King s College Hospital Board of Directors

Transcription

1 King s College Hospital Board of Directors PUBLIC AGENDA Time of meeting 14: Date of meeting Tuesday, 18 December 2012 Venue Dulwich Committee Room, King s College Hospital Members: Prof. Sir George Alberti (GA) Graham Meek (GM) Marc Meryon (MM1) Christopher Stooke (CS) Faith Boardman (FB) Sue Slipman (SS) Prof. Ghulam Mufti (GM1) Tim Smart (TS) Angela Huxham (AH) Dr. Michael Marrinan (MM) Roland Sinker (RS) Simon Taylor (ST) Dr. Geraldine Walters (GW) Jane Walters (JW) - Non-voting Director Jacob West (JW1) - Non-voting Director In attendance: William McKee (WM) Sally Lingard (SL) Tamara Cowan (TC) Trust Chair Non-Executive Director, Vice Chair Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Chief Executive Director of Workforce Development Medical Director Chief Operating Officer Chief Financial Officer Director of Nursing & Midwifery Director of Corporate Affairs Director of Strategy Director of Transition and Transformation Associate Director of Communications Assistant Board Secretary (Minutes) Apologies: Circulation to: Board of Directors Circulation List

2 Enclosure Lead Time 1. STANDING ITEMS G Alberti 14: Apologies 1.2. Declarations of Interest to receive 1.3. Chair s Action 1.4. Minutes of Previous Meeting 29/11/2012 Enc Matters Arising/Action Tracking Enc FOR REPORT/DISCUSSION 2.1. KHP Update Verbal W McKee 14: Chair s and Non-Executive Directors Report Enc. 2.2 G Alberti 14: Update on Council of Governors Activities Verbal G Alberti 15: Chief Executive s Report Verbal T Smart 15: Finance Report Month 08 Enc. 2.5 S Taylor 15: Performance Report Month 08 Enc. 2.6 R Sinker 15: Winter Resilience Enc. 2.7 R Sinker 15: Quality & Safety Focus: Quarterly Patient Safety Report Enc M Marrinan 15:45 3. FOR INFORMATION 16: Confirmed Board Committee Minutes Finance & Performance 30/10/2012 Enc ANY OTHER BUSINESS 16:05 5. DATE OF NEXT MEETING Tuesday, 29 January 2013 at 14:30 in the Dulwich Committee Room

3 Enc 1.4 King s College Hospital NHS Foundation Trust Board of Directors - PUBLIC Minutes of the meeting of the Board of Directors held at 14:30 on Tuesday, 29 November 2012 in the Dulwich Committee Room, King s College Hospital. Members: Prof Sir George Alberti (GA) Trust Chair Graham Meek (GM) Non-Executive Director, Vice Chair Marc Meryon (MM1) Non-Executive Director (until item 12/174) Chris Stooke (CS) Non-Executive Director Faith Boardman (FB) Non-Executive Director Sue Slipman (SS) Non-Executive Director Tim Smart (TS) Chief Executive Angela Huxham (AH) Director of Workforce Development Dr. Michael Marrinan (MM) Medical Director Roland Sinker (RS) Chief Operating Officer Simon Taylor (ST) Chief Financial Officer Jane Walters (JW) Non-voting Director Director of Corporate Affairs In attendance: Prof John Moxham (JM) item 012/148 Chief Executive, KHP Sally Lingard (SL) Associate Director of Communications (until item 12/176) Paula Townsend (PT) Deputy Director of Nursing (Deputising for GW) Tamara Cowan (TC) Assistant Board Secretary (Minutes) Nanda Ratnavel Public Governor Gavin Ward 3M Dermot Martin 3M Tim Killen Astellas Pharma Joseph Cheng Graham Neill Apologies: Prof. Alan McGregor (AM) Dr. Geraldine Walters (GW) Jacob West (JW1) - Non-voting Director Non-Executive Director Director of Nursing & Midwifery Director of Strategy Item Subject Action 012/165 Apologies Apologies for absence were noted. 1

4 Enc 1.4 Item Subject Action GA reported that Professor McGregor s term of office as Non Executive Director on the Board comes to an end on 30 November. The Board extended its gratitude to him for his enormous contribution to the Board over the last 9 years. 012/166 Declarations of Interest There were no declarations of interest. 012/167 Chair s Action There were no chair s actions. 012/168 Minutes of previous meetings 30 October 2012 The minutes of the meeting held on 30 October 2012 were approved as a correct record. 012/169 Action Tracking/Matters Arising 012/170 KHP Update The action tracker was noted and there were no matters arising. Professor John Moxham gave a verbal update on matters relating to King s Health Partners reporting the following key points: One of the areas of major focus for KHP partners have been the issues related to South London Healthcare Trust. KHP partners have not only been working on the KHP response to the consultation but have been supporting KCH in its development of its proposals to acquire the Princess Royal University Hospital (PRUH); The Academic Health Science Network (AHSN) interview process will begin in January AHSNs have been set up to drive collaborative working. AHSNs will be the vehicle for linking Academic Health Sciences Centres throughout South London with other health bodies. KHP continues to support the work of the Health and Wellbeing Boards and a number of their areas of focus link in with KHP strategies, such as the reduction of smoking and alcohol intake; and KHP has various projects in progress to strengthen its public health agenda. 2

5 Enc 1.4 Item Subject Action 012/171 Chair s and Non-Executive Directors (NED) Report The report on the activities of the Chairman and non-executive directors for the period was noted. 012/172 Update on Council of Governors Activities The Chair provided an update on Council of Governor activities: An extraordinary meeting of the Council, convened at short notice, on 8 November gave the Board the opportunity to engage with Governors about the TSA s Consultation on South London Healthcare Trust (SLHT) and the Trust position; The next Council meeting is on the 5 December where the Trust will take the opportunity to further engage with Governors about SLHT. Governors will also be considering the recommendations from the Nominations Committee which met on 21 November to interview the successor to AM as KCL nominee to the Board; A Joint Governors meeting of the Governors from the 3 Foundation Trusts will be held at 5.30 pm, Boardroom at King s on 12 December; and There is a Governor Surgery on the 13 December with a number of informal discussions around particular topics of interest. Part of the time that day may be devoted to an extra private Council of Governors meeting regarding SLHT. 012/173 Chief Executive s Report The Board noted the Chief Executive s report for the period. TS highlighted the following key points: The Trust is still as busy as it has ever been but this is the same story across the sector and only a small number of trusts managing to stay ahead of the national targets; The financial situation remains challenging because of the continuing capacity and increasing emergency pressures; The Trust has been working on its response to the Trust Special Administrator s South London Healthcare Trust Consultation in addition to conducting preliminary due diligence regarding the proposals that the Trust acquires the Princess Royal University Hospital; 3

6 Enc 1.4 Item Subject Action The Trust has a plan to increase maternity capacity on this site. In the short-term the Trust has increased the number of staff and technical support workers in these areas; and The Integrated Care Programme (ICP) is work in progress and the appointment of a Director to lead the project is imminent; It is recognised that there is some correlation between reductions in social care provision and the increased attendances of frail older people to emergency departments across the sector. It is hoped the ICP programme will support the refinement of pathways and relieve some of the pressures in the system. It is unlikely that the Trust will see any significant changes for the coming winter period but over a longer period of time, it is hoped that it will have a noticeable impact in reducing avoidable hospital admissions for this patient group. 012/174 Finance Report Month 7 ST presented the finance report for month 7. It was noted that the Finance and Performance Committee had conducted an extensive review and discussion around the finance report earlier. The Board noted the report and the following key points: The Trust was slightly off-plan because of its inability to complete its elective activity as a result of the capacity pressures exacerbated by increasing emergency activity. The tariff for emergency activity over and above the Trust s quota is paid at a lower premium; and Although income is ahead of plan there has not been as much increase in the Trust s margins. 012/175 Performance Report Month 7 RS presented the performance report for month 7. It was noted that the Finance and Performance Committee had conducted an extensive review and discussion around the performance report earlier. The Board noted the report and the following key points: Month 7 performance has been strong with all access, referral to treatment (RTT) and cancer wait targets achieved; and Performance challenges going forward include continued delivery of RTT admitted and incomplete targets, Emergency Department and diagnostic wait times. 4

7 Enc 1.4 Item Subject Action QUALITY AND SAFETY FOCUS 012/176 Quarterly Patient Experience Report JW presented the patient experience report. The Board noted the report and the following key points: Preparations are underway to implement the new national Friends and Family Test initiative which asks patients whether they would recommend the hospital to their friends or relatives. The initiative will be introduced in April 2013 via NHS Choices and the Trust is starting this process in December by introducing an additional question in its How are we doing questionnaire. Where possible, the Trust will try to align its approach with KHP Partners; The Trust is working with KHP partners to develop a set of joint patient experience indicators to improve the quality of patient experience across King s Health Partners; The results of the National A&E Department Survey will be publicised next week but preliminary results indicate that the Trust s results are encouraging; In response to a question, the Medical Director confirmed that the Trust s end-of-life practices are sound and the Liverpool Care Pathway is a methodically collaborative approach which is conducted in conjunction with the patient, friends and family; and During this quarter, positive feedback from inpatients has continued with the overall How are we doing score achieving target scores for the first half of the year, although scores dipped by 1 point in October. 012/177 GMC Revalidation Medical Staff MM presented the report on the Trust preparations and readiness for the implementation of the GMC revalidation process. The Board noted the following: The revalidation arrangements begin in December 2012; Trust personnel have undergone the necessary training to provide the enhanced appraisals; MM is the Responsible Officer; 5

8 Enc 1.4 Item Subject Action Ed Glucksman has been engaged to conduct the necessary administration of the appraisal system; The Trust has identified the relevant doctors which need to be appraised; and If doctors fail the appraisal process they can retain their registration but will not be issued with a licence to practice. MM advised that he can provide assurances to the Board that the Trust is fully compliant with all that is required to complete these 360 appraisals and the relevant doctors have been advised. 012/178 Foundation Trust Constitution The Board noted the proposed changes to the Trust s constitution which have been mandated by Monitor in response to the commencement of some of the provisions of the Health & Social Care Act The Board: 1. Approved the proposed changes and recommended that the Council of Governors consider and approve the revised Constitution on 05 December 2012; and 2. Noted that the Trust Secretary continues to review the Trust s Constitution, as the other provisions of the Act come into force also taking into account any future transactions which may necessitate further changes, for approval, in due course by the Board of Directors and Council of Governors. 012/179 Confirmed Board Committee Minutes The Board noted the Finance and Performance Committee minutes 25 September /180 Any Other Business There were no other items of any other business raised for discussion. 012/181 Date of Next Meeting Tuesday, 18 December 2012 at 14:30 in the Dulwich Committee Room. 6

9 Board of Directors Public Meeting Action Tracker Enc 1.5 Meeting Date Due 25/09/2012 C12/134 Annual Workforce Report - It was agreed that the Trust would look, with the leadership of AH, at how best to have regular engagement with staff about how they are doing which would supplement the annual review and allow the Trust to better understand and address any emerging issues. It was suggested that this could be by way of a regular staff survey, which would enable correlation with patient survey results. Item Action Who Due Date Notes AH/All 18/12/2012 AH to provide an update to the Board in December. Not Due 30/10/ /149 PE would return in six months to give an update on progress to implement the cancer patient experience action plan. 30/10/ /149 JW would undertake some research into the demographics of the cancer survey respondents and report back to the Board in due course. PE/LM 30/04/2013 JW Early 2013 Board of Directors Meeting 18 December of 1

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11 Enc. 2.2 Report to: King s College Hospital Board of Directors Date of meeting: 18 December 2012 By: Subject: George Alberti Chairman and Non-Executive Directors Report Graham Meek - Acting Chairman 27 th Nov Chaired King s Commendation Ceremony 29 th Nov Chaired Finance & Performance Committee Attended Board of Directors meeting (Private) Attended Board of Directors meeting (Public) 30 th Nov Chaired King s Commercial Services Ltd meeting Attended KCH Annual Awards Ceremony 4 th Dec Attended Business Integration Committee 11 th Dec Attended Public Board Meeting 13 th Dec Attended Business Integration Committee George Alberti 29 th Nov Attended Finance & Performance Committee Chaired Board of Directors meeting (Private) Chaired Board of Directors meeting (Public) Attended Quality and Diversity Committee 30 th Nov Attended King s Commercial Services Ltd meeting 5 th Dec Private Council of Governors Public Council of Governors 11 th Dec Academic Advisory Group 12 th Dec Extra-ordinary CoG Joint Governors Sue Slipman 23 rd Nov Chaired Board Strategy Sub-Committee Sept 29 th Nov Attended Finance & Performance Committee Meeting

12 Enc. 2.2 Attended Board of Directors Meeting (Private) Attended Board of Directors meeting (Public) Made Go See visit to A + E 30 th Nov Attended Commercial Services Board meeting 5 th Dec Attended Council of Governors Meeting Chris Stooke 29 th Nov Attended Finance and Performance Committee Attended Private Board Meeting Attended Public Board Meeting 30 th Nov Attended Kings Commercial Services Ltd Meeting Attended TSA Meeting in Orpington 4 th Dec Chaired BIC 10 th Dec Attended Governors Transport Feeder Group 11 th Dec Chaired BIC Meeting with KOMG Internal Audit 13 th Dec Chaired Board Interpretation Committee Marc Meryon 23rd Nov Chaired Consultants Selection Panel 28th Nov Attended Healthcare Thought Leadership dinner 29th Nov Attended Finance & Performance Committee Attended Private Board Meeting Chaired Equality & Diversity Committee Attended Public Board Meeting 4th Dec Attended Board Integration Committee 11th Dec Attended Board Integration Committee 13 th Dec Attended Business Integration Committee Faith Boardman 29 th Nov Attended Equality and Diversity Attended Private Board Meeting Attended Public Board Meeting 4 th Dec Attended Business Integration Committee 13 th Dec Attended Business Integration Committee

13 Enc 2.5 Finance Report Month 8 (November) 2012/13 Board of Directors 18 th December 2012

14 Enc 2.5 Report to: Board of Directors Date of meeting: 18 th December 2012 Subject: Finance Report Month 8 (November 2012) Author(s): Presented by: Sponsor: History: Status: Simon Dixon, Nicola Hoeksema, Iris Lewis Simon Taylor, Chief Financial Officer Simon Taylor, Chief Financial Officer First submission to Finance and Performance Committee Decision/Discussion/Information 1. Purpose The Finance Reports includes information on the Trust s financial performance and position which support the in-year submissions to Monitor on a quarterly basis. This report covers the Income & Expenditure position, Cost Improvement Programme, Capital and Working Capital Plans. 2. Action required The Board is asked to approve the Finance Report Page 2

15 Enc Key implications Legal: Financial: Assurance: Clinical: Equality & Diversity: Performance: Strategy: Workforce: Estates: Reputation: Other:(please specify) Reporting to Monitor and Commercial Bank Trust reports financial performance and position against published plan and notifies the committee of financial risks, cost pressures and action plans to mitigate any material variance from financial targets. The summary and appendices provide assurance that the Trust is meeting Financial targets (internal and those set by Monitor) and is compliant with its terms of authorisation. There is no direct impact on clinical issues There is no direct impact on E&D Financial Performance against annual plan, budgets, CIPs and Monitor Risk Ratings and Limits. Performance against the Trust s Annual Plan including Risk Ratings There are implications for workforce recruitment in respect to service developments and vacancies. There are implication on the Trust s estates strategy. Finance Committee Report is provided to Monitor and Commercial Bankers as additional information to support the quarterly Monitor Return. None. Page 3

16 Contents Enc 2.5 Page(s) Executive Financial Summary 5 Financial Risk Rating Ratios 6 Forecast Outturn Position 2012/ I&E Summary 9-17 CIP Update Capital, Working Capital & Cash Summary Statement of Financial Position Glossary 38 Page 4

17 Month 8 Executive Financial Summary Enc 2.5 Annual Budget YTD Budget YTD Actual Month 8 YTD Variance Month 7 YTD Variance Movement in Month '000 '000 '000 '000 '000 '000 Income (excluding off Tariff Drugs) 621, , ,432 6,687 4,507 2,180 Off Tariff drugs Income 24,950 16,633 19,367 2,734 2, Pay (368,040) (245,086) (244,919) (482) Non-Pay (excluding off tariff drugs) (303,568) (192,367) (201,871) (9,504) (7,273) (2,231) Off Tariff Drugs Expenditure (24,950) (16,633) (19,367) (2,734) (2,600) (134) Capital Charges, Interest and Dividends 44,172 26,455 26,270 (185) (138) (47) SLR/Internal Recharges (159) 162 Total (6,000) 751 (2,081) (2,832) (2,414) (418) Income and Expenditure Position - The Trust is reporting a year to date deficit position of 2.081m, 2.832m adverse from plan, and an adverse movement of 418k from Month 7. The Monitor Rating for the year is 3 in line with the Annual Plan target to date. The Trust is still forecasting a 10m impairment ( 4m accrued to date) in respect to the 6m deficit target. This is after taking into account the planned operating surplus of 4m. The District Valuer has been on site to revalue the Clinical Research Facility and the impairment value should be agreed in January Key Drivers of the Financial Position The overall income position remains positive with a favourable movement on PCT patient-related activity contracts of 6.687m to date and a continuation of off-tariff drug over-performance of 2.7m to date. However, the non-pay cost pressures and off-tariff drugs associated with the additional activity are not delivering a sufficient margin to achieve the 4m operating surplus. The CIP programme is off target by 4.488m YTD, primarily due to income generation schemes such as RTT activity targets and Private Patient activity income. Although the Red RAG-rated schemes total 9.609m as on page 20, the mid-case variance for the year is 8.961m on page 18. The mid-case CIP adverse variance for all the Divisions and Corporate departments is incorporated in the year-end projection on page 8. The year-end forecast variance is lower than the overall CIP gap due to additional funding for emergency admission activity and specialist services contracted with the NSCG and LSCG. The Trust is projecting an operating break-even position and financial rating of 3 as presented on page 7 and 8. Page 5

18 Financial Risk Rating Ratios Enc 2.5 Financial Criteria Weight (%) Metric to be scored Month 8 Month 8 Rating 12/13 Plan 12/13 Plan Rating Achievement of Plan 10 EBITDA achieved (% of plan) 87.4% % 4 Underlying Performance 25 EBITDA Margin (%) 5.4% 3 5.6% 3 Financial Efficiency 20 Net Return after Financing (%) 0.5% 3 0.8% 3 20 I&E surplus margin (%) 0.4% 2 0.6% 2 Liquidity 25 Liquidity Ratio (days) FINANCIAL RISK RATING {Weighted Average of Financial Criteria} 3 3 Financial Criteria Metric to be scored RATING CATEGORIES Achievement of Plan EBITDA achieved (% of plan) <50 Underlying Performance EBITDA Margin (%) <1 Financial Efficiency Net Return after Financing (%) <-5 I&E surplus margin (%) <-2 Liquidity Liquidity Ratio (days) <10 Finance Risk Rating Rating 5 Rating 4 Rating 3 Rating 2 Rating 1 Lowest Risk - no regulatory concerns No regulatory concerns Regulatory concerns in one or more components. Significant breach of Terms of Authorisation unlikely. Risk of significant breach in Terms of Authorisation in the medium term, e.g. 9 to 18 months in the absence of remedial action. Highest Risk - high probability of significant breach of Terms of Authorisation in the short-term, e.g. less than 9 months, unless remedial action is taken. Page 6

19 Forecast Outturn Position 2012/13 Enc 2.5 The year end forecast position for the year reflects the additional outturn income agreed with LSL PCTs and the final agreement of NSCG and LSCG funding for Paediatric Liver services and HIV/Renal services. The adverse variance to plan is 5.4m and therefore the 4m operational target is not achievable. In order to maintain a Monitor financial rating of 3 the Trust needs to break-even and improve the current year end adverse financial projection by 1.5m. The Divisional and Corporate departments need to ensure all stringent financial controls are in place and to improve upon their current year end financial projections. Senior finance staff will meet with Divisional Managers to agree improved financial targets for the year-end. A key area of improvement will be to improve the CIP performance and in particular the RTT income target which is projected to be 3.2m adverse from the annual target. Actions are in place to ensure this happens by managing the winter activity pressures with the expansion of CDU, AAU and general medicine beds to ring-fence elective beds. Further work to create a short stay elective surgery unit and the additional Endoscopy capacity will all contribute to improving the RTT income position. There are still other financial risks that need to be managed such as: 1. Payment of Project Diamond Funding ( 2.7m as per original allocation) 2. Funding for SLHT Business Planning ( 500k to date)

20 Forecast Outturn Position 2012/13 Enc 2.5 M7 Forecast M8 Forecast Variance Variance Division/Department Income Exp Total Total Movement Reason for movement in forecast LRS -1,192-3,253-4,445-3, Income underperformance plus additional Nursing and Medical costs Networked Services 2,324-5,545-3,221-2, Income underperformance plus additional Nursing and Medical costs Private Patients -1, ,785-1, Additional paediatric and drugs expenditure. Income down on last month Facilities ,101-1, Utility price increases and day to day maintenance costs TEAM 2,804-3, Income underperformance and recharges for patient outliers Commercial services Income underperformance and consultancy costs W&C 1,912-2, PICU/NICU income revised projection Operations Finance & Information Overhead recharges to Divisions PFI Legal Costs Human Resources Unit 4 Training and Education setup costs ENPDT Corporate Dental Ambulatory 3,861-3, Additional drugs expenditure in M8, partly offset by Income Captial Charges Donated capital income under new accounting rules Strategic Development CCTD 1, Increased ITU activity and validation of Medtrack patient data R&D 372 1,507 1, CLRN income and additional commercial R&D surplus income CSDS 1, ,351 1, Increased external pathology income Corporate Income 3, ,000-1,000 4,000 Additional Income for Emergency admission activity (LSL) and NSCG/LSCG services. Reduction of Bad Bebt provision. Total Forecast Variance 13,992-19,380-5,388-8,942 3,554 Key: Less planned operating surplus 4,000 LRS - Liver, Reanl & surgery W&C - Womens & Childrens Financial Gap to breakeven -1,388 ENPDT - Executive Nursing CCTD - Critical Care, Theatres & Diagnostics CSDS - Clinical Scientific Diagnostic Services Page 8

21 I&E Summary Enc 2.5 This Chart shows the subjective over and underspends across the trust in month. It is important to note the relationship between drugs spend and income over-performance, which offset one another. Monthly movement negative Monthly movement - positive Page 9

22 I & E Summary Enc 2.5 Income is over-performing by 9.4m YTD. However, 2.7m of this relates to off tariff drugs, without which the net over-performance drops to 6.7m. Significant over-performance is being seen in Emergency activity, and also within Obstetrics, where activity is higher compared to previous years. There was a favourable movement in month of 2.3m where we ve seen an improvement in day case, outpatient and critical care income over and above trend of previous months. However elective and tertiary activity continues to under-perform. Pay is under-spent year to date by 167k, an adverse movement in month of 482k. Nursing moved by 557k this month and is now 1.6m over-spent YTD. The unfavourable movement this month was mainly in LRS, NWS, TEAM and W&C. All other areas of staffing remained broadly within budget in the month. Non Pay is overspent by 12.4m, an adverse movement of 2.3m: The main drivers of this overspend are Drugs ( 6.1m) and Clinical supplies ( 4.3m). These have both moved adversely in the month ( 1.2m and 1.1m respectively). This adverse movement is in line with the increase in activity which has resulted in an improvement in the income position this month. Premises and fixed plant costs ( 1.15m):Energy 856k price inflation, additional insurance costs, maintenance costs as previously stated. External Contracts ( 1m) :Medihome, Consultancy this includes EY PMO costs, and various external contractors providing operational and legal support to various projects e.g. outpatient transformation, interpreting. The Provision for Bad Debts variance is 378k to date, a favourable movement in month of 401k. Page 10

23 Temporary Pay Analysis Trend Enc 2.5 The graph to the left shows spend on bank and agency nursing over the previous periods. The trend is on the increase, agency usage has increased particularly in TEAM, LRS and W&C. The Trust is reviewing the rates charged by agencies in line with LPP rates and updating bank rates. Acuity has increased on wards increasing staffing levels. Actions are to recruit substantive staff where possible to increase establishments, and to reduce the agency rates being charged in each area, and also to switch to bank. The graph to the right highlights the reduction in spend on agency medical staffing over the previous period, with a steady downward trajectory. This is in the main due to additional posts being built into the establishment and recruited to substantively. Increasing activity demands may put pressure on the usage of agency medical staff in coming months in order to achieve planned RTT targets, and this must be monitored closely as access to beds and theatres will limit productivity. Page 11

24 Temporary Pay Analysis by Division Enc 2.5 Agency spend (shown to the left) is 4% down on the same period year to date last year, with reductions in CSDS and Critical Care offset by increases in all other areas. Bank spend (shown to the right) is 4% down on the same period year to date last year, with reductions in LRS, W&C and Critical Care, and increased in Networked services, and TEAM Page 12

25 Divisional Financial Performance Enc 2.5 This Chart shows the Divisional adverse (red) and positive (green) variances against plan. Page 13

26 Divisional Variance Analysis Enc 2.5 Material off-track variances to plan are as follows: Cardiac - 1.5m adverse, 306k adverse movement. This is mainly due to income being less than anticipated in September but FCE s are now back up to expected levels. There has been a decrease in drugs and devices income this month and an increase in consumables expenditure resulting in this months adverse movement. Neurosciences - 1.4m adverse, 300k adverse movement. Income is 437k adverse where Neurosurgery RTT and CIP targets are not being achieved. Drugs are 451k overspent, although this is mostly recovered through income. (Removing the effect of drugs will move the income position further adversely). Some beds have been re- opened on David Marsden ward resulting in an increase in nursing expenditure. Liver 2.2m adverse, 290k adverse movement. Income is only 40k adverse but under-performance in Gastro, hepatology and HPB is being offset by over-performance in LITU. Nursing is 429k overspent, particularly in theatres and LITU. Drugs are 725k overspent, although this is mostly recovered through income. (Removing the effect of drugs will move the income position further adversely). Liver are also 202k overspent YTD on bed-days within medicine Surgery - 2.2m adverse, 500k adverse movement. Income is 1.6m adverse, shown in General Surgery and relating to bariatric RTT activity. Projected RTT income has not yet been achieved in Surgery, as on-site and off-site options are delayed and expensive. Pay in surgery is beginning to overspend particularly in Medical and Nursing, this has been steadily increasing over the last few months and relates to Locum cover for ED trauma and the increased nursing establishments for which budget has yet to be allocated. Private Patients - 1.2m adverse YTD. Income targets were set 700k above outturn, to account for the full year effect of increased charges possible because of refurbished Guthrie beds. However, international referrals from Greece and Cyprus in particular have reduced due to the economic situation Child Health - 1.3m adverse YTD, 444k adverse movement. Nursing is 813k overspent, including NICU ( 301k) this despite increased funding and PICU ( 275k). Income is over-performing but NICU income is underperforming by 144k YTD. Page 14

27 Expenditure By Type Enc 2.5 Annual YTD YTD YTD Last Month Movement Budget Budget Expend Variance Variance in Month '000 '000 '000 '000 '000 '000 PAY Medical Staff (122,430) (81,692) (80,889) Nursing Staff (139,901) (93,042) (94,622) (1,580) (1,023) (557) A&C Staff/Senior Managers (54,375) (36,215) (35,521) (16) PAMS (18,166) (12,099) (11,650) Directors (1,419) (946) (1,019) (73) (64) (9) Scientific/Professional (29,696) (19,723) (19,922) (199) (215) 16 Other (2,053) (1,369) (1,296) Sub-total (368,040) (245,086) (244,919) (482) NON-PAY Clinical Supplies (59,396) (39,487) (43,789) (4,302) (3,198) (1,104) Drugs (58,090) (38,727) (44,840) (6,113) (4,912) (1,201) Non Clinical Supplies (31,901) (21,391) (22,632) (1,241) (1,095) (146) PFI (25,617) (17,078) (17,155) (77) 18 (95) Capital Charges (25,041) (13,782) (13,739) Interest and Dividends (19,131) (12,673) (12,531) SLR Recharges (7) (4) (7) (3) 48 (51) Recharges (111) Misc. Other Operating Exp (65,156) (39,399) (40,268) (869) (1,280) 411 Sub-total (284,339) (182,541) (194,961) (12,420) (10,170) (2,250) Total Expenditure (652,379) (427,627) (439,880) (12,253) (9,521) (2,732) All Income 646, , ,799 9,421 7,107 2,314 Income and Expenditure (6,000) 751 (2,081) (2,832) (2,414) (418) Page 15

28 Income and Expenditure by Division Enc 2.5 Annual Budget YTD Budget YTD Actual YTD Variance Last Months Variance Movement Division Heading '000 '000 '000 '000 '000 '000 Income 103,939 69,082 71,522 2,440 2, Pay (44,099) (29,385) (28,173) 1,212 1, Non-Pay (24,542) (16,434) (19,223) (2,789) (2,267) (522) Recharges (174) (116) (118) (2) (1) (1) AMBULATORY SERVICES Total 35,124 23,147 24, ,149 (288) Income 154, , ,867 1,246 1, Pay (57,009) (38,011) (38,671) (660) (444) (216) Non-Pay (46,163) (30,651) (33,338) (2,687) (2,239) (448) Recharges NETWORKED SERVICES Total 52,466 35,401 33,389 (2,012) (1,603) (409) Income 40,754 26,765 29,158 2,393 1, Pay (66,660) (44,388) (43,900) Non-Pay (55,360) (36,856) (40,899) (4,043) (3,267) (776) Recharges CRITICAL CARE, THEATRES AND DIAGNOSTICS Total (81,266) (54,479) (55,335) (856) (995) 139 Income 136,071 91,158 89,920 (1,238) (1,221) (17) Pay (56,175) (37,454) (38,436) (982) (673) (309) Non-Pay (25,695) (17,009) (17,211) (202) (43) (159) Recharges (32) (45) 13 LIVER, RENAL AND SURGERY Total 54,541 36,923 34,469 (2,454) (1,982) (472) Income 73,297 48,411 50,491 2,080 2,108 (28) Pay (51,068) (33,910) (34,021) (111) 19 (130) Non-Pay (6,184) (4,117) (5,272) (1,155) (921) (234) Recharges Trauma, Emergency and Acute Medicine Total 16,045 10,384 11, ,206 (392) Income 94,237 61,823 63,461 1,638 1, Pay (53,149) (35,424) (36,006) (582) (445) (137) Non-Pay (7,819) (5,204) (6,242) (1,038) (801) (237) Recharges WOMENS AND CHILDRENS Total 33,269 21,195 21, (73) Income 16,302 10,868 10,151 (717) (667) (50) Pay (2,774) (1,851) (1,881) (30) (15) (15) Non-Pay (4,036) (2,691) (2,430) (87) Recharges (1,005) (670) (888) (218) 30 (248) Private Patient Service Total 8,487 5,656 4,952 (704) (304) (400) Income 26,803 16,650 18,229 1, ,110 Pay (37,107) (24,664) (23,828) Non-Pay (95,423) (56,816) (57,808) (992) (1,277) 285 Recharges (19,131) (12,673) (12,531) Interest and Dividends (284) (396) (379) (17) Corporate Services Total (124,688) (77,391) (76,222) 1,169 (337) 1,506 Income 646, , ,799 9,421 7,107 2,314 Pay (368,041) (245,087) (244,916) (479) Non-Pay (265,211) (169,778) (182,423) (12,645) (10,467) (2,178) Interest and Dividends (284) (396) (379) (17) SLR Recharges 11 (85) (3) (29) Recharges (19,308) (12,789) (12,254) (29) Trust total Total (6,000) 751 (2,081) (2,832) (2,414) (418) Page 16

29 Private Patient Income Enc 2.5 Private Patient Projected Cap % 2012/ /2012 '000 '000 Private patient income * 15,227 16,882 Total patient related income ** 551, ,093 Proportion (as percentage) 2.76% 3.10% * 2012/2013 figures are forecast to year-end based on current month actuals ** 2012/2013 figures as per annual plan Section 44 of the 2006 Act requires that the proportion of private patient income to the total patient related income of the NHS Foundation Trust should not exceed 3.5 per cent, its proportion when the organisation was an NHS Trust in 2002/03. Page 17

30 2012/13 CIP YTD Summary Enc 2.5 PERFORMANCE AGAINST PLAN CIP variance CIP YTD Target YTD Actuals Variance Forecast Identified ACLN 1,981 1,319 1, CCTD 3,565 2,162 1, TEAM 1, LRS 2,580 1,626 1, NWS 4,140 2,713 2, ,216 W&C 2,342 1,413 1, Facilities Corporate 1, Trustwide 21,913 13,825 11,008-2,816-5,259 TOTAL 39,119 24,718 20,229-4,488-8,961 Year to date under performance against CIPs amounts to 4,488k, 82% achievement. The forecast Year end CIP variance position is 8.961m, with the major variances as follows :- ACLN: 267k Pharmacy schemes ( 208k of which relates to drugs purchase schemes) CCTD: 333k MRSA, 300k OP Project, Divisional Income schemes 84k TEAM: 237k Reduction in outliers, Divisional Income schemes 101k LRS: 237k Reduction in diagnostics tests, 100k immunosuppressant savings, 75k Hepatitis supplies re-tender, 98k Pharmacy drug purchase schemes, 50k FP10 reduction NWS: 262k additional EP/ NSTEAC list income, 350k Spinal/ Cardiac tenders (Procurement led), 200k Libyan BMT patients, 119k Pharmacy drugs purchase schemes, 80k Cardiac theatre cross cover income, 37k Neuro increased list cover W&C: 127k NICU Bank & Agency reduction, Diagnostics reduction 29k, Drug purchase schemes 27k, 16k St Heliers patients Facilities: Reduction in Consultant / Legal fees Corporate: Negligible Trustwide: 3.2m RTT, 1m Private patient / commercial income, 350k Noteless, 250k Nursing establishment reviews, 178k Service reviews, 112k Coding optimisation, 117k Medical Productivity (due to inclusion in Divisional trackers), 100k HR Workforce CIP Recovery Action plans Finance / CIP meetings held w/c 26/11/12 to determine substitution plans Key focus on RTT, diagnostic tests (MRSA & LRS), and resolution of Procurement tender savings with respect to Spinal & Cardio Implementation of winter pressure capacity developments: AAU, CDU and elective short stay Surgery (transfer of Renal to Dulwich and other satellite units) to reduce medical outliers Page 18

31 2012/13 CIP YTD Performance by Key Themes Enc 2.5 Key Variance Notes Cost saving Division specific Cost saving Agency Staff Reduction Cost saving Medical Productivity Cost saving Integrated Service Reviews Cost saving Energy infrastructure savings 1,622k relates to RTT income under achievement, most notable in Bariatrics ( 931k), Neurosurgery ( 375k), Liver ( 118k), and Orthopaedics ( 95k). 3.7m of these schemes are RAG rated Red. 717k relates to Private Patient/ Commercial income under achievement. Although at full capacity the activity is low value patient case-mix and Liver transplant work has been transferred to the Private Sector (London Bridge Hospital). 100k relates to Libyan BMT patients. 345k relates to an income shortfall based on productivity targets (e.g. reduced patient length of stay) across specific Divisional wards. 328k relates to coding optimisation income targets either led centrally by the Contracts/Coding team ( 305k) or Divisional management teams ( 23k). 311k relates to diagnostics demand management targets not being achieved across specific Divisions. 162k relates to Procurement savings schemes the majority of which is due to the Neurosurgery Spinal implant tender ( 150k) The CIP targets are phased towards the second half of the year. If they were equally spread across the year, the plan to date would be have been 26.1m. Although a total CIP of 39.1m has been identified to date, 9.6m is red RAG rated. The data analysis for the and coding optimisation income CIP is based on 6 months activity and the savings achieved are potentially understated. The Trust-wide income target above includes RTT activity, PCT activity QIPP and repatriation targets, central coding optimisation and Private Patient income targets. Income RTT activity Income PCT Demand Management failure Cost saving Cost saving Income Coding Income Commercial Income Productivity Procurement Pharmacy improvements / Private Patients Gains Total Original Plan 12,000 2,800 1,000 2, ,000 2,000 1,000 9,000 2,600 42,300 Revised Plan 10,132 1, ,218 3,863 1,200 9,000 3,646 39,119 YTD Plan 6,300 1, ,136 2, ,000 2,156 24,718 YTD Actual 5, ,513 2, ,000 1,811 20,229 YTD Variance -1, , ,488 Page 19

32 2012/13 CIP YTD Risk Assessment Enc 2.5 RAG RATING OF SCHEMES Green Amber Red ACLN 1, CCTD 2, TEAM LRS 1, NWS 2, ,286 W&C 1, Facilities Corporate 1, Trustwide 10,947 5,402 5,564 TOTAL 23,637 5,873 9,609 Top 2 Red RAG rating drivers by Division This section below outlines the key red RAG rated CIP schemes with reference to the annual CIP scheme target ( ). The rating for each scheme is either on current delivery performance or lack of assurance regarding future delivery. ACLN: CCTD: 281k Drug purchases savings substitution by Pharmacy 60k Specific drugs savings Division to implement 400k Pathology Demand Management - reduced MRSA testing agreed with Divisions (duplicate tests for patients moving wards) 300k Pharmacy rationalisation of OP dispensing services substitution required m CIPs identified against a stretch gross target of 42.3m. However 9.609m (24.6%) are Red RAG rated. RAG ratings are based on YTD performance if scheme has already started:- Red less than 50% achievement Amber less than 95% achievement Green over 95% achievement TEAM: LRS: NWS: W&C: 237k Reduction in Outliers - substitution required 60k Income from GP appointment substitution required 267k Pathology Demand Management no detailed plan 100k Immunosuppressant savings substitution required 300k Additional EP/NSTEAC lists substitution required 200k Libyan BMT Patients awaiting contract signature 150k NICU Bank & Agency savings plan to recruit 36k Drug purchases savings substitution by Pharmacy If scheme has not yet started, RAG rating is based on delivery plan status. Trust wide: 2.1m Bariatrics RTT income capacity issues & demand 1m Neurosurgery RTT income - capacity issues & demand Page 20

33 2012/13 CIP YTD Performance by Division Enc 2.5 ACLN: CCTD: TEAM: 182k adverse variance: 178k Pharmacy schemes under achievement (of which 139k relates to purchase schemes) 265k adverse variance: 222k Demand Management, 53k activity increase (2 schemes) 125k adverse variance: 47k reduction in outliers (high risk going forward 237k target M8-12), 23k Coding, 42k Divisional income opportunities, 17k Pharmacy purchases schemes under achievement. LRS: 314k adverse variance: 79k Diagnostics reduction, 60k Drug purchases schemes, 34k FP10s, 32k Hepatitis supplies retender, 33k immunosuppressant savings, 28k Transplant co-ordinator vacancy, 17k Nursing workforce shift pattern overlap reduction NWS: W&C: Facilities: Corporate: Trustwide: 646k adverse variance: 200k Neuro Spinal implant tender, 100k Cardiology Saturday lists, 100k Libyan BMT patients, 91k Pharmacy schemes under achieved (of which 86k relates to purchases), 56k additional EP sessions, 53k Cardiac Theatre utilisation, 25k increased cover for Neuro lists 93k adverse variance: 54k NICU bank and agency use reduction, 18k Pharmacy drugs purchase schemes, 10k Diagnostics reduction, 7k additional St Helier patients 46k adverse variance: 42k Reduction in Consultancy / Legal fees 1k adverse variance: Occupational Health Drugs savings not achieving 2,816k adverse variance: 1,622k RTT income, 617k Private Patient / Commercial income, 305k Coding optimisation income (Months 7 & 8 based on Months 1-6 actuals), 117k Noteless, 83k Nursing establishment review, 39k Medical Productivity, 33k Shift pattern review Page 21

34 2012/13 CIP Annual plan target review Enc 2.5 Allocation of CIPs to budgets : 35.9m as at Month 8 Within the CIP monitoring plan, 21m is classified as Trust-wide income. The following elements have been allocated to the respective Division s income targets to ensure accountability: Demand Management - 9m. This represents a level of activity undertaken in 11/12 but removed from 12/13 contracts, by PCT Commissioner s, without any robust plans. Coding - 2.7m. This is being led by the Contracts Department who have a detailed plan of actions to ensure this is achieved. RTT - 8.2m. This is in line with the RTT funding bid and phased schedule of work. NHSL have agreed 5.1m for SEL PCTs. 2.7m relates to non-sel PCTs and 345k relates to diagnostic targets. Private Patient/Commercial income - 1m. 700k has been allocated to Guthrie Ward and 300k to Commercial. Nursing establishment reviews/cns ( 700k) and Service Reviews ( 250k) are still to be resolved and allocated to budget reports. This includes work on nursing shift overlaps > 1hour and overlaps in unsocial hour transfers. The PMO is reviewing sickness levels and this should help reduce staff budget over-spends (agency costs) rather than enable budget reductions at this point in time. The following areas will not deliver against the savings targets as per the Annual Plan: 1. Pharmacy outpatient dispensing site location options and no. of dispensing areas still under review. 2. Estates utilities and maintenance savings programme investment plan to be provided by Schneider Electric, 12th October. Board approval will be required and the investment plans will require 3-4 months to mobilise. 3. Procurement - Floor Stock tender will not deliver savings as proposed by Director of Procurement/LPP Initiative. Other LPP opportunities are also based on supplier desk-top reviews and provide no evidence to substantiate savings. 4. Agency usage Target has been reduced due to activity pressures and ability to recruit (Critical Care/NICU/Surgery). Page 22

35 2012/13 CIP YTD Results by Monitor Category Enc 2.5 SPLIT OF CIP YTD TARGETS BY MONITOR CATEGORY Income Pay Drugs Clinical Supplies Non-Clinical Supplies Other Misc Total ACLN ,319 CCTD ,162 TEAM LRS ,626 NWS 1, ,713 W&C ,413 Facilities Corporate Trustwide 13, ,825 TOTAL 16,820 3,361 1,212 1,804 1, ,718 SPLIT OF CIP YTD ACTUALS BY MONITOR CATEGORY Non- Income Pay Drugs Clinical Supplies Clinical Supplies Other Misc Total ACLN ,137 CCTD ,897 TEAM LRS ,313 NWS 1, ,067 W&C ,320 Facilities Corporate Trustwide 11, ,008 TOTAL 13,800 2, ,476 1, ,229 SPLIT OF CIP YTD VARIANCES BY MONITOR CATEGORY Income Pay Drugs Clinical Supplies Non-Clinical Supplies Other Misc Total ACLN CCTD TEAM LRS NWS W&C Facilities Corporate Trustwide -2, ,816 TOTAL -3, ,488 Page 23

36 2012/13 CIP Plan by Theme and Division Enc 2.5 Cost saving Division specific SPLIT OF CIP PLANS TARGETS BY PLAN THEME Cost saving Agency Staff Reduction Cost saving Medical Productivity Cost saving Integrated Service Reviews Cost saving Energy infrastructure savings Income RTT activity Income PCT Demand Management failure Cost saving Cost saving Income Coding Income Commercial Income Productivity Procurement Pharmacy improvements / Private Patients Gains Total ACLN 1, ,981 CCTD 2, ,565 TEAM ,104 LRS 2, ,580 NWS 1, ,140 W&C ,088 2,342 Facilities Corporate 1, ,243 Trustwide ,218 2,700 1,000 9, ,913 TOTAL 10,132 1, ,218 3,863 1,200 9,000 3,646 39,119 Page 24

37 Month 8 Capital Summary Enc 2.5 Capital Plan The annual budget at m for month 8 as no additional donated income has been received. Capital Expenditure YTD Capital expenditure to month 8 was m against a reforecast year-to-date budget of m, a YTD underspend of 106k. Capital Scheme Projected Variances The forecast overspend to year-end is 4.224m (25% of current capital budget) against the revised plan. CCU Enabling Works : 1.960m The capital budget includes 800k for CCU Building Works and the corresponding external borrowing. Emergency Department : 100k Additional external works for transformers. Endoscopy : 550k - Additional costs due to decontamination equipment requirements, unforeseen works, changes to specification and contract programme delayed by 3 months caused by work stoppages due to noise (site located in main site with adjacent clinical services). Provision of a further X-ray room. Unit 4 & Unit 6 : 342k - Unit 6 change of use of 1 st Floor to clinical area (Assisted Conception Unit) and Unit 4 additional cost to include transformer for power supply. Transfer of Renal Services to Dulwich : 175k Winter Bed Pressure Capacity Planning Brunel Ward : 250k Reconfiguration of Brunel Ward to accommodate additional Winter pressure capacity requirements. MRI Building Works : 130k Time delays leading to contract extensions and additional design fees. Other Major/Minor Work Schemes : 389k Medical Equipment purchases : 316k Purchase of urgent medical equipment approved through BRSG. In order to reduce the forecast overspend, the Trust is proposing to: Request an adjustment to the phasing of the CCU external borrowing drawdown from the FTFF in order to incorporate the costs of the CCU enabling works ( 1.9m). Historically, IT schemes have been under-spent at year end. Therefore the current schemes will be reviewed with the potential to defer 500k to 2013/2014. Minor works will also be reviewed in order to potentially reduce these by 300k. These measures will reduce the projected overspend to approximately 1m (6% of the current capital budget). Page 25

38 Projected 3 Year Capital Plan Enc 2.5 Key Projects ACTUALS 2012 / / / / / / / / / / / 12 Plan Additional Total Plan Additional Total Plan Additional Total Total '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 1 Maternity (MLU/MAU Expansion) 2,322 1,000 (650) 350-1,150 1,150 2 Emergency Centre (excludes MH/Suite 1) 6, ,100 1,200 3 Endoscopy (Building costs - incl Decontamination and refurbishment of corridor/steam pipe removal) 460 2,500 1,000 3, Clinical Research Facility (Building) 9,827 1, , Unit 6 Development 2,605 2,127 2, Mapother House Relocation Unit 4 Development (2 Floors - Training Rooms / Offices) 1,700 1,700 1,500 (1,500) Energy Performance Contract 250 (150) 100 3,500 1,800 5,300 1,600 1,600 9 Windsor Walk Development - development lease space for Paeds expansion , , Refurbishment/Upgrade of Day Surgery (Start works Oct 2012 Complete Nov 2012) Liver Lab Research Facility (Donated 435k) , Refurbishment of Brunel Ward (PP) - pending Infill Block 4/5-1,050 (1,050) - - 2,300 2, Byron Adult Cystic Fybrosis Inpatient Facility - pending Infill Block 4/5-1,000 (1,000) Renal Dulwich Site - 0-1,500 1, Cardiac Catheter Lab ( 4.3m) - pending Infill Block 4/ Paediatric Expansion ( 300k) - pending Infill Block 4/ Critical Care (2 Storey option incl. Plant) - Phase ,000-13, ,483 (23,683) 6,800 15,000 18,700 33, CCU Enabling Works - Upgrading of Underground Oil Tanks and Roadway - 1,000-1, CCU Enabling Works - Fibre Optic Cabling CCU Enabling Works - Decanting/Infrastructure (Infill Blk 4) (500) CCU Enabling Works - Decanting/Infrastructure (Infill Blk 5) 500 (500) Critical Care (2 Storey option incl. Plant) - Phase , CC Expansion (Waste Compound) - Phase (300) CDU Enabling Works AAU move to old Endoscopy Consulting Rooms for ATOS (Funded by ATOS) Pharmacy Dispensing Expansion Helideck (Drawings for submission for Planning Permission) Portakabin B transfer to Dental Carpark Proposed Annual Plan 30 Pet CT Scanner Enabling Works - 1,200 1, Cyber Knife Enabling Works Other Major Works Refurbishment of Wards (Cathlab/Angio Recovery) (183) MRI - Building Works (BRSG) _ Start 17 Sept (3 months) Ultrasound - Building Works (Single Sex / Diginity) (500) Diabetic Foot Clinic - Environmental (H&S) - ON HOLD (250) Outpatients Refurbishment / Dulwich Transfer (Suite 4) (114) Minor work schemes 1,068 1,200 (9) 1,191 1,300 1,300 1,300 1, Information Technology - Tangible Assets 1,359 1,000 (50) 950 1,500 (500) 1,000 1,500 1, Information Technology - Intangible Assets (337) Medical Equipment new and replacement (incl Donated) 1, ,000 (500) 500 1,000 1,000 Total 27,948 31,558 (14,733) 16,825 40,683 (16,923) 23,760 29,300 21,800 51,100 18,700 Available Funding details Cash from operations Depreciation non-cash charge 14,043 14, ,996 16, ,292 17, ,466 Charitable donations Acorns to Oaks Appeal (CRF) Charitable Trust (Critical Care Equipment) Liver Lab Facility Pledges Paediatric Expansion Funding (300) Cystic Fybrosis Foundation (430) Consulting Rooms for ATOS (Funded by ATOS) Medical Equipment purchases PDC Received PDC Cash from External Loans FTFF (Critical Care Development) 16,000 (15,200) ,783 (23,983) 6,800 15,000 18,700 33,700 18,700 Utilisation of Internal Cash Resources 5,750 (760) 1, (6,741) 6,200 (541) (3,166) 3,100 (66) Total 20,634 31,558 (14,733) 16,825 40,683 (16,923) 23,760 29,300 21,800 51,100 18,700 Page 26

39 Capital Expenditure Summary Month 8 Enc 2.5 Total per capital category Annual Plan 12/13 Budget Period Budget Actual YTD Expenditure Cost to Complete Total Cost 12/13 Major works 12,280 9,549 10,120 6,006 16,126 Minor works 1, ,241 Medical Equipment 1,452 1, ,780 IT and infrastructure Intangibles (IT) Donated - Major Works Donated - Medical Equipment Total Capital Position : Overspend (+) / Underspend (-) 16,825 12,575 12,469 8,580 21,049 Budget Period Budget Actual to date Anticipated Changes Y/E Forecast Gross capital expenditure b/f 16,825 13,851 12,469 8,580 21,049 Gross Cost 16,825 13,851 12,469 8,580 21,049 Less: Capital Donations held on Trust, NOF monies Total Capital Charge against Capital Resource Limit 16,036 13,325 11,726 8,534 20,260 Depreciation non-cash charge 14,996 9,738 9,694-14,996 PDC Received External Borrowings Internal Cash Resources 240 3,587 2,032 7, FT Capital Plan 16,036 13,325 11,726 8,534 16,036 Variance : + over / (-) under ,224 Page 27

40 Month 8 Working Capital Summary Enc 2.5 Working Capital Summary As at month 8 outstanding debtors totalled 28.4m including Private Patient and Overseas Visitors debts. Total outstanding debts relating to 2011/12 total 1.32m. This includes: PCT SLA Over-Performance 166k. PCT SLA invoices outstanding 526k NCA invoices outstanding 254k (including Scottish, Irish and Welsh Health Bodies) Provider-to-provider Diagnostic Service 169k Staff recharges to other NHS organisations 256k The remaining debt relates to various NHS and Non-NHS organisations and includes Clinical, Commercial and Non-commercial Trial income, Course fees and other Patient and non-patient related income. PCT SLA Over-Performance 2012/13: A net total of m of PCT SLA over- and under-performance invoices have been raised to date relating to the period for April to September m of this was raised in November 2012 relating to September To date (December 2012), 9.33m has been received leaving a net outstanding balance of 3.877m. Prudential Borrowing Limit The Trust s Tier 1 borrowing limit is 141m for 2012/13. The Trust is currently utilising m (63%) of its 2012/2013 Tier 1 Prudential Borrowing Limit (Long-term borrowing) of 141.0m leaving headroom of m. The Critical Care business case has been submitted to the Foundation Trust Financing Facility requesting external borrowing of 60m. Formal approval of this borrowing is expected in December. The Trust will not exceed its Prudential Borrowing Limit as these funds will be drawn down over 3 years. The Trust s tier 1 Limit is expected to increase over these years due to the forecast increase in Trust income. Page 28

41 SLA Over-Performance Invoices 2012/13 Enc 2.5 Month 1&2 Month 3 Month 4 Month 5 Month 6 Date Invoiced 31-Jul Aug-12 2-Oct Oct Nov-12 Net Total Cash Received Outstanding Cash Southw ark 822, , , , ,276 3,356,268 (2,109,129) 1,247,139 Lambeth 1,231, , , ,919 1,861 3,259,726 (2,604,946) 654,780 Croydon 405,637 58, , , ,286 1,409,793 (807,641) 602,152 E of E (NSC) (63,437) (21,884) 266,011 78, ,455 85, ,776 Croydon (for Renal) 0 143,350 60, ,727 3, , ,789 E of E (All Contracts) , , ,325 SACS (for WEST SUSSEX PCT) 361, ,157 62,268 80,372 79, ,393 (494,103) 222,290 Medw ay 48,939 (91,655) (62,693) 85,106 93,626 73, , ,733 SACS (for EAST SUSSEX PCTs) 89, ,698 47, ,134 (69,592) 367,035 (211,153) 155,882 Barnet 104,971 (11,495) (19,459) 30,669 32, , ,365 Yorkshire and Humber SCG 55,675 (29,898) (26,697) 18, , ,552 (25,777) 106,775 Kingston 24,474 23,816 54,354 28,189 21, ,184 (48,290) 103,894 Lew isham 88, , , ,577 (101,435) 688,777 (601,636) 87,141 Eastern and Coastal Kent (266,008) (64,485) 61, ,208 (155,016) (182,625) 268,817 86,192 Surrey 154,366 83, , ,586 84, ,422 (577,529) 84,893 South West SCG 73,084 58,703 (10,954) 313,943 71, ,818 (434,776) 71,042 E of E (Bedfordshire) (15,765) 40,247 27,104 39, ,367 (24,482) 66,885 E of E (SOUTH ESSEX) 27,901 81,628 47,523 7, ,622 (109,529) 55,093 Haringey Teaching 16,242 (3,458) 15,199 (9,761) 31,805 50, ,027 Tow er Hamlets (447) (30,051) 27,828 35,008 (7,308) 25,030 2,670 27,700 Brent Teaching 38,867 (10,216) 28,209 7,921 16,191 80,972 (56,860) 24,112 East Midlands SCG (Trent) 43, ,558 47,738 24, ,568 (108,496) 24,072 Richmond and Tw ickenham 9,118 (11,515) (13,784) (18,500) 56,042 21,362 2,397 23,759 Kensington and Chelsea 69,987 17,975 (9,451) (8,706) 22,356 92,161 (69,805) 22,356 Wandsw orth (19,096) 6, ,026 (1,336) 19, ,120 (90,680) 18,440 City and Hackney (3,318) (26,251) 18, (769) (11,379) 29,569 18,190 Barking and Dagenham 15,239 9,697 10,385 2,867 15,542 53,730 (38,188) 15,542 Ealing 10,192 5,540 17,885 (13,639) (5,811) 14, ,167 Harrow 20,215 (15,494) 21,338 2,584 10,348 38,991 (26,059) 12,932 Sutton and Merton 24,790 (14,163) 19,801 (293) 10,799 40,935 (30,428) 10,507 Hillingdon (886) (4,488) 17,619 (8,754) 5,479 8, ,970 New ham (74,887) 2,927 (5,710) (8,360) 8,781 (77,248) 86,030 8,782 East Midlands SCG (Leics) (4,275) (16,555) 3,799 12,526 8,448 3,943 4,505 8,448 E of E (NORTH ESSEX) 37, ,339 25,622 (17,371) 0 160,527 (152,275) 8,252 Havering 30,879 17,979 23,926 20,099 7, ,223 (92,883) 7,340 E of E (Herts) (11,374) 25,486 11,667 (8,332) 0 17,447 (14,112) 3,335 East Midlands SCG (Northants) (34,789) 135,671 (11,407) (5,665) (231) 83,580 (83,811) (231) Enfield (15,890) (13,706) (1,548) 17,887 11,671 (1,587) 0 (1,587) Westminster 111,732 23,015 (1,172) (3,596) (4,711) 125,268 (133,575) (8,307) Redbridge 5,074 1,267 (11,766) (7,286) (9,517) (22,228) 12,711 (9,517) Hammersmith and Fulham (11,569) (15,357) 5,003 5,314 (11,588) (28,196) 16,609 (11,587) Waltham Forest (68,429) (20,043) (5,575) (22,384) (20,097) (136,529) 116,431 (20,098) West Kent 5, , ,987 (180,901) (23,155) 407,658 (430,814) (23,156) Camden 4,317 (5,867) (27,519) (8,584) 8,061 (29,593) 0 (29,593) Bexley Care 544, , ,966 28,816 (60,914) 1,012,286 (1,044,385) (32,099) Hounslow (26,727) (32,773) (12,553) 32,258 5,920 (33,875) 0 (33,875) Islington (27,673) (18,933) (5,452) (6,020) (7,450) (65,528) 0 (65,528) East Midlands SCG (Milton Keynes) (105,996) (69,227) (47,272) (39,219) (68,302) (330,017) 261,715 (68,302) Bromley (136,228) 239, ,481 8,011 (270,685) 9,351 (272,025) (262,674) Greenw ich Teaching (6,341) (83,778) (62,444) (186,741) (85,185) (424,488) 152,563 (271,925) South Central SCG (222,744) (132,274) (107,444) (59,240) (90,188) (611,889) 222,744 (389,145) 3,361,683 2,245,410 3,833,554 2,621,402 1,141,297 13,203,346 (9,325,896) 3,877,450 This table has been prepared as at 11 December 2012 and reflects all invoices raised and payments received to that date. Monthly PCT SLA Overperformance invoices are raised approximately 2 months after the end of the month to which it relates. This is due to the SUS timetable and the data validation process. Payment against these invoices should be received by the 15 th day of the following month although if there are any queries or disputes outstanding, payment is delayed. In effect, it takes the Trust a minimum of 3 months to recover the cost of overperformance from the PCT. Page 29

42 Working Capital - Debtors Enc 2.5 Total Outstanding 0-30 days days days Over 90 days NHS Bodies Primary Care Trusts 5,676,173 1,654,883 1,412,878 1,306,697 1,301,715 Department of Health / SHA 3,428,816 1,170,546 2,241,328 3,268 13,673 Provider Trusts 3,868,628 1,444, , ,697 1,080,960 NHS Trade Debtors 12,973,617 4,270,111 4,264,494 2,042,663 2,396,349 Provision for Bad Debts (1,092,032) (1,092,032) NHS Bodies Total 11,881,585 4,270,111 4,264,494 2,042,663 1,304,317 Non NHS Bodies Scottish, Welsh & Irish Health Bodies 870, , ,944 59, ,643 King's College London University 4,259,162 2,438, , ,429 1,512,027 King's Charitable Trust 175, ,250 37,154 2,683 24,742 Other Non NHS Bodies 3,472,305 2,030, , ,246 1,003,558 Non NHS Trade Debtors 8,777,885 4,689, , ,390 3,015,970 Provision for Bad Debts (563,400) (563,400) Non NHS Bodies Total 8,214,485 4,689, , ,390 2,452,570 Total Accounts Receivable 21,751,502 8,959,700 4,871,430 2,508,053 5,412,319 % of Total Outstanding - Month 8 100% 41% 22% 12% 25% Month 7 100% 56% 17% 4% 23% Private Patients Accounts Receivable 3,867, ,721 1,006, ,556 1,533,303 Provision for Bad Debts (137,931) (137,931) Private Patients Accounts Receivable Total 3,730, ,721 1,006, ,556 1,395,372 Overseas Visitors Accounts Receivable 2,809, , ,628 49,940 1,911,527 Provision for Bad Debts (617,887) (617,887) Overseas Visitors Accounts Receivable Total 2,191, , ,628 49,940 1,293,640 Total PP & Overseas Visitors Accounts Receivable 6,677,662 1,361,302 1,293, ,496 3,444,830 Provision for Bad Debts is based on debts outstanding over 6 months. The NHS Provision has been adjusted for debts which are not contested and are considered recoverable. Page 30

43 Working Capital - Creditors Enc 2.5 Overall Total 0-30 days days days Over 90 days NHS Bodies 3,605, ,988 1,479, ,854 1,096,933 Non NHS Bodies 26,019,522 7,802,918 9,780,260 6,282,054 2,154,290 Total 29,625,158 8,108,906 11,260,121 7,004,908 3,251,223 % of Total Outstanding - Month 8 100% 27% 38% 24% 11% - Month 7 100% 28% 48% 12% 12% Invoiced trade creditors excludes accruals and employer costs Page 31

44 Cash Summary Enc 2.5 Cash Balances The Cash balance at the end of Month 8 was m against a forecast cash balance of m. The Trust s Working Capital Facility is 35m and the Trust has not utilised this Facility in the current financial year. Cash Flow Variances The Cash balance at the end of Month 8 was m, 796k less than the forecast cash balance of m. PCT Debtors have increased and this has resulted in the slowing down of creditor payments. PCT contract over-performance payments of 3.87m remain outstanding (see page 29). To 30 November 2012, income of 1.8m above forecast has been received from the Joint Venture, GSTS Pathology. This level of income is due to continue for the remainder of the year and the forecast cash flow has been amended accordingly. Payroll payments, including National Insurance and P.A.Y.E. were 6.4m less than forecast to 30 November This is partly due to staff vacancies. Payments to NHS Professionals for bank and agency staff were 2m less than forecast in November 2012 and are scheduled to be paid over the next 2 months (December 2012/January 2013). Capital invoice payments were 900k more than the re-forecast plan to date due to phasing of capital budgets compared to the payment of invoices. It is expected that these payments will move in-line with budget over the remainder of the year but a year-end forecast overspend of 4.2m is projected if external funding cannot be rephased or schemes deferred. Revenue creditors were paid 1.7m less than forecast due to the non-receipt of income above. Creditor payments will increase as PCT Over-performance income is recovered. Page 32

45 Cash Flow Enc 2.5 TOTAL QTR 1 QTR 2 Oct-12 Nov-12 QTR 3 QTR 4 ANNUAL PLAN 2012/ / / / / /13 Forecast ACTUAL ACTUAL ACTUAL ACTUAL Forecast Forecast '000s '000s '000s '000s '000s '000s '000s Balance B/F 27,607 27,607 16,969 19,689 18,850 19,689 19,657 Income NHS Clinical Income Southwark PCT SLA (Excl Merit Awards) 100,924 24,983 25,608 8,177 8,432 25,040 25,293 Lewisham PCT SLA 39,910 9,879 10,027 3,334 3,334 10,002 10,002 Lambeth PCT SLA 85,708 21,403 21,612 7,116 7,116 21,348 21,345 LSL PCT Other (Palliative Care) 2, , , SLAs : Other PCTs (incl PICU, NICU, BMT, HIV, Neuro Rehab) 182,610 45,541 45,347 16,490 17,153 46,566 45,156 LSCG ( Croydon) 62,042 11,069 20,859 5,019 5,059 15,057 15,057 Provider to Provider Income 16,343 4,210 3, ,977 4,298 3,992 PCT NCAs 2, DoH - patient activity (NSCAG) 23,917 6,066 5,949 1,997 1,997 5,971 5,931 RTA's 1, Patient SLA Overperformance 2012/ , ,879 3,513 3,004 9,252 11,105 Patient SLA Overperformance 2011/2012 3, ,247 1, ,114 0 Private Patients 15,229 3,658 4,145 1, ,425 4,001 Research and Development 2, ,074 Training & Educ: SIFT facilities, placement & HD 20,172 5,043 5,043 1, ,043 5,043 Training & Educ: MADEL & PGME 14,070 3,529 3, ,854 3,565 3,525 Training & Educ: Dental (SIFT) 7,392 1,848 1, ,232 1,848 1,848 Training & Educ: SELSHA WDC & Dental NMET 3, , , Merit Awards 3, , Pathology (Joint Venture) 16,022 5,301 5,178 1, ,909 2,634 Caregroup Operational Income 35,122 9,703 6,323 4,171 2,205 9,556 9,540 VAT reclaims 18,978 3,574 5,868 1,599 1,937 5,036 4,500 Consultant's Fees income (Private Patients) 3, sub-total 686, , ,844 61,798 58, , ,054 Expenditure Pay monthly (incl Pay Awards) 195,169 47,516 47,902 16,373 16,430 49,540 50,211 PAYE/NIC/SUPER (CHAPS) 146,065 36,225 36,514 12,113 12,281 36,627 36,699 Agency Spend (NHSP Bank) 28,502 6,541 7,842 2,517 1,823 6,619 7,500 Consultants' Fees 3, PFI project 29,671 8,422 7,779 2,674 2,596 7,320 6,150 AAH 4,367 1,126 1, ,200 Pathology (Joint Venture) 34,248 8,648 8,736 2,832 2,832 8,464 8,400 NHSLA Clinical Negligence 9,987 2,996 2, , Non-pay Direct Debits (leases, rates) 12,151 3,462 2,370 1, ,019 3,300 Non-pay Revenue Trade Creditors (Incl. CIPs) 193,194 48,163 43,124 20,708 15,269 54,178 47,729 sub-total 656, , ,144 59,658 53, , ,132 Cash from operations 29,533 (3,209) 14,701 2,140 5,021 7,120 10,922 Capital & Financing Items Capital gross exp (Purchased) 15,724 3,866 4,993 2,036 1,689 4,510 2,355 Capital gross exp (Donated) 1, Capital Income (Donated) (1,931) 0 (61) 0 0 (990) (880) PDC Dividends (TDR) 8, , ,174 Loan Received (800) (800) Loan Repaid (Energy Centre) Loan Repaid (Business Park) Salix Loan Repaid Capital Element of Finance Lease repayment Interest on investments (72) (16) (20) (7) (6) (19) (17) Interest Paid on Revolving Credit Facility Interest on Loans (Energy Centre) Interest on Loans (Business Park) Interest on PFI & Finance Leases 7,513 1,879 1, ,878 1,878 PFI Contingent Rental Payments 2, sub-total 34,305 7,429 11,981 2,979 2,642 7,151 7,744 Net Inflow / Outflow (4,772) (10,638) 2,720 (839) 2,379 (31) 3,178 Forecast Balance C/F 22,835 16,969 19,689 18,850 21,228 19,657 22,835 Page 33

46 '000 Analysis of Cash Balances (Monthly) Enc 2.5 GRAPH A Monthly Net Cash Balances (incl. Overdraft) Monthly Cash Balances NatWest GBS- Citibank Cash Balance 30,000 25,000 20,000 15,000 10,000 5,000 - Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Date Graph A shows the monthly net cash balance based on actual cash flows. The level of balances held on the Citi Bank and Natwest accounts are frequently reviewed in order to maximise interest receivable and minimise interest payable and bank charges. Page 34

47 '000 Analysis of Cash Balances (Daily) Enc 2.5 GRAPH B Daily Movement of Cash Balances (Net of Overdraft) Daily Cash Balances Balance ( '000) 70,000 60,000 50,000 40,000 30,000 20,000 10, Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov-12 Date Graph B shows the fluctuation of cash balances on a daily basis. This graph highlights the receipt of SLA contract income around the 15 th of each month (indicated by the peaks between 30-40m), and the reduction of our cash balance between the 17 th and 24 th when large monthly payments e.g. payroll, P.A.Y.E and N.I. are paid. Page 35

48 Statement of Financial Position (Balance Sheet) Enc 2.5 STATEMENT OF FINANCIAL POSITION AS AT 31 March 2012 Qtr 1 30 June 2012 Qtr 2 30 September October 30 November Consolidated Annual Plan Forecast March 2013 '000 '000 '000 '000 '000 '000 NON-CURRENT ASSETS Intangible Assets 1,276 1, , Property, Plant & Equipment 271, , , , , ,735 Investments in associates (and joined controlled operations) On-Balance Sheet PFI 75,679 75,155 74,630 74,455 74,280 73,438 Trade and Other Receivables, Non- Current 3,530 3,530 3,530 3,530 3,530 3,530 Total Non-Current Assets 351, , , , , ,777 CURRENT ASSETS Inventories 10,963 11,070 11,151 11,037 10,704 11,500 Trade Receivables 23,535 21,692 27,107 42,633 27,216 26,900 Other Receivables 8,352 19,143 9,016 5,247 14,780 8,800 Impairment of Receivables (2,756) (3,033) (3,592) (3,754) (3,516) (4,000) Other Financial Assets 8,668 18,455 21,270 9,054 17,364 8,246 Prepayments 3,844 4,056 7,100 6,401 7,373 4,000 Cash & Cash Equivalents 27,607 16,970 19,689 18,850 21,229 22,835 Total Current Assets 80,213 88,353 91,741 89,468 95,150 78,281 CURRENT LIABILITIES Interest-Bearing Borrowings (1,135) (629) (567) (567) (567) (1,135) Deferred Income (6,181) (6,793) (6,353) (5,786) (6,013) (4,700) Provisions (983) (838) (649) (1,196) (1,152) (990) Current Taxes Payable (7,939) (7,901) (7,787) (7,325) (8,038) (8,200) Trade Payables (22,849) (16,770) (27,217) (28,371) (29,633) (23,900) Other Payables (9,742) (14,811) (12,090) (12,598) (14,912) (9,500) Other Financial Liabilities (26,159) (34,165) (33,716) (25,631) (29,916) (24,529) Total Current Liabilities (74,988) (81,907) (88,379) (81,474) (90,231) (72,954) Total Assets less Current Liabilities 357, , , , , ,104 NON-CURRENT LIABILITIES Interest-Bearing Borrowings (12,083) (12,084) (12,084) (12,084) (12,084) (25,948) Provision (6,232) (6,232) (6,232) (6,232) (6,232) (5,542) Other Financial Liabilities (76,388) (76,388) (76,388) (76,388) (76,388) (75,659) Total Non-Current Liablilities (94,703) (94,704) (94,704) (94,704) (94,704) (107,149) Total Assets Employed 262, , , , , ,955 Financed By (taxpayers' equity): Public Dividend Capital 135, , , , , ,678 Revaluation Reserve 85,979 86,212 85,919 85,891 85,872 87,667 Income & Expenditure Reserve 40,643 41,863 36,770 37,670 38,562 34,610 Total Taxpayers' Equity 262, , , , , ,955 Trade and Other Receivables includes NHS and Non-NHS debtors on page 30 Trade and Other Payables includes NHS and Non-NHS Creditors on page 31 Page 36

49 Public Sector Payments Policy Enc /13 Paid to NHS Organisations Amount Paid on Time Through Direct Through Direct Public AP Sector Debit Total Payments AP Policy Debit Total % of % of % Paid Cum Ave '000 '000 '000 '000 '000 '000 AP DD on Target on Target April 2,100 2,593 4, ,593 3,247 31% 100% 69% 69% May 4,549 3,531 8, ,531 4,475 21% 100% 55% 62% June 2,136 3,415 5, ,415 4,257 39% 100% 77% 67% July 161 2,861 3, ,861 2,972 69% 100% 98% 75% August 2,169 3,919 6,088 1,026 3,919 4,945 47% 100% 81% 76% September 1,641 4,061 5, ,061 4,662 37% 100% 82% 77% October 4,142 2,897 7,039 2,467 2,897 5,364 60% 100% 76% 77% November 2,312 2,823 5, ,823 2,892 3% 100% 56% 74% 19,210 26,100 45,310 6,714 26,100 32,814 35% 100% 72% Paid to Non NHS Organisations Amount Paid on Time 2012/13 Through AP Direct Debit Total Through AP Direct Debit Total % of % of % Paid Cum Ave '000 '000 '000 '000 '000 '000 AP DD on Target on Target April 14,533 7,404 21,937 11,715 7,404 19,119 81% 100% 87% 87% May 14,098 8,438 22,536 7,258 8,438 15,696 51% 100% 70% 78% June 14,714 8,429 23,143 10,436 8,429 18,865 71% 100% 82% 79% July 18,757 7,405 26,162 9,734 7,405 17,139 52% 100% 66% 76% August 12,906 7,414 20,320 5,981 7,414 13,395 46% 100% 66% 74% September 12,918 7,583 20,501 4,142 7,583 11,725 32% 100% 57% 71% October 18,644 8,218 26,862 8,178 8,218 16,396 44% 100% 61% 70% November 14,718 7,549 22,267 5,602 7,549 13,151 38% 100% 59% 68% 121,288 62, ,728 63,046 62, ,486 52% 100% 68% Page 37

50 Glossary Enc 2.5 CIP Cost Improvement Plan SLA Service Level Agreement PDC Public Dividend Capital PSPP Public Sector Payment Policy Working Capital Facility - represents a sum of money reserved by the relevant bank for potential use by the Foundation Trust Asset - An asset is a resource controlled by the enterprise as a result of past events and from which future economic benefits are expected to flow to the enterprise Liability - an entity's present obligation arising from a past event, the settlement of which will result in an outflow of economic benefits from the entity Equity - the residual interest in the entity's assets after deducting its liabilities EBITDA Earnings before Interest, Taxation, Depreciation and Amortisation EBITDA Achieved (% of Plan) measures the achievement of earnings against plan EBITDA Margin (%) Measures Earnings as a percentage of total income indicating underlying performance Return on Assets excluding Dividends Net surplus before Dividends as a percentage of average assets indicating financial efficiency I & E Surplus margin net of dividends Net surplus as a percentage of total income indicating financial efficiency Liquidity Ratio (days) - The liquidity ratio (days) indicates the number of days that net liquid assets can cover operating expenses without further cash coming from cash sales of fixed or long-term assets. Page 38

51 Enc 2.6 Board of Directors Month 8 Performance Roland Sinker Chief Operating Officer 1

52 Enc 2.6 Report to: Board of Directors Meeting Date of meeting: 18 December 2012 Subject: Performance Report, Month /2013 Author(s): Presented by: Sponsor: Peter Fry, Assistant Director of Performance and Contracts Roland Sinker Roland Sinker History: Status: For Information 1. Background/Purpose This report provides the details of performance achieved against the governance indicators defined in the Monitor Compliance framework for the interim Quarter 3 November 2012 position. It also contains an update on the Trust s contractual position at Q2 in relation to its CQUIN performance. 2. Action required Alongside the Monitor interim Quarter /13 report, the Board is asked to approve the performance reported against the governance indicators defined in the Monitor Compliance framework for Quarter 3 as detailed within this Month 8 Performance Report. 2

53 Enc Key implications Legal: Statutory reporting to Monitor and the DH. Financial: Assurance: Trust reports financial performance against published plan. The summary report provides assurance that the Trust has met all targets as defined within the Monitor compliance framework for the interim Q3 position in 2012/13. Clinical: Equality & Diversity: Performance: There is no direct impact on clinical issues. There is no impact on equality & diversity issues. The summary report demonstrates that the Trust has achieved all performance indicators for the interim Q3 position as defined in the Monitor compliance framework. Strategy: Workforce: Estates: Performance against the Trust s annual plan forecasts and key objectives. None. There is no direct impact on Estates. Reputation: Other:(please specify) Trust s quarterly and monthly results will be published by Monitor and the DH. None 3

54 Executive Summary (1/4) Enc Trust Wide Performance for Month 8: Due to the early Board meeting being held in December, a shortened Performance paper is being presented prior to scorecards being available for the Month 8 reported position. Good Performance Whilst the Emergency Department continues to see high volumes of patients, the Trust achieved the overall 4-hour waiting time standard for A&E in November (96.4% compared to 97.6% last month). Q3 performance is 97% to date, therefore achieving the 95% target. Patient access targets for all Referral To Treatment (RTT) and cancer waiting times have also been achieved for the quarterly position to November. No further MRSA cases were attributed to the Trust during November so the Trust has 1 case YTD which is lower than our quota of 3 cases for the interim Q3 position. It is now over 230 days since the first case was reported this year. 5 further c-difficile cases were reported during November, so the Trust has declared 44 cases to date, lower than our quota of 50 cases for the same period. This compares favourably to the 71 cases that were reported at this point last year. Despite the drop in How Are We Doing (HRWD) performance reported last month, all HRWD section and overall survey section scores have achieved their targets for survey responses in November. Performance challenges Delivery of the 4-hour A&E waiting time standard remains a concern given the sustained emergency pressure that the Trust is having to manage, but the current quarter-to-date position is being achieved into December. Delivery of the RTT Admitted target for December still remains a risk as previously reported, as the Trust is still planning to treat more long-wait patients, but overall activity will be lower due to planned operating list closures that have been agreed for the Christmas period. The Trust still expects to achieve the RTT Non- Admitted and Incomplete RTT targets for December, despite the lower levels of activity expected for this month. 4

55 Executive Summary (2/4) Enc 2.6 Actions The number of patients waiting over 6 weeks for diagnostic tests increased from 63 cases in October to 77 cases in November, representing 1.6% of the waiting list compared to the 1% national target. The number of endoscopy breaches increased to 51 at the end of November, due to capacity being reduced to facilitate the move into the new endoscopy unit from 17 December The number of MRI breaches reduced from 28 cases at end of October to 20 cases at the end of November. Emergency Access Targets: The Winter Resilience Plan is being presented to the Board at the December meeting which sets out how the Trust is planning to manage the expected seasonal increase in emergency activity and change in patient flow over the winter period. As previously reported, this Plan incorporates the winter action plans for each division which have been developed at their winter workshops throughout November. The Plan comprises escalation polices to optimise patient turnaround, agreed changes to patient pathway management and additional capacity that becomes available from mid-december to manage both emergency demand as well as protect elective activity. To support the delivery of the Winter Resilience Plan, daily A&E breach meetings with the Chief Operating Officer and weekly meetings of the Emergency Care Board Operational Group will continue. Performance against the proposed divisional action plans will be picked-up at these meetings. Waiting List Access Targets: The Winter Resilience Plan also makes provision to protect elective activity during the winter period. Additional capacity in the form of a 12 short-stay elective ward will be created in mid-january 2013 for ring-fencing elective activity. The Trust will also continue to use off-site capacity during Q4 to treat its long-wait and 52-week wait patients. Achieving the RTT Admitted target in December and for each month in Q4 therefore remains a risk. Diagnostic Access Targets: After the new endoscopy unit opens from 17 December, the Trust will have full capacity to manage demand going forwards. The reduction in MRI breaches is dependent upon the new scanner becoming operation in mid-february Health Care Acquired Infection (HCAI): 1 MRSA bacteraemia has been attributed to the Trust YTD to November and remains a risk, but no regulatory action will be taken if the number of cases remains lower than the de minimis limit of 6 cases for the remainder of the year. 5

56 Executive Summary (3/4) Enc 2.6 C-difficile remains a risk due to the low trajectory that has been set for this year. Managing infection control and the early seasonal-outbreak of norovirus throughout the winter period will be challenging. Enhanced actions from the HCAI Action Plan continue into the new financial year, and additional measures have been incorporated into the Trust s Winter Resilience Plan. The Infection Control team attend the daily bed meetings and monitor any cases of diarrhoea, vomiting and influenza; which enables early management, confinement and prevention of an outbreak across the Trust. The Infection Control enclosure (ICE) facilities that had been ordered are also now being installed in the Trust. Other areas of concern: Slips, Trips & Falls: 146 cases were reported in November compared to the target of 94, with nearly 30 more cases reported than the previous month. Complaints: Timely response to complaints remains low at 45.1% compared to the internal target of 70% as the Trust focus is to clear the current backlog of complaints replied to within 25 days, as reported last month. Tighter controls are being put into place to improve response rates going forwards, however, the number of complaints received for November also increased to 73, compared to the 62 received in October. Mixed Sex Accommodation: There were 42 Single Sex accommodation breaches reported in November 2012, a slight decrease compared to the 46 cases reported last month. 35 of the breaches were delayed discharge patients from surgical and medical critical care units, but there were also 7 breaches reported in the Day Surgery Unit. Maternity: Actions reported last month continue, responding to capacity pressures. Actions have been incorporated into the Trust s Winter Resilience Plan. Day Surgery Unit: A mock CQC inspection has led to a number of actions which will be tracked by the Quality and Governance Committee and Divisional performance meetings. 6

57 Executive Summary (4/4) Enc Regulatory Monitor Q3 interim position The Trust achieved all performance indicators in November 2012 and is therefore rating itself a provisional score of 0 in the Monitor Compliance Framework for the interim Q3 position, giving the Trust a governance risk rating of Green. Care Quality Commission (CQC) Quality Risk Profile (QRP) 3. Contractual The latest QRP profile for December was published on 5 December 2012 with no significant adverse movements to report. There were marginal adverse movements but none concerning in: Outcome 2 Consent to Care and Treatment, Outcome 4 Care and Welfare, Outcome 6 Cooperating With Other Providers, Outcome 17 Complaints and Outcome 21 Records due to the addition of data items from the CQC A&E Survey and Information Centre for Health & Social Care. CQUIN 2012/13 The Trust has now received formal confirmation from the commissioners that we have achieved 100% of the CQUIN scheme deliverables for both Q1 and Q2 as expected. This represents a cumulative financial value of 3.8m. Significant progress has been made in the following CQUIN areas: Alcohol CQUIN, Cancer Staging (Q3 signed off in principle), VTE training, Dementia Training and antipsychotic prescribing review and End Of Life Care (Friends Stroke Unit added as an Amber Care Bundle ward). Key areas of risk for schemes in Q3 and Q4 include ensuring that EPR development work is completed in time to support data collection and reporting for the Alcohol and Dementia CQUINs. Further work is also required to meet uptake and improvement targets in relation to the new Outpatient experience survey across all specialties, and to increase the opportunities for patients to complete the survey on-line whilst in clinic. Internal monitoring arrangements also need to be agreed and put in place to effectively monitor patient survey rates. 7

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59 Enc 2.7 Winter Capacity Plan Winter Capacity Plan 2012/13 12/12/12 Version 4.1

60 Enc 2.7 START DATE: October 2012 REVIEW DATE: October 2013 COMMITTEE APPROVAL DISTRIBUTION: LOCATION: Chief Operating Officer All Staff Chair s Signatures: X drive Emergency Preparedness Plans, Kwiki CSM office, Major Incident Silver Control Room, Major Incident Bronze Control Room RELATED DOCUMENTS: 2012/13 Winter Plans Major Incident Plan/Mass Casualties Business Continuity Plans Bed Capacity Escalation Policy and Procedure Bed Management Policy Trust Cold Weather Plan AUTHOR/FURTHER INFORMATION: PERSONNEL RESPONSIBLE FOR UPDATES KEY LEADS Liz Wells/Sue Field Divisional Managers Head of Emergency Planning and Clinical Site Management Head of Capacity Management Chief Operating Officer or Deputy (Divisional Manager) Head of Clinical Site Management VERSION NUMBER 4.1 Winter Capacity Plan 2012/13 12/12/12 Version 4.1

61 Enc 2.7 CONTENTS 1. Introduction Background Key objectives of the Winter Capacity Plan Scope Key Personnel Measures to Optimise Patient Turn Around Emergency Department Escalation Plan Meet and Greet Patient Advice and Liaison Officer Service The Mental Health Liaison Team Multidisciplinary Community Liaison Ambulance Tracking London-wide Capacity Management System Access for Emergency and Elective Patients Ring fenced elective beds Capacity Clinical Decision Unit 8 additional beds Acute Assessment Unit 12 additional beds Short Stay Surgical Unit 12 additional beds Liver 2 additional beds Critical Care Capacity Maternity capacity Potential Additional Capacity Offsite Longer Term Capacity Developments Bed planning Christmas & New Year Divisional Winter Planning by Speciality Other Measures Annual Leave Planning Winter Capacity Plan 2012/13 12/12/12 Version 4.1

62 Enc Flu Vaccinations Infection Control Snow Escalation Process and Risks The escalation process applicable is covered by the Trust Escalation Plan Risks Appendix Appendix Appendix Winter Capacity Plan 2012/13 12/12/12 Version 4.1

63 Enc Introduction Typically over the winter months the NHS experiences a significant increase in emergency attendances and a corresponding increase in admissions. In order to ensure that the NHS is prepared for this seasonal change in patient flow, Trusts are required to draw up capacity plans to demonstrate that they are able to deal with the increased demand. This document sets out the King s College Hospital NHS Foundation Trust (the Trust/King s) Winter Capacity Plan for 2012/2013. It covers how the plan was put together, the objectives of the plan and the measures that have been put in place to deal with winter pressures. 2. Background At King s, demand for emergency treatment and emergency admissions have risen steadily over the past few years. Last year alone there was an increase in Emergency Department (ED) attendances of 2.8% and particularly high levels of demand were and continue to be experienced at weekends and on Mondays. With the event this summer of the London Olympics, a huge transient increase in London s population was anticipated. The Trust participated in a London-wide planning process to ensure sufficient capacity would be available for the likely increase in patient flow. This plan for dealing with emergency admissions during the winter of 2012/2013 is based on our experience of the past few years and takes into account lessons learnt during the winter 2011/2012 and Olympic planning exercises. It has been prepared on the assumption that we will have to cope with a significant increase in demand over the next few months. Furthermore, it has been drafted on the basis that any proposed system wide reform (external to the Trust) will not change significantly the demand for emergency care at King s, nor improve the external discharge processes in time to help with the coming winter. It should be noted that the likely high levels of demand for emergency treatment and of admissions over the winter pose a significant risk and expense for the Trust. Over the past year, to accommodate the steadily increasing pressure on our emergency services, King s has already introduced a number of key changes to the emergency patient pathway. These changes were made as part of the Trust s Transformation Programme. Looking forward, all specialities have attended winter planning workshops and have developed local action plans. The Trust s Winter Capacity Plan has two main emphases; to further optimise patient turn around, and to maximise relevant bed capacity, with particular focus on dealing with surges in patient attendance. We are confident that we have a robust plan in place for the coming winter. However, there is much that remains to be done in the wider health community to deliver the system wide improvements which will reduce demand and improve discharge in the medium to long term. Winter Capacity Plan 2012/13 12/12/12 Version 4.1

64 Enc Key objectives of the Winter Capacity Plan 1. To ensure that quality of care is not compromised over the winter period. 2. To ensure King s has plans in place to manage the predicted level of emergency admissions over the winter months. 3. To support ED staff in light of the likely increase and in particular, surges in demand. 4. To ensure that all staff and services are prepared and understand their roles and responsibilities. 5. To have clear escalation plans and processes in place to deal with peaks in demand. 6. To ensure that patients are able to leave the hospital promptly when they are clinically fit to do so. 7. To minimise the impact on elective activity of the increase in emergency activity. 8. To ensure that King s continues to meet the requirements of the eight clinical quality indicators when faced with higher attendances over the winter months. 9. To ensure that the Trust is able to maintain current performance against national targets over the winter period. 4. Scope The plan will apply without exception to all individuals within the Trust who are involved in providing inpatient services to patients. 5. Key Personnel Key personnel who have responsibility in Winter Resilience Plan are: Chief Operating Officer Senior Operations Team Divisional Managers Clinical Site Management Team. Bed Managers/Patient flow co-ordinators Medical Staff Nursing Staff ED Staff Discharge Co-ordinators Hospital Discharge Team (Lambeth and Southwark) Heads of Nursing Facilities housekeeping, porters and linen. Winter Capacity Plan 2012/13 12/12/12 Version 4.1

65 Enc Measures to Optimise Patient Turn Around 6.1. Emergency Department Average ED attendances have increased significantly since last year and continue to increase. The Trust has developed Trauma, Stroke and Primary Angioplasty for Myocardial Infarction (PAMI) services. The growth in demand relates to these services and also to Paediatrics, Elderly Medicine and Mental Health. A number of measures have been put in place to improve throughput and so to eliminate avoidable trolley waits and waits in the ED. These measures are discussed below Escalation Plan Of particular concern are the fluctuations in attendance with a daily mean of between 360 and 464 (a variance of over 29%). An ED escalation process has been developed to unblock bottlenecks which can occur due to a surge of ambulances into Majors, delays in speciality referral or lack of capacity (see Appendix 1) Meet and Greet There is a Meet and Greet nurse who will triage patients on arrival and if appropriate, redirect the patient to the most appropriate service for their needs e.g. patient s own GP, Lister GP walk in service, or advice on the national flu line if appropriate. This has proved successful in managing the minor injury attendances and early intervention for more seriously ill patients who self present Patient Advice and Liaison Officer Service Within the reception area is a Patient Advice and Liaison Officer Service (PALS). This offers help to patients with regards to registering with a GP service, redirects patients to primary/community services if the patient does not require emergency treatment and provides information to patients about local NHS services within the community The Mental Health Liaison Team The Mental Health Liaison Team, which comprises nursing staff, doctors and crisis practitioners, are based within ED to ensure 24/7 cover. Patients are seen, assessed and treated in a timely manner to expedite admissions to the appropriate ward or discharge home Multidisciplinary Community Liaison Within the Clinical Decision Units there is a Social Worker, Physiotherapist and Occupational Therapist. They work closely with the community services to enhance referral to appropriate agencies in providing home care packages and enable admission avoidance. Winter Capacity Plan 2012/13 12/12/12 Version 4.1

66 Enc Ambulance Tracking The London Ambulance Service (LAS) has provided access to their tracking system which enables the performance manager in the ED to track incoming ambulances and monitor the number of crews in the ED waiting to handover patients. The objective is to meet the 15 minute handover target with a further 15 minute deadline to have the ambulance ready for the next call London-wide Capacity Management System The Capacity Management System is a web based tool which provides an overview of the busyness of acute trusts in London. The system is draws on information about capacity and ED activity to calculate an access pressure score. Trusts are RAG rated (Green, Amber, Red and Black). Thus a trust working well within its capacity, able to receive ambulances would be rated Green. At the other extreme a trust under significant capacity pressure would be rated Black. Data is collected every two to four hours and gives a snapshot of activity which is interpreted by the LAS and the Sector. If particular pressures are identified at the Trust, the LAS will commence sending ambulances to neighbouring trusts for an hour to aid relief of pressure within the ED. They will send a Divisional Service Officer (DSO) to the Trust to assess and work with the Trust to recover. The Sector also monitors the RAG rating across the patch and will call when trusts have a Red RAG rating, to monitor whether pressure is within capabilities. Where necessary they will convene a Sector conference call to discuss the need for a Divert Access for Emergency and Elective Patients Effective and Efficient Turn Around of Emergency Medical, Surgery and Trauma Admissions The Trust has developed an Acute Assessment Unit (AAU) with twelve trolleys and an Acute Medical Unit (AMU) that comprises 60 inpatient beds. Both units are staffed by senior nurses and an Emergency Medical team led by a consultant. The AAU is for patients who may require extended assessment to establish the need for admission or discharge with follow up. Such follow up may be from community or specialist out-patient clinics. The AMU ensures that medical patients are admitted promptly and timely referral initiated to specialists and /or accelerated care pathways as required. All ED patients referred to the medical team are transferred to AAU. All general medical admission will be admitted to the AMU. Appropriate management by specialist teams reduces length of stay and therefore frees up capacity for emergency admissions (Appendix 2, AAU Operational Policy). The Acute Surgical and Trauma Unit accommodates both trauma patients and acute surgical admissions. Working to the model of the AMU but for trauma and surgery, this will support emergency admissions and enable elective activity during the winter months. Winter Capacity Plan 2012/13 12/12/12 Version 4.1

67 Enc Ring-fenced elective beds The development of elective only protected beds has been initiated. This will ensure elective activity continues and efficiency can be monitored via the utilisation of these beds. It should be noted that, if there were a Major Incident, these beds would be freed up as necessary Bed Management Bed meetings operate twice a day over the winter (13.00 with Bed Managers and with Chief Operating Officer and Divisional Managers teams). These work to balance elective work with emergency patients. The Daily Bed report with internal RAG rating will continue to be sent to the management teams at and Weekend planning across all Divisions is collated on Friday. Assurance about the sufficiency of weekend planning is provided by the Divisions to the Chief Operating Officer. ED performance is discussed daily at this includes any issues within ED and across the Trust. The Electronic Patient Status Board (epsb) across all wards will provide transparency of available capacity to enable management of patient requirements. Having visibility of capacity and numbers within the ED will enable proactive measures to manage daily capacity Escalation, Discharge & Repatriation There are clear routes of escalation internally within the Divisions and externally with Sector conference calls and CMS evaluations. The Trust has a Bed Capacity Escalation Procedure which sets out the trigger points, actions and responsibilities to manage bed pressures. Policies for the repatriation of patients from the HASU and the Trauma Centres are in place. The Trust Discharge Teams work to ensure a smooth discharge process is in place at all times to prevent bed blocking. Any increase in the number of delayed transfers of care will be escalated via Discharge Teams in the morning to enable prioritisation of case management. Successful repatriation and escalation processes contribute to improve patient turn around and hence emergency capacity. In turn this will enable timely access for tertiary emergency referrals into some specialities. 7. Capacity To help the Trust manage increased emergency admissions and continue to reduce the RTT backlog during this winter, additional capacity is planned to come on-line in the next two months. This includes eight ED beds and an additional 26 acute beds and other developments/measures as set out below. Winter Capacity Plan 2012/13 12/12/12 Version 4.1

68 Enc Clinical Decision Unit 8 additional beds Eight additional CDU beds in a modular unit linked into the ED, giving a total of 14 CDU beds. The 14 beds will be located in three separate locations within the ED as two three bedded areas and an eight bedded area. This development is anticipated by mid-december. 7.2 Acute Assessment Unit 12 additional beds Twelve additional acute medical beds will be created by moving the AAU from a ward location to a new facility in the current endoscopy unit; this will be created once endoscopy has moved into its the new development on 17 December. The AAU move is anticipated for mid-january. 7.3 Short Stay Surgical Unit 12 additional beds A twelve-bedded short-stay surgical unit, that will be ring fenced for elective activity only, is being created in the current renal dialysis unit. 7.4 Liver 2 additional beds Two beds are being created on Todd ward for planned Liver activity 7.5 Critical Care Capacity To alleviate the pressure within the medical and surgical critical care units, the following plans have been put in place: o Renal to increase from two to four HDU beds to accommodate acute renal injury/failure patients. o Cardiac recovery unit to open from four to six beds to accommodate cardiac and cardiothoracic elective and emergency patients. o Murray Falconer to open four post operative recovery beds for elective patients which will free up Kinnier Wilson HDU beds to accommodate timely step down from critical care unit. o Specialities to transfer patients discharged from critical care by These measures should increase flow through both critical care units. Winter Capacity Plan 2012/13 12/12/12 Version 4.1

69 Enc Maternity capacity The service will continue to use four Katherine Monk beds to meet times of peak demand (particularly high demand is anticipated in January). This will however, reduce the level of beds available to support other emergency pressures. 7.7 Potential Additional Capacity Offsite In addition, discussions continue with the South London Healthcare Trust about utilising spare day case lists at either Queen Mary s Sidcup or Princess Royal University Hospital, Farnborough to enable activity to transfer from King s Day Surgery Unit (DSU). The freed up lists in DSU would be used to provide additional rapid access lists to reduce the level of emergency inpatient admissions. 7.8 Longer Term Capacity Developments A new modular building is under development to be operational at Denmark Hill from May It will comprise 47 beds, twelve of which are single rooms with en-suite and will provide a net increase of one theatre 7.9 Bed planning Christmas & New Year The usual system of a Trust wide co-ordinated flexible bed plan will be in place to cover the holiday period and early into the New Year to ensure that emergency access is maintained throughout and that elective work comes back on line quickly after the holiday period. All divisions were required to submit their bed plans for Christmas and the New Year by beginning of November 2011 for central co-ordination. The Trust has allocated wards and protected speciality beds for elective and tertiary referral admissions throughout the autumn and winter to ensure that performance against waiting time targets is sustained. A predictor tool is used for emergency admissions, to proactively monitor number of beds required on a daily basis. Critical Care facilities are managed by the intensive care consultant for each adult unit and for the paediatric unit. All Critical Care units use their capacity flexibly and, as described above, plans have been devised to increase capacity if required during the winter. There are also plans for managing and if necessary cohorting patients during a seasonal flu outbreak. 8. Divisional Winter Planning by Speciality All of the Divisions have attended a workshop to discuss the challenges of winter for each speciality. They have made plans to ensure that they have the capacity to manage their own patients within their protected bed pool. Mindful of the levels of Winter Capacity Plan 2012/13 12/12/12 Version 4.1

70 Enc 2.7 demand for emergency admission, the surgical specialties have been asked to align the demand for elective admissions with annual leave requests and theatre capacity. The Clinical Site Management team will promote the rapid access list during the holiday period to continue admission avoidance for minor surgery and trauma cases. The key points are:- An increase the consultant presence, across all specialties particularly in the receiving and assessment wards and in the Emergency department (ED) Assigned expected date of discharge for all patients To ensure medical ward/board rounds before 10 am every morning Daily visits to assessment wards by specialties who have patients in those areas and enforcement of a requirement that those specialties make arrangements to transfer their patients to the base wards within 18 hours Daily senior clinical assessment of all patients and assigned expected date of discharge Escalation process for cancelling elective activity: Agreed strategies to control and support medical outliers Trust Wide agreement on planned escalation process Planned Increased bed capacity and back up plans to further increase beds in response to excess levels of demand 9. Other Measures 9.1 Annual Leave Planning Systems of planning leave for extended holiday periods are in place with executive and general management cover co-ordinated via the Chief Operating Officer. Division and directorate management teams are required to be mindful of the anticipated changes in demand over the winter when approving staff requests for annual leave. 9.2 Flu Vaccinations All Trust staff will be offered the flu vaccine via Occupational Health. There is a staff vaccination programme; this includes group vaccinations in a central area, open clinics and visits to speciality/vulnerable areas. See Staff Vaccination Campaign Appendix Infection Control The Infection Control team attend the daily bed management meetings and monitor any cases of Diarrhoea and Vomiting, influenza etc. This enables management, Winter Capacity Plan 2012/13 12/12/12 Version 4.1

71 Enc 2.7 confinement and prevention of an outbreak across the Trust. There is Trust Outbreak and Operational Policy. 9.4 Snow Planning for extreme/wintery weather conditions is in place and is covered by the Trust Cold Weather Plan. 10. Escalation Process and Risks 10.1 The Escalation Process The applicable escalation process is covered by the Trust Escalation Plan Risks Risk Mitigation Excess Bed Pressures Capacity and activity restraints due to works within the ED resus and move to majors department Ward/Beds close due to an infection Excessive demand for emergency admissions Extensive planning and communication both internal and externally. Support from LAS and partner organisations in the event of patient risk due to capacity restraints These beds would be managed by medical nursing staff and supported by a Modern Matron and Discharge Co-ordinator; the ward would be used to take patients who no longer require acute medical care and are waiting for transfer to a community facility Excessive numbers of delayed discharges Inability to repatriate patients to other hospitals - a particular problem for regional specialties e.g. neurosurgery, where to maintain the service it is essential that we are able to repatriate New lead and centralisation of Discharge coordinators to provide support and expert advice Weekly meetings with Social Services and discharge teams Additional PTS journeys Receiving Trust to receive 24hrs notice of intention to transfer patients Centralisation of repatriation process and WTE to ensure follow up Follow Trust repatriation process and Winter Capacity Plan 2012/13 12/12/12 Version 4.1

72 Enc 2.7 patients Pandemic Flu escalation The Trust has plan in place Support Services Unanticipated delays in the provision of clinical diagnostic and support services. Transport delays Social services Discharge delays Single sex requirements Avoidance of mixed sex breaches clearly reduces the flexibility in the bed management system Delays in Mental health assessments of patients in ED and on acute wards The daily board meetings on each ward will monitor the process of each patient and take action to mitigate delays and expedite discharge. Change of EDD can be used on EPR The Trust will commission additional journeys at weekends and evenings which is essential to allow timely discharges and transfers Weekly Joint Meetings Discussion at Cluster teleconferences The weekly discharge meeting, attended by social services should continue with TEAM driving the processes Daily Board Rounds Escalation procedures to prevent unnecessary breaches covering both sites and coordinated by Clinical Site Manager and Back up Manager There is a Psychiatric Liaison Nurse team based in ED and an inpatient service lead by a Consultant Psychiatrist. Work is ongoing to address training of both nursing and clinical staff in dealing with patients with mental health issues, also the legalities involved in sectioning under the mental health act. Winter Capacity Plan 2012/13 12/12/12 Version 4.1

73 Enc 2.7 Appendix 1 Emergency Department Escalation Plan Winter Capacity Plan 2012/13 12/12/12 Version 4.1

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75 Enc 2.7 Appendix 2 TEAM Emergency Care Pathway: AAU & AMU ACUTE ASSESSMENT UNIT (AAU) EXT 5442 Located on Oliver ward - 8 trolleys Medical Take Team will be based in AAU with a dedicated nursing team from 0800hrs 2100hrs All ED patients referred to the medical team will be transferred to AAU for medical assessment and clerking for admission All referrals for assessment will continue to go through the Med Reg (blp 101) The Med Reg (blp 101) will see all patients referred from the Resus room within the ED The standards we will be working towards are: Referral to medical take team <90mins Emergency Department Assessment & clerking, DTA and placed within a bed BED MANAGEMENT The AMU (Acute Medical Unit) bed manager (blp 750) will be informed of DTAs from the AAU NiC All information will continue to be recorded on symphony until the patient is admitted to AMU The AMU bed manager will work from hrs They will bleep CSM (333) for a handover at 0800hrs They will contact CSM (333) at 2015hrs to handover the beds for the nightshift All patients in AAU will be allocated a bed by the bed manager before handover to the CSM Vanessa Sweeney Clinical Manager KH5678 Winter Capacity Plan 2012/13 12/12/12 Version 4.1

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77 Enc 2.7 Appendix 3 Get your skates on and get protected against flu! Even if you don't have any flu symptoms you may still be carrying the virus and passing it on to others. The sooner you are vaccinated, the sooner you are protected. You can get your flu vaccination tomorrow (Friday 28 October) in the Boardroom. This is the start of a number of sessions in the Boardroom that have been scheduled between now and Christmas. The next two dates for Boardroom vaccinations are: Friday 4 November 8.30am - 4pm Friday 25 November 8.30am pm If you don't get the chance to go to the Boardroom, Occupational Health is holding sessions every Thursday morning between 9am and 2.30pm, third floor Jennie Lee House. For ward visits or for more information about whether you should have the flu jab, please speak to Occupational Health on ext Protect yourself, your family and our patients against flu. Winter Capacity Plan 2012/13 12/12/12 Version 4.1

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79 Enc 2.7 Appendix 4 Actions to be taken by the Back-up Manager in the case of escalation due to lack of capacity CSM - Should have already 1. Contact Med/ED registrar to review patient to confirm need for admission. 2. Review patients in CDU for potential space. (Take into Consideration patients needs and the admission criteria) 3. Contacted Bed Managers to follow up predicted discharges, relevant patients to Lewisham and chase up results if required. 4. Contacted Discharge Lounge to facilitate and expedite movement of patients for discharge. 5. Contacted Matron/ HoN/General Manager (Speciality). Out of Hours: Clinical Bleep Holder 6. Assessed:- unused capacity a).are there beds blocked/closed? B). reasons? 7. Identify patients on the post take ward/mau round that may be fit for discharge following review discuss with clinician. 8. Is there a bed available of the opposite sex if yes, inform patient of decision to offer this bed. If late at night do not waken other patient to inform them. Move any patient in this category within 24 hours. Step 1 Escalation (Without Backup Manager consent - go ahead) Is nuclear medicine bed in use on Trundle? Are there any private beds available? Move female patients from Gyne to maternity if possible discuss with Maternity Manager on call. Is the dialysis bed free on Fisk if so use and inform Renal management. Are there any PIU beds on Trundle available. If closed open. Inform Neuro manager or out of hours Clinical Bleep Holder. Are there any empty beds on the elective only wards? (Brunel, Matthew Whitting, Trundle) Winter Capacity Plan V.3.0 draft 18

80 Enc 2.7 Step 2 To be discussed with General Manager/ Back-up Manager or Chief Operating Officer before you do. 1. Use CDU capacity out of hours 2. Philip Issac Unit (Paediatrics) is it possible to open? 3. Open 7 PIU beds on Waddington (Use specialist medicine staff out of hours and inform nurse in charge to book for dayshift) 4. Open closed beds on David Marsden (8 beds) 5. Cohort elective patients to vacate bays on Matthew Whitting and Trundle to use for emergency admissions 6. If Critical care full treat and transfer patients to other critical care units (CSM to inform EBS/HEMS &LAS) 7. If all capacity full and no imminent recovery then discussion with ED Consultant/CSM Trust to ask LAS for Divert (London Divert Policy) Winter Capacity Plan V.3.0 draft 19

81 Enc 2.7 Winter Planning Action Plan Appendix 5 Area Action Lead By When Managing Undertake winter planning modelling at specialty level SF 21 Oct Capacity inc. emergency trend, cancer growth & RTT position Review bed allocations in light of modelling SF / LW 1 Nov Review bed protection arrangements SF / LW 1 Nov Provide clear guidance on use of protected and unprotected beds SF/ LW 1 Nov Confirm the use of 4 David Marsden beds SF / LW 1 Nov Confirm location of flexible winter capacity RDL or Twining Protocol established on when and how to open the flexible winter pressure capacity as additional acute medical beds Clear processes in place on all emergency pathways from ED to reduce the use of CDU and ensure its not a holding bay and we can manage with 6 CDU beds with no impact on ED breaches All divisions to have processes in place to manage discharges from CC Policy in place for the use of side-rooms admission and discharge criteria Agreement on whether we convert 2 bedded bays to single rooms with en-suite Establish standards for key diagnostics should be the same standards 7 days a week and an action plan for scoping and then working towards achieving may need to be phased, focus on biggest wins Next FSH Workshop to revitalise momentum and improve performance SF / SB / EM ST / GJ SB / IJ / EM / SD DMs VS SF SF / PF LW / VS 4 Nov 4 Nov 1 Nov 4 Nov 1 Nov 4 Nov TBC 9 Nov Winter Capacity Plan V.3.0 draft 20

82 Enc 2.7 Reducing demand for beds Priority ambulatory pathways in place in medicine & surgery to reduce level of amissions to MAU & ASU Rapid access lists established in DSU VS 11 Nov AW/IJ/SD 31 Oct Maximise the use of medihome list of conditions expected to be referred to be circulated Establish a process to challenge missed Medihome opportunity Ensure robust trust-wide repatriation process in place, with 52 week cover and clear escalation process AW / DMs SF / PF EM 4 Nov 11 Nov Proposal to PIG on 1 Nov Other Flu plans updated trust and depts. LW / DMs 28 Oct Additional actions for Resus Phase 3 Change back up managers for the 3 week period LW 21 Oct Inform LAS acute cluster that for a 2-3 week period resus will be operating within majors LW / BS 28 Oct Request quicker response from SLAM LW / BS 28 Oct Winter Capacity Plan V.3.0 draft 21

83 Enc Report to: Board of Directors Date of meeting: 18 th December 2012 Subject: Author(s): Presented by: Sponsor: Status: Quarterly Patient Safety Report Mr Michael Marrinan (Medical Director) & Richard Hinckley (Head of Patient Safety & Risk) Mr Michael Marrinan (Medical Director) Mr Michael Marrinan (Medical Director) For discussion 1. Background/Purpose This report outlines the key patient safety issues that have been reported through the governance framework in the quarter July-September Action required The Board of Directors is asked to note the contents of this report and make any recommendations as necessary. 3. Key implications Legal: Financial: Assurance: Clinical: There are no direct legal implications Financial impact from failure to maintain discount on CNST insurance premium (2012/13 contribution without risk discount is c M) This summary highlights key patient safety issues and the actions taken to mitigate risk where this has been possible Significant clinical issues affecting the safety of patients are highlighted Equality & Diversity: Equality and Diversity issues are highlighted, where appropriate Performance: Strategy: Summary performance against the Trust s Safety Quality Priorities is provided Risk identification as outlined in Risk Management Strategy 1 P a g e