

Expense

Employee Benefits Expenses (Pay) (23,823) (24,174) 351 (147,932) (148,941) 1,009 2 (268,587) (269,171) 584 2 (284,677) (244,783)

Drug Costs (4,370) (4,458) 88 (30,085) (30,435) 350 (51,359) (51,513) 154 (51,134) (49,028)

Clinical Supplies (3,857) (3,694) (163) (25,554) (25,863) 309 3 (43,267) (43,394) 127 3 (48,063) (45,062)

Non Clinical Supplies (465) (453) (12) (3,226) (3,158) (68) (5,702) (5,586) (116) (5,014) (5,401)

Research & Development Expenses (1,536) (1,536) (0) (10,104) (10,104) 0 (17,277) (17,277) 0 (18,669) (18,257)

Misc. Other Operating Expenses (4,250) (3,932) (318) (24,194) (23,935) (259) (43,643) (42,980) (663) (55,607) (39,060)

Cost Improvement Programme 0 (117) 117 0 (346) 346 0 0 (0) 0 0

Reserves 0 (50) 50 0 (350) 350 (8,470) (9,070) 600 0 0

Total Costs (38,301) (38,414) 112 (241,095) (243,132) 2,037 (438,305) (438,991) 686 (463,164) (401,591)

EBITDA 2,151 2,164 (14) 10,800 10,510 290 12,860 12,800 60 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 (1,022) (1,043) 21 (7,025) (7,046) 21 (12,375) (12,375) 0 (12,255) (15,406)

Total operating surplus (deficit) 1,129 1,121 7 3,775 3,464 311 485 425 60 406 (13,518)

4 9 (5) 38 61 (23) 104 104 0 104 84

Total interest payable on Loans and leases (58) (58) 0 (421) (421) 0 (706) (706) 0 (706) (773)

PDC Dividend (534) (537) 3 (3,733) (3,737) 4 (6,419) (6,419) 0 (6,400) (5,848)

Taxation payable

Net Surplus/(deficit) 541 535 5 (341) (633) 292 (6,536) (6,596) 60 (6,596) (20,055)

KEY MOVEMENTS

1 Clinical income is under-performing particularly within Orthopaedics, Cardiology, Ophthalmology, Urology, General Surgery and Intensive Care Unit. Healthcare for Older People, General Medicine, Dermatology and Medical Oncology are

the main areas overperforming.

2 Pay - underspends on Nursing (£622k) and other staff (£1.0m) are offset with an overspend on Medical staff (£603k). Pay is forecast to be £784k 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 which will increase in the second part of the year in line with additional activity.

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 31/10/2016 to Budget to Plan to Budget to Plan

Month 7 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) 195,996 199,620 (3,624) 1 199,620 (3,624) 221,722 221,789 (67) 221,789 (67) 199,991

Non NHS Trade Receivables, Non-Current 1,218 839 379 839 379 839 839 0 839 0 972

Assets, Non-Current, Total 197,214 200,459 (3,245) 200,459 (3,245) 222,561 222,628 (67) 222,628 (67) 200,963

Assets, Current

Inventories 7,060 7,725 (665) 2 7,725 (665) 7,025 7,725 (700) 7,725 (700) 6,664

Trade and Other Receivables, Net, Current 30,217 19,252 10,965 3 22,750 7,467 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 10,296 13,603 (3,307) 4 9,228 1,068 5,288 6,693 (1,405) 6,693 (1,405) 16,507

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

Assets, Current, Total 47,573 40,580 6,993 39,703 7,870 34,061 33,216 845 33,216 845 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 (13,130) (11,337) (1,793) 5 (11,337) (1,793) (11,226) (11,276) 50 (11,276) 50 (14,301)

Deferred Income, Current (2,902) (2,230) (672) (2,230) (672) (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 (5,436) (4,980) (456) (4,980) (456) (5,622) (5,622) 0 (5,622) 0 (4,586)

Other Financial Liabilities, Current (15,473) (13,345) (2,128) 6 (13,345) (2,128) (14,455) (14,455) 0 (14,455) 0 (12,292)

Liabilities, Current, Total (38,495) (33,447) (5,048) (33,447) (5,048) (35,151) (35,136) (15) (35,136) (15) (34,511)

NET CURRENT ASSETS (LIABILITIES) 9,078 7,133 1,945 6,257 2,821 (1,091) (1,921) 830 (1,921) 830 6,278

TOTAL ASSETS LESS CURRENT LIABILITIES 206,292 207,592 (1,300) 206,715 (423) 221,471 220,708 763 220,708 763 207,241

Liabilities, Non-Current

Loans, Non-Current, non-commercial (DH, FTFF, NLF, etc) (13,226) (13,863) 637 (13,863) 637 (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 (392) (376) (16) (376) (16) (376) (376) 0 (376) 0 (362)

TOTAL ASSETS EMPLOYED 192,674 193,353 (679) 192,476 198 207,758 207,739 19 207,739 19 193,018

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) 16,079 15,320 759 14,443 1,635 9,362 8,427 935 8,427 935 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 192,674 193,356 (682) 192,479 194 207,763 207,744 19 207,744 19 193,019

KEY MOVEMENTS

1

2 Inventories are £665k 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 higher than plan, mainly relating to accrued expenses being higher than planned.

Year to Date Outturn

The value of property plant and equipment is £2.7m lower than the plan, mainly due to an underspend on the capital program of £2.3m.

Trade and other receivables are £6.6m higher than plan including outstanding Sustainability and Transformation funding (£2.7m), accrued income and outstanding amounts from SW Specialist Commissioners and Northern Devon.

The cash balance is £10.3m. The increase in cash is mainly due to changes in working capital balances, in particular trade payables and accrued expenses being higher than planned.

Trade and other payables are £2.7m higher than plan. NHS Trade Creditors are £2.3m 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.



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

Cash Flow Statement Variance Plan Variance Variance Plan Variance

Period ending 31/10/2016 to Budget to Plan to Budget to Plan

Month 7 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 (341) (633) 292 (580) 238 (6,536) (6,597) 61 (6,596) 60 (20,055)

Non-cash flows in operating surplus/(deficit)

Finance (income)/charges 383 360 23 53 330 602 602 0 602 0 689

Depreciation and amortisation 7,025 7,046 (21) 993 6,032 12,375 12,375 0 12,255 120 15,406

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

PDC dividend expense 3,733 3,737 (4) 533 3,200 6,419 6,419 0 6,400 19 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 11,141 11,143 (2) 1,579 9,562 19,396 19,396 0 19,257 139 21,951

Increase/(Decrease) in working capital

(Increase)/decrease in inventories (396) (1,061) 665 (200) (196) (361) (1,061) 700 (200) (161) 1,361

(Increase)/decrease in NHS Trade Receivables (7,830) 2,338 (10,168) 0 (7,830) (4,660) (1,160) (3,500) 0 (4,660) 1,161

(Increase)/decrease in Non NHS Trade Receivables 437 880 (443) 525 (88) 880 880 0 525 355 (356)

(Increase)/decrease in other receivables 751 103 648 463 288 453 103 350 463 (10) 361

(Increase)/decrease in accrued income (882) (1,235) 353 (1,589) 707 (2) (2) 0 (356) 354 (700)

(Increase)/decrease in prepayments (5,075) (3,720) (1,355) (2,719) (2,356) (801) (1,001) 200 0 (801) 931

Increase/(decrease) in Deferred Income (excl. Donated Assets) 1,173 501 672 (170) 1,343 501 501 0 (170) 671 (648)

Increase/(decrease) in provisions (19) (35) 16 0 (19) (35) (35) 0 0 (35) 35

Increase/(decrease) in Trade Creditors (1,707) (2,552) 845 (451) (1,256) (3,275) (3,525) 250 (1,424) (1,851) 1,256

Increase/(decrease) in tax payable 850 394 456 380 470 1,036 1,036 0 1,022 14 30

Increase/(decrease) in Other Creditors 281 (27) 308 9 272 424 424 0 460 (36) 193

Increase/(decrease) in accruals 2,590 459 2,131 (749) 3,339 2,163 2,163 0 955 1,208 45

Increase/(Decrease) in working capital, Total (9,827) (3,954) (5,873) (4,501) (5,326) (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 (380) (28) (352) (28) (352) (595) (1,521) 926 (1,521) 926 (110)

Property - maintenance expenditure (285) (46) (239) (46) (239) (3,040) (1,858) (1,183) (1,858) (1,183) (3,438)

Plant and equipment - Information Technology (836) (26) (810) (26) (810) (1,510) (446) (1,064) (446) (1,064) (1,549)

Plant and equipment - Other (1,528) (148) (1,380) (148) (1,380) (6,870) (8,573) 1,703 (8,573) 1,703 (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 255 (385) 640 (418) 673 (224) 76 (300) 43 (267) (1,191)

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

Net cash inflow/(outflow() from investing activities, Total (2,774) (633) (2,141) (666) (2,108) (12,240) (12,325) 85 (12,358) 118 (9,136)

Net cash inflow/(outflow) from financing activities

PDC Dividends paid (3,200) (3,204) 4 0 (3,200) (6,419) (6,419) 0 (6,400) (19) (5,848)

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

Interest (paid) on commercial loans (363) (360) (3) 0 (363) (706) (706) 0 (706) (0) (773)

Interest received on cash and cash equivalents 38 61 (23) 9 29 104 104 0 104 0 84

Repayment of non-commercial loans (635) 2 (637) 0 (635) (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 (246) 133 (379) 0 (246) 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 (4,406) (3,367) (1,039) 9 (4,415) (8,156) (8,156) 0 (8,272) 116 (7,288)

Net increase/(decrease) in cash and cash equivalents (6,207) 2,555 (8,762) (4,159) (2,048) (11,214) (9,360) (1,854) (6,694) (4,519) (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 10,300 19,062 (8,762) 9,228 1,072 5,293 7,147 (1,854) 6,693 (1,399) 16,507

Year to Date Outturn


Royal Devon and Exeter NHS Foundation Trust

Capital Expenditure

Period ending 31/10/2016

Month 7 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 102 835 733 1,691 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 Jan-17

CRIC 65 897 832 940 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 805 804 (1) 11 816 804 (12) 816 816 (0) Nov-16

Unapproved 0 298 298 0 0 698 698 0 0 0 N/A

CRIC 254 0 (254) 86 340 0 (340) 651 651 (0) Dec-16

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

CRIC 372 0 (372) 175 547 0 (547) 547 547 0 Dec-16

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

CRIC / Unapproved 1,431 2,502 1,071 3,148 4,579 4,745 166

3,029 5,336 2,307 9,676 12,705 12,398 (307)

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

0 0 0 0 0 0 0

3,029 5,336 2,307 9,676 12,705 12,398 (307)

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

Theatres and 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 31/10/2016

Month 7 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 R/A/G R/A/G

Business As Usual

Medical Services 856 754 101 1,744 (1,744) 1,400 (344) 252 594 (342) 713 A G

Specialist Services 1,014 1,018 (4) 1,083 1,927 (844) 1,926 (1) 361 607 (246) 607 G G

Surgical Services 902 1,035 (133) 1,376 2,207 (831) 2,207 (0) 131 935 (804) 899 G G

Operations Support Unit 222 221 1 984 422 563 422 (0) 36 223 (187) 223 G G

Corporate 877 340 537 349 528 (180) 1,352 823 0 270 (269) 291 G G

0 0 0 0

3,870 3,368 502 5,001 6,828 (3,036) 7,307 479 780 2,628 (1,848) 2,733

Trustwide Projects

Bed Based Care 0 167 (167) 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 507 496 11 869 850 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 2,041 2,041 0 3,499 3,499 0 3,499 0 3,060 3,060 0 3,060 G G

0

2,548 2,704 (156) 4,368 5,349 (981) 4,393 (956) 3,929 9,549 (5,620) 5,630

Central Unidentified (excl BAU and Trustwide Projects) 0 0 478 478 0 3,814 G G

6,418 6,072 346 9,368 12,177 (4,018) 12,177 (0) 4,708 12,177 (7,469) 12,177

Summary by Planning Status

Achieved 9,368 4,708

Firms Plans Medium Risk 25 0

Low Risk 379 60

Plans being Scoped High Risk 1,142 1,515

Medium Risk 151 1,315

Low Risk 349 210

Unidentified High Risk 763 4,369

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


Royal Devon & Exeter NHS Foundation Trust

Surplus / (Deficit) by Directorate based on SLR reporting

Period ending 30th September 2016

Year to Date Month 6 2016/17

Surgical Services Medical Services

Specialist

Services

Corporate and

other TrustTotal

NHS Clinical Income 56,362 60,502 53,990 4,705 175,559

Non-patient income - staff 240 368 153 0 761

RTA income 135 147 80 0 362

Services provided 3,164 3,875 3,058 0 10,098

Education income 2,430 2,745 1,510 0 6,685

R&D income 3,199 4,918 1,250 0 9,366

Non-patient income - other 2,396 2,872 2,363 65 7,696

Total Clinical Income 67,926 75,427 62,403 4,770 210,527

Pay CostsMedical staff 15,937 12,389 8,463 0 36,790

Nursing staff 14,785 19,193 9,532 1 43,510

Admin. staff 4,754 4,464 3,936 9 13,163

AHP staff 4,569 4,737 5,511 0 14,817

Other staff 1,418 1,836 893 2 4,149

Non Pay CostsDrugs 4,206 10,464 10,837 0 25,507

Clinical Supplies 8,421 7,188 6,294 0 21,902

Non Clinical Supplies 680 856 288 0 1,824

Other non Pay 6,623 5,056 6,081 665 18,425

Total Pay & Non Pay Expense 61,392 66,183 51,836 676 180,088

Contribution 6,534 9,244 10,567 4,094 30,439Contribution % 9.6% 12.3% 16.9% 85.8% 14.5%

Overheads 7,763 8,410 5,644 8 21,826

[exclude interest, depreciation, PDC and impairments]

EBITDA -1,229 834 4,923 4,086 8,614

EBITDA % -1.8% 1.1% 7.9% 85.7% 4.1%

Depreciation & (Profit)/Loss on asset disposal 2,241 1,890 1,850 0 5,981

Profit / loss on asset disposals 0 0 0 0 0

Exceptional Income/ Costs & Impairments **

Total Depreciation 2,241 1,890 1,850 0 5,981

Total operating surplus (deficit) -3,470 -1,057 3,073 4,086 2,633

PDC Dividend and net interest payable 1,395 983 1,136 0 3,514

Total interest receivable/ (payable) - inc committed WC

facilities -12 -13 -10 0 -34

Total interest payable on Loans and leases 123 134 104 0 362

PDC Dividend 1,284 861 1,041 0 3,185

Net Surplus/(deficit) -4,865 -2,039 1,938 4,086 -881

Net Margin % -7.2% -2.7% 3.1% 85.7% -0.4%

£4.5m corporate income relates to Sustainability and Transformation


YTD M7 YTD M7

Actual Budget

£m £m

Green

Red

Red

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 £341k has been incurred (£375k favourable to plan) and a

forecast year-end deficit of £6.5m is expected in line with plan.

Patient Income variance £'m 210.2 211.7 380.9 381.2

Clinical and Private patient income is under-recovered by £1.5m year to date, reflective of the

operational capacity pressures experienced during the first 7 months of the year. Clinical

income is forecast to under recover by £218k at year end.

Income and Expenditure - Actual v Budget -0.3 -5.0 -6.5 -6.6

Commercial income is under-recovered by £249k year to date which relates to a provision

that has been made against a recharge the Trust may not receive. Commercial income is

forecast to end the year with an under recovery of £407k.

Pay costs variance £'m -147.9 -148.9 -268.6 -269.2

Pay has underspent by £1.0m, relating to underspends on Nursing (£622k) mainly in theatres

and other staff (£1.0m) which offset with an overspend on Medical staff (£603k). Pay is

forecast to be £584k under spent at year end.

Commercial income variance £'m 30.7 30.9 51.8 52.2

Drugs expenditure is underspent by £350k which is spread across the Divisions. An

underspend of £154k is forecast at year end.

Clinical supplies variance £'m -25.6 -25.9 -43.3 -43.4

Clinical supplies are underspent by £309k year to date which mostly relates to reduced

expenditure on prosthesis and medical & surgical items, this is mainly due to reduced activity.

Exeter Mobility expenditure is underspent in line with reduced income. This is offset

withoverspends on chemicals and reagents and dressings. Clinical supplies are forecast to

underspend by £127k by year end as additional spend is required to catch up activity.

Drug costs variance £'m -30.1 -30.4 -51.4 -51.5

Expenditure on non clinical supplies is overspent by £68k which mostly relates to cleaning

equipment (£55k). Non clinical supplies are forecast to be £116k overspent by year end,

which mostly relates to overspends on cleaning equipment (£104k) and patients clothing

(£14k) offset with an underspend on laundry (£16k).

Misc other operating expenses variance £'m -24.2 -23.9 -43.6 -43.0

Misc. other operating expenses are currently overspent by £259k, mostly relating to

overspends on admin expenses (£151k), maintenance equipment (£169k), services received

(£147k) and consultancy costs (£104k) offset with underspends on training (£120k),

maintenance agreements (£69k), travel (£39k) and ground and gardens (£37k).

Non clinical supplies variance £'m -3.2 -3.2 -5.7 -5.6

3 6 9 12

Actual


YTD M7 YTD M7

Actual Budget

£m £m

Green

Amber

Red

Red

Green

Red

Amber

Red

Amber

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 9.4 12.2 12.2 12.2

The CIP requirement for 2016/17 is £12.2m. £9.4.m of the target has been achieved in the

current year. Schemes totalling £4.7m have been achieved on a recurrent basis.

Recurrent - achieved v budget

EBITDA % 4.29% 4.14% 2.84% 2.83%

The Capital programme has currently underspent by £2.3m against the plan year to date and

is forecast to be £307k overspent by year end due to the addition of the schemes slipped

from 2015/16, plus new charitable and grant funded schemes, offset by schemes which have

been deferred to 2017/18.

Inventories YTD - Actual v Budget 7.1 7.7 7.0 7.7

Inventories are £665k lower than plan due to a reduction in the value of inventories held at

the year end.

4.7 12.2 12.2 12.2

Capital spend - Actual v Budget 3.0 5.3 12.7 12.4

NHS Trade receivables are £6.6m higher than estimated, including £2.7m of Sustainability and

Transformation funding not yet received.

Trade and Other Payables YTD - Actual v Budget -13.1 -11.3 -11.2 -11.3

Trade and other payables are £2.7m higher than plan. NHS Trade Creditors are £2.3m higher

than plan, including charges relating to Community Theatres, which were transferred over to

the Trust later than anticipated. Other Financial Liabilities are £1.4m higher than plan,

relating to accrued expenses.

Trade and Other Receivables YTD - Actual v Budget 30.2 19.3 21.7 18.8

The cash balance is £10.3m and is £5.6m higher than plan. The increase in cash compared to

plan is mainly due to changes in working capital balances, in particular Trade and Other

Payables being higher than planned, and capital expenditure to date being lower than

planned. The forecast cash balance at the end of the financial year is estimated to be £1.4m

lower than plan..

Capital Service Cover Rating (introduced 1st October 2016) 2.0 2.0 3.0 3.0

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

end.

Cash - Actual v Budget 10.3 4.7 5.3 6.7

Liquidity is currently a level 1 and is anticipated that this will drop to a level 2 by year end.

Amber

I&E Margin Rating (introduced 1st October 2016) 3.0 3.0 4.0 4.0

I&E margin is currently a level 3 and is anticipated that it decreases to level 4 by year end.

Red

Liquidity Rating (introduced 1st October 2016) 1.0 2.0 2.0 3.0

Agency rating (evaluating how close to the agency ceiling the Trust is) is currently rated at

level 1 and is expected to remain at a level 1

Green

Finance and Use of Resource Score (introduced 1st October 2016) 2.0 2.0 3.0 3.0

Finance and Use of Resource Score is currently a level 2 and is anticipated that it will decrease

to a level 3 by year end.

Agency Rating (introduced 1st October 2016) 1.0 1.0 1.0 3.0

3 6 9 12

Actual


YTD M7 YTD M7

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 6% below plan, 6% lower than October last year and 7% lower than the previous

month. For the year so far activity is 1% below plan and 3% higher than the same period in 2015/16.

Day-case Activity 32,120 31,404

Day case activity for the current month is 4% below plan however 1% above plan year to date. Activity is 5% lower than

September and 8% lower than October last year. The year to date activity is 2% higher than the same period of 15/16.

Elective Inpatient Activity 5,980 6,924

Elective activity for the current month is 11% below plan and 13% below plan year to date. Activity is 3% higher than last

month and 8% lower than October last year. For the year so far activity is 11% lower than the same period last year.

GP Referrals 39,173

GP referrals are 5% lower than last month and 5% higher than first 7 months of the last financial year. 4% higher than

October last year.

Non-Elective Inpatient Activity 18,639 18,802

Non elective activity for the current month is 2% below plan and 1% below plan year to date. This is 3% higher than last

month and 3% higher than October last year. For the year so far activity is 4% higher than the same period in 2015/16. NB.

This data is for all 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 2% below plan year to date.

Activity is 4% lower than the previous month and 8% lower than October a year ago. For the year so far activity is the same

as the same period last 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 October 89.7% of Fractured Neck of Femur patients received surgery within 36 hours. This represents 4 patients waiting longer than 36hrs for theatre with only 1 patient more than required to meet the 90% target. This is a significant improvement on previous months. Trauma theatre capacity continues to be closely monitored and an additional Fractured Neck of Femur list has been implemented as a pilot on a Saturday. “Fire Break” lists during elective hip lists have been identified during the week, which will also be used for fractured neck of femurs. The graph below shows a daily breakdown of the volumes of trauma patients, against the volume of fractured neck of femurs to give context on some of the operational challenges.

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

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Number of Patients with a Fractured Neck of Femur October 2016

#NoF's 36hr Breaches Trauma*


Action

By Whom

Timescale

Progress

Include on the daily Bed Forecast the number of #NOFs that are fit awaiting surgery to stimulate daily performance management.

Clinical Lead Cluster Manager T&O Lead Trauma Nurse

21/11/2016 - CM to liaise with Site Management

Pilot an additional NOF list on a Saturday, initially until the 31st Dec 16

Clinical Lead On-going - Additional lists up and running and staffed until the 31

st Dec 16. This will

be reviewed over December.

Reaffirming with trauma consultants the need to prioritise #NOFs.

Clinical Lead Cluster Manager T&O

30/11/2016 Complete and ongoing.


7. Cancer Waiting Times Standards Performance by Tumour Site

Month: 10 - 16/17 Inf services check: OK

Census date run: 16/11/2016

Target Position Worst CaseAcute

Leukaemia

Brain &

CNSBreast Gynae Haem

Head &

NeckLower GI Lung Sarcoma Skin Testicular

Thyroid/

Endocrine

Unknown

PrimaryUpper GI Urology Blank

Breaches 50 0 0 2 4 0 5 20 1 2 5 0 0 0 8 3

Total 1437 0 14 216 102 11 107 197 42 39 363 2 3 1 185 155

Position 96.52% 100.00% 99.07% 96.08% 100.00% 95.33% 89.85% 97.62% 94.87% 98.62% 100.00% 100.00% 100.00% 95.68% 98.06%

Breaches 1

Total 53

Position 98.11%

Breaches 11 11 0 0 1 0 0 0 2 1 0 3 0 0 0 0 4

Total 321 277 4 1 37 20 23 11 23 17 2 80 2 0 3 26 72

Position 96.57% 96.03% 100.00% 100.00% 97.30% 100.00% 100.00% 100.00% 91.30% 94.12% 100.00% 96.25% 100.00% 100.00% 100.00% 94.44%

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

Total 85 80 2 0 40 5 12 1 5 2 0 4 0 0 0 0 14 0

Position 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 0 0 0 0 0 3 0

Total 86 73 0 0 18 7 0 2 2 0 2 34 0 0 0 0 21 0

Position 95.35% 94.52% 100.00% 100.00% 100.00% 50.00% 100.00% 100.00% 85.71%

Breaches 3 3 0 0 0 0 0 0 0 1 1 0 0 0 0 0 1 0

Total 161 137 0 1 46 10 9 9 1 10 1 7 0 0 0 5 62 0

Position 98.14% 97.81% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 90.00% 0.00% 100.00% 100.00% 98.39%

Breaches 40.0 40.0 0 2.5 2 1 4 3.5 0.5 0 2 0 1 4 19.5

Total 190.0 164.5 0 24.5 14.5 8 8 9 8 1.5 48 0 1 20 47.5

Position 78.95% 75.68% 89.80% 86.21% 87.50% 50.00% 61.11% 93.75% 100.00% 95.83% 0.00% 80.00% 58.95%

Breaches 3.5 3.5 0 0 0 0 0 3 0.5 0 0 0 0 0 0

Total 16.5 14.5 0 12 0 1 0 3 0.5 0 0 0 0 0 0

Position 78.79% 75.86% 100.00% 100.00% 0.00% 0.00%

Breaches 4.5 4.5 0 0 0 0 0 2 0 0 0 0 0 0 2.5

Total 41.5 35.0 0 0 1.5 7 2 8 4 0 6 0 0 2.5 10.5

Position 89.16% 87.14% 100.00% 100.00% 100.00% 75.00% 100.00% 100.00% 100.00% 76.19%

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 49.0 0 3 2 1 4 4 1 0 3 0 2 4 25

Total 210.0 0 25 16 10 9 10 9 2 52 0 2 21 54

Breaches 4.0 0 0 0 0 0 3 1 0 0 0 0 0 0

Total 17.0 0 12 0 1 0 3 1 0 0 0 0 0 0

Breaches 5.0 0 0 0 0 0 2 0 0 0 0 0 0 3

Total 44.0 0 0 2 7 2 8 4 0 7 0 0 3 11

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

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